text:
The Market Made Us Do It: Increasing Low Level Employees' Health Plan Deductible While Paying Executives Millions
A small news item from the Seattle public radio station, KUOW, provides our latest example of the contrasts between how hired executives and "regular" employees are treated even at non-profit health care organizations, and between these organizations' actions and their stated missions.
Hospital Employees Strike Against Reductions in their Health Insurance
The report was about a small job action going on at a single hospital. Ironically, the strike is over the employees' own health insurance.
Along with housekeepers, nursing assistants and other staff, surgical technologist Bob Wilson is a member of the Service Employees International Union local 1199NW.
'You see all the guys on TV that hand the doctor the scalpel? That's me,' he said from the picket line on Friday. 'We're out here because we think we deserve affordable health care.'
The union and Providence St. Peter have been in contract negotiations since last summer. SEIU represents about one fourth of the hospital's employees.
In January, employees' health insurance changed. The union says the higher deductibles and out of pocket expenses hurt for a union whose median member makes $31,000 a year.
I'm forgoing care,' Wilson said. 'I'm not going and seeing a doctor unless I absolutely have to. A lot of people here at Providence are doing the same thing: They're trying to save their money.'
An piece on the Huffington Post further described the strikers' concerns about the new health plans' deductible amounts:
The employees' new $3,000 annual deductible for families is 10 percent of the average worker's pay and a sharp boost from the $750 yearly deductible in their previous health plan.
Millions for Hired Managers
The first contrast is between the strikers' relatively low pay and modest insurance coverage with the compensation given to the hospital system's top managers. Per KUOW,
Providence St. Peter is part of Providence Health & Services. The Catholic organization runs hospitals in five western states. Its headquarters is in Renton.
The union says Providence can afford to do better given what it pays its CEO, John Koster.
The union just learned of Koster's 2011 pay on Thursday after reading Providence's latest filing with the IRS. Providence reported Koster's compensation as $6.4 million, up from $3.1 million in 2010.
Providence's IRS filing reveals that 19 employees of the Catholic ministry earned at least $1 million in 2011. Eight of those employees earned at least $2 million. The top five executives earned more than $3 million each.
Note further that the organization's filing acknowledged that some of its most highly compensated employees received "first-class or charter travel," "tax indemnification and gross-up payment[s]," discretionary spending account[s]," "housing allowance[s] or residence[s] for personal use," and "payments for business use of personal residence."
Serving the "Poor and Vulnerable?"
The second contrast is between the hospital system's stated mission and how it treats different kinds of employees. The Providence Health & Services web-site states:
Providence Health & Services is a not-for-profit Catholic health care ministry committed to providing for the needs of the communities it serves – especially for those who are poor and vulnerable. Providence Health & Services continues a tradition of caring that the Sisters of Providence began more than 155 years ago.
It does not seem unreasonable to claim that low level employees making about $31,000 a year given a health plan with a $3,000 deductible are likely to become poor and vulnerable were they to be unlucky enough to sustain any major illness or injury.
The Market Made Us Do It
However, instead of considering its mission, Providence Health & Services spokespeople invoked the market as justification for its less than generous health plan versus its exceedingly generous pay of top managers.
In an email to KUOW, "Providence officials" described its contract offer and health plan as "competitive with other health care providers."
Regarding its compensation practices,
In an email, Providence spokeswoman Colleen Wadden said Providence sets its compensation the same way, whether it's for housekeepers or executives: Base salaries are set at the middle of the market.
Note that we have discussed the "market made me do it" justification for huge executive compensation from health care organizations as a talking point that is used again and again by public relations operatives and board members (e.g., look here). Its use in this case, though, is particularly unfortunate.
In this example, we have a huge health system (with over $3.6 billion in revenue in 2011) whose mission is to be a "Catholic health care ministry" that serves the "poor and vulnerable" also claiming that the almighty market means it must pay its executives more than one hundred times what it pays its lowliest employees, compensate them with first class travel, tax gross-ups, and so forth. Moreover, presumably this dictatorial market also makes sure this ministry cannot provide its lowliest employees with health insurance that seems sufficient to prevent them from becoming poor and vulnerable should a severe illness strike.
Maybe Providence Health & Services executives and public relations people should read what one prominent Catholic theologian wrote (here, and see this post) about the market in health care:
Hospitals and other facilities 'must rethink their particular role in order to avoid having health become a simple 'commodity,' subordinate to the laws of the market, and, therefore, a good reserved to a few, rather than a universal good to be guaranteed and defended,'
That theologian was the current Pope Emeritus, Benedict XVI.
So this is a new, vivid example of how leaders of big health care organizations may preach about the mission while acting to put their own self-interest way ahead of that mission.
As we have said until blue in the face,...
Health care organizations need leaders that uphold the core values of health care, and focus on and are accountable for the mission, not on secondary responsibilities that conflict with these values and their mission, and not on self-enrichment. Leaders ought to be rewarded reasonably, but not lavishly, for doing what ultimately improves patient care, or when applicable, good education and good research. On the other hand, those who authorize, direct and implement bad behavior ought to suffer negative consequences sufficient to deter future bad behavior.
If we do not fix the severe problems affecting the leadership and governance of health care, and do not increase accountability, integrity and transparency of health care leadership and governance, we will be as much to blame as the leaders when the system collapses.
Labels: executive compensation, health insurance, mission-hostile management, Providence Health Systems
The Push Back Continues: the Mayor of Pittsburgh Sues UPMC Claiming it is No "Public Charity"
There is another indication that push back against the power of large health care organizations is getting more significant.
In February, 2013, we noted that the Governor of the state of Connecticut publicly criticized lavish executive compensation at a small regional hospital system, compensation partially fueled by government funded health insurance payments, and in contrast to hospitals' claims that insufficient reimbursement was driving them to poverty.
The Suit Challenging the Charitable Status of UPMC
Now the outgoing Mayor of Pittsburgh has launched a lawsuit challenging the status of huge, nominally non-profit health system UPMC as a public charity. A summary of the arguments comes from an article in the Pittsburgh Post-Gazette. First, in the state of Pennsylvania, a Supreme Court description set out a test to determine if a particular organization is a public charity, the status the UPMC currently claims:
The Supreme Court's 1985 ruling involving the Hospital Utilization Project (or HUP) set out a test that requires that a purely public charity must fulfill all five of the test's points that it: advances a charitable purpose; donates or renders gratuitously a substantial portion of its services; benefits a substantial and indefinite class of persons who are legitimate subjects of charity; relieves the government of some of its burden; and operates entirely free from private profit motive.
That ruling was reaffirmed by the Supreme Court in April in a case involving an Orthodox Jewish summer camp in Pike County that was found to not deserve its property tax exemption.
The city's lawyer, E.J. Strassburger of Strassburge Mckenna Gutnick & Gefsky, argued that UPMC does not pass that test:
Mr. Strassburger wrote, first and most strongly, that 'it seems virtually certain that UPMC would fail to carry its burden of proving that it satisfies the fifth prong of the HUP test by 'operating entirely free from profit motive.''
He cited UPMC's nearly $1 billion surplus over the last two years and $3 billion in reserves as evidence of this, and that UPMC 'is carefully structuring its operations to prioritize profits-generation over charity.'
In addition, Mr. Strassburger wrote that UPMC does not 'advance a charitable purpose' in part because UPMC 'maintains an 'open admissions policy' in name only' and it does not make all of its health care available to everyone, regardless of ability to pay.
the review says UPMC fails to provide sufficient charity care, operates far-flung international operations that are losing money, and has closed operations in poor communities only to open or expand into richer ones.
But it also cites what it terms 'excessive' benefits of UPMC executives, including CEO Jeffrey Romoff's $5.9 million salary; the fact that more than 20 employees are paid more than $1 million; UPMC's corporate jet; Mr. Romoff's 'lavish' Downtown headquarters (which it claims includes a private chef, chauffeur and private dining room).
The Post-Gazette also sought the advice of experts,
Nicholas Cafardi, dean emeritus and professor at Duquesne University's Law School, said he believes the argument that UPMC is not free from a private profit motive is the strongest one in Mr. Strassburger's review, in part because of how far-flung UPMC has become.
'The more they do that gets them away from their core purpose, the more they open themselves up to the argument that they aren't doing charity,' he said.
In addition, Mr. Cafardi said, UPMC's extensive advertising campaign --sometimes directly against rival Highmark -- makes it look like the organization is operating for profit.
'A lot of things like that make them look like they're operating for a private profit,' he said. 'You advertise because you're in competition. That's the private profit motive.'
Gary M. Grobman, former head of the nonprofit Pennsylvania Jewish Coalition and author of 'The Pennsylvania Nonprofit Handbook,' said UPMC would have a fight on its hands.
'Based on what [Mr. Strassburger] has written, which may or may not be true, it seems some staff at the hospital are paid quite well and some decisions are made based on achieving as much revenue as possible instead of providing as much charity as possible,' he said. 'And if all of that is true, they don't deserve their not-for-profit status.'
So the main issues brought up by the city are similar to issues we have raised about numerous nominally non-profit health care organizations. We have shown that many particular organizations appear not to act like charities when they appear to put short-term revenue ahead of the organization's mission, a process sometimes called financialization, and put lavish compensation of top hired managers ahead of the organization's general financial well-being; and when their leadership appears to subvert the organization's mission.
The UPMC Response versus Anger in the Community
Of course, UPMC public relations disagreed with the premises of the lawsuit:
'We think the 13-page memo that a local law firm wrote for the City is very weak and reaches its conclusions entirely based on opinion, not fact,' UPMC spokesman Paul Wood wrote. 'Rather than responding to partisan politics and blatant union pandering by the Mayor, UPMC looks forward to demonstrating in a court of law that we meet all five prongs of the HUP test and that our hospitals easily qualify for the tax-exempt status they unquestionably deserve. Interestingly, by hiring an outside law firm the City is prepared to waste millions of dollars of taxpayer funds on an unsuccessful attempt to pursue this case.'
