Doctors Wrestle With A.I. in Patient Care, Citing Lax Oversight

Christina Jewett

The New York Times

Originally posted 30 October 23

In medicine, the cautionary tales about the unintended effects of artificial intelligence are already legendary.

There was the program meant to predict when patients would develop sepsis, a deadly bloodstream infection, that triggered a litany of false alarms. Another, intended to improve follow-up care for the sickest patients, appeared to deepen troubling health disparities.

Wary of such flaws, physicians have kept A.I. working on the sidelines: assisting as a scribe, as a casual second opinion and as a back-office organizer. But the field has gained investment and momentum for uses in medicine and beyond.

Within the Food and Drug Administration, which plays a key role in approving new medical products, A.I. is a hot topic. It is helping to discover new drugs. It could pinpoint unexpected side effects. And it is even being discussed as an aid to staff who are overwhelmed with repetitive, rote tasks.

Yet in one crucial way, the F.D.A.’s role has been subject to sharp criticism: how carefully it vets and describes the programs it approves to help doctors detect everything from tumors to blood clots to collapsed lungs.

“We’re going to have a lot of choices. It’s exciting,” Dr. Jesse Ehrenfeld, president of the American Medical Association, a leading doctors’ lobbying group, said in an interview. “But if physicians are going to incorporate these things into their workflow, if they’re going to pay for them and if they’re going to use them — we’re going to have to have some confidence that these tools work.”

The info is here.

My summary: 

This article delves into the growing integration of artificial intelligence (A.I.) in patient care, exploring the challenges and concerns raised by doctors regarding the perceived lack of oversight. The medical community is increasingly leveraging A.I. technologies to aid in diagnostics, treatment planning, and patient management. However, physicians express apprehension about the potential risks associated with the use of these technologies, emphasizing the need for comprehensive oversight and regulatory frameworks to ensure patient safety and uphold ethical standards. The article highlights the ongoing debate within the medical profession on striking a balance between harnessing the benefits of A.I. and addressing the associated uncertainties and risks.

What Should Health Care Organizations Do to Reduce Billing Fraud and Abuse?

K. Drabiak and J. Wolfson

AMA J Ethics. 2020;22(3):E221-231.
doi: 10.1001/amajethics.2020.221.

Abstract

Whether physicians are being trained or encouraged to commit fraud within corporatized organizational cultures through contractual incentives (or mandates) to optimize billing and process more patients is unknown. What is known is that upcoding and misrepresentation of clinical information (fraud) costs more than $100 billion annually and can result in unnecessary procedures and prescriptions. This article proposes fraud mitigation strategies that combine organizational cultural enhancements and deployment of transparent compliance and risk management systems that rely on front-end data analytics.

Fraud in Health Care

Growth in corporatization and profitization in medicine, insurance company payment rules, and government regulation have fed natural proclivities, even among physicians, to optimize profits and reimbursements (Florida Department of Health, oral communication, September 2019). According to the most recent Health Care Fraud and Abuse Control Program Annual Report, in one case a management company “pressured and incentivized” dentists to meet specific production goals through a system that disciplined “unproductive” dentists and awarded cash bonuses tied to the revenue from procedures—including many allegedly medically unnecessary services—they performed. This has come at a price: escalating costs, fraud and abuse, medically unnecessary services, adverse effects on patient safety, and physician burnout.

Breaking the cycle of bad behaviors that are induced in part by financial incentives speaks to core ethical issues in the practice of medicine that can be addressed through a combination of organizational and cultural enhancements and more transparent practice-based compliance and risk management systems that rely on front-end data analytics designed to identify, flag, and focus investigations on fraud and abuse at the practice site. Here, we discuss types of health care fraud and their impact on health care costs and patient safety, how this behavior is incentivized and justified within current and evolving medical practice settings, and a 2-pronged strategy for mitigating this behavior.

The info is here.

Confidential deals can obscure sexual misconduct allegations against doctors

Jayne O'Donnell
USA TODAY
Originally published January 5, 2018

Here are two excerpts:

Hospitals will often take over doctors' liability in confidential settlements, which Washington plaintiffs' attorney Patrick Malone calls a "frequent dodge" to keep medical negligence claims out of the National Practitioners Data Bank. Before they hire doctors, hospitals check the data bank, which also includes disciplinary actions by hospitals, medical societies and boards, which also have access to it.

