A Classroom Encounter Leads to a New Conflict of Interest Policy for Harvard Medical School

Last week, the Harvard Crimson reported from another angle on the issue of conflicts of interest affecting academic medicine:

In early September, the first-year Harvard Medical School students in a biochemistry class expected to learn about protein degradation. Instead, they came out of lecture ready to push for more comprehensive conflict of interest policies.

Addressing a weekly clinic for 'The Molecular and Cellular Basis of Medicine,' a required introductory course for first-year medical and dental students, Medical School professor Paul G. G. Richardson was accompanied by a patient diagnosed with myeloma, a potentially deadly blood cancer.

The patient was being successfully treated with a bortezomib-based therapy, a drug marketed as Velcade by the Cambridge-based Millennium Pharmaceuticals. Students said that during the clinic discussion, Richardson suggested bortezomib can now be used as a first-line treatment—meaning that physicians can prescribe use of the drug at diagnosis, rather than only as a second or third-line therapy when the disease has recurred.

Intrigued by his presentation, several students later looked up some of his peer-reviewed articles and found that Richardson was on Millennium’s advisory board—a potential conflict of interest that was not disclosed during the session with Richardson and his patient.

Richardson, a physician and clinical researcher at the Harvard-affiliated Dana-Farber Cancer Institute, did not violate any existing policies. In an interview, he said that he did not disclose his ties to Millennium because he wanted to keep the discussion centered on the patient and because it would have been insensitive to bring up the tie with Millennium in front of him.

It turns out that this incident was the catalyst for a long-discussed change in the medical school's conflict of interest policy.

'I think that the student-administration cooperation on the [conflict of interest] issue to this point hasn’t been wonderful,' said [first year medical student Daivd C] Tian, who is also a member of the Harvard Chapter of the American Medical Student Association.

Shamsher S. Samra, a first-year medical student, said that students had been prodding the administration to revamp the Medical School’s conflict of interest policies for roughly six years to little effect.

But after the latest incident,

In response to the student concerns, the school’s curriculum committee revised the school’s student handbook last month to include a section of new policies mandating that faculty and students disclose all financial ties to pharmaceutical companies when discussing drugs developed by those companies.

If Richardson were to give the same presentation on bortezomib today, he would be required to disclose his relationship with Millennium, though he said he would likely do this either on the syllabus or on the course Web site.

Well, it only took six years, but I supposed Harvard Medical School should get at least polite applause for finally getting around to writing a conflict of interest policy covering the education of medical students.

Note Professor Richardson's response to his failure to disclose his relationship to Millenium, that doing so would be insensitive. Medical academics often seem so uncomfortable talking about their financial relationships. And one aspect of the anechoic effect is that it has become impolite, if not politically incorrect, to discuss such relationships. But if talking about such relationships is uncomfortable, then the relationships themselves should inspire discomfort among those who cultivate them.

Medical Informatics and Leadership of Clinical Computing: Ivy League University Decides On An Enlightened Approach

It is not often that the Healthcare Renewal blog offers praise to large healthcare organizations, but this is one such case.

In late 1998, ten years ago almost to the day, I initiated a web site entitled "Medical Informatics and Leadership of Clinical Computing." (That site has evolved into its present form here and is now subtitled "Medical Informatics, Information Technology Leadership, and Clinical IT Success.")

In that 1998 site I explicitly called, perhaps for the first time, for actual leadership of clinical IT initiatives by Medical Informatics professionals, who were formally educated and experienced in that domain, as opposed to the traditional leadership model by business IT personnel. The latter most often had backgrounds only in management information systems and lacked biomedical credentials and experience.

I created the web site, in fact, after a number of years as Chief Medical Informatics Officer at a large healthcare system and as faculty at an academic medical center, where I was exposed to alarming healthcare IT mismanagement. The first two stories at the current site chronicle several of my experiences. Further, my attempts to improve the situations and protect multi-million dollar IT investments from rejection and failure - and protect patient lives - were often met with opposition in the form of active or passive aggression by powerful CIO's and other IT staff, with (at best) passive and unsupportive responses by senior management. I realized there was almost no literature to turn to regarding this phenomenon and thus started the site.

I've experienced a degree of ostracism even within my own professional community for "airing the dirty laundry" and speaking my mind, and even today the website remains nearly unique. A google search on "healthcare IT failure" or similar expressions demonstrates that. (One could - hyperbolically speaking, of course - argue that only the National Security Agency does a better job of keeping information out of the public eye...)

Yet despite these efforts and that of others in writing about health IT difficulties, informaticists in similar roles experience the same issues, a decade later.

I therefore view with great interest a major Ivy academic healthcare system that has apparently decided to "do healthcare IT the right way", as evidenced by the following position solicitation seen at the Association of American Medical Colleges website AAMC.org (link). Note bolded passages in this excerpt:

Founding Director, Penn Institute for Biomedical Informatics and Associate Dean, Information Technology

The University of Pennsylvania School of Medicine invites applications for the position of Founding Director of a new Penn institute focused on biomedical informatics. This new institute is intended to span from clinical informatics, to translational informatics, to public health informatics, and bridge as well to library sciences, computational biology, and bioinformatics. This new leader will establish the institute, bring together current informatics-related faculty from several School of Medicine departments, hire new School of Medicine faculty, and reach out to informatics faculty in other Penn schools.