Note that the unsubstantiated allusions to "partisan politics" and "pandering" appear to be an appeal to ridicule, "a fallacy in which ridicule or mockery is substituted for evidence in an 'argument.'" We have noted before how public relations flacks working for top executives of health care organizations seem to be very good at using such logical fallacies.
Mr Wood also scoffed at the naive notion that having a $1 billion surplus and $3 billion in reserves means the organization operates like a business:
Mr. Wood wrote that 'numerous people have tried to distort the meaning of that component to attain a political result.'
'It does not mean a nonprofit shouldn't strive to have a positive operating margin -- organizations that don't do that go out of business,' he added.
Note that Mr Wood seems to be arguing that the only alternative to a very large surplus and a very large reserve is a deficit. By ignoring another obvious alternative, having a small surplus and a small reserve, his argument thus is derived from the logical fallacy known as the false dilemma. He also seemed to be arguing that a deficit inevitably leads to bankruptcy. Of course prolonged deficits might lead to bankruptcy, but a single deficit would not necessarily do so. Thus he also employed the logical fallacy known as the slippery slope.
On the other hand, a Post-Gazette columnist showed the depth of community concern over the role of UPMC:
Someone in power is taking official action against the biggest corporate bully in town. Can I get an Amen?
In fact, I can get many Amens, and that says a lot about the behavior of the region's dominant hospital system.
Has there ever been a 'charity' so disliked and mistrusted by the people it's supposed to serve and the people it employs? You rarely hear anyone say 'I cannot stand CARE,' or 'I despise Doctors Without Borders.' But you hear it all the time about UPMC, notwithstanding the jobs it creates, the medical innovations it advances, the life-saving care its doctors deliver and its commitment of $100 million for the Pittsburgh Promise scholarship fund. With all that to its credit it should be beloved, but the opposite is true.
Not helping matters is its corporate public relations, which is increasingly tone deaf. In an emailed response to the mayor's announcement, UPMC spokesman Paul Wood said the lawsuit 'appears to be based on the mistaken impression that a non-profit organization must conduct its affairs in a way that pleases certain labor unions, certain favored businesses, or particular political constituencies.'
No, Mr. Wood. It's based on the correct impression that a nonprofit hospital's top priority should be the patients, not building a monopoly. And that a $10 billion system with a billion-dollar surplus and $2 billion to $3 billion in reserves should be taking care of many more indigent sick people than UPMC has been treating -- especially when it owns land that a Post-Gazette investigation valued at $1.6 billion, even as it enjoys a $20-million tax break every year, underwritten by the good citizens of Pittsburgh and Allegheny County. You can try blaming the SEIU organizing campaign or your arch-enemy, Highmark the insurer, or politics, but this is so much bigger than any of those things. And the public knows it.
Keep in mind that the current discussion of UPMC in the media focuses on very recent events. On Health Care Renewal, we have posted frequently over the last eight years about problems with the leadership of UPMC. We started in 2005 with their inability to prevent a fraud perpetrated by some UPMC middle managers. In 2008, we discussed the apparent mismanagement of the highly touted UPMC liver transplant program. Starting in 2009, and continuing through 2013, InformaticsMD chronicled how the leadership has presided over health care information technology so problematic that it has been blamed for patient deaths. In 2009, we noted sanctions against UPMC's public relations. In 2010, we noted conflicts of interest and apparent self-dealing and nepotism affecting the UPMC board of trustees and UPMC executives.
For at least a generation, health care leaders and health policy makers have been pushing for consolidation of health care organizations in the name of efficiency. We now have a health care system dominated by fewer, larger organizations, and whatever efficiencies have been produced mainly seem to have benefited organizational insiders. Maybe now, though, some are beginning to remember that monopolists - starting at least with John D Rockefeller, I believe - have historically touted their ability to improve efficiency and rationality. The results, however, have been higher prices and poorer results for everyone else.
Hospitals and hospital systems have been particularly good at getting away with the efficiency argument despite the fact that health care prices in the US have been soaring ever since the "vertical integration" craze in the early 1990s. I believe such organizations have been getting away with this nonsense because of their revered status within their communities. Now, however, as huge hospital systems drive up prices and make their top executives rich, maybe we will remember Theodore Roosevelt's warnings about trusts and malefactors of great wealth.
There is no good evidence that large hospitals and even larger hospital systems take better care of patients, or provide better teaching and research. Not only should we question whether huge hospital systems like UPMC are public charities, we should wonder how we ever let them get so big, and proceed to break up these new sorts of "trusts."
Labels: concentration of power, logical fallacies, non-profit organizations, oligopoly, public relations, UPMC
Boulder Community Hospital computer records back on line - but something does not add up
This post is in followup to my March 20, 2013 post "Boulder Community Hospital computer system crash: Either you're in control of your information systems, or they're in control of you".
At a March 24, 2013 Denver Post article "Boulder Community Hospital computer records back on line" the following statements are made:
The computer system that Boulder Community Hospital uses to manage patient records, which had been down for almost two weeks, is now up and running again, hospital officials said Saturday.
Meditech, the system used by the hospital to manage patient records, went down March 12 and affected the hospital, its Foothills campus, eight laboratories and six imaging centers. It was put back into full service at about 3 p.m. Friday, according to hospital spokesman Rich Sheehan.
Sheehan said an investigation showed the outage was a result of a malfunction in one of the main computer servers ... the hospital has replaced the hard drives for the server that failed and are inspecting the remaining servers ... [the failure] resulted in the system being unable to access patient information. The malfunction affected both the primary server and a backup server kept off-site.
A hard drive failure led to a two-week outage of an entire EHR system and its offsite backup server? A mission-critical system in a hospital is so fragile that a hard drive failure caused a two week outage?
If so, that itself shows, at best, poor overall system design with regard to reliability and redundancy (any server worth its salt has hard drives in a failure-tolerant configuration e.g., RAID), but also is not quite credible on its face. A remote server should not be taken down by the failure of a local server. I suspect the failure was more than just a hard drive failure, including software bugs or configuration errors, mass hardware and/or network failure, or even sabotage.
The following statement also lacks believability on its face:
... All patient data was recovered except for an eight-hour period the day of the outage. Sheehan said the hospital had to re-create, re-enter and validate the patient information for that eight-hour period before the system could resume normal operations.
If an information system is down for two weeks, there's two weeks worth of data lost.
... Sheehan said the hospital has replaced the hard drives for the server that failed and are inspecting the remaining servers. The hospital is also now doing data backups every four hours as opposed to every six hours, and is planning on doing hourly backups by the end of the week.
Replacing a failed hard drive is an inadequate precaution. A 'system redundancy makeover' seems in order for when the next hard drive fails. Hard drives have a very well known MTBF (mean time between failure) and annual failure rate. (The very Seagate ST3750528AS hard drive in the PC I am typing this blog post on has an Annualized Failure Rate of 0.34%, per the manufacturer's publicly-available literature.)
... An independent consulting firm also has been hired to conduct an investigation. The hospital said it expects a report within a few weeks.
As other organizations are using Meditech products, Joint Commission Safety Standards (as I wrote in a 2009 JAMA letter to the editor "Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards" available at this link) call for sharing the results of that report with other organizations. I had discussed this letter numerous times with senior Joint Commission leadership.
Will sharing of the independent consultant firm's report happen? Probably not.
However, rest assured the Plaintiff's attorneys of Colorado will request it in malpractice suits that arose during the time period of outage.
Labels: Boulder Community Hospital, glitch, healthcare IT crash, healthcare IT risks, Joint Commission, Meditech, Rich Sheehan
EHR Advertising Obscenity ... Is This An Emergency Department, or a Bar Mitzvah?
Regarding unregulated, unvetted information technology installed in acute care environments such as ED's, that slows physicians down and increases risk, this video is perhaps typical of the cavalier attitudes of hospital executives and IT hyper-enthusiasts.
I have personally observed potentially serious malfunctions involving allergy lists and med lists exhibited by particular system, in fact.
Click the image below to play the video. Have nausea bag nearby:
Click on this image or here to see a charmingly disgusting song & dance.
ED's are all about dancing:
If you change your mind, I'm the first in line
Honey I'm still free
Note the (not so subliminal) message shown by the nurses and their dollar-sign glasses in the video ... higher billing ... more revenue:
Money, money, money - Must be funny - In the rich man's world ... I see dollar signs everywhere!!
Yes, ED's are just filled with fun and laughter and dancing while doctors and nurses toil with distracting EHRs ... to rake in more dough, which makes it all OK, right?
I note that ED's are places where people are regularly brought in with major traumas and in fact regularly die; they are the most serious of environments.
This video advertisement is absolutely tasteless on its face.
I've downloaded a copy of this video, in case it disappears off YouTube. Such things are known to happen in the health IT world.
3/27/13 Addendum:
For similar tastelessness direct from HHS, see my May 2012 post "ONC's 'Health Data Palooza' - A Title of Exceptionally Bad Taste."
Labels: hospital advertising, PICIS Pulsecheck
NYU Faculty Vote No Confidence in their President
Faculty at large American universities, in which most of the country's medical schools and teaching hospitals are embedded, are becoming increasingly concerned about the leadership and governance of their organizations, and whether the universities are putting their academic (and clinical) missions ahead of other concerns, like making money and rewarding top executives.
In January, 2013, we discussed a an informal, anonymous vote faculty at the University of Miami medical school expressing no confidence in their dean and his chief lieutenant.
The NYU No Confidence Vote
The faculty of a major component of another big US university have just openly voted no confidence in their president, and are raising questions about their board of trustees. The setting was New York University. Some background comes from a New York Times article this month:
Embarking on an ambitious expansion at home, constructing a network of new campuses around the globe, wooing intellectual superstars and raising vast amounts of money, John Sexton of New York University is the very model of a modern university president — the leader of a large corporation, pushing for growth on every front.