Duncan's case, however, was a "miscellaneous tort claim," filed after Ohio's one-year statute of limitations for medical malpractice claims had passed.

That's just one of the many laws working in the favor of the Cleveland Clinic and the health care industry in Ohio. Plaintiff lawyer Michael Shroge, a former Cleveland Clinic associate general counsel, says major health care systems are "very often more interested in protecting their brand than protecting the health of patients."

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Critics of settlement deals' gag clauses say they compromise patients' health and safety and are unethical.

Confidential settlements are particularly problematic when it comes to health care, as "we take off our clothes in front of doctors," said Malone, who specializes in medical malpractice cases. "For a doctor to violate that in a sexual way is the ultimate wrong," he said, adding that he only agrees to confidential settlements if his client insists and only of the settlement amount.

The information is here.

Drug Companies’ Liability for the Opioid Epidemic

Rebecca L. Haffajee and Michelle M. Mello
N Engl J Med 2017; 377:2301-2305
December 14, 2017
DOI: 10.1056/NEJMp1710756

Here is an excerpt:

Opioid products, they alleged, were defectively designed because companies failed to include safety mechanisms, such as an antagonist agent or tamper-resistant formulation. Manufacturers also purportedly failed to adequately warn about addiction risks on drug packaging and in promotional activities. Some claims alleged that opioid manufacturers deliberately withheld information about their products’ dangers, misrepresenting them as safer than alternatives.

These suits faced formidable barriers that persist today. As with other prescription drugs, persuading a jury that an opioid is defectively designed if the Food and Drug Administration approved it is challenging. Furthermore, in most states, a drug manufacturer’s duty to warn about risks is limited to issuing an adequate warning to prescribers, who are responsible for communicating with patients. Finally, juries may resist laying legal responsibility at the manufacturer’s feet when the prescriber’s decisions and the patient’s behavior contributed to the harm. Some individuals do not take opioids as prescribed or purchase them illegally. Companies may argue that such conduct precludes holding manufacturers liable, or at least should reduce damages awards.

One procedural strategy adopted in opioid litigation that can help overcome defenses based on users’ conduct is the class action suit, brought by a large group of similarly situated individuals. In such suits, the causal relationship between the companies’ business practices and the harm is assessed at the group level, with the focus on statistical associations between product use and injury. The use of class actions was instrumental in overcoming tobacco companies’ defenses based on smokers’ conduct. But early attempts to bring class actions against opioid manufacturers encountered procedural barriers. Because of different factual circumstances surrounding individuals’ opioid use and clinical conditions, judges often deemed proposed class members to lack sufficiently common claims.

The article is here.

Medical errors: Disclosure styles, interpersonal forgiveness, and outcomes

Hannawa, A. F., Shigemoto, Y., & Little, T. (2016).
Social Science & Medicine, 156, 29-38.

Abstract

Rationale

This study investigates the intrapersonal and interpersonal factors and processes that are associated with patient forgiveness of a provider in the aftermath of a harmful medical error.

Objective

This study aims to examine what antecedents are most predictive of patient forgiveness and non-forgiveness, and the extent to which social-cognitive factors (i.e., fault attributions, empathy, rumination) influence the forgiveness process. Furthermore, the study evaluates the role of different disclosure styles in two different forgiveness models, and measures their respective causal outcomes.

Methods

In January 2011, 318 outpatients at Wake Forest Baptist Medical Center in the United States were randomly assigned to three hypothetical error disclosure vignettes that operationalized verbally effective disclosures with different nonverbal disclosure styles (i.e., high nonverbal involvement, low nonverbal involvement, written disclosure vignette without nonverbal information). All patients responded to the same forgiveness-related self-report measures after having been exposed to one of the vignettes.

Results

The results favored the proximity model of interpersonal forgiveness, which implies that factors more proximal in time to the act of forgiving (i.e., patient rumination and empathy for the offender) are more predictive of forgiveness and non-forgiveness than less proximal factors (e.g., relationship variables and offense-related factors such as the presence or absence of an apology). Patients' fault attributions had no effect on their forgiveness across conditions. The results evidenced sizeable effects of physician nonverbal involvement-patients in the low nonverbal involvement condition perceived the error as more severe, experienced the physician's apology as less sincere, were more likely to blame the physician, felt less empathy, ruminated more about the error, were less likely to forgive and more likely to avoid the physician, reported less closeness, trust, and satisfaction but higher distress, were more likely to change doctors, less compliant, and more likely to seek legal advice.

