The Ether Way

And Now for Something Completely Different, Not!

'May you live in interesting times' - an ancient Chinese curse that people understand more deeply as they get older.

First, there is this very nice apology for how the US health care system stacks up to those of Europe, and why the most commonly cited statistic - life expectancy - is stacked against the USA:

http://www.chicagotribune.com/news/columnists/chi-oped0816chapmanaug16,0,1666314.column

Americans (US, not Canadians) pay more than other countries for our health care, but the data Chapman reviews suggests that we get what we pay for - the best cancer and heart care in the western world.  This is not a fact trumpeted by the advocates of health care reform.

More ironically, while many are concerned that opposing health care reform might get them reported to the White House and added to the 'enemies list', it is pretty clear that criticizing the NHS is regarded as somewhere between disloyal and treason.

http://news.bbc.co.uk/2/hi/uk_news/politics/8200817.stm

I especially liked this quote:

"If 80% of Americans are getting better health care than we are in the UK then we ought to ask why, and we ought to ask how are we going to deliver equally good results."

which speaks for itself.  The performance of the NHS is clearly an issue in UK politics, far more so than most proponents of health care reform in the US acknowledge. 

The most troublesome thread in the BBC story is the outrageous deceptions perpetrated by parties on both sides of this debate - in the UK!  In that sense, the US and UK political systems are alike.

In follow-up to my recent posts about the black market in organs, there is this news item from today:

http://news.yahoo.com/s/ap/20090818/ap_on_re_us/us_black_market_kidneys

I have no way of verifying the facts of this story, or following up on the allegations.  This story names names.  It would seem as if several regulatory bodies would now have an imperative to conduct an investigation of some sort. 

Finally, on a lighter note, some scientists have a great sense of humor:

http://news.bbc.co.uk/2/hi/science/nature/8206280.stm

The Blackest of Black Markets

In the1970s, science fiction author Larry Niven envisioned a world where the rich were so anxious to procure organs for transplantation that the death penalty was expanded from murder to traffic infractions(1). The liberal application of the death penalty and the likely unconsented harvesting of organs from the condemned in China is a variant of the world that Niven envisioned (2).  Multiple sources report that the timing of executions in China, as well as the way they are carried out (a single bullet into the back of the head of the condemned) is intended to optimize organ recovery. Niven also wrote stories of criminal gangs that kidnapped people and sold their organs to those desperate for a transplant.  He termed this practice ‘organlegging.’  For more than a decade, the western press has run stories of organ selling and organ theft in other countries, most commonly 3rd world countries such as Brazil(3).  Such stuff has been fodder of supermarket tabloids and internet conspiracy theorists far more than serious news outlets.

 

The desecration of the dead and profiteering from the sale of their tissues has been a source of sensational news in recent years.  It is generally accepted that taking tissue from the deceased without the knowledge or consent of their families is a grisly and heinous crime, to be punished with severe criminal penalties, as in the case of the Michael Mastromarino and his company, Biomedical Tissue Services(4).  Please note, BTS had two sets of victims, the families of the dead, and the recipients of the hopelessly inferior tissues BTS was selling.  The most disturbing part of this story is that this is not a story of a couple of sleazeballs in the basement of a single funeral home, but a collection of funeral home directors and employees in 4 cities in at least 3 states. A lot of people had to look the other way for years. For the medical profession, the saving grace in this story is that none of the principles was a health care professional.

 

Patients with end stage organ failure are miserable, and many become desperate for the transplant that could improve their everyday existence.  Those with means become willing to expend enormous sums of money to jump to the head of the line, even in first world countries.  The purchase of organs from living donors is explicitly illegal in most of the western world; any market that facilitates the transfer of organs from living donors to paying recipients is (at least presently) properly viewed as a black market.  The existence of such black markets is the inevitable consequence of any schema that allocates organs by needs instead of means; where a need based allocation system is utilized instead of a free market.  Recent news items shed some light on this, the black market of organ donation. 