To some within N.Y.U., Dr. Sexton is a hero who has transformed the university. The trustees have thanked him by elevating his salary to nearly $1.5 million from $773,000 and guaranteeing him retirement benefits of $800,000 a year.
But to others, he is an autocrat who treats all but a few anointed professors as hired help, ignoring their concerns, informing them of policies after the fact and otherwise running roughshod over American academic tradition, in which faculty members are partners in charting a university's course.
'He has a very evangelical sense of purpose,' said Andrew Ross, a professor of social and cultural analysis, 'that does not extend beyond the concept that the university should be an entity of his own making.'
'I think,' he added, 'when other administrations see that they say, Well that's what leadership should be. And when faculty see that they say, That is not what university leadership should be. It's the style of a maverick C.E.O.'
The debate over Dr. Sexton's presidency will come to a head this week. The faculty of the university's largest school, Arts and Science, has scheduled a five-day vote of no confidence. Given Dr. Sexton's international stature, the vote may serve as the most important referendum yet on the direction of American higher education.
President Sexton lost the no-confidence vote, as noted in another NY Times article a week later:
The vote, 298 to 224 (with 47 abstaining), took place via electronic balloting from Monday through Friday. Full-time tenured and tenure-track professors were asked to respond to the statement: 'The faculty of Arts and Science has no confidence in John Sexton's leadership.' Voter participation was 83 percent.
Top Executives Usurp Power from Faculty
An op-ed in the NY Times by a leading dissenting faculty member further explained the issues. He charged that the President ignored faculty concerns about an ambitious plan to expand the physical plant of the university:
How did Dr. Sexton lose the confidence of so many faculty members? By ignoring us. Of course, many professors everywhere feel overlooked by today's generation of jet-setting university presidents. But we have very specific complaints: above all, Dr. Sexton has consistently refused to address concerns about plans to expand N.Y.U. offices and dorms into the part of Greenwich Village south of Manhattan's Washington Square Park, where many of us live.
This expansion plan is known as N.Y.U. 2031, indicating the year in which all the building will be complete. The very name told us that we'd be living on a construction site for a couple of decades.
Not surprisingly, this did not go over very well with many faculty members. We were also concerned about where the money would come from to pay for this expansion, as no business plan for the project has been made public.
Thirty-nine departments and schools passed resolutions last year against the 2031 plan. These resolutions were typically passed unanimously or nearly unanimously. And yet Dr. Sexton's response was a deafening silence.
Academic Values, Particularly Academic Freedom and Free Speech Ignored
Furthermore, the faculty were concerned about plans to expand the university overseas to nations not known for their vigorous support of academic freedom and free speech:
Many of us are also concerned with Dr. Sexton's plans to expand N.Y.U. overseas, including branch campuses in Abu Dhabi and Shanghai, with inadequate faculty involvement or oversight. It is doubtful that faculty members would have chosen to build campuses in countries where academic freedom, and free speech generally, are so parlous.
Executives Enriching Themselves at University Expense
Finally, the faculty were concerned about top university executives immodestly enriching themselves from the coffers of a non-profit university:
As the faculty vote approached, more trouble arose for Dr. Sexton in the form of news reports about lavish compensation for NY administrators. The central but by no means sole figure in this scandal is Jacob J Lew, the Obama administration's new Treasury secretary, who worked at N.Y.U. in the early 2000s for a salary that eventually reached $900,000, larger even than Dr. Sexton's at the time.
Mr. Lew received loans to buy a nice home, which apparently were largely forgiven. He also received a severance of some $700,000 when he left for a well-paid position at Citigroup. Severance? For someone who leaves voluntarily?
Dr. Sexton himself is to receive a salary of more than $1.4 million this year, and a 'length of service' bonus of $2.5 million in 2015. (Full disclosure: the university gave me a set of mugs when I completed 25 years of teaching.) And he will receive $800,000 a year after he retires.
Other top administrators make similarly extravagant salaries. Some experts believe there may even be something illegal in the way Dr. Sexton has rewarded them; N.Y.U.'s chapter of the American Association of University Professors has asked New York States's attorney general to investigate.
All of which raises a question for many N.Y.U. faculty members: Should administrators be able to enrich themselves like this at educational institutions? N.Y.U. is not a Wall Street firm, but a tax-exempt university that gets millions in taxpayer dollars, not least from student loans. In fact, our students have the highest total debt load of any university in the country. Rather than expanding, or paying huge salaries to top administrators, why doesn't N.Y.U. do more to help its alumni pay off their debts?
Forsaking the Academic Mission
An article in Inside Higher Education underlined how the dispute is really about the mission of the university in this brave new corporate era:
As Rebecca Karl, an associate professor of East Asian studies and history recently told Inside Higher Ed, 'We've become very critical of the whole idea of 'expand or die,' which of course is a corporate maxim, but we don't understand why it needs to become our maxim.'
Mark Crispin Miller, a professor of media, culture and communication in NYU's Steinhardt School of Culture, Education and Human Development, who has been an outspoken critic of the Greenwich Village plan [said]. 'The fact is we see NYU as a school, we see our mission as educational. Sexton and the trustees who support him view NYU as a bundle of assets whole value they will apparently do anything to maximize on paper. We believe that this approach is destroying this university.'
By the way, maybe in retrospect the trustees' role should not be so surprising. Back in 2011 we posted about a group of extremely rich corporate and finance leaders who attacked critics of their growing power as "imbeciles," among other terms. Several of the individuals featured in the news article which inspired this post were trustees of New York University. These included Kenneth Langone and John Paulson. A quick look at the list of current trustees shows that it includes many top leaders of finance firms, including firms whose actions were alleged to have helped cause the great recession/ global financial collapse or have been subsequently accused of other financial shenanigans, e.g., Steven S Miller, a Vice President of JP Morgan Chase, and Maurice Greenberg (a life trustee), former leader of AIG, E John Rosenwald Jr (a life trustee), Vice Chairman Emeritus of JP Morgan Chase, and William R Salomon (a life trustee), honorary chairman of Citigroup.
In summary, the issues that inspired the no-confidence vote against the President of New York University appeared to be allegations that university:
- administration usurped power, particularly from the faculty
- administration used this power to put corporate priorities, like expansion for its own sake, and increasing short-term revenue ahead of the academic mission
- administration took advantage of their power to enrich themselves
- trustees, who are supposed to exert stewardship that ensures the university upholds its mission, instead aided and abetted all this
All of these should be very familiar issues to Health Care Renewal readers. We have discussed the rise of generic managers of health care organizations, trained supposedly in general management skills, but not in health care, and indifferent at best to the values of health care professionals. At times their power has gotten so great as to constitute a manager's coup d'etat. We have discussed how managers of health care organizations often put short-term revenue ahead of all other concerns, sometimes called financialization. In doing so, they may end up perpetrating mission hostile- management. We have discussed how managers are able to command often outrageous levels of executive compensation. Boards of trustees, who are supposed to exert stewardship over the organization, and see that its leadership upholds its values, often come from management backgrounds themselves, and are at best clueless about, if not hostile to the mission.
It is time for university faculty to defend their institutions' mission. Students, alumni, and patients at academic medical centers, medical school clinics, and of academic health professionals ought to be equally fervent in support of the academic and academic health care missions. Academic medicine needs to be lead and stewarded by people who understand that mission, value it, uphold it, and are accountable for that. These leaders and stewards should eschew management fads, cronyism, and excess personal enrichment.
Maybe the vote of no confidence at NYU is a small step on the path back to the academic and academic medical missions. But do not expect those who are enriching themselves in the current system to go quietly.
ADDENDUM - see also this post by Prof Margaret Soltan on the University Diary blog.
Labels: academic freedom, accountability, boards of trustees, executive compensation, free speech, New York University, transparency
Boulder Community Hospital computer system crash: Either you're in control of your information systems, or they're in control of you
Yet another health IT crash, "prolonged" this time, from some unspecified "glitch":
Boulder Community Hospital computer system crash frustrates patients
Officials say it could take until Friday for outage to be resolved
By Brittany Anas
Camera Staff Writer
Posted: 03/18/2013 07:23:23 PM MDT
Updated: 03/18/2013 07:24:16 PM MDT
A prolonged computer system outage is preventing Boulder Community Hospital from accessing patient records -- making it difficult for people to schedule surgeries, get test results and make appointments for routine blood work.
Meditech, the system used by the hospital to manage patient records, went down in the middle of last week. It could take the hospital until Friday to get the system back up, said Rich Sheehan, spokesman for Boulder Community.
That fits my definition of "prolonged."
While information technology officials are investigating what caused the outage, Sheehan said patient records are protected and hospital officials don't believe they've been hacked.
That's not very reassuring, considering the length of the outage.
The outage affects the hospital, its Foothills campus, eight laboratories and six imaging centers.
Patients are on its face put at-risk ... for example, I know of several deaths of infants and adults from delayed x-ray reports alone ... but the clinicians, not the IT seller or hospital IT staff, are liable.
"We know medical care is important to people, so we understand the concerns those in the community have," Sheehan said. "We have a lot of people working on this, doing the best they can to solve this problem in a safe manner and as quickly as possible."
"We know medical care is important to people?" No, really?
In the meantime, the hospital is using manual paper record-keeping systems and traditional paper charts for its inpatients. Hospital officials say the system allows them to continue treating patients, provide diagnostic services and collect important clinical information that will be entered later into each patient's electronic health record.
But that concerns Eroca Lowe, whose mother was in the hospital Thursday through Sunday with gallbladder pain.
Lowe said the outage made it extremely difficult for doctors and nurses to do their jobs while hunting down lab results. She criticizes the hospital for not having a backup computer system and resorting to paper records.
"That's not a hospital in 2013," she said.
It's a good bet the paper records and HIM personnel managing them are not what they used to be pre-computer.
... Dina Huber said it took her and her significant other six days to schedule an appointment for a hernia surgery because the system used for scheduling is down.
"If they can't keep their computer system running, how can we trust them to perform surgery?" Huber said.