The successful applicant will have a distinguished international record in biomedical informatics, with experience in leadership appropriate for a center director. Applicants must have an M.D. and/or Ph.D. and have demonstrated outstanding expertise in education, research, and leadership ...

... As Associate Dean for Information Technology, the candidate will oversee Penn Medicine’s Chief Information Officer, jointly with the Chief Administrative Officer of the University of Pennsylvania Health System. In this role, the candidate will have a leadership role in formulating and implementing an enterprise-wide vision for research and administrative IT in the School of Medicine, and for clinical IT for the health system.

A leader with a distinguished academic record in biomedical informatics overseeing a healthcare system CIO (who most often have a traditional business IT background) is a bit of a precedent. While there may be other examples, this is exactly the type of organizational arrangement I have been calling for now for a decade. Clinicians will no longer be answering to business computing personnel.

I applaud the University of Pennsylvania for taking the initiative and creating this role in this manner. I can only hope the role will be supported by senior health system management and university administration when the inevitable sociotechnologic issues arise between clinical practitioners and researchers, and IT personnel.

Finally, while my aforementioned web site and this June '08 Healthcare Renewal post probably played no role in Penn's formulation of the new role, I can imagine that someone there read them (there have been hits from U. Penn from time to time) and at least might then have had a greater inclination to support such a position formulation.

That's how the introduction of new ideas that challenge the dominant paradigm (a.k.a. "subversion") works, I suppose.

I also hope other healthcare organizations will begin to follow Penn's lead.

-- SS

Should The U.S. Call A Moratorium On Ambitious National Electronic Health Records Plans?

We are now engaged in a worldwide economic crisis, the likes of which have probably not been seen since the 1920's.

In "Bank Bailout Puts £12.7bn NHS Electronic Medical Record Project In Jeopardy" I commented on how the world financial crisis of 2008 combined with chronic project difficulties and mismanagement was creating such high levels of doubt about the UK's Connecting for Health (CfH) national program for electronic health records (EHR's), that the program was under consideration for cancellation.

From that post:

Christine Connelly, the Department of Health's recently appointed head of informatics, is understood to be reviewing whether the programme is a cost-effective way of improving the quality and safety of patient care.

She will have to find compelling arguments to stop the Treasury earmarking health service IT as a candidate for cuts to compensate for the billions spent on the bailout of the banks. However, the high cost of cancelling contracts with IT suppliers may be a factor saving the programme from cancellation.

More on Connelly, the "recently appointed head of informatics" later.

In the United States, we need to consider the implications of this towards our own ambitious plans for national health records.

Either we get it right, or we should not pursue it at all under the current economic downturn. There are millions of uninsured and underserved people in this country who would benefit far more tangibly from funding of healthcare services rather than funding of ambitious health records projects that transfer scarce capital from the healthcare to the IT sector. These are initiatives that are demonstrably fraught with peril (as in the UK), that healthcare organizations and clinicians may not truly want to succeed, and with unproven ROI and unclear quality improvement benefits (see "Do Healthcare Organizations Truly Want Electronic Health Records To Succeed?").

If we are going to stay on our present course and commit billions of dollars to ambitious IT projects that might be better spent on healthcare provision, we damn well better learn something from the UK experience. I am unfortunately doubtful of this.

As I state at my academic site on HIT difficulties (link), learning from others' mistakes - learning what not to do, aside from "best practices" - is important. However, one fundamental lesson to be learned of the highest importance is on leadership of HIT. Towards that end I provide additional material on the UK's national EMR difficulties.

At Healthcare Renewal, Roy Poses and I have often noted the lack of biomedical or healthcare credentials in the "C" level and board leadership of healthcare delivery and healthcare supporting organizations such as pharmaceuticals and medical devices and technology companies.

Here is more on the stunning UK CfH problems, followed by an interesting (and predictable!) finding on its new leadership.

From The Telegraph:

NHS IT system 'at a standstill'

By Kate Devlin, Medical Correspondent Last Updated: 6:24PM GMT 28 Oct 2008

The roll-out of a flagship £12billion NHS IT system has come to a standstill in many parts of the country because of problems with the system, the NHS has admitted. Ministers want the computer programme, one of the largest in the world, to eventually contain the medical records of every patient in the country. But NHS bosses in London have decided to halt the roll-out of the electronic care records to hospitals indefinitely, to sort out technical problems.

From E-Health Insider:

Political row over NPfIT: London on hold
28 Oct 2008

Opposition politicians have renewed their condemnation of the National Programme for IT in the NHS following press reports that the programme is “grinding to a halt.”

Conservative shadow health spokesman Stephen O’Brien said the reports confirmed that, with the “hugely expensive” programme “desperately behind schedule” suppliers were “deserting in droves” and “frontline professionals” were “voting with their feet and insisting on local solutions.”

Meanwhile, Liberal Democrat health spokesman Norman Lamb issued a statement saying that the “centralised project” had been “a shambles from the start” and it was “time for a re-think on how to proceed.”

The latest round of political attacks on the national programme follow the publication of an article in the Financial Times, arguing that progress on one aspect of the £12 billion project, the deployment of “strategic” care records systems, has stalled.

