Retaliation against physicians reporting EHR flaws that cause use errors? Physicians subpoenaed in Rhode Island, allegedly after reporting EHR risks

It appears that way to my eye.  First, on use errors (as opposed to user errors from carelessness):

“Use error” is a term used very
specifically by NIST to refer to user interface designs that will
engender users to make errors of commission or omission. It is true that
users do make errors, but many errors are due not to user error per se
but due to designs that are flawed, e.g., poorly written messaging,
misuse of color-coding conventions, omission of information, etc. From NISTIR 7804: Technical Evaluation, Testing and Validation of the Usability of Electronic Health Records. It is available at (PDF).

Now this:

Becker’s Hospital Review
Physicians subpoenaed in Rhode Island, allegedly after reporting EHR risks
Jessica Kim Cohen
January 25, 2019

The Rhode Island Department of Health reportedly has served at least four emergency room physicians at Providence-based Rhode Island Hospital with subpoenas, according to the Politico Morning eHealth newsletter.

The subpoenas allege the physicians participated in behaviors that fall under the umbrella of medical misconduct, on account of mistakes the physicians reported themselves. The mistakes, which didn’t injure any patients, reportedly were meant to draw attention to risks associated with the hospital’s EHR.

This is outrageous if accurate, especially considering the issues I raised in my Nov. 4, 2011 post “Lifespan (Rhode Island): Yet another health IT ‘glitch’ affecting thousands – that, of course, caused no patient harm that they know of – yet” at

The RI Dept. of Health owes the public an explanation.

The subpoenas primarily relate to medical scans, such as X-rays, which were mistakenly ordered by the physicians. EHR experts who spoke with Politico said these errors are common because it’s easy to click on the wrong icon or patient name in complex system interfaces.

That is classic “use error” and results from poorly-designed, mission-hostile user interfaces of bad health IT as defined by myself and Australian informatics expert Dr. Jon Patrick at at

Bad health IT is IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy, lacks evidentiary soundness permitting concealment of alterations, or otherwise demonstrates suboptimal design and/or implementation. 

I covered the issue of ‘mission-hostile health IT’ at a 10-part series in 2009 at

Physicians and EHR safety researchers have raised concerns over the subpoenas, suggesting that the department’s response could discourage future clinicians from voluntarily reporting medical errors.

Not “could.” 

Will, and likely by design in my opinion.  The ultimate motive for the subpoenas and those behind them, which may extend outside the DOH, needs to be determined.

“Anyone punishing individual providers for these events is punishing the wrong thing,” Jason Adelman, MD, chief patient safety officer at NewYork-Presbyterian Hospital in New York City, told Politico. “These are system issues, not the provider being reckless. The focus should be on things like EHR usability and safety.”

I am aware of patient injuries and deaths as a result of mis-clicks due to mission-hostile user interfaces that confuse users and lack appropriate safety alerts and notifications.  This includes ER mistakes.

The corporate response followed the expected boilerplate:

When asked about the subpoenas Jan. 25, Rhode Island Hospital spokesperson David Levesque [Director of Media Relations, Lifespan,] provided the following statement to Becker’s Hospital Review:

“Rhode Island Hospital is deeply committed to the safety of our patients and the continual improvement of our healthcare environment, including the processes our caregivers and staff follow. Furthermore, the hospital’s culture of transparency remains a point of pride and is unwavering. Rhode Island Hospital supports our world-class physicians, nurses and other staff and appreciate their tirelessly work in providing world-class healthcare.”

As one colleague of mine observed, “the hospital’s culture of transparency
remains a point of pride” seems to mean that “you can prosecute staff for
being transparent, and it is not a contradiction.”

I wrote Mr. Levesque regarding this story:

From: S Silverstein
Date: Tue, Jan 29, 2019 at 10:07 AM

Subject: Re: Physicians subpoenaed in Rhode Island, allegedly after reporting EHR risks

“Rhode Island Hospital is deeply committed to the safety of our patients and the continual improvement of our healthcare environment, including the processes our caregivers and staff follow. Furthermore, the hospital’s culture of transparency remains a point of pride and is unwavering. Rhode Island Hospital supports our world-class physicians, nurses and other staff and appreciate their tirelessly work in providing world-class healthcare.”


After the debacle I documented at , I think this is an outrage.

I am passing this story on to trial lawyers who will likely pass it to the national trial lawyer’s listserv.  I believe these actions are retaliation against the physicians.

I am aware of patient injuries and deaths following “wrong clicks” in ER’s.


Scot Silverstein MD

The stated source of the subpoenas, DOH, seems odd.  The hospital should strongly defend its doctors against DOH if the DOH was the sole source of the subpoenas and accusations of medical misconduct, not just provide boilerplate.  If DOH was influenced by some other party to take this action, that needs to be revealed.