Fortunately, surgeons perform surgery ... not computers, IT staff or management. Doctors, as the enablers of healthcare, don't need computers to save lives.
However, making their job harder is not a good idea.
A physician who works at Boulder Community Hospital, speaking on the condition of anonymity, said he doesn't think the outage is compromising the health or safety of patients. But, he said, the backup response "seems a little haphazard, and it's not an organized plan." He said physicians are left chasing down records.
If a prolonged outage "is not compromising safety", then why did the hospital spend tens of millions on computers?
Sheehan said the hospital is prioritizing accuracy and patient safety while getting the records system up and running.
Once it's running again, there is significant risk of data now recorded manually being lost, thus again increasing error risk.
"We apologize for the delays, but this was an unavoidable situation," Sheehan said.
("We apologize for the chilly water, but this was an unavoidable situation." - Captain of the HMS Titanic?)
If an injury occurs, how will that sound to a jury?
Let me answer that: like bull***.
My response to Mr. Sheehan and Meditech, and the IT personnel involved: "Either you're in control of your information systems, or they're in control of you."
It seems the latter clearly applies here.
I pray nobody gets injured ... and that the principals don't end up before plaintiff attorneys I've educated on the issues of bad health IT.
Labels: Boulder Community Hospital, glitch, healthcare IT crash, healthcare IT risks, Meditech, Rich Sheehan
Doctors' Dubious Excuses for Taking Pharmaceutical Companies' Money
Pro Publica has updated their database of payments by pharmaceutical payments to physicians and organizations. It now has data from 15 companies totaling more than $2 billion from 2009 to 2012.
To accompany Pro Publica's report, a number of news outlets wrote about payments given to local or regional doctors. These included, in semi-random order, the Los Angeles Daily News (via the Inland Valley Daily Bulletin), the Salt Lake (City, Utah) Tribune, the San Jose (California) Mercury News, NewsChannel5 in Nashville, Tennessee, the Pasadena (California) Star-News, the Bergen and Passaic, New Jersey Record Herald via NorthJersey, the Philadelphia Inquirer, and the Columbus (Ohio) Dispatch.
The combined reports showed that many physicians, including prominent academics and community practitioners, are still getting a lot of money from pharmaceutical firms. Since Pro Publica was only able to get data from some US drug companies, albeit those who accounted for 47 percent of US drug sales, it is likely that many more doctors than those in the data base got such payments, and the doctors in the data base may have gotten more money from companies that do not report their payments. In addition, it is likely that many more doctors get similar payments from medical device companies, health care information technology companies, and other for-profit corporations that promote health care products and services.
We had discussed Pro Publica's initial reporting from its database here. While there is evidence that most payments to doctors by pharmaceutical companies are intended to promote marketing, we discussed here how some doctors rationalized their payments as fully professional and proper.
Now the updated reporting has provided many examples of - not to put too fine a point on it - physicians making dubious excuses for their acceptance of payments, often large, from pharmaceutical companies. Their themes included
It's Education, What Could Possibly Go Wrong?
From Pro Publica,
[Dr Rakesh] Jain, of Lake Jackson, Texas, has earned $582,049. [Dr Vladimir] Maletic, of Greer, SC, made $527,850, according to Dollars for Docs.
Jain said he loves teaching and delivers the same lectures about drugs and medical conditions regardless of whether a drug company is paying him.
'I am not a marketer, I am an educator,' Jain said.
Maletic said he speaks about treatments for mood disorders, schizophrenia and sleep-wakefulness disorders because he believes that 'good quality education about pharmaceutical products may be beneficial to both physicians and their patients.'
The LA Times found someone with a similar opinion.
'Pharmaceutical companies used to take doctors to dinner, but that was banned years ago,' said Dr. Arthur Chanzel Jeng, an infection control specialist at UCLA-Olive View Medical Center in Sylmar. 'Now they must provide some educational content.'
Jeng was paid $80,500 by Pfizer last year for several speaking engagements. As an infection control specialist at Olive View, he and others in his field are concerned about drug resistant diseases and the limited number of antibiotics. Drug companies have little incentive to produce new antibiotics, he said, so if they do, physicians in his field want to know more about the drugs. That's why he agrees to speak.
'We (speakers) provide education when a new antibiotic does get released,' he said. 'There needs to be education among doctors on how to use this new antibiotic.'
In addition, the Salt Lake Tribune noted that
[Dr Eliot] Brinton received two of the single largest payments in Utah, both in excess of $85,000, for promoting drugs by GlaxoSmithKline, ProPublica's database shows. He describes the lectures as educational and based on science.
'I love the science and I love to teach. And doctors are glad to better understand the drugs and how to use them. I'm careful not to act as a cheerleader,' he said. 'If I'm a shill for the drug company I lose my integrity and integrity is really all I have to offer my patients and the drug companies.'
The physicians above all asserted that since their activities were "educational," they must be worthwhile.
Note that the ostensibly educational activities described above all appear to be "drug talks," that is talks sponsored by the drug companies, probably through speakers' bureaus, and given probably not as part of formal, accredited continuing medical education. Since the publication of "Dr Drug Rep" in the New York Times in 2007, the public has learned that such talks mainly include content provided by the pharmaceutical companies, and are meant by the companies as marketing exercises. From that case we also learned that physicians who deviate from the marketing message do not last long on speakers' bureaus. (See posts here and here.)
In addition, pharmaceutical companies often pay physicians deemed to be "key opinion leaders," whose opinions are promoted supposedly for their brilliance and erudition. However, as noted here and here, the companies buying their services believe they have bought the services of sales people. Evidence about key opinion leaders actually performing like marketers has come from documents revealed during litigation (e.g., see this recent example of a huge monetary settlement made of charges that GlaxoSmithKline, a major multinational drug company committed fraud among other things, and in the course of its unethical activities used key opinion leaders as marketers). Also, see the Neurontin marketing plan (see post here), and the Lexapro marketing plan (see post here) for examples of how company keaders view key opinion leaders as marketers.
Given the volume of evidence about drug talks, speakers' bureaus, and the marketing purposes of key opinion leaders, the assertion that because they were in some sense educational, these doctors' corporate financed talks were worthwhile is at best a silly excuse.
More formally, it may arise from a logical fallacy. The doctors appeared to be arguing that education is an unalloyed good. However, obviously not all education is good education, or unbiased education. Specifically in this case, logic, and evidence from several cases in which pharmaceutical companies' intentions as documented in communications revealed in litigation (see examples here) suggest that these companies pay physicians for education that they believe serves marketing purposes.Thus the doctors seem to be using the composition fallacy, the logical fallacy that an entire class (in this case, all of education) can be judged by some of its members (examples of unbiased, accurate, good education.)
It's Research, What Could Possibly Go Wrong?
Similarly, the doctors who get paid to do research say it's all about the research. The Salt Lake Tribune reported on
CRI LifeTree Research, which has received at least $3.4 million in drug company payments since 2009, according to ProPublica.
Co-founder Lynn Webster, an anesthesiologist, is listed as having received the single largest payment in the state: $1,687,771 from Cephalon, a big maker of pain medications. Only three other doctors in the country received more from Cephalon.
Nationally, Webster is among the top 50 for single largest payments received, behind marquee hospitals, such as the Mayo Clinic, Cleveland Clinic and Duke and Harvard Universities.
A nationally recognized expert in pain management, Webster is under investigation by the U.S. Drug Enforcement Administration, which is looking into opioid overdose deaths of patients of his former pain clinic. A Senate Committee is probing his financial ties to Big Pharma.
Webster insisted,
Research payments to him cover overhead and other costs, including his salary as a lead researcher, he said.
'Research inevitably leads to better education, better systems and better therapies — things that are indispensable for medical advancement and quality care,' he said.
The Pasadena Star-News provided this version,
Pasadena-based plastic surgeon John Edward Gross received more than $770,000 from Allergan, the maker of Botox and some breast implants.
In 2011-12, Allergan paid Gross to conduct research, consult, serve on health care panels and business travel.
'What I'm doing for Allergan is to advance breast surgery,' said Gross, a board certified surgeon and a former chemical engineer. 'Much of the research you do is industry-supported. They have a motivation to make better and new products.'
It is pretty amazing to see the notion that all clinical research is irreproachable in print. We and others have documented huge numbers of cases and volumes of evidence that clinical research may be manipulated, and, if necessary, suppressed to support the commercial goals of those who make products or provide services assessed by such research. In fact, the prestigious Institute of Medicine's report on Conflict of Interest in Medical Research, Education and Practice included the recommendation (4.1) that "individuals may not conduct research with human participants if they have significant financial interest in an existing or potential product or a company that could be affected by the outcome of research." Given the volume of this evidence, the assertion that all pharmaceutical company clinical research should be irreproachable is just plain silly.
Again, formally the physicians' arguments, if they should be dignified with that name, seem to arise from the same logical fallacy discussed above. The underlying argument seems similar to that made above about education: "I am doing research. All research is good, unbiased, helpful to patients. So what I am doing is good, unbiased, helpful research." So it appears the composition fallacy again was in play.
It's Not Really My Money
The San Jose Mercury News provided this example,
The database links Dr. Gurkirpal Singh to more than $248,000 in Pfizer payments it lists for speaking, consulting, travel and meals since 2009. He said all the money went to Institute of Clinical Outcomes Research and Education in Palo Alto, where he is the chief scientific officer. Singh said the money paid for research.
'I receive nothing -- let me be very clear on that,' said Singh, who is an adjunct clinical professor at Stanford University.
The Columbus Dispatch added,
Dr. Henry Nasrallah, a psychiatrist at the University of Cincinnati, netted $647,341 in speaking and consulting fees from drug companies, ranking him as Ohio's top recipient of such payments over that four-year period. Cincinnati's College of Medicine put that money toward his $222,232 annual salary.
'The (pharmaceutical) companies have a signed agreement with the university for my activities, not with me personally,' Nasrallah wrote in an email to The Dispatch.