 

The FBI recently arrested a man (previously mistakenly identified by myself as a Rabbi) in New Jersey who is alleged to have brokered the sale of kidneys from donors in Israel to recipients in the US.  Press reports represent that he purchased the kidneys for $10,000 from the donors, and was selling them to the recipients for $160,000 (5).  They also imply that he had been in this unusual line of business for at least a decade.  A few observations are in order:

 - we don’t in fact know how many times the accused successfully orchestrated such a transfer.  It could be once, it could be dozens of times.

 - even if he managed to pull it off once, it would have required an entire network of health care providers to look the other way.  Quite seriously, the surgeon and transplant coordinator (and likely the transplant nephrologists as well) had to be aware that this was an ‘international’ kidney donation that circumvented all of the usual channels.(‘so where did you say this kidney came from?')

 - as with all black-markets, the broker is the one who makes all of the money. In this instance, maybe more than anyone else involved.

- the Black Market value of a kidney is presently somewhere between 10 and 160 thousand dollars.  No one can say what the open market value would be, but it would almost certainly be lower for the buyer and higher for the seller.

 

Please note, while it is generally agreed that organs should be allocated according to need, I am not opposed to the notion that people should be able to sell their organs. Other physicians have argued the myriad risks and benefits that would arise if this was allowed(6).  A regulated market in live kidney donation would likely decrease the cost to the purchaser and increase the compensation to the donor, at the expense of the profit margin of the broker.

 

Why now, and not 30 years ago when Larry Niven first imagined this? There are likely multiple causes or explanations. The internet, email, and cellular communications have dramatically simplified the logistics.  Increased ease arranging the wire transfer of funds and increased international trade have made it much easier to ship anything of value across international borders. Even the increased volume of organ transplantation has made the expertise, equipment, and drugs required to do this more available than ever before. Perhaps more importantly, the community of health care providers, including physicians, may have learned to ‘look the other way’ over the past quarter century.

 

If the allegations in this case are upheld at trial, it will be proof positive that there is a black market in organs in the US. 

1. http://en.wikipedia.org/wiki/Organlegging

2. http://en.wikipedia.org/wiki/Organ_theft

3. http://findarticles.com/p/articles/mi_m1134/is_n8_v107/ai_21191220/

4. http://www.foxnews.com/story/0,2933,199099,00.html

5. http://www.cnn.com/2009/CRIME/07/23/nj.corruption.kidney/

http://www.latimes.com/news/nationworld/nation/la-na-nj-corrupt24-2009jul24,0,922290.story

6. http://jama.ama-assn.org/cgi/content/full/288/13/1640

http://jme.bmj.com/cgi/content/extract/29/3/137

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2802%2908030-3/fulltext

Lost in Cyberspace

Once again, I have to thank my colleague Richard Cook for calling to my attention several news items, all of them relevant to my recent posts about Information Technology and health care.

Backround: Wait-times in England's NHS are long, very long, and have been a source of growing dissatisfaction with the NHS.  The resultant political pressure has produced programs to 'manage' and decrease wait-times. Recording and reporting wait-times has become a major marker of performance for the NHS.

Claim: With the power of computers, we should be able to very accurately track every patient and their progress.  A computerized information system will enable the NHS to very accurately track wait-times.

Reality: One of the largest NHS trusts in England has 'lost' lists containing at least two thousand patients.
What is the consequence? All of these patients waited well in excess of the 18 weeks (yup, you read that correctly - more than 4 months) for the treatment that their GP prescribed.

http://www.computerweekly.com/blogs/tony_collins/2009/04/barts-responds-to-criticisms-i.html

http://www.computerweekly.com/Articles/ArticlePage.aspx?ArticleID=235815&PrinterFriendly=true

How did this happen? No one knows for sure.  There are at least two plausible explanations; neither of them is a cause for optimism.  The first is that the electronic tracking system is so complex that it is almost impossible to track information as its purchasers and operators intend.  This is very plausible. The second possibility is that the NHS trust, recognizing that it didn't like the report it was going to generate(e.g. their wait times were terrible), decided to torpedo their IT system, which would deflect criticism from their overall inability to deliver quality care in a timely fashion.  There are other possible explanations, but these two suffice.