The article reviewed a number of recent stories that suggest this and questioned whether the programme would ever be completed.

... It noted that hospitals that have taken the London Release 1 version of Cerner’s Millennium care record service are experiencing problems with it and that further deployments that were scheduled for this year are showing no sign of going ahead.

And it noted that although health ministers promised that the much-delayed first installation of iSoft’s Lorenzo care record system would take place in Morecambe Bay this summer, the system has not gone live and neither the trust nor NHS Connecting for Health can give a date for go-live.

Jon Hoeksma, editor of E-Health Insider, was quoted as saying that while other parts of the programme continue to make progress, “this key part seems to be simply stuck. It has ground to a halt.”

Other national papers picked up the story, prompting an apparent admission that in London at least further deployments have been put on hold indefinitely.

This from Financial Times:

NHS records project grinds to halt
By Nicholas Timmins, Public Policy Editor
Monday Oct 27 2008 18:30

Progress on the £12bn computer programme designed to give doctors instant access to patients' records across the country has virtually ground to a halt, raising questions about whether the world's biggest civil information technology project will ever be finished.

Since [its launch in 2002], however, just one of the scores of acute care hospitals due to install the underlying administration system required in order for the patient record to work has done so. The hospital, Royal Free NHS Trust in London, continues to have difficulties getting it to operate properly.

... Health ministers originally promised the long-delayed first installation of patient record software in the north of England would finally take place in June at Morecambe Bay on the Lancashire/Cumbria border. But four months on, the system has still not gone live and neither Morecambe Bay nor Connecting for Health can give a date when it might.

CfH's most recent published plans for the next three months do not include a single installation of a patient administration system into any acute hospital trust.... Hospital chief executives, he said, did not want to take a new system "until they have seen it put in pretty flawlessly elsewhere".

And this from the Evening Standard (UK):

£12bn NHS computer system crashes at the first attempt
Anna Davis
Oct. 30, 2008

THE roll-out of a new computer system to every London hospital has been frozen after being installed in just one organisation.

IT experts have stopped setting up the software across the capital and have rushed to sort out problems caused by the system at the Royal Free Hampstead NHS trust the only acute hospital to have installed it so far.

It is the latest blow for the £12billion national programme, designed to give doctors access to patients' records wherever they are in the country.

The system has been beset with software glitches and design faults. One internal health service document said it could put seriously ill patients at risk of being inaccurately diagnosed.

According to the document, it is routinely crashing, intermittently losing patient information, and some staff are reverting to pen and paper.

It seems this UK program, which has already resulted in the expenditure of billions of dollars, is not at all meeting expectations. In fact, it may die.

This raises a few questions:

• Could this CfH debacle have been prevented?

• Could this scenario find itself repeated here in the United States?

I offer the opinion that the answer to both of these questions is a resounding "yes."

On the first question, the answer is related directly to the issue of leadership expertise as I explain in some detail at my academic teaching site "Sociotechnologic Issues in Clinical Computing: Common Examples of Healthcare IT Difficulties." At that site I wrote:

... diffusion of clinical information technology (IT specifically intended for use by clinicians in clinical care settings) after 30-plus years of effort and billions of dollars spent remains limited.

... This website is concerned with the reasons for this apparent paradox ... While clinical IT is now potentially capable of achieving many of the benefits long claimed for it such as improved medical quality and efficiency, reduced costs, better medical research and drugs, earlier disease detection, and so forth, there is a major caveat and essential precondition: the benefits will be realized only if clinical IT is done well. For if clinical IT is not done well, as often occurs in today’s environment of medical quick fixes and seemingly unquestioning exuberance about IT, the technology can be injurious to medical practice and biomedical R&D, and highly wasteful of scarce healthcare capital and resources.

Those two short words “done well” mask an underlying, profound, and, as yet, largely unrecognized (or ignored) complexity. This website is about the meaning of "done well" in the context of clinical computing, a computing subspecialty with issues and required expertise quite distinct from traditional MIS (management information systems, or business-related) computing.

Of note regarding leadership changes in the UK CfH electronic medical records program and its IT leadership:

Two senior management appointments for NHS National Programme for IT announced
12 August 2008

The Department of Health has announced the two long-awaited senior management appointments for the National Programme for IT ... The Department announced in February that it was recruiting the two positions as part of a revised governance structure for handling informatics in the Department of Health.

Christine Connelly will be the first Chief Information Officer for Health and will focus on developing and delivering the Department's overall information strategy and integrating leadership across the NHS and associated bodies including NHS Connecting for Health and the NHS Information Centre for Health and Social Care.

Christine Connelly was previously Chief Information Officer at Cadbury Schweppes with direct control of all IT operations and projects. She also spent over 20 years at BP where her roles included Chief of Staff for Gas, Power and Renewables, and Head of IT for both the upstream and downstream business.

Martin Bellamy will be the Director of Programme and System Delivery. He will lead NHS Connecting for Health and focus on enhancing partnerships with and within the NHS. Martin Bellamy has worked for the Department for Work and Pensions since 2003. His main role has been as CIO of the Pension Service. He has also held the positions of Group Applications Director in Corporate IT, and as Senior Responsible Officer for Information Management in the DWP Change Programme. He was previously a partner with KPMG Consulting in London, and has also worked in Reuters where his roles included Head of Real Time Technology and Director of News Products Development.