'This is another reason why I maintain scientific and clinical impartiality about the various drugs I teach, because I do not have a direct personal gain,' wrote Nasrallah, a former chairman of Ohio State University's psychiatry department.
Really, the boss doesn't care whether he brings in any money?
These doctors seem to be denying that money is fungible. In other words, they seem to be arguing that money going to the organizations that pays them is different from money going directly to them, and that their bosses do not in fact care whether their activities bring any revenues to the organization. This just flies in the face of common sense.
Someone Needs to Pay
NewsChannel5 was able to interview the top earner on the Pro Publica list, Dr Jon W Draud, who said among other things,
it was only fair to accept payments for his speaking engagements because it makes up for what he would otherwise make while working at his practice.
'It's not essential, I suppose, but I consider it a reasonable, fair compensation for being gone and traveling, and spending time away from my home and family,' Draud said.
If Dr Draud was providing education, a useful service, it seems reasonable that someone should pay for it. However, he appears to beg the question of who should pay for it? Underlying this question is the concern that since it was pharmaceutical companies, not students, who were paying, the education was being done primarily to benefit the former, through marketing, rather than the latter. The apparent argument, that because it is not reasonable to get paid for services, any source of payment is acceptable, is again just plain silly.
Who Cares About Money?
NewsChannel5 also reported that Dr Draud said
accepting so much money did not create a conflict of interest between him and his patients. He said the information he gives out was not biased towards the drug companies.
However, the Institute of Medicine report on Conflict of Interest in Medical Research, Education and Practice defined conflict of interest as "circumstances that create a risk that professional judgments or actions regarding a primary interest will be unduly influenced by a secondary interest." Asserting that receiving over $1 million could not create even a risk that his educational presentations were biased towards the interests of those who gave him that money seems like simple denial.
The FDA Said it Was True
Top earner Dr Draud also said according to NewsChannel5,
It has to be vetted by the FDA as being fair, balanced and non-biased toward the pharmaceutical company....
From the Philadelphia Inquirer, re Dr Warren S Joseph, a podiatrist who received over $650,000
Joseph acknowledged the payments in an email to Philly.com.
'All of my lectures given for the Pharma industry follow strict FDA guidelines and are consistent with the corporate integrity agreements entered into between the companies and the government,' Joseph said. 'There is full disclosure of this fact at all lectures.'
These justifications appear to be just plain wrong. As far as I know, the US Food and Drug Administration does not pre-approve "drug talks" given by physicians for pharmaceutical companies.
By the way, the statement by Dr Joseph approaches self parody. As we have discussed, corporate integrity agreements are usually the products of legal settlements of charges of wrongdoing. Drug companies do not sign such agreements because of previous good behavior. Moreover, I have never heard of such an agreement that required pre-approval of drug talks, either.
Trust Me, I'm an Expert
As reported by NorthJersey,
One of the top recipients in North Jersey was Thomas Dayspring, an internist and expert in cholesterol management, who earned just under $400,000 from Merck and GlaxoSmithKline. Dayspring said he was paid for lectures at conferences for doctors arranged by the drug companies, as well as continuing medical education programs.
'I've logged over 2 million miles, all over the world and in all 50 states,' said Dayspring, who served as the director of the North Jersey Institute of Menopausal Lipidology in Wayne until last summer. 'Guys like me who are nationally known attract a big audience. Not every speaker can trot out a CV like mine.'
New Jersey, you gotta love it. The most charitable characterization of this is an appeal to authority, albeit an amazingly egotistical one.
Two years after Pro Publica's report, pharmaceutical companies are continuing to pay substantial sums to physicians and other health professionals, nominally for education and research. Because these arrangements are financially beneficial to the professional recipients of the money, and likely financially beneficial via their marketing effects to the companies that provide the money , it should be no surprise that they are continuing in the absence of any regulatory restrictions.
What is saddest about the latest reporting is the silliness of the excuses made by the conflicted physicians. Professionals with four years of education post-college, and multiple years of experience, and who are often respected as academics or practitioners ought to be able to reason and argue better than they did in the examples above. Of course, people who make a lot of money often come to believe they really deserve it. And conflicts of interest produce conflicted thinking. As Joe Collier wrote in the BMJ, " people who have conflicts of interest often find giving clear advice (or opinions) particularly difficult." (Look here.)
The IOM report on conflicts of interest suggested full disclosure of all payments that could be considered conflicts of interest, banning clinical research by conflicted individuals, prohibiting academic physicians from giving "drug talks" whose content was provided by industry, and developing methods to fund continuing medical education independent from industry. This report, and its recommendations have gotten scant attention, maybe because they would threaten a status quo that enriches conflicted health professionals and the companies that create these conflicts. However, in my humble opinion, implementing all the report's recommendations would only be a beginning down the road of restoring the integrity of clinical care, teaching, and research.
Posted by Roy M. Poses MD at 12:29 PM 2 comments:
Labels: conflicts of interest, key opinion leaders, logical fallacies, marketing, pharmaceuticals, stealth marketing
Bad Science (and Perhaps Conflict of Interest) At ONC / HHS
This article recently appeared, quoting Jacob Reider, M.D., chief medical officer at ONC on an upcoming Health IT Safety Plan:
Health Data Management
http://www.healthdatamanagement.com/news/HIMSS13-ONC-HIT-safety-plan-45809-1.html
ONC Sets Early Summer for Release of HIT Safety Plan
The Office of the National Coordinator for Health Information Technology anticipates releasing a final health information technology safety plan by early summer, officials announced on March 5 at HIMSS13 in New Orleans.
ONC released a draft plan in December and accepted public comment until February 4. The draft followed an Institute of Medicine report that ONC commissioned that highlighted the need for better understanding of the HIT impacts on safety, as well as shared responsibilities among all stakeholders to improve safety, Jodi Daniel, director of the ONC office of policy and planning, said during an educational session.
There is little doubt that use of I.T. results in fewer medical errors, particularly medication-related because of electronic prescriptions and clinical decision support, noted Jacob Reider, M.D., chief medical officer at ONC. "It's obvious that in many areas there will be fewer errors, but at the same time, in other areas there will be more errors." Consequently, a priority of the plan will be implementing a framework to help the industry better understand what the trouble areas will be as I.T. use increases.
Less than 1 percent of patient safety events are related to HIT, Reider contended, but the industry needs more data to better understand the level of harm from such events and how to improve the technology. HIT-related errors, he reminded the audience, are not always the fault of vendors; providers can introduce risk when customizing their systems.
The upcoming safety plan release is fine and good, but I, for one, wonder if it can be trusted.
The level of bias and lack of knowledge of the domain, evidence of incomplete research, and/or poor scientific judgement inherent in the statements I bolded above are disturbing. They are also reminiscent of the problems in the ONC-authored paper discussed at this link.
There is little doubt that use of I.T. results in fewer medical errors
On the contrary, there is significant well-researched doubt in that the evidence is quite contradictory. Let's cite the IOM's 2012 report on health IT risk:
… "For example, the number of patients who receive the correct medication in hospitals increases when these hospitals implement well-planned, robust computerized prescribing mechanisms and use barcoding systems. But even in these instances, the ability to generalize the results across the health care system may be limited. For other products— including electronic health records, which are being employed with more and more frequency— some studies find improvements in patient safety, while other studies find no effect.
IOM (Institute of Medicine) 2012. Health IT and Patient Safety: Building Safer Systems for Better Care (PDF). Washington, DC: The National Academies Press.
Let's quote one of the IOM study panel members, an international authority on safety, Dr. Richard Cook:
... HIT's cornucopia has been promised repeatedly since the 1960's. Nothing like the promises has materialized. Indeed, the IOM committee that was commissioned to evaluate the best evidence on this subject found no persuasive evidence that HIT improved patient safety. I know because I was there.
The body of literature here also contains relevant studies contradicting Dr. Reider's quoted, dispositive statement.
It's obvious that in many areas there will be fewer errors
This statement requires no response, but I'll respond anyway.
In science, stating something is "obvious" (i.e., what is referred to at the site "36 Humorous Methods of Proof" as "Proof by obviousness") is, on its face, bad science.
Less than 1 percent of patient safety events are related to HIT
The aforementioned IOM report was quite clear on the following:
... Several reasons health IT–related safety data are lacking include the absence of measures and a central repository (or linkages among decentralized repositories) to collect, analyze, and act on information related to safety of this technology. Another impediment to gathering safety data is contractual barriers (e.g., nondisclosure, confidentiality clauses) that can prevent users from sharing information about health IT–related adverse events. These barriers limit users' abilities to share knowledge of risk-prone user interfaces, for instance through screenshots and descriptions of potentially unsafe processes. In addition, some vendors include language in their sales contracts and escape responsibility for errors or defects in their software (i.e., "hold harmless clauses"). The committee believes these types of contractual restrictions limit transparency, which significantly contributes to the gaps in knowledge of health IT–related patient safety risks. These barriers to generating evidence pose unacceptable risks to safety.
... The magnitude of the risk associated with health IT is not known.
Likewise, FDA has concluded that what they know on HIT-related patient safety events is likely "the tip of the iceberg" due to systematic impediments to knowing, as has the ECRI Institute who has only now begun to study the issue with any degree of rigor. (The results are of great concern to anyone who should know, or should have made it their business to know, as at this link.)
Perhaps Dr. Reider needs a lesson on basic epistemology: "We simply don't know what we don't know."
HIT-related errors, he reminded the audience, are not always the fault of vendors; providers can introduce risk when customizing their systems.
I find it remarkable that a government official uses a public/industry platform HIMSS to defend an industry, while at the same time stating more study is needed to understand the causative factors of harm from the industry's products.
This raises the question of conflict of interest, and the possibility this official is not impartial or trying to be "fair" but aiming towards protecting an industry he once worked for - and to where he's likely to return at some point. (See Roy Poses' posts on "revolving doors" for examples of that.)