To their credit, the administrators of the trust elected to forego issuing a mandatory report on wait-times, because they had absolutely no confidence in the data used to generate the report. So much for precision tracking.  Sadly, this precedent will make every consumer of information eminating from the NHS wonder about its reliability.  Bad data, whether favorable or unfavorable, can only generate further problems for the NHS.  Discussions based on conjecture are worse, but seem inevitable.

Champions of CHIT will contend that experts should, given time and resources, be able to implement a system that works.  The experience NHS thus far reveals the lie beneath this. Two of the 4 major contractors have walked away from  $ 1 billion + deals, taking a loss just to get out.  The is a maelstorm of criticism of the product of the remaining vendor. 

http://www.guardian.co.uk/society/2009/apr/28/nhs-it-cerner-computers-hospitals

We are forced to conclude while it is possible for CHIT to permit precision tracking of patients, that there are no vendors on this planet that have been able to generate a product that might work for the NHS, at least not yet.

This problem is not unique to England, Australia has similar failures looming on the horizon:

http://www.theage.com.au/articles/2009/04/16/1239474999842.html

The Australian story also suggests that the system they have implemented has little or no capability to improve medication safety, one of the major motivators of the mandates to procure such systems.

One final point: These failures receive much less play in the English press than they would in the US press, because all of the 'subscribers' to the NHS have become accustomed to the exceedingly long wait-times associated with the system.  They're not subscribers or consumers as much as they are sheep, herded by the leadership of the NHS.  They don't even bleat in protest of this kind of failure.  No US hospital would survive the aftermath of a failure like this - except one run by the government....

The Pen is Mightier than the Computer

    When it comes to Computerized Health Information Technology (CHIT), also known as the Electronic Medical Record (EMR), the pen is mightier than the computer.

    Why? Because regulators and billing professionals seek comprehensive documentation, and believe that more information generates a clearer, more useful picture of what is happening (and has happened to) a particular patient. Malpractice attorneys and quality experts lust for this level of detail, as it will afford them the opportunity to point out the myriad failings of the health care system, and serve as a perch from which they can direct the continuous improvement in the quality of care. Patients, anxious that critical elements of their medical story might be lost or unappreciated, are anxious that every caregiver have complete and total awareness of the details and trajectory of their medical history. While noble, this aspiration is part of the problem with CHIT, and perhaps the major obstacle to its being a solution to any problem in medicine.

    The relentless quest for higher resolution of detail has driven a relentless increase in the detail provided.  Unfortunately, the coding available is often a poor fit for the clinical information (a mild dilation of the aorta classifies out as an aortic aneurysm, the former something that bears minding over decades, the later a potentially life threatening medical problem that commands close follow-up).  Worse, much of this coding is generated by administrators remote from the bedside, and who typically are deprived of the information required to code accurately.  The imperative to code something, anything, invariably trumps accuracy, and little inaccuracies creep in to the documentation in droves at this point.  Please note the shift in language from record to documentation in the last sentence.  Only outsiders regard such documentation as containing useful information about a patient; you will likely never meet a healthcare provider who has this view.  You will never hear ‘Could you please request Mr H’s medical and billing records from his hospitalization at memorial hospital?’ Not gonna happen. In fact, practitioners know that there is more noise than information in this documentation, which is why they do not and have never had any interest in it.  It is almost certainly the case that the cost of improving the accuracy of this documentation far surpasses any benefit that might accrue to the patient.  The fantasy that you can monitor the quality of health care from this perch, or improve it, is, well, a fantasy.  This has not stopped major players from falling for this, hook, line, and sinker:

http://www.boston.com/news/nation/washington/articles/2009/04/13/electronic_health_records_raise_doubt/?page=full
(this is a news story of how the incorporation of such billing information completely corrupted a Google medical record).