Cadbury Schweppes? The candy and Dr. Pepper/Snapple company? Gas and Power? Pension services? To lead a national health IT initiative?

The absence of biomedical, healthcare and medical informatics expertise in this "revised governance for handling informatics" is quite remarkable.

Can government really be the sponsor of ambitious health IT projects, I wonder? Should they?

On the second question, could the UK scenario find itself repeated in the United States, the answer is most definitely 'yes.'

While there are informatics professionals at high levels within the HHS/ONC-led national initiative (not yet a formal program), the clinical IT initiatives of rank and file healthcare organization are still largely under the model of leadership by non-medical IT personnel.

Amateurs in health IT are running heath IT. One impact is a high failure rate for EHR implementations [1]. By analogy, in the field of Amateur (“ham”) Radio, I am among an uncommon group of physicians who hold high-level radio telecommunications licenses from the FCC, the Extra class, obtained after a series of examinations. I have built, operated and repaired sophisticated and powerful radio transmitters, receivers and other equipment. I can set up an emergency station with local, regional and international coverage in a very short time and communicate readily with others if needed.

Even with this background, I would not for a moment believe I should be telling commercial broadcasters, emergency services, and the military how they should be implementing and operating their wireless technologies, or managing those functions. I do not have the level of training and experience necessary. In radio, I am an amateur, not a professional.

In Electronic Health Records (EHR’s) and related clinical IT, however, a wide variety of “amateurs”, including technologists, clinicians and politicians, are telling medicine - as a field - how to implement and operate this modern and increasingly important tool of the profession.

Those IT professionals with success in the business computing field, or clinicians with some knowledge (often self taught) about information technology, are not best equipped to manage the issues in health IT. These personnel are, consistent with my amateur radio analogy above, “amateurs” in such settings, if one is truly honest about it.

As in radio, this label is not meant in a pejorative way. It is simply reality. However, the results of such a leadership model are predictable.

In effect, every HIT delay, failure, or difficulty is simply a transfer of wealth from the healthcare sector to the technology sector with one root cause being an unlikely leadership model.

"Irrational exuberance" for any technology or innovation can create - as we have learned - massive unexpected problems. This is certainly the case in IT.

Considering the uncertain ROI and QI data about healthcare IT, questionable leadership models, current financial turmoil, local clinical IT problems paralleling the more widespread problems in the UK CfH program, and the many uninsured and medically underserved communities in the U.S., I wonder if national EMR's may be an unwise pursuit in the U.S. at this time. Perhaps a moratorium on large scale healthcare IT efforts in the U.S. is warranted.

Such a move might also allow time to objectively and scientifically resolve some of the above issues.

This will certainly be an issue for the new U.S. administration.

Billions of dollars that might be spent on IT misadventure in a time of unprecedented national financial challenges and hardships might perhaps be better spent for the time being on delivery of needed medical services, health insurance and other "safety net" interventions.

-- SS

Note:

[1] Market Barriers and Challenges to Widespread Adoption of Health Information Technology. U.S. Office of the National Coordinator for Health Information Technology (accessed Nov. 13, 2008).

Who Leads in Intellectually Challenged Responses to Medical Informatics Backgrounds, The U.S. or Europe?

This is another personal account of rather strange experiences in the field of Medical Informatics, whereby I sometimes feel I am in a parallel world known in the comics as Htrae, Earth spelled backwards (see my earlier post here on the "parallel" worlds of medicine vs. IT).

I feel case accounts such as this, while admittedly anecdotal, may illuminate larger issues in medicine, healthcare information technology and leadership issues in both domains.

At "Should The U.S. Call A Moratorium On Ambitious National Electronic Health Records Plans?" I noted the appointment of a new Chief Information Officer for Health, a new leader for the massively troubled, multibillion dollar UK national electronic medical records program Connecting for Health (CfH).

The new leader had been a CIO at a candy and soft drink company as well as a gas and power utility. The are certainly fine qualifications to lead a national medical informatics initiative:

Christine Connelly was previously Chief Information Officer at Cadbury Schweppes with direct control of all IT operations and projects. She also spent over 20 years at BP where her roles included Chief of Staff for Gas, Power and Renewables, and Head of IT for both the upstream and downstream business.

The newly appointed Director of Program and System Delivery has a like background. Simply stunning. A multi-billion dollar EMR program on the verge of cancellation, with a history of ineffective leadership by non medical IT personnel, tries to redeem itself via the same old tired script despite ample availability of materials that suggest better ways, e.g. here.

Based on this type of story and my own anecdotal experiences, I am beginning to wonder if perhaps Europe has more dysfunctional attitudes regarding medical informatics expertise than the U.S.

For example, I'd personally been told several years ago that "there's nothing in my resume of value to a clinical research organization" by a British Sr. VP for Biometrics and Data Management of Europe-based CRO Icon Clinical who refused to speak with me directly (see "CRO's: we don't need Medical Informatics here.")