Conclusion

The findings of this study imply that physician nonverbal involvement during error disclosures stimulates a healing mechanism for patients and the physician-patient relationship. Physicians who disclose a medical error in a nonverbally uninvolved way, on the other hand, carry a higher malpractice risk and are less likely to promote healthy, reconciliatory outcomes.

The article is here.

How a doctor convicted in drugs-for-sex case returned to practice

Danny Robbins
Atlantic Journal Constitution
Part of a series on Physical and Sexual Abuse

Here is an excerpt:

“The pimp with a prescription pad” is what one prosecutor called him during a trial in which it was revealed that more than 400 sexually explicit photos of female patients and other women had been discovered in his office.

In some states, where legislatures have enacted laws prohibiting doctors who commit certain crimes from practicing, Dekle’s career would be over. But in Georgia, where the law gives the medical board the discretion to license anyone it sees fit, he was back in practice two years after leaving prison.

More than a dozen years later, that decision still leads some to wonder what the board was thinking.

“It’s particularly damning that he was using his ability to write prescriptions to further his sexual activities,” said Chris Dorsey, the Georgia Bureau of Investigation agent who led the probe that sent Dekle to prison. “A doctor burglarizes a house and then pays his debt to society, could he be a good doctor? I could argue it both ways. But when you have someone who abused everything centering on a medical practice to victimize all these people, that’s really a separate issue.”

The article is here.

How Well Does Your State Protect Patients?

By Carrie Teegardin
Atlantic Journal-Constitution
A series on Physicians and Abuse

Here is an excerpt:

In most states, doctors dominate medical licensing boards and have the authority to decide who is fit to practice medicine and who isn’t. Usually the laws do not restrict a board’s authority by mandating certain punishments for some types of violations. Many licensing boards — including Georgia’s — say that’s how it should be.

“Having a bold, bright line saying a felony equals this or that is not good policy,” said Bob Jeffery, executive director of the Georgia Composite Medical Board.

Jeffery said criminal courts punish offenders and civil courts can compensate victims. Medical regulators, he said, have a different role.

“A licensing board is charged with making sure a (doctor) is safe to practice and that patients are protected,” he said.

With no legal prohibition standing in the way in most states, doctor-dominated medical boards often decide that doctors busted for abusive or illegal behaviors can be rehabilitated and safely returned to exam rooms.

New Jersey licensed a doctor convicted of sexual offenses with four patients. Kansas licensed a doctor imprisoned in Ohio for a sexual offense involving a child; that doctor later lost his Kansas license after making anonymous obscene phone calls to patients. Utah licensed a doctor who didn’t contest misdemeanor charges of sexual battery for intentionally touching the genitals of patients, staff members and others.

The article is here.

Psychological principles could explain major healthcare failings

Press Release
Bangor University
Originally released on

Here is an excerpt:

In the research paper, Dr Michelle Rydon-Grange who has just qualified as a Clinical Psychologist at the School of Psychology, applies psychological theory to find new understandings of the causes that lead to catastrophic failures in healthcare settings.  She explains that the aspect often neglected in inquiries is the role that human behaviour plays in contributing to these failures, and hopes that using psychological theories could prevent their reoccurrence in the future.

The value of psychological theory in safety-critical industries such as aviation and nuclear power has long been acknowledged and is based upon the notion that certain employee behaviours are required to maintain safety. However, the same is not yet true of healthcare.

Though there may not be obvious similarities between various healthcare scandals which have occurred in disparate areas of medicine over the last few decades, striking similarities in the conditions under which these crises occurred can be found, according to Rydon-Grange.

The entire pressor is here.

When Bad Doctors Happen to Good Patients

By Thomas Moore and Steve Cohen
The New York Times
Originally published August 31, 2015

Here is an excerpt:

That Lavern’s Law wasn’t allowed to come up for a final vote is Albany’s shame. The greater shame is that hospitals don’t put more emphasis on patient safety. As the Lavern’s Law travesty makes clear, we need better solutions. Don’t limit what injured people may collect, and don’t make it more difficult for victims to get their cases heard. Even better for all concerned, keep the negligent act from ever happening in the first place. And there are practical ways to do that.