From his government biography here:
Dr. Jacob Reider
Director, Office of the Chief Medical Officer
Jacob Reider, MD is a family physician with 20 years of experience in health information technology and special interest in clinical innovation, user experience, and clinical decision support. His background includes leadership roles in nearly all facets of the health IT domain – from small start-up companies to academic facilities, primary care medical groups, and large health IT development organizations. Dr. Reider has served as a member of the Board of Trustees of the American Medical Students Association, the Society of Teachers of Family Medicine, and has served in directorial positions on boards of several innovative health IT companies.
I note I do not find evidence of formal medical informatics education, which selfsame ONC recommends for leadership roles in health IT (see my Dec. 2009 post "ONC Defines a Taxonomy of Robust Healthcare IT Leadership"), but I do find roles such as:
Chief Medical Informatics Officer
Allscripts
June 2009 – January 2011 (1 year 8 months)
March 2007 – June 2009 (2 years 4 months)
MedRemote (Now Nuance)
November 1999 – December 2002 (3 years 2 months)
One might reasonably wonder what personal gains might accrue to Dr. Reider from the promotion of health IT - which includes downplaying its current risks - from an influential government perch. (I for example held many Merck stock options after my late 2003 departure. They remained underwater until expiration, but even a a $10 or $20 increase in stock price could have bought me, say, a new sports car or even house.)
I also note that the former CEO of Allscripts, Glen Tullman was, in fact, a close confidant of our current President and advisor on health IT during his first campaign:
A tireless advocate of technology in medicine, Tullman has been featured in virtually every major news outlet. An early supporter of fellow Chicagoan Barack Obama, Tullman introduced him to the Electronic Health Record (EHR) and served on his finance and healthcare committees during the 2008 presidential campaign.
Is it any wonder, then, that my expectation is that the forthcoming ONC HIT safety plan will be biased towards industry, reflect poor science and incomplete/selective research, and overall be a whitewash?
I'll be presenting on issues such as this to the Plaintiff's Bar. They seem to be the last protectors of people's/patient's rights where clinical IT is concerned - a role they seem most familiar with in other sectors.
I emailed Dr. Reider a link to this post with a request that if he has robust evidence to support his assertions that is not publicly available, to please release it.
Mar. 16, 2012 Addendum:
A correspondent asked me the following that I thought deserved mention beyond the comments section:
"How would he know, exactly, when we know, that they never tallied the thousands of e-Rx errors from a national Siemens defect that was disclosed only at the Brown Medical Center Hospitals (Lifespan) but was a systemwide defect; nor from the Cerner convert to e-Rx defect that was evident at the Trinity Health System; and millions of other errors from when the e-Rx system was unavailable. Or, do they simply do not count those?"
My response? No, they probably consider those "anecdotal."
Posted by InformaticsMD at 1:13 PM 3 comments:
Labels: Allscripts, bad science, Jacob Reider MD, ONC, ONC Health IT Safety Plan
The Market Made Us Do It: Increasing Low Level Emp...
The Push Back Continues: the Mayor of Pittsburgh S...
Boulder Community Hospital computer records back o...
EHR Advertising Obscenity ... Is This An Emergenc...
Boulder Community Hospital computer system crash: ...
Doctors' Dubious Excuses for Taking Pharmaceutical...
Bad Science (and Perhaps Conflict of Interest) At ...
IRS faces class action lawsuit over theft of 60 mi...
Minimizing Legal Liability or Upholding the Missio...
JAMA: "Improving the Electronic Health Record—Are...
But don't worry, your EHR information is secure
The Dangers of Big Corporate Health Care: Deceptiv...
When "Human Error" Causes EHR Downtime, Who is Lia...
Far more concern about Linux user experience than ...
Twitter EHR "revolt": #EHRbacklash
On EHR's: See No Evil, Hear No Evil, Speak No Evil...
Deadly Over-Doses and Private Equity - the Case of...
Medscape re: Class Action suit: "Doctors Who Sued ...
On EHR's: See No Evil, Hear No Evil, Speak No Evi...
Solutionism: are all healthcare issues transparent...
More Cause for Hope - After Novartis Chairman's Re...
Comments by Dr. Reed Gelzer on RAND Health IT Repo...
Wisdom from the Medical Journal of Oz: "Good HIT ...
Michael Millenson and "the adamant refusal by hosp...
JAMIA: Reduction in medication errors in hospital...
Dr. Richard Cook on the Health IT Sector's Ills


text:
HomePunditPundit explains why Man United players should turn their back on Mourinho
Pundit explains why Man United players should turn their back on Mourinho
December 15, 2018 Jordan Street Pundit 0
Manchester United's biggest game of the season takes place at Anfield tomorrow, as Jose Mourinho looks to continue to try and keep himself in a job.
I think it's fair to say that the Red Devils are struggling. Two wins in seven, for a team that are supposed to challenge for major honours just isn't good enough.
On the flip side, Liverpool are in great form. Ahead of the game, the BBC's Martin Keown has, quite astonishingly, told United players to ignore their manager, because his tactics just aren' working.
"These performances are some of the worst we've seen from United in 25 years," Keown told the BBC.
"They are there for the taking – these United players almost need to stop listening to their manager now.
"If this is how they're being told to play, the players are on their own – I don't know the identity of this United team."
While I agree that United are playing horrendously, suggesting that the players such blatantly turn their back on the manager is the worst possible thing that could happen right now.
If they begin to disrespect Mourinho, things will only continue to get worse, not better. It's not him who is missing guilt-edged opportunities, it's not Mourinho making defensive mistakes. I'm a firm believer in the fact that, if he'd have been delivered a centre-back this summer, things may well have been different.
Now obviously Mourinho isn't perfect, far from it in fact, but this is just absurd from Keown. He's a player I never liked, and as a pundit he comes out with some rubbish from time-to-time. This latest quote is the latest in a long line of awful statements from him…
Toby Alderweireld's latest social media activity sends Man United fans into overdrive
Picture: Chris Smalling all-smiles after signing new Man United contract
Ex-Red hints that Mourinho may lose his job with a loss to Liverpool
December 15, 2018 Jordan Street Manager 0
Manchester United vs Liverpool games are already hotly contested. This weekend's clash at Anfield will be no different. With that said, the two sides head into this one in completely contrasting form. Jurgen Klopp's side […]
Jose Mourinho angry at Man United as two players without new contract offers: report
March 1, 2018 Jordan Street Players 0
Jose Mourinho is unhappy with Manchester United Football Club, as talks are yet to get underway regarding new deals for both Marcos Rojo and Anthony Martial. That's what the Daily Mail says anyway, per the […]
Zidane drops big hint he wants to manage in Premier League, favourite for Man United job
September 28, 2018 Jordan Street Manager 0
Manchester United manager Jose Mourinho could be feeling the pressure right about now – particularly after a poor run of results coupled with a huge fallout with superstar midfielder, Paul Pogba. During the self-proclaimed Special […]

redpajama_set_name: RedPajamaCommonCrawl


Changes are sometimes only visible when we start to make comparisons: for example, we are seeing less stock on the shop floor in the production department. The racks there used to be much fuller. We're now producing pretty much to order. Recently, a platform ordered by a customer took just one and a half weeks to produce, whereas previously this would have taken eight weeks.
Boom-based Sky Man International has successfully transitioned from being a traditional metalworker into a specialist in manufacturing niche products. Today, the company, operating from its two global sites, has become a world player in for example designing and manufacturing maintenance cages for high-rise buildings and other inaccessible locations.
The company wanted to optimize its production systems and stock management, and also achieve more efficient collaboration between the various divisions, resulting in quicker through times to production. Looking around for solutions to these problems, Sky Man management took a masterclass on QRM organised by Sirris. With Sirris's help it was decided to set up a 'Quick Response Office Cell' (Q-ROC) to enhance cooperation, communications, and lead times and so make order processing more efficient. For a year Sirris provided on-site support for the establishment, operation and implementation of the Q-ROC, through training, advice, and support.
When rolling out the first Q-ROC, the various departments, which were physically separated from each other, worked independently of each other and issued assignments to each other. This resulted in inefficient cooperation, meaning that sometimes information was lost and time was wasted. Against this backdrop, a single unit made up of 10 members from the different departments was established which worked together in the same office and was responsible for processing orders, starting from the customer stating its requirements and running through to their realization on the ground. This resulted in the members having continuous, direct contact with each other, fostering more and better-quality communications and faster reaction times, so speeding up the whole process.
The Q-ROC operated differently from what the participants were used to, with two weekly stand-up meetings coordinating all the projects. These meetings use a series of boards displaying all the project information. The meetings go over the status of each project, and actions are discussed and the boards are updated. Using these boards makes sure that everyone is fully aware of the state of affairs.
Another major change is that the team is largely 'self-managing', with indeed the organisational structure being altered to make this possible. Active cooperation and involvement within the team was a radical change for some. But it works. As a result of direct consultation, problems, whether within the company or with customers, are often dealt with by the individuals concerned rather than by getting a manager involved.
The success enjoyed by the first unit led to the establishment of another two office units. The production department is now also made up of three units. Soon, changes could be clearly seen, for example less stock on the shop floor in the production department and Sky Man working pretty much to order. The new approach means not only impressive reductions in lead times but also more projects being completed.
The next step in the production optimisation process is to adjust the layout of the production department with a view to achieving smoother flows and even better lead times.


1. Make the Most of Your Vacuum: Make full use of your vacuum by using it to wash more than just floors. Use it to clean furniture such as mattresses, sofas, walls, windows, window sills, and window treatments. You can also invest in specialty attachment add-ons. Soft brush attachments work well as dusters and can clean lampshades, window coverings, upholstery, and books. You can also use the crevice tool to clean inside and around radiators, vents, and window casings.
2. Tackle the Heavy-Duty Tasks First: Spring cleaning is for working on tasks that are usually avoided the rest of the year. To be more productive, focus on the big jobs first before the smaller, easier tasks. Start by cleaning areas such as windows, storage spaces, HVAC systems, and appliances.