I've been told by a European GSK VP of Informatics & Knowledge Management who also refused to speak with me directly - even after an unsolicited call, interview and highly positive recommendation by GSK's own prestigious British retained recruitment firm - that my background was unsuitable for pharma informatics (despite my prior leadership role at Merck Research Labs - an American company!) This was because such work required someone with “an extensive CS background to write algorithms to solve business problems" (see my post "GSK, Avandia and Medical Informatics: More on Why Pharma Fails" for a series of significant questions raised by this information technologist's misinformed and profoundly tunnel-visioned view of Medical Informatics).

From another Europe-based clinical research organization: "Just wanted to follow up with you about the [informatics management] position. They sent us an e-mail today communicating that you are a great candidate but just a little too heavy on the Informatics side for this position."

I won't even attempt to parse that bizarre, duncical response.

Most recently, it happened again.

I've been told by another Euro company that I don't have enough experience.

I received an unsolicited message from Philips Research recruiting:

From: "Blimberg, Paul"
Date: 10/20/2008 03:39PM
Subject: Philips Research

Hello Scott,

We are presently conducting a search for viable candidates for our Open Head of Biomedical Research Informatics position (see attached). It was my hope that you may be able to recommend possible referrals or perhaps be interested yourself? Please contact me to discuss further.

Best Regards,

Paul Blimberg
Sourcing Team Lead - N.A.
Philips Shared Services - Recruiting

In the job description:

Title: Senior Director and Research Department Head
Group: Biomedical Informatics Research

The department performs research in areas of “representation, storage, retrieval, presentation, sharing, and optimal use of biomedical data, information and knowledge for problem solving and clinical decision-making”. Specifically, the research concentrates on clinical decision support. That is, the design, development, validation and evaluation of computer-supported software applications and solutions that unify knowledge discovery with engineering methods for deployment in the healthcare environment.

Responsibilities included:

• Local Line management of technical professionals (MD/PhD/MS level);Program project management: project content, resources, staffing, funding, etc;
• Project renewal for value creation;
• Technical interaction and visibility in regional technical and professional organizations;
• Develop and manage research relationships with universities, scientific institutions, government contracts, etc.
• Establishing and expanding the IP portfolio for biomedical informatics and clinical decision support;
• Networking worldwide with Philips Research group leaders, project leaders and researchers to set the agenda and manage the relationships that will solidify and grow the CDS research activities.

Desired Candidate Background included:

• Experience in leading technical research in biomedicine driven towards clinical & business outcomes;
• Line management and strategy development skills;
• Technical recognition in field of expertise;
• PhD or equivalent in Biomedical Informatics or Biomedical Engineering with healthcare organizational experience; MD a significant plus;
• PhD in Computer Science will be considered if accompanied by significant work experience in healthcare or clinical medicine.

This was a good fit to my background. I wrote back:

Attached is my CV towards this position. I am a very close fit to its requirements, and in fact a key issue is my background not just in medicine and IT, but in electronics and telecommunications as well. I converse with technology professionals as easily as with medical professionals and executives, a skill that I believe is uncommon.

I proceeded to have an intensive telephone screen with the Philips recruiter, who then said he would pass along my CV to the hiring manager and team and that I would likely hear back in a few days or a week.

I have heard that line before, I thought.

After two weeks I heard nothing. I sent followup emails and voicemails on several occasions, still nothing in reply.

I had a strong feeling that the reason was going to be another case example from the "Medical Informatics Theater of the Absurd."

I finally sent a message expressing that I was "troubled" about not hearing back, and got the following reply:

From: "Blimberg, Paul"
Date: 11/12/2008 02:06PM
Subject: RE: Philips Research

Hi Scott,

We are still recruiting candidates for the role. I did also receive feedback from the team indicating that they would like for me to identify additional candidates with more established industry experience. Unfortunately, They will not continue to consider yourself and a few other candidates I have recently presented. So the quest continues.

As a former hiring manager in Big Pharma providing advanced informatics support for pharmaceutical research and development to 6,000 scientists worldwide, as well as being clinical IT project leader in an international collaboration with a Middle Eastern oil-producing country as well as at a number of large academic and non academic medical centers, I'm not sure what "more established industry experience" in informatics means ...

In any case, Philips was telling me I did not have enough experience, based on a piece of paper; the hiring manager or staff made this decision without any direct communications. It's not as if people with formal Medical Informatics backgrounds are falling out of the woodwork ...

I am beginning to sense a pattern.

What was the background of the hiring manager?

B.Sc. Honours degree in Physics and Music and a Ph.D. in the measurement of blood flow with ultrasound from University College Cardiff, U.K. ... was an ATL Ultrasound Technical Fellow and is a Fellow of the American Institute of Ultrasound in Medicine ... joined Research in North America in 2002 as Department Head in Healthcare Systems and IT to focus existing competencies in medical information technology ...

Notably lacking: formal credentials in medicine or Medical Informatics.

It's their company, but that doesn't stop me from asking probing questions. Being an inquisitive person, I wrote to the CEO of Philips Research, Peter Wierenga, PhD. After a short summary of the events above, I wrote:

Dear Dr Wierenga,

I note your opinion at this press release :

Peter Wierenga, CEO of Philips Research adds: “ Talent is one of the essential drivers of our innovative power. Without talent there is no innovation."

I tend to agree.

My question to you is: how can talent be evaluated from a paper CV and an HR conversation, without any direct contact between the hiring manager (presumably a domain expert) and a potential employee?