Doctors and hospitals must do a better job of policing themselves. Six percent of all doctors were estimated to be responsible for 58 percent of all malpractice payments between 1991 and 2005. State licensing agencies must do a much better job of keeping those worst of the worst out of hospitals. The threshold for state medical licensing agencies to initiate reviews should be reduced; in New York it takes six malpractice judgments or settlements. It should be three at most.

The entire article is here.

Expansion of ‘Right to Try’ legislation raises ethical, safety concerns

By HemOnc Today
Originally published April 25, 2015

Early access to experimental drugs has historically been reserved for patients enrolled on clinical trials.

In 2009, the FDA revamped its 1980’s expanded access program, which allows terminally ill patients ineligible for clinical trials and for whom no alternative, approved therapies exist to ask pharmaceutical companies for access to an investigational drug in their pipeline. More than 1,500 patients received an experimental treatment through the FDA’s program in 2014.

Now, some legislatures are going a step further by adopting so-called “Right to Try” legislation, intended to give terminally ill patients comparable access to investigational drugs but removing the FDA from the process.

Since 2014, thirteen states have passed Right to Try laws, and legislators in 20 more states have plans to introduce similar legislation this year.

The entire article is here.

An analysis of electronic health record-related patient safety concerns

By D. W. Meeks, M. W. Smith, L. Taylor and others
J Am Med Inform Assoc doi:10.1136/amiajnl-2013-002578

Here is a portion of the Discussion Section

Our findings underscore the importance of continuing the process of detecting and addressing safety concerns long after EHR implementation and ‘go-live’ has occurred. Having a mature EHR system clearly does not eliminate EHR-related safety concerns, and a majority of reported incidents were phase 1 or unsafe technology. However, few healthcare systems have robust reporting and analytic infrastructure similar to the VA's IPS. In light of increasing use of EHRs, activities to achieve a resilient EHR-enabled healthcare system should include a reporting and analysis infrastructure for EHR-related safety concerns. Proactive risk assessments to identify safety concerns, such as through the use of SAFER guides released recently by The Office of the National Coordinator for Health Information Technology, can be used by healthcare organizations or EHR users to facilitate meaningful conversations and collaborative efforts with vendors to improve patient safety, including developing better and safer EHR designs.

The entire article is here.

Best practices for remote psychological assessment via telehealth technologies

By David Luxton, Larry Pruitt, and Janyce Osenbach
Professional Psychology: Research and Practice, Vol 45(1), Feb 2014, 27-35.
doi: 10.1037/a0034547
Special Section: Telepractice

Abstract

The use and capabilities of telehealth technologies to conduct psychological assessments remotely are expanding. Clinical practitioners and researchers need to be aware of what influences the psychometric properties of telehealth-based assessments to assure optimal and competent assessments. The purpose of this review is to discuss the specific factors that influence the validity and reliability of remote psychological assessments and to provide best practices recommendations. Specific factors discussed include the lack of physical presence, technological issues, patient and provider acceptance of and comfort with technology, and procedural issues. Psychometric data regarding telehealth-based psychological assessment and limitations to these data, as well as cultural, ethical, and safety considerations are discussed. The information presented is applicable to all mental health professionals who conduct psychological assessment with telehealth technologies.

The entire article is here, behind a paywall.

Episode 1: What Psychologists Need to Know about Divorce, Mediation, and Collaborative Law

In this inaugural podcast, John interviews Attorney James Demmel about divorce, litigation, mediation, and collaborative law.  Psychologists frequently find themselves working with individuals contemplating a divorce or actually going through the divorce process.  The purpose of this podcast is to give psychologists an overview of issues surrounding divorce, litigation, mediation, and collaboration.

At the end of this podcast, the listener will be able to:

1. Describe collaborative law,
2. Differentiate between collaborative law and mediation, and,
3. Describe the benefits of mediation and collaborative law.

Click here to purchase 1 APA-approved Continuing Education credit

Find this podcast in iTunes

Or listen directly here.