    Many EMRs read like Madlibs(for those of you old enough to remember what they are), because they are in fact cut-and-pasted snippets of data from other parts of the EMR, put in place to fulfill some billing documentation requirement or some regulatory imperative. Free text annotation is often discouraged, and  frequently impossible to juxtapose next to the appropriate snippet of information in the chart.  Some systems make it very difficult to generate any kind of free form documentation, and consequently critical events in the course of a hospitalization are never documented.  In most or all hospitals, practitioners have developed a shadow chart that incorporates all of the critical information that practitioners need to know to care for a patient.  The existence of these shadow charts has been driven by the hijacking of the medical record for billing and regulatory purposes.  The creation of these charts represents additional effort for everyone who directly participates in the care of patients.  That such busy people are willing to do this is striking.  Little you want to know is in the chart; everything you need to know is in the shadow chart.

http://content.nejm.org/cgi/content/full/358/16/1656
(this is a nice piece from the NEJM about the pitfalls & failures of the current crop of EMRs.  The authors describe the practitioner driven to keeping note-cards on his patients)

http://ukpmc.ac.uk/articlerender.cgi?artid=1023477
(this is a manuscript about sign-out sheets – the most common form of shadow chart – I am a co-author).

    Why is the pen mightier than the EMR? Before the modern era, the chart contained whatever information practitioners caring for the patient thought would be useful to others, either at present, or in the future for review.  Writing with a pen is effortful and time consuming. It forces the writer to abstract and extract critical information, and to synthesize whenever and wherever possible. Information is only duplicated if it is essential to the story that is being told.  The pen permits the writer to organize a note as they see fit, incorporating information wherever it makes sense to them.  If a picture saves a thousand words, then a sketch is likely to be incorporated into the note. Notations in the medical record call the readers attention to what the writer thinks is important and why it is deemed so.  The exclusion of extraneous information is as critical as the inclusion of crucial information.  Charts that are a concatenation of such notes are exceptionally useful in telling the stories of patients, but are a thing of the past (sadly, an increasingly remote past).  I have an ICU colleague who writes 3-7 sentence notes about patients.  His notes are as brilliant as they are concise, and everyone who reads them admires them, and envies his ability. In almost every instance, his notes are the only thing worth reading in the chart. While such brevity is possible with the EMR, it is not cultivated by it. Worse, synthesize seems to be an unnecessary undertaking whose execution is poorly supported by the EMRs of the present.

    How will we know an effective EMR when we see one? Easy.  The story of the patient will not merely discoverable, but self-evident.  Practitioners will cease making shadow-charts, because they will no longer be worth the effort.  Stalinist regulation to compel this might create the appearance of success, but only in the minds of the regulators and administrators who generated it.  Sharp end practitioners would be profoundly hampered by any such mandate.  Indeed, any regulation at all of shadow medical records is likely to significantly hamper medical care, which is why almost no one studies them, and why there is little or no discussion of them outside of the community of practitioners.

    The fantasy is that the chart is the repository of all of the facts of a patients care.  The reality is that the chart should tell the story of a patient’s care, clearly and concisely.  Anyone who reads it should come away with the patient’s story, not a mountain of seemingly vaguely related facts, as is the case with the EMRs of  today.  The pen promotes this, the EMR of the present actively obstructs it. For now, the pen is indeed mightier than the EMR.

An article about CHIT that everyone should read!

The article here:

http://medicaleconomics.modernmedicine.com/memag/article/articleDetail.jsp?id=590411&pageID=1&sk=&date=

highlights several important problems with the electronic medical record.
- Cutting and pasting is easy, writing is hard.  Hence EMRs are filled with mountains ofduplicate information, and almost nothing about what happened to a patient, or why.  The article intimates that a single 3x5 card might contain more useful information about a patient than megabytes of EMR.
- Rather than improving practitioners ability to withstand audits,they may create a circumstance where it is dificult or impossible for a practitioner to survive one.  The article points out that required documentation and coding may not be supported by individual systems (this will require constant updating). The absolute lack of concordance between documentation and effort severs a long established assumption: that extensive documentation reflects extensive contact and participation.

Stay tuned for further details!