3. Create Cleaning Zones: Some areas in your home need more attention than others during spring cleaning. You can separate important areas into zones such as the kitchen, garage, windows, and outdoor spaces. Designating zones will help you stay more organized during the cleaning process and allow you to budget your time better.
4. Declutter First: Cleaning a space that is cluttered will be a lot more time-consuming and difficult. Create a plan or to-do list to clean up any items and clutter lying around before you tackle the bigger job of cleaning.
5. Clean From Top to Bottom: Cleaning from the top of your room to the bottom will help you stay more organized and speed up the process. Start from the ceiling and work your way down to the floor, clearing away cobwebs in the corners of the ceilings, washing the windows, cleaning the furniture, and finally, vacuuming the floor.
6. Use Natural Cleaners: Mixing together chemical-based cleaners can be toxic and harm both you and your furniture. Instead, try using alternatives such as vinegar, which acts as a substitute for a general cleaning solution in rooms such as the kitchen and bathroom. Vinegar not only makes your job safer but easier, as you do not have to go to the store to look for cleaning products.
7. Recruit Help: Getting others to help you in the cleaning process will not only save some time, but give you company as well. Recruit your kids, roommates, or significant other and divvy up the work so that you do not have clean everything by yourself.


text:
Brad Pitt Just Revealed Leonardo DiCaprio's Nickname for Him, and It's Too Good
"It's a bit confusing, but I roll with it."
Jan 20 2020, 10:01 am EST
Brad Pitt made quite an impression at the SAG Awards 2020, especially when he reunited with ex-wife Jennifer Aniston.
On the red carpet, Pitt revealed the strange nickname that Leonardo DiCaprio calls him by.
"It's a bit confusing, but I roll with it," the actor joked.
Brad Pitt had so many incredible moments at the SAG Awards. From hanging out with his ex Jennifer Aniston backstage, and maybe grabbing her hand in a flirty way, to giving a hilarious speech mentioning his Tinder profile, Pitt was basically on fire. And he also decided to reveal what fellow actor Leonardo DiCaprio calls him.
Speaking to Entertainment Weekly on the red carpet, Pitt explained, "'Lover.' He calls me 'lover.'" As for how he acquired that particular nickname, Pitt said, "It's a bit confusing, but I roll with it."
And when it comes to working with his Once Upon a Time... in Hollywood costar, Pitt said, "You'll find, with most of the guys, I would say we're all pretty much rooting for each other, we all have respect for each other, we all have a good laugh with each other. And it plays. And it's pretty easy."
Pitt and DiCaprio sat next to one another inside the SAG Awards, and their love was evident.
Kevin MazurGetty Images
The Ad Astra star took home the Best Male Actor in a Supporting Role award for his part in Quentin Tarantino's Once Upon a Time... in Hollywood. During his hilarious speech, Pitt said, "Let's be honest, it was a difficult part—a guy who gets high, takes his shirt off, and doesn't get on with his wife. It was a big stretch."
Brad Pitt and Jen Aniston Reunite at the SAGs
More From Celebrity News
Amanda Gorman Almost Didn't Go to the Inauguration
J.Lo Looks Amazing in Leather Cutout Bandeau
Serena Taught Her Daughter a Mean Backhand Swing
J.Lo Wore Sky-High Platforms with a Maxi Skirt
We Get It, You're Edgy
Julia Fox Might Be Cast in Madonna's Biopic
Cardi B Gives Back to the Bronx After Deadly Fire
Bella Hadid Opens Up About Mental Health Struggles
Priyanka Chopra Revealed Meghan Markle's Nickname
Brad Pitt Brought His Tiny Ponytail to the Oscars
Brad Pitt Takes Up a Surprising Hobby Post-Divorce
Brad Pitt to Celebrate Christmas with Just 3 Kids
Brad Pitt Dedicates Oscars Win to His Children
LAPD Not Investigating Brad Pitt for Child Abuse


text:
School Spirit: The 2016 Canadian Innovators in Education Award Winners
By Stéphanie Verge, Reader's Digest Canada
Saluting the winners of our 2016 Canadian Innovators in Education Awards, which honours Canada's top teachers.
Photo: Reader's Digest Canada
Reader's Digest Celebrates Innovative Canadian Teachers, Principals and Administrators
We Canadians count on our teachers, principals and administrators. We ask that they watch over our children with compassion. We want them to inspire and encourage, to embrace the future and respect the past, to display mastery and ingenuity. We hope they will be dynamic orators and careful listeners, thoughtful team players and fearless leaders.
At Reader's Digest, we couldn't be prouder to celebrate, in partnership with the Canadian Education Association, a handful of educators who exemplify all of the above and even more. Through inventive strategies deployed inside and outside the classroom, they have created programs that promise long-term benefits for students, parents and the school system at large.
We applaud their achievements and look forward to watching these initiatives grow.
Photo: Karen McKinnon
First Place, $25,000: Fine Arts eCademy at Navigate, Courtenay, B.C.
At Fine Arts eCademy, it really does take a village. More precisely, to help children thrive, it takes a team made up of fully engaged parents, "community champions" (an aunt or a neighbour, say) and teachers. But the real key to success is the kids themselves. Each fall, the 120 students enrolled in the five-year-old Comox Valley program spend their first week in interviews uncovering a passion-a "spark," in FAE parlance-with the help of their support system.
"We focus on the children's gifts from the very outset," says Jeff Stewart, the principal at Navigate, the public school out of which FAE is based.
The idea that every child is unique and learns in his or her own way isn't new. The province of British Columbia, for example, launched an education plan in 2010 that homed in on personalized learning. But it's highly unusual to let students' decisions dictate the shape of the school year. That crucial difference-developed at Navigate in response to B.C.'s new plan-is one that Stewart, vice-principal Marieke Holtkamp and FAE's six teachers have embraced with gusto.
Whether they choose to explore topics such as nature, hockey, "building things" or animals, FAE students (ranging from kindergarten to Grade 8 and grouped into five multi-age classes) then connect their passions to the fine arts, which are integrated into projects. And each school year has an overarching theme: in 2015-2016, it was the four elements. Through singing, drumming, painting, acting, dancing, video and other disciplines, students shared their knowledge of how oxygen sustains life and how to harness wind's kinetic energy and convert it into electricity.
Adaptability is essential to both the students and the program. The school's calendar is far from orthodox: each interview week is followed by an eight-to-10-week learning cycle that fosters the students' sparks. Then comes a showcase, where family and friends gather for displays and performances related to that cycle as well as that year's theme; and a "compass week," during which pupils attend workshops and visit local artisans while parents and teachers reassess the personal education plans and discuss progress. The entire process is repeated three more times throughout each year.
FAE is also unorthodox in its approach to location: learning isn't restricted to within the school's walls; students receive face-to-face classroom instruction three days a week and work from home the remaining two. This mix of on-site education and distributed (or distance) learning is at the heart of the program's philosophy: knowledge and experience can accumulate in many different ways and in many different places.
"There are students who thrive in the bricks-and-mortar, five-days-a-week traditional classroom," says Holtkamp. "But many do not. Having an option for them, somewhere they can be successful and thrive, is important. It's huge."
FAE students are developing skill sets that extend beyond drama, choir, rhumba, bhangra, pottery and video arts. By taking ownership of their own learning, they're figuring out how to create their own solutions.
The same can be said of family members. Parental involvement isn't just vital to students' success, it's part of FAE's genetic makeup. When Dr. Jonathan Kerr packed in his Belleville, Ont., family practice in 2014, the move was motivated by a desire for balance, not just for him but for his wife, Christy Wagner, and their two children (Gwen, now eight, and Tobin, six). When they then relocated to B.C., FAE was a major factor in their decision.
"We do believe it takes a community to raise a child," says Kerr, and he treats that commitment seriously. He and Wagner are co-treasurers of the school's Parent Advisory Council, and they helped fundraise for the community garden. For her part, Wagner volunteers weekly with the FAE sewing club.
Kerr has also reduced his work schedule for the next few years so the family can spend time together the two extra days a week that the children are at home. This allows both Kerr and Wagner to be deeply involved in the learning process (among other things, FAE parents are tasked with assisting their kids with reading and writing on home days) and gives the family time to explore their surroundings through library visits and nature walks.
Most importantly, says Kerr, "this schedule has reduced the stress in our lives. Living and learning at a relaxed pace keeps the kids involved and motivated. Plus it's been wonderful to watch Gwen and Tobin get excited for upcoming performances as they rehearse their parts in the car, at the dinner table and even on hikes in the forest."
Moving away from a one-size-fits-all education model requires ingenuity, determination and clear-eyed commitment. But trusting students, engaging parents and revolutionizing the timetable pays dividends now-and into the future.
"Our children are learning how to come up with multiple responses to one challenge," says Stewart. "They aren't going to rely on other people to provide them with opportunities-they're going to make their own."
Photo: Zoe Ferguson
Second Place, $10,000: Continuing the Journey with the Elders, Cranbrook, B.C.
"Culture cannot be programmed; it is lived." For Aboriginal-education support worker Debbie McPhee, this statement-the philosophy behind Continuing the Journey With the Elders-is a beacon. Her seven-year-old project to enhance the education of Aboriginal learners, developed for B.C.'s School District 5 Southeast Kootenay, is based out of Mount Baker Secondary School in Cranbrook. It's proven invaluable to the 1,000-strong student body, of which 15 per cent identify as First Nations or Métis. Since the initiative's inception, there has been an increase in district-wide graduation outcomes for that group-at 76 per cent, it is now just two per cent below the non-Aboriginal rate and 10 per cent higher than it was a half-decade ago. What can't be calculated is the tremendous pride the project has instilled in its participants.