Resources

Link to Attorney Demmel's website

Frequently Asked Questions about Collaborative Law and Mediation

Items Needed to Analyze Marital Assets - From Demmel Law Office

Link to The International Academy of Collaborative Professionals

Link to Collaborative Professionals of Central Pennsylvania 

Listener feedback about this episode can be sent to John Gavazzi

Watchful Eye in Nursing Homes

By Jan Hoffman
The New York Times
Originally published November 18, 2013

Here are some excerpts:

In June, Mike DeWine, the Ohio state attorney general, announced that his office, with permission from families, had placed cameras in residents’ rooms in an unspecified number of state facilities. Mr. DeWine has moved to shut down at least one facility, in Zanesville, where, he said, cameras caught actions like an aide’s repeatedly leaving a stroke patient’s food by his incapacitated side.

The recordings can have an impact. Based on Ms. Racher’s videos, one aide pleaded guilty to abuse and neglect. The other appears to have fled the country. Similar scenes of abuse have been captured in New Jersey, New York, Pennsylvania, Texas and other states by relatives who placed cameras in potted plants and radios, webcams and iPhones.

(cut)

But the secret monitoring of a resident raises ethical and legal questions. Families must balance fears for their relative’s safety against an undignified invasion of their privacy. They must also consider the privacy rights of others who pass through the room, including roommates and visitors.

Proponents of hidden cameras argue that expectations of privacy have fallen throughout society: nanny cams, webcams and security cameras are ubiquitous.

The entire article is here.

Talking with Patients about Other Clinicians' Errors

By Thomas H. Gallagher, Michelle M. Mello, and others
The New England Journal of Medicine
Originally published November 6, 2013

Here is an excerpt:

The rationales for disclosing harmful errors to patients are compelling and well described. Nonetheless, multiple barriers, including embarrassment, lack of confidence in one's disclosure skills, and mixed messages from institutions and malpractice insurers, make talking with patients about errors challenging. Several distinctive aspects of disclosing harmful errors involving colleagues intensify the difficulties.

One challenge is determining what happened when a clinician was not directly involved in the event in question. He or she may have little firsthand knowledge about the event, and relevant information in the medical record may be lacking. Beyond this, potential errors exist on a broad spectrum ranging from clinical decisions that are “not what I would have done” but are within the standard of care to blatant errors that might even suggest a problem of professional competence or proficiency.

The entire article is here.

Thanks to Gary Schoener for this information.

U.S. Nursing Homes Reducing Use of Antipsychotic Drugs

By Alan Mozes
MedicineNet.com
Originally published August 27, 2013

A year-old nationwide effort to prevent the unnecessary use of antipsychotic medications in U.S. nursing homes already seems to be working, public health officials report, as facilities begin to opt for patient-centered approaches over drugs to treat dementia and other related complications.

So far, the program has seen more than a 9 percent drop in the national use of antipsychotics among long-term nursing-home residents, when comparing the period of January to March 2013 with October to December 2011.

The entire story is here.

Learning From Litigation

By Joanna C. Schwartz
The New York Times - Op Ed
Originally published May 16, 2013

MUCH of the discussion over the Affordable Care Act has focused on whether it will bring down health care costs. Less attention has been paid to another goal of the act: improving patient safety. Each year tens of thousands of people die, and hundreds of thousands more are injured, as a result of medical error.

Experts agree that the best way to reduce medical error is to gather and analyze information about past errors with an eye toward improving future care. But many believe that a major barrier to doing so is the medical malpractice tort system: the threat of being sued is believed to prevent the kind of transparency necessary to identify and learn from errors when they occur.

New evidence, however, contradicts the conventional wisdom that malpractice litigation compromises the patient safety movement’s call for transparency. In fact, the opposite appears to be occurring: the openness and transparency promoted by patient safety advocates appear to be influencing hospitals’ responses to litigation risk.

I recently surveyed more than 400 people responsible for hospital risk management, claims management and quality improvement in health care centers around the country, in cooperation with the American Society of Health Care Risk Managers, and I interviewed dozens more.

The entire story is here.

VETS Act Expands Veterans Access to Care, Protects Patient Safety

The American Telemedicine Association strongly supports the proposed Veterans E-Health and Telemedicine Support Act (H.R. 2001,) lauding it as a key step in improving healthcare quality by minimizing regulatory barriers for interstate telemedicine.