I hope I am wrong about the retaliation issue, and that this has all been a misunderstanding.  Perhaps Mr. Levesque will clarify.  Perhaps the subpoenas against the physicians who reported the EHR use error issue were issued by the DOH to gain more information about the alleged EHR problems.  If not, I hope they will be summarily dropped. 

If not, I hope the matter gets wider attention, especially at a time when bad health IT is contributing considerably to clinician burnout per numerous studies and reports (see for instance my Jan. 23, 2019 post at  Burnout increases risk of medical error for everyone.

Supposed accusations of any type of “professional misconduct” are outrageous, and will have a chilling effect on other like-minded, candid clinicians (including nurses) confronting bad health IT.

— SS

OASIS D Classes *FREE*

To: Federally Certified Skilled Home Health Facilities Administrators, Directors of Nursing, OASIS Coordinators, Billing and Coding Personnel, Licensed Home Health Facilities Administrators

From: The Education and Technical Assistance (ETA) Branch of the Health Facilities and Emergency Medical Services Division (HFEMSD)

“OASIS D: Changes for 2019” webinar was aired on Dec 5, 2018. A replay is available at

ETA will offer classes on specific OASIS topics in Denver, La Junta, Grand Junction, Boulder and Craig featuring OASIS D items and guidance. You may choose to take sessions all at once or individually as your interest and needs dictate. All registration is first-come, first-served, even for sessions within a specific facility.

ETA reserves the right to cancel classes with low registration. Early registration is helpful.

OASIS D Basics (One Session): Course ID 1082008
This beginning three-hour class is how to get started with OASIS D.

OASIS D Item-by-Item (2 Sessions): Course ID 1082009
This practical application class reviews item-by-item data set completion. We will follow Mrs. Green’s assessment, which will require two sessions to complete. Attendance at both sessions is required to complete this class.

OASIS Quality Measures (One Session): Course ID 1066910
This course assumes familiarity with the OASIS D Item Set, covering more advanced content and application.

To see additional session details and register for on-site attendance for one of these offerings:
1. Go to 
2. Log in to your existing TRAIN account, or new users click “Create an Account”
3. Once you’ve logged in, or created an account, Search (top right) for the appropriate Course ID. (See above for desired training)
4. Click link for desired course.
5. Click the “Registration” tab.
6. Click the “Register” button for the session you wish to attend.
7. Remember to register separately for each desired course.

A detailed example of the above process (if needed)

Questions?: Please email

Watching the Detectives: Logical Fallacies and Unsubstantiated Claims to Denigrate Investigations of Leaders’ Conflicts of Interest and Alleged Corruption

Introduction: Logical Fallacies and Unsubstantiated Claims in Defense of Conflicts of Interest in Health Care

We have long been concerned about deceptive marketing to sell health care products, and deceptive public relations to push policy positions favorable to health care organizations’ leaders.  Deceptive marketing and public relations may morph into stealth marketing and stealth advocacy, and then  outright propaganda and disinformation.

At the same time, we have long been concerned about how leaders have become unaccountable for the conflicts of interest generated and outright criminal and corrupt behaviors by their organizations.  They have thus exhibted impunity.

These concerns have sometimes merged.  We have occasionally written posts about how prominent figures in health care, thought leaders, or as health care marketers like to call them, key opinion leaders with impressive credentials, have used questionable data and logical fallacies to defend their and other health care leaders’ conflicts of interest.  For example, most recently, in 2015, I discussed a commenary in the prestigious New England Journal of Medicine defending conflicts of interest affecting health care academics.  At the time, I wrote:

It was more surprising, given the reach of this journal, that these articles featured a catalog of logical fallacies in support of their arguments.  We have noted that logical fallacies
have been a stock in trade of those who actively defend laissez faire
policies about conflicts of interest, and other kinds of interactions
among health professionals and industry.  However, I would not have
believed that the New England Journal of Medicine would go along with
this sort of thing.

The logical fallacies I cited were burden of proof, appeal to authority, ad hominem, appeal to pity, and the straw man fallacy.

I concluded with:

The series of articles about conflicts of interest that just appeared in
the New England Journal, while ostensibly scholarly, published by the
journal’s “national correspondent” in the Medicine and Society section,
appear to be polemical.  They deployed a substantial number of logical
fallacies to make the point that medicine and society have gotten too
tough on conflicts of interest.  They are notably short on logical,
dispassionate discussion of the evidence.  Thus, they seem more like
posts on a very opinionated blog site rather than commentaries in a
scholarly medical journal.