I claim it cannot, and will make the claim - in my opinion - that your personnel who believe it can be, as evidenced by their not even talking to several candidates with backgrounds similar to my own, may be causing harm to your company and to U.S. informatics efforts.

I await an answer to my question.

(I am assuming, of course, that what I was told was straightforward, and that there is no "sweetheart candidate" - with a sham recruitment process conducted to show that required internal hiring procedures were followed. This happens ... however, I will assume straightforwardness. I report, you decide.)

As bad as U.S. companies have been regarding informatics expertise, anecdotally the most intellectually challenged responses to medical informatics backgrounds I've experienced have indeed come from European companies. Ironically, the Saudis thought more highly of the field than the supposedly refined "from each according to their ability" Europeans, in my experiences as co-PI of informatics in the Saudi-Yale collaboration in clinical genetics.

I am also beginning to sense that the UK's massive problems in its Connecting For Health national EMR initiative may not be an entirely nonlinear phenomenon explainable only by chaos theory.

-- SS



Htrae!

The Leadership of an Elite American University - Brought to You by the People Who Brought You the Global Financial Collapse

In which we revisit some questions about the leadership and governance of Dartmouth College, a leading US university....

Last year, we posted several times, most recently here, about the leadership and governance of Dartmouth College, which is, despite its name, one of the elite American universities, and home to a prestigious medical school. Dartmouth is unusual in that it allows some of its board of trustees to be elected by alumni. Furthermore, it allows candidates to be nominated by petition of the alumni. Many US colleges and universities' boards are entirely self-appointed. Those that allow elections usually restrict these to a few seats, and usually only permit candidates chosen by the board, university administration, or their agents. Therefore, the top leadership of most US higher educational institutions is mostly self-appointed. Dartmouth is a partial exception to this pattern, and seems to have a governance structure that is more representative (at least of one key constituency, alumni) and more transparent than most US institutions of higher education.

However, the unelected members of the Dartmouth board felt uncomfortable with the proportion of elected board members, once nearly half of the board. They proposed to increase the number of self-appointed trustees. The board chairman, Charles E Haldeman, Jr, justified this change as a way to make sure that the board "has the broad range of backgrounds, skills, expertise, and fundraising capabilities needed to steward an institution of Dartmouth's scope and complexity." He also asserted that the enlarged board would be "representing even more diverse backgrounds [which] will help us enhance board engagement with key areas of the college."

At the time, it was not clear to me whether these supposed advantages would compensate for the possibility that the new board, more enriched with self-appointed members, would be less representative and transparent.

Although there was considerable opposition to this plan, it was eventually put into action in 2007. The board has now been enlarged. I thought it would make sense, one year later, to see what the enlarged board looks like, and especially to see how broad its "backgrounds, skills, and expertise" are, and whether its members have "even more diverse backgrounds."

Dartmouth at least makes the biographies of its trustees easily available (link here), so here is a brief summary of the current roster of self-appointed trustees, first those whose appointments came before 2007:

- Leon D Black - "Leon Black founded Apollo Management, L.P. a global alternative asset manager, with a proven track record of successful private equity, distressed debt and mezzanine investing."
- Russell L Carson - "Mr. Carson has been a General Partner of Welsh, Carson, Anderson & Stowe (WCAS), one of the country's largest private investment firms, which he co-founded."
- R Bradford Evans - "Brad Evans is a Managing Director of Morgan Stanley and a Vice Chairman of the Firm's Investment Banking Department. "
- Karen C Francis - "Currently Ms. Francis is consulting with venture capital firms and Silicon Valley companies...."
- Charles E Haldeman Jr (Chair) - "Ed Haldeman is Chairman of Putnam Investment Management, LLC. He has been a Trustee of the Putnam Funds since 2004 and President of the Funds since 2007."
- Pamela J Joyner - "Pamela J. Joyner has more than 25 years of experience in the investment industry. She is the Managing Partner and Founder of Avid Partners, LLC. Ms. Joyner's expertise is advising investment managers and private investment groups in developing and implementing investment strategies in the alternative investment arena."
- Albert G Mulley Jr - "Albert Mulley is Chief of the General Medicine Division and Director of the Medical Practices Evaluation Center at Massachusetts General Hospital and Associate Professor of Medicine and Associate Professor of Health Policy at Harvard Medical School."

So, six of seven "charter" trustees appointed before their numbers were expanded are leaders of finance, and one is an academic physician. The six in finance are "diverse" to the extent that two appear to be in asset and investment management, one in private equity, one in what used to be investment banking, one in venture capital, and one in mutual funds.

Now, consider the new appointees:

- Jeffrey R Immelt - "Mr. Immelt was appointed as CEO in 2001 to lead GE...."
- Stephen F Mandel Jr - "Steve Mandel is the founder of Lone Pine Capital (LPC), a long/short and long-only equity money manager which he started in 1997."
- Sherri C Oberg - "Ms. Oberg is president, chief executive officer and director of Acusphere, Inc., a specialty pharmaceutical company."
- John A Rich - "Chair, Department of Health Management and Policy and Director, Center for Academic Public Health Practice, Drexel University School of Public Health."
- Steven Roth - "Chairman and Chief Executive Officer, Vornado Realty Trust"
- Diana L Taylor - "Ms. Taylor joined Wolfensohn & Company, a strategic consulting and investment firm, in 2007...."