Initially a monthly lunch between youth leaders and community elders designed to build cross-generational bonds, it has grown into a full-blown residence for five elders from the Ktunaxa and Métis nations. They have a Gathering Place and Elders' Room, attend classes, make presentations, speak at assemblies, help students trace their genealogy, sit on committees and share their knowledge of indigenous languages.
For Ktunaxa elder Joan O'Neil, "culture cannot be programmed; it is lived," is a hard-earned truth. Every Monday afternoon, O'Neil drives the hour and a half from her home in Windermere-where, at 76, she still works part-time at a gas station-to her daughter's house in Cranbrook. And every Tuesday she heads to Mount Baker, where she might drop in on a photography or law class. She might speak to students about her experiences as a residential school survivor or about Bill C-31-which, when it was passed in 1985, amended the section of the Indian Act that revoked the status of women, like O'Neil, who married non-Aboriginal men.
"I tell students that for more than 20 years, I was nobody. When you're disenfranchised, you're not white. You're not an Indian. Who are you?" says O'Neil. "When I got my status back, I became a person again. And being asked to be part of Mount Baker made me feel even better. I was coming home."
O'Neil wants the teens at the school and throughout District 5 to have that same sense of belonging. "A lot of the youth don't know or have lost their grandparents. Many of them were fostered or adopted out. We try to reconnect them not only with the past but with themselves so they have something to look forward to in the future."
For Kaitlyn Hoeksema, 20, "culture cannot be programmed; it is lived," is a game-changer. By Grade 10, she was floundering, spending more time doing drugs and drinking than participating in class. After two years at an alternative school, she returned to Mount Baker and joined the Wild Warriors, a leadership group. Now a student mentor at College of the Rockies ("I fell in love with school and didn't want to stop"), she credits much of her success to having the opportunity to sit with the older generation-and to learning how to dance, sing and play the drum.
When she was eventually asked to teach younger students in the area, she consulted with the elders (since she's of Cree, Nez Perce and Peguis descent, southeast B.C. isn't her territory) and was given the green light. "They have always been very supportive," says Hoeksema. "They've encouraged me to look toward my heritage and history, and advocated for forging my own identity."
Students aren't always quite as receptive as Hoeksema, but the calming influence the elders have had on the school cannot be denied. "Every- one is better behaved-from students to parents to superintendents," says McPhee, laughing. "It's like having your grandparents watching you."
Photo: Geoff Howe
Third Place, $5,000: Maker Educators Collaborative: Innovation in the Learning Commons, West Vancouver, B.C.
A toy bear with hand-carved wooden snowshoes and a tiny crocheted hat. If Michelle Davis thinks back, that childhood Christmas gift-a handmade collaboration between her parents and her grandmother-is where everything started. It's what led her to get a graduate degree in educational technology and design, and what inspired her to transform her place of work.
"Growing up, there was always a sewing room or a workshop at home. I was always encouraged to create," she says.
When Davis, a teacher-librarian, first arrived at Gleneagles Ch'axay Elementary School in West Vancouver two years ago, she knew she wanted to replicate that experience on a larger scale. The answer: a "makerspace," a physical area where students from kindergarten to Grade 7 could use equipment, whether a sheet of cardboard or a 3-D printer, to design, explore and, ultimately, learn.
In cooperation with col- leagues from three local grade schools and a high school, Davis set up a space in the Gleneagles "learning commons" (a.k.a. the library) where students could tinker. (All four of the schools currently have makerspaces in varying stages of development; Davis and her collaborators would like to equip other institutions across the city, as well.)
For Kelly Richter's daughters, eight-year-old Ava and seven-year-old Sabina, the makerspace is part of what makes their school cool. And experimenting, rather than following instructions, lets them risk failure-as important a lesson as any. "I was struck by how Ava and a friend became engrossed with figuring out how electronic building blocks could work together in different ways," says Richter. "They were fearless about making mistakes."
Davis sees the learning commons as a "library plus," a hub where traditional skills like reading are complemented by creative problem solving and critical thinking. Working with the different grade levels, she chose five themes to launch its makerspace: robotics, video creation, fabric shop, engineering and building, and design challenges.
Participants have made murals on a giant Lego wall, built an igloo out of 400 milk jugs, come up with a concept for a GPS-equipped dog collar and programmed robots to navigate a handmade obstacle course. But literacy is the engine driving all this innovation. Reading a book about a robot begat the design of a robot, which begat the composition of a story about a robot. And because the kids were writing about something they constructed, their level of investment grew. "By asking the children what they want to make, we are helping them realize that they aren't just consumers," says Davis. "They can create new knowledge and give back."
The students aren't the only ones who feel empowered. Maker education is grounded in the spirit of community, and that's reflected in the West Vancouver collective. "We're made up of teacher-librarians, a vice-principal and teachers at both the grade-school and high-school levels," says Davis. "You don't often see this kind of cross-pollination. Pooling our resources has made this experience richer."


Do you have students who struggle with their behavior in the classroom: who have extreme reactions to trivial problems, who blurt out in class, or who have trouble making friends? You can help them with Zoo U®, an evidence-based, online social skills game for students in grades 2-4. Educators, you can evaluate Zoo U with your students for free (see form at the bottom of this page).
Zoo U, the prestigious school for young zookeepers, is accepting new students!
Helping classmates and educators care for a variety of animals nurtures compassion, encourages friendship, and builds confidence. Players make a tonic to help re-grow an owl's feathers, train a lion to do tricks, and catch a mischievous toucan flying loose in the classroom, among other challenges.
The first step to enrollment is for students to create an avatar to represent them in the game!
Six short scenes at the beginning of the game provide a baseline for how students are doing with social and emotional skills: communication, cooperation, emotion regulation, empathy, impulse control, and social initiation.
Students then have an opportunity to play up to 30 scenarios to improve and reinforce learning for each of these skills.
As an example, the scene below depicts a classmate being teased after Lester the bird drops smelly fruit on him.
After students complete a scene, Principal Wild, the quirky but helpful school administrator, provides positive and constructive feedback on their choices. In this example, did the student choose to laugh along with his classmates, or stand up for his embarrassed friend?
The entire Zoo U game takes 10-15 hours to complete. We encourage you to spread out gameplay over a semester or the school year by having students play one or two times a week for approximately 30 minutes per session. However, you know your students best, so it's your decision as to exactly how you want to use the program.
Just like Matthew's students, thousands of students nationwide have improved their social and emotional skills using Zoo U, and your kids will be no different.
Educators, you can evaluate Zoo U for free for 30 days, and when you are satisfied, you can purchase student licenses for only $10 per student. There is no minimum purchase required.
Parents and Homeschool Educators: You can purchase Zoo U for use at home here.
All we need is your name and contact information entered in the form below. We'll create your Zoo U educator account in less than one business day.
If Zoo U is effective, how will you use the program more broadly?
I agree to use Zoo U with one or more students.


Share with me for what you are looking, and in short time, I'll put all wheels in motion to find what you're looking for. After I find the car or parts you're looking for, I will contact you with photos and a price.
Fill out the Search Request Form below.
If you are in Europe and found something on the internet that is in our area, I can arrange to go look at it.
For me to visit and check out an item, mileage will be calculated with Google Maps and paid in advance. $1.00 per mile.From A to B and from B back to A. If you want multiple item visits, the round trip price will be calculated. From A to B to C to D and back to A.
From the viewing location, I will send you detailed photos and description of the condition of the item. If you decided to purchase, please remit the payment plus 2.9% in the US or 3.9% if you are outside the US, immediately via PayPal.
I'll wait at the the sellers place until your money arrives (30 minutes maximum). As soon as your payment is made to our PayPal account, I'll pay the seller for your item, and bring it back to Sunburst at no extra charge.
PayPal is the largest and most respected online payment processor on the Internet with well over 8 million users. Many people are hesitant to provide credit card information over the Internet. PayPal provides a secure server (SSL) so your transaction is safe.
As Cool Stuff Montana is an expanded branch of European Antiques, all purchases are handled through our Antique Store.
Larger "Cool Stuff" will need to be picked up at our place by you.
You can pick up your new jewel/item, pack it for oversea shipping, or complete some work in my large garage.
Upon request though, I will send you smaller items by mail to Switzerland.
Please give a short, detailed description and price range of the item you are looking for.


Eric Margolis, journalist and author of American Raj, discusses the Obama administration's refusal to call Egypt's military coup by name; the imminent return of Hosni Mubarak; how American military aid to Egypt violates the law; and why Saudi Arabia's monarchy hates and fears the Muslim Brotherhood's Islamic governance style.
4 of the 32 ships with missiles in the Mediterranean Sea arrived in Cadiz. To defend us from Iran ? Russia doesn't think so. The Russians will have no choice but Launch On Warning by 2017 because of the missiles in Romania and Poland. There is no defense against Launch On Warning and we'll commit Suicide by mistake because of the bloody fools in the Pentagon. Only missile engineer Bob Aldridge-www.plrc.org-resigned because pursuing a Disarming First Strike Capability is Suicidal.
Since you apparently will not publish my thoughtful comments on this interview I must sadly conclude the Scott Horton show is a fraud. Prove me wrong by publishing the entire previous entry.
While you were talking about my country, the USA, it became evident that you were talking about a pretty evil government, a government that constantly does acts of evil. Why aren´t we using the "E" word in reference to the leaders in the USA? Don´t we want to hurt somebody´s feelings? The "Evil Empire" would be appropriate, and appropriately describe America´s actions throughout the world. Until we Americans face what we´ve become as a nation, there can be little corrective action or hope.


inscription: Printed in black under the image is "Copyright Vietnam Moratorium Committee 1970 All Rights Reserved." Bottom right corner of the image is "Bob Zoell" printed in black.
Poster is a long rectangle with a center image of a squirrel wearing a soldier hat firing a machine gun at another squirrel that is being torn apart by the bullets. They are standing in a desert scene and have "Have a Heart" printed in red above them. Below the center image is "Vietnam Moratorium Concert February 22, 1970. 10 AM to 10 PM Los Angeles Coliseum" in black.