Update on CHIT

Since my last post on CHIT, the economic stimulus package has been passed, and includes on the order of $20 billion to support the development of electronic medical records.  A few observations:

- The UK had a nationalized health care system, with standardization at many levels, for decades before it embarked upon its still floundering efforts to create an electronic medical record.  The amount budgeted is far less than what the UK has spent thus far.  The population of the US is several times larger than the UK, our health care system is nearly completely decentralized, and there is little standardization outside of health care directly provided by the US government.  It is likely that several times this amount would be required to arrive at the same point as the British – which is close to nowhere.  In short, the amount allocated is not even close to enough to begin to deal with the US problem, let alone craft any functioning product.  If the US experience replicates the UK experience, then the amount of money budgeted is far, far short of what will be required. 

- How is this money to be spent? This is not a trivial question, but in fact a central question.  There are major vendors of CHIT in the US, but their business model is of proprietary software and databases.  The kind of portability and accessibility that proponents of the EMR (Electronic Medical Records) tout are anathema to the business models of these vendors. Are the feds to choose one (and compel the scrapping of the competitors)? If history has taught us anything, it is government granted monopoly to any private corporation is a prescription for delay, cost overrun, inefficiency, and corruption.  Are the Feds to start from scratch? Are they to stipulate some sort of standard? Either would have the effect of undoing a substantial percentage of the experience and investment in systems to date.

- Can we even find efficient use for the money that has been allocated? Quite seriously, no one has ever had this kind of money to spend on the development of an EMR before. We’re clearly not ready to commence production, and we may not even know where we are in development.  Can there possibly be enough researchers and developers to efficiently and effectively utilize $20 billion dollars in funding?  The most likely answer? Somewhere between doubtful and inconceivable.  Make no mistake: the funds at issue will generate a huge number of ‘instant experts’ and draw everyone with remotely relevant experience into the endeavor. Sadly, there is no one with a large scale success to be recruited, because no one has had success on a large scale.

It's All CHIT To Me

There is enormous enthusiasm for Clinical Health Information Technology both from within health care and from the outside as well. There is enormous enthusiasm for provide rapid access to information about patients, with widespread belief that such systems will improve the quality of care and the satisfaction of both patients and providers.  There is no question that, on a small scale, such systems can work, and work extremely well. For instance, my own direct experience with my own department's pre-op clinic software, designed and developed by a clinician, was simply phenomenal. Satisfaction with locally developed systems is generally quite high.  More broadly, the larger the scale, the lower the performance and satisfaction. 

Our new administration is calling for increased utilization of CHIT at the national scale, and seems poised to spend a substantial amount of money for this purpose.  Once again, it makes sense to evaluate the English experience. The results are not encouraging. Worse, the bad news does not seem to have traveled well across the Atlantic.  My colleague Richard Cook has been following this story for some time, and you can read his bog posting about it here:

U.K. NHS computer system on verge of collapse & implications for the U.S investment in CHIT

There is also an interesting article, forwarded to me by  him, here:

http://business.timesonline.co.uk/tol/business/industry_sectors/technology/article5636437.ece

His other posts on the subject in the RIsks forums are also very much worth reading:

http://catless.ncl.ac.uk/Risks/25.44.html

This one is both erudite and humorous:

http://catless.ncl.ac.uk/Risks/23.81.html#subj6.1

Like so many things in health care, it is far easier to get this woefully wrong than most outsiders appreciate. As importantly, the financial costs of these failures are staggering.  The vast majority of CHIT systems in use or under development today have cost far, far more than projected, and taken far longer to go-live than their proponents represented.  Put differently, I am not aware of any system that was completed on time and under budget. 

In 2002, Cedars-Sinai in LA tried to bring up an electronic medical record. A caregiver revolt forced them off-line, back into the functional world of paper and pen.

Here is follow-up from the Cedars-Sinai implosion from years ago:

http://www.washingtonpost.com/wp-dyn/articles/A52384-2005Mar20.html

And finally, even when you go live with such systems, you confront potentially insuperable security and privacy problems:

http://www.latimes.com/news/local/la-me-cedars-sinai23-2008dec23,0,6381180.story

http://www.consumeraffairs.com/news04/2006/05/va_laptop.html

Be certain: in this, the electronic world mirrors the real world: security and easy access/ease--of-use struggle to co-exist.  Secure systems will be painful to their users, and easy to use systems will be riddled with security vulnerabilities.

Big Brother: Coming Soon to a Hospital Near You!