So with the addition of this new group, nine of 13 "charter" trustees are leaders in finance, now including three in asset management, two in private equity, one in the field formerly known as investment banking, one in venture capital, one in mutual funds, and one in strategic consulting and investment. Of the remaining four, one is the CEO of a large diversified corporation that has a major finance subsidiary. The remaining three are two physicians and a pharmaceutical corporate CEO.

This is a diverse board? Chairman Haldeman had to be joking, or maybe his idea of diversity means including private equity along with investment banking and mutual funds, etc...

So the ostensible changes made to make Dartmouth leadership more diverse and broadening their array of talents seems instead to have maintained a leadership dominated by people in only one small sector of the economy, finance.

Maybe this could be justified if we knew that leaders of finance were particularly brilliant, and had skills and values particularly useful to the supervision of academic institutions.

Up to this year, there were those who did believe that people in finance were particularly brilliant. That, of course, was before the global economic meltdown, or financial collapse of 2008, or whatever it will be called. There is considerable consensus about the causes of this collapse, so I think it would be apt to quote the Conference Declaration from the recently concluded 13th International Anti-Corruption Conference:

In the final months of 2008, the world has faced a financial and economic crisis unprecedented in recent history. Illuminating a new level of interconnectedness; market failure has moved outwards from the mortgage sector to engulf credit and stock markets, and the global economy more broadly.

Facing a prolonged and painful recession, the gains of emerging economies are already being erased and the economies of the lowest-income countries are being put under further strain. We recognised the central role of transparency and accountability in mitigating the crisis and preventing future failures. And we underscored that the poor are not able to bear the cost of the greed and mismanagement of financial professionals half a world away and that better development - to which the fight against corruption is central - must remain at the top of the global agenda.

There is considerable consensus that globally the leaders of finance exhibited stunning "greed and mismanagement," and many have also charged they have exhibited arrogance, stupidity, and in some instances corruption. At the moment, and in retrospect of course, it would be hard to identify a group of people less appropriate to lead an elite academic institution than members of the group once dubbed "the masters of the universe."

Yet leaders of the now mostly discredited finance sector had managed to take over the leadership of a storied academic institution, home to a renowned medical school. It is quite possible that further investigation will show that the former "masters of the universe" took over the leadership of quite a few revered academic institutions, including academic medical institutions. Perhaps this will turn out to explain some of many problems that have afflicted academia, and academic medicine in the last 20 years.

In any case, all who care about education, and about academic health care, need to start thinking about how to re-engineer the leadership and governance of our formerly admired institutions.

What is Not Taught About "Leadership in Healthcare"

One of our scouts forwarded me a link to the curriculum from an MBA program from the distinguished Yale School of Management designed especially for would-be health care leaders. The program is entitled "MBA for Executives: Leadership in Healthcare."

Here are the required courses, in alphabetical order:
- Competitive Strategies
- Corporate Finance of Biotechnology
- Economic Analysis
- Enhancing Negotiation Skills
- Entrepreneurial Business Planning
- Field Studies in Healthcare Management
- Financial Accounting
- Financial Management
- Financial Reporting
- Healthcare Policy, Finance & Economics
- Hypothesis Testing and Regression
- Independent Study
- Integrated Leadership Perspective
- Law & Management
- Leadership
- Managerial Controls
- Marketing Management
- Operations Management
- Policy Modeling & Decision Analysis
- Probability Modeling & Statistics Estimation
- Quality Management
- Services Marketing: Strategies for Nonprofits & For-Profits
- Strategic Environment Management
- Valuation I and II
- Visiting Scholars Program

The link provides more detailed course descriptions.

So what is missing? There seem to be two obvious areas that are not taught.

The first is health care. There are only two courses in this curriculum on "healthcare policy" and "healthcare management." There descriptions are as follows:

Field Studies in Healthcare Management

The Field Studies Program is a year-long combination of integrative coursework and hands-on, faculty-mentored consulting to active healthcare organizations. It serves as a capstone for the MBA-E, bringing together skills learned in the classroom with knowledge and perspective gained from the Visiting Scholars to explore their application in a variety of healthcare settings. The coursework covers funds flow and value creation in the healthcare system, competitive and cooperative strategies in the world of healthcare, managerial controls in the healthcare setting, designing and refining operating processes in healthcare, current applications and issues in healthcare information technology, and managing transformational change in a healthcare setting. Past consulting projects have included reducing order-to-report cycle time for a diagnostic imaging department, coordinating and cross-checking diagnostic and therapeutic processes across different clinical departments, strategic planning for a community-based HIV/AIDS care program, developing a clinical quality management plan, capacity planning for a new nursing unit, and strategic and financial analysis of different adoption alternatives for a newly-introduced artificial vertebral disk.

Healthcare Policy, Finance & Economics
Teaches students critical skills in analyzing and working within the healthcare industry. The first portion of the course focuses on the Economic and Financial drivers of the domestic healthcare system, including private and public financing and delivery models. In the latter portion of the course, the students learn about current issues of importance to this $1.4 trillion industry. The course is part didactic/part seminar style and includes significant team projects and presentations.