Press Release
The American Telemedicine Association
Originally published May 16, 2013

The American Telemedicine Association voices its strong support for the new Veterans E-Health and Telemedicine Support Act (H.R. 2001) as one key step in lowering regulatory barriers to 21st century healthcare. The bi-partisan bill, introduced by Representatives Charles Rangel (D-NY) and Glenn Thompson (R-PA) and cosponsored by 21 Members of Congress, would permit U.S. Department of Veterans Affairs health professionals to treat veterans nationwide with a single state license.

This bill, known as the VETS Act, builds on the unanimous congressional enactment of the 2011 STEP Act (Servicemembers' Telemedicine and E-Health Portability Act,) which provides a similar provision for healthcare providers in the U.S. Department of Defense. A similar licensing rule for patients and providers of Medicare, Medicaid and other major federal health programs was included in a comprehensive telemedicine bill submitted by Rep. Mike Thompson (D-CA) in December 2012.

“These bills are a simple way, while preserving the states’ role to license, to address shortages of medical specialists, to improve patient access to the best qualified physicians, and to accommodate mobile Americans and multi-state health plans,” said Jonathan Linkous, Chief Executive Officer of the American Telemedicine Association. “They accommodate both patient choice and patient safety. We would like to see a similar act for all federal patients and providers.”

Presently, most providers who practice interstate telemedicine must be licensed both where the patient and provider are physically located. Such regulation increases the cost of healthcare and is an artificial barrier, favoring the business interests of local physicians over patient choice. Some state medical boards are even imposing stricter licensing requirements for telehealth providers than they do for in-person care, such as requiring a prior face-to-face examination for each and every case.

“Access to quality healthcare is, ultimately, the foremost safety issue for the patient,” concluded Linkous. “It’s time that we allow patients to make an appointment and see a qualified licensed health provider regardless of where the patient or provider is located."

About the American Telemedicine Association

The American Telemedicine Association is the leading international resource and advocate promoting the use of advanced remote medical technologies. ATA and its diverse membership, works to fully integrate telemedicine into transformed healthcare systems to improve quality, equity and affordability of healthcare throughout the world. Established in 1993, ATA is headquartered in Washington, DC.

For more information visit http://www.americantelemed.org.

After my daughter’s death, I work to prevent future deaths

By Martha Deed
KevinMD.com
Originally published March 17, 2013

Here are som excerpts:

Another disturbed and disturbing night. It doesn’t happen often three years later. Now – when it does happen – I generally know why.

I am preparing to make a presentation of a sentinel event from my daughter’s final illness to a group of medical professionals and patient advocates. Last night, I was working on key points. What issues seem most important for hospital staffs to address after these years of reflection?

I am convinced – have understood for some time – that the fundamental issue is not that my daughter is dead or even how she died. The basic issue is, “Can we learn anything to prevent future deaths?”
The conference presentation makes use of the past to inform the future. I am co-presenting with a chief medical officer of a hospital system in another state.

Recently, he asked me how I am able to do this – stare into the disaster, sort it out, convey a message of hope. He asks, “What separates people like me who work toward improving safe and competent care from people who cannot move beyond paralyzing grief and anger?”

(cut)

My obligation as a parent and as a social scientist engaged in patient advocacy is to do what I can to help health care providers in their work. As a layperson, I can’t do much to improve patient outcomes; I have neither the education, nor the position to change anything within a hospital or medical office.

The entire blog entry is here.

Thanks to Ed Zuckerman for this information.

Survey: Too many EHR alerts could lead to missing test results

By Andis Robeznieks
ModernHealthcare.com
Originally posted March 4, 2013

The information deluge unleashed by electronic health-record systems could cause physicians to miss notifications of abnormal test results, according to a survey of primary-care practitioners with the U.S. Veterans Affairs Department. Missing those notifications could delay needed care for patients, according to the physicians, nurse practitioners and physicians assistants surveyed.

Researchers from several Houston institutions—including the Houston VA Health Services Research and Development Center of Excellence—surveyed almost 2,600 VA primary-care practitioners from June 2010 through November 2010 regarding EHR-based alerts. Almost 30% acknowledged missing notification of test results that led to care delays, according to a research letter in the American Medical Association journal JAMA Internal Medicine (formerly the Archives of Internal Medicine).

The entire story is here.