A prevailing belief in the modern world of health care is that outcomes would be a lot better if people would just do what the best-evidence dictates. In clinical practice, best evidence is incarnate in guidelines and protocols generated by societies, associations, and various empowered committees in hospitals and health care organizations. Concerns about conflicting outcomes in the clinical literature, the extension of the results from the study population to patients in general, and whether the cost of the program is worth the payoff are all safely classified as reactionary obstructionism by the leaders of this revolution. Pay 4 Performance was sold as a way to reward those who conform to ‘best practice.’ While it continues to have advocates, sharp-end practitioners have collectively come to the realization that P4P is a hoax intended to further reduce payments (mostly government) to health care providers.

http://docsurg.blogspot.com/2008/07/oops-p4p-slip-is-showing.html

It is already the subject of caustic irony, published in top-shelf peer reviewed journals:

http://jama.ama-assn.org/cgi/content/full/300/3/255

Finally, it is a dark day when Dilbert is smack-on about the world of health care:

http://www.dilbert.com/strips/comic/2008-09-03/

Where does all of this leave us? Well, at the highest levels, the backers of best-practice believe that the problem is that we have not gone far enough. Like the British generals prior to the Somme, their belief is that success requires the same template executed on a larger scale. In this instance, the belief is that practitioners routinely ignore best practice, in spite of whatever the documentation they generate might represent. Hence the only way to verify what happened is to create an enduring, reviewable record.

http://www.arrowsight.com/public/as/html/Medical/videos.asp

While the vendor appears to be marketing comprehensive systematic nearly prospective review; in reality such evaluations are certain to be extraordinarily expensive. Worse, performing them on a large scale would require an enormous number of hours, which would only be affordable if the work was done by less-skilled reviewers, or exported ‘off-shore.’ Realistically, this record will be used to ‘look back’ and determine the causes of bad outcomes. Do those who will be using this system for this purpose possess the necessary expertise (e.g. training as the NTSB would require)? I am unaware of any evidence to support this assertion; in fact, I would be flabbergasted if this was the case. Even in their infomercial, it is clear that they are focused on ‘Who are the bad actors?’ rather than ‘Why aren’t these practitioners doing what we want?’ This is not a trivial distinction; it is the difference between mindless, punitive inspection and actually the kind of human factors analysis necessary to improve performance (see The Inspections Will Continue…..). Woe to the ‘bad practitioner,’ this technology provides a mechanism to acquire evidence and levy sanctions.

Beware the briar patch. While many hospital administrators thirst for information this detailed, most do not realize that it could consume all of their time, and generate liability on a scale that they previously have not encountered. Some observations for health care organizations that are contemplating purchasing this technology:
1. If you don’t sanction practitioners for failure to comply, you’ll have to justify that decision. If you apply sanctions appropriately, there may be no one to do the work.
2. If practitioners comply with all applicable regulations and guidelines, economic failure is certain in any but the most lucrative practice environments. Nothing will get done.
3. Conflicting guidance will create organizational conflict. Where guidelines conflict, practitioners will either act in accord with their best judgment, or worse, compel institutions to generate guidance. This technology requires the organization to have an opinion about best-practice in every domain.
4. Legally, the enforcer assumes all of the risk. Plaintiff’s attorneys will love this: it makes the hospital/clinic accountable for every action of every practitioner. There will be no excuses for either not knowing or not acting.
5. The ‘rules’ you enforce had better be defensible in the face of litigation and continuously up-to-date. Every single one is likely to be tested in the courts.

Of this I am certain: this technology will be a weapon to silence counter-revolutionaries and reactionaries.

This post was written by Mike O'Connor

The Inspections Will Continue Until the Quality Improves...