Thus, these courses seem to have little if anything to do with the care of actual patients. Furthermore, there are no courses that seem to have anything to do with biology or biomedical science, or with the practice of medicine or nursing.

The second area missing is ethics, particularly the business ethics of health care. There are simply no courses even remotely related.

As we have discussed before, since the 1980s, the health care professions have been systematically dis-empowered, with the goal of breaking up the "physicians guild," while bureaucrats, managers, and executives have taken over health care. A quick perusal of the curriculum meant to train top level health care executives at an elite US university suggests that such executives may be completely untutored in biology, medicine and nursing, and of how patients actually receive care. Furthermore, such executives may not receive even rudimentary training in ethics, despite the severe problems we have documented on Health Care Renewal with the business ethics of health care, and the effects of such problems on patients and society.

We need to rethink the advisability of having health care controlled by bureaucrats, managers and executives, especially in an era marked by widespread arrogance, greed and foolishness among even the top executives of our most prestigious industries (finance in particular). If we must continue some control by such people, at the least they should be educated in biology, the values of health care professionals, the context in which patients actually receive care, and the ethics of business applied to health care.

Yet More Investigations of UMDNJ

We have frequently discussed the plight of the University of Medicine and Dentistry of New Jersey (UMDNJ), the largest health care university in the US. Facing indictment for federal crimes, the university operated under a deferred prosecution agreement and the supervision of a federal monitor from 2005 to 2007. We most recently blogged about UMDNJ here, and see links backward.

UMDNJ may no longer be under the monitor's supervision, ostensibly because of internal reforms of its management, but a recent story on NJ.com from the Newark Star-Ledger questioned the success of these reforms.

The state's medical university was overcharging the federal government by millions of dollars, even while under federal oversight for similar violations of the law, according to internal reports.

Those documents show administrators at the University of Medicine and Dentistry of New Jersey inflated medical expenditures by at least $21 million a year -- boosting Medicaid and Medicare reimbursement rates. The abuses were allowed to continue even after a consultant repeatedly warned them about the problem.

It is unclear how long the overbillings took place, but reports obtained by The Star-Ledger show they occurred as recently as last year, despite the fact the school was undergoing an administrative shake-up following earlier reports of widespread financial abuse. Those earlier abuses included the university's deliberate $4.5 million overbilling of Medicare, which was the spark that led to a 2005 federal investigation and the appointment of a federal monitor.

The new allegations raise questions about the impact and pace of reforms at UMDNJ and its University Hospital in Newark nearly a year after they emerged from the monitor's oversight.

U.S. Attorney Christopher Christie said he was troubled by the revelations. He said part of the reason his office agreed to end the federal oversight last year was the assurance by both the state and the university that there would be continuing efforts to resolve UMDNJ's long-standing internal problems.

As to the specific problems uncovered,

At issue were inflated rates paid to physicians on the UMDNJ faculty, as well as free support services -- such as office space and clerical help -- that the hospital provided to doctors in private medical practices. Those costs were submitted to federal officials to generate higher reimbursement levels than were warranted, according to the documents. The extra money was used to plug holes in the medical school's budget.

In addition, the final report by the federal monitor raised a series of issues:

Questions about the validity of the university's Medicare cost reports and possible violations of federal law -- as well as other allegations of financial abuses lodged by former medical school officials -- were also underscored by the federal monitor in a final report issued to UMDNJ administrators in December.

That confidential document, reviewed by the newspaper, raised red flags over charges of legal and ethical breaches that were to have been addressed by the university. The monitor, former federal judge Herbert J. Stern, said in the report that outside auditors were pressured to 'gloss over' findings that physicians were being paid more than market rates would dictate. As a result, the final report 'substantially understated problems which continue to exist.'

Among the monitor's other findings:

--Nurses working at the privately operated Robert Wood Johnson University Hospital in New Brunswick, another UMDNJ teaching affiliate, were on the university payroll -- and getting state benefits -- despite having no teaching responsibilities.

--On cost reports submitted to federal officials, UMDNJ improperly included the services of nurse practitioners and physician assistants who were employed in private practices.

--University Hospital was allegedly double billing for emergency room services when patients were waiting in the ER for an available hospital bed.

--UMDNJ retained and paid for legal representation of faculty members and other employees in disputes "tangentially related" to the university and "outside the scope of employment."

The allegations in the Star-Ledger article lead to announcements that a NJ State Senate Committee will investigate the university (see article here), and the US attorney opened a new inquiry, involving subpoenas served on the institution, and for its president and executive vice president to appear before a grand jury (see article here).

Of course, these latest reports involve allegations, not facts proven in a court of law. Nonetheless, they do suggest that the management of the country's largest health care university has not been reformed all that much. A corporate culture of deception and sleaze still seems to envelop the institution's executive suites. One wonders whether contributing to its entrenchment are 1) the "anechoic effect," which still has confined discussion of UMDNJ's woes to the local media and a few blogs; and 2) the lack of negative consequences so far suffered by any individual UMDNJ managers. Although UMDNJ as an institution was "punished" by a deferred prosecution agreement, individual managers, not the institution as a whole, were responsible for any misbehavior. While individual managers escape punishment, I doubt that the many honest people who work at UMDNJ can escape demoralization, and that ultimately it is the students and patients who will suffer.