Not-so-long ago, on this continent, one of us was Chief of Staff at a local Columbia Hospital when the Joint Commission for Accreditation of Hospitals (JCAHO or here, JC) appeared for a scheduled survey. Surveys were a little different then; they were announced long in advance, and, if a hospital did exceptionally well, they would receive accreditation with commendation; sort of a gold star. RFI's (recommendation for Improvement) were called  "Type 1" recommendations, and were taken as show-stoppers by all parties, requiring follow-up to ensure correction/compliance. Enough Type 1s and you lost your accreditation, which meant financial ruin. At that time, the Columbia hospital chain owned over 300 hospitals, and had convinced the Joint Commission that their operating practices were so different from other hospitals that they needed their own dedicated surveyors. During the inspection at issue, the physician on that surveying team insisted on a type 1 recommendation based upon his sense that medical staff leadership was marginalized by administration (or some such- the actual wording was never shared with the clinicians). Subsequently, administration announced that this type 1 recommendation had been "rescinded" and that the hospital had received "Accreditation with Commendation." Rumor circulated that said physician was henceforth dis-invited from surveying Columbia hospitals...

The JC was once a consensus building organization that followed the lead of its subscribers and accomplished a great deal. When Congress conveyed "Shall Deem" authority for medicare certification upon the JC, it wrested control of the JC from it’s subscribers and transformed it into a regulatory limb of congress and CMS. While the JC is undeniably under the direction of honorable people, their efforts have become distorted by the politics of money and power which surround them. It's no secret around hospitals that practitioners see no connection between the Joint Commission process and quality of care. Indeed, every practitioner understands that some of the worst hospitals attain JC accreditation almost effortlessly, while some of the best struggle to maintain their certification. Historically, JC inspection was centered on physical plant and policy/procedure. Dreadful care was fine, as long as the policy and procedure manual was up to date and concordant with the most recent guidance. Joint Commission accreditation was, and is, a high stakes game, and unfavorable decisions are very likely to be contested in court (or with the threat of litigation). Consequently, JC regulatory activity has progressively focused on inspection activities that can withstand such litigation. This trajectory has relentlessly uncoupled Joint Commission inspection and accreditation from even a remote relationship to quality of clinical care.  High scores and necessary accreditation have become contingent upon putting up a temporary facade of strict compliance, which frequently obstructs, rather than enhances, care. For the past two decades, the closest thing to a Potemkin village in the American culture has been a hospital preparing for a JC survey.

The Saga of the NHS continues - in the BBC & elsewhere

I'm long overdue to post... and hope that this entry will serve.....

Several of my previous posts have dealt with the failings and trade-offs associated with government administered health care.  Unbeknownst to most Americans, Britain's NHS 'devolved' into 4 'national' services some time ago, serving, England, Scotland, Wales, and Northern Ireland. 

This recent series of articles by the BBC:

http://news.bbc.co.uk/2/hi/health/7149423.stm

http://news.bbc.co.uk/2/hi/health/7140980.stm

describes how England, Scotland, Wales, and Northern Ireland have diverged in their provision of health care since the 'national' system was broken into 4 parts some time ago.  While each participates in the 'NHS', the reality is that each independently administers its own Health Service.

As readers of this blog might have predicted, there has been propaganda about the benefits associated with 'devolution':

http://news.bbc.co.uk/2/hi/uk_news/scotland/3850805.stm

but when serious analysts wanted reliable data, most of what they got was rubbish:

http://news.bbc.co.uk/2/hi/health/4361964.stm

Commendably, interested parties have persisted in their efforts to understand the NHS, and the first two stories from the BBC above summarize their findings.  Below is a cut and paste from one of them about the characteristics of the different national systems:

England - NHS market created whereby hospitals and community services have to compete with the private sector for patients, resulting in big falls in waiting times

Scotland - Doctors have much more of a say in services, with limited involvement from the private sector. Meanwhile, patients enjoy free personal care, unlike the means-tested systems elsewhere

Wales - Close working relationship between the NHS and local government, which has meant more innovation on public health, but less emphasis on waiting times

Northern Ireland - Somewhat hamstrung by political situation, but re-organisation of trusts pushed through and good integration between social care and NHS

More information is available from these sites (the BMA site is rich with info, the others are rich with flavor):

http://www.bma.org.uk/ap.nsf/Content/devolution2007~devolution2007political

http://www.guardian.co.uk/society/2008/jan/02/nhs.health?gusrc=rss&feed=networkfront

http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2008/01/02/nhs702.xml