I had written similarly in 2012 on logical fallacies employed in a report by the European Society of Cardiology defending, again, conflicts of interest, and again on logical fallacies employed by the new Chancellor of UCSF in the Wall Street Journal, again to defend conflicts of interest affecting academic medicine.

Now, in 2019, we stil see academics with impressive credentials making arguments in national media based on poor data and logical fallacies, but now to defend the highest leaders of our country from charges of conflicts of interest and corruption.

Victor Davis Hanson’s Nationally Syndicated Challenge to the Postulated Over-Investigation of the Trump Administration

Here is one recent, vivid, widely published example.  An op-ed appeared in my local newspaper, the Providence Journal, an abbreviated version of a commentary by Victor Davis Hanson which appeared in the National Review, and was syndicated to numerous other right-wing or conservative publications, such as RealClear Politics, TownHall, and in syndication to multiple news media.  Per the ProJo version, Hanson professes to be “a classicist and historian at the Hoover Institution, at Stanford University.”  His official Hoover Institute biograpshy states “Victor Davis Hanson is the Martin and Illie Anderson Senior Fellow at the Hoover Institution; his focus is classics and military history.”  It claims he has received multiple awards, and has hundreds of publications.  Thus Hanson claims to be a public intellectual, not a polemicist, and may well fit the definition of a thought leader.

Hanson’s main point was that President Donald Trump was being unfairly investigated.  He started with quoting the famous question, “who will watch the watchers,” and then goes on to suggest that Trump’s watchers (auditors, investigators) need to be reined in, implying that it was unreasonable that the Trump administration ” has become the most investigated, the most audited, and the most closely examined presidency in history.”

I my humble opinion, in support of his contention, Hanson offered arguments were often illogical, and lacked any substantiating evidence.  Therefore, his piece appeared to be propaganda.   Let me first list some of its illogic.

Hanson’s Logical Fallacies

Logical Fallacy: Affirming the Consequent

Hanson’s main assertion was:

Given President Trump’s unconventional background, his wheeler-dealer past, and the hatred he incurs from the left, few ever give him the benefit of the doubt.

The paradoxical result is that his tenure in just two years has become the most investigated, the most audited, and the most closely examined presidency in history.

Note that the superlative claims, that is those about the “most investigated,” “audited,” and “closely examined” presidency, are not substantiated.  These are the essence of  Hanson’s argument is that Trump has been scrutinized for (morally) bad reasons, e.g., “hatred from the left.”  Hanson is arguing this based on the truth of the result, that his presidency is the most scrutinized.  Yet even if it is, that does not prove the reasons were “hatred from the left,” etc.  Thus, this is an example of the logical fallacy of affirming the consequent, presenting an argument in an if p, then q format, but then stating that if q is true, p must have true as well. 

Another example of this fallacy was a little way down the page:

his most frequent accusers — the media — have set themselves up as the
country’s moral paragon. Journalists now see themselves as
social-justice warriors who are immune from the scrutiny to which they
subject others.

The result of such self-righteous moral exemption has led to
journalism’s nadir, with an unprecedented lack of public confidence in
the media. ‘Fake news’ now abounds, from CNN to BuzzFeed.

The argument here is a caustive one: if journalists are “immune” “social-justice warriors, then the result is “journalism’s nadir,” and “fake news.”

Again, even if it is true that journalism is at its nadir, that does not mean Hanson’s postulated cause, journalists as immune social-justice warriors, is true.  However, Hanson’s argument, that the investigations are unreasonable, and the auditors need to be audited, arises from his claim that the original auditors, the journalists, are “immune from scrutiny” and need to be reined in.  Again, he states if p, then q, but then argues that because q, then p.

Logical Fallacy: Hasty Generalization

Trying strengthen his case that journalism as at a “nadir,” with “fake news” abounding, Hanson then cited the case of a recent BuzzFeed article:

Recently, BuzzFeed (which first published the unsubstantiated
Steele dossier) alleged that there was proof that Trump had ordered his
erstwhile lawyer, convicted felon Michael Cohen, to lie.


the BuzzFeed yarn drew a rare rebuke from Special Counsel Robert Mueller’s team, which disputed the veracity of the story.

That was one case, one anecdote.  Hanson did not cite any other examples of faulty journalism in his commenatry.  So this appears to be a version of the logical fallacy of hasty generalization, also known as an argument from small numbers, or anecdotal reasoning.  Citing an anecdote of a particular pheonomenon means that the phoenomenon is possible, but obviously does not mean that the pheonomenon is common, or important.

Again, Hanson made his argument that the investigations of Trump by law enforcement are alos excessive,

The Department of Justice and the FBI are supposed to be our preeminent
guardians of justice. But former director James Comey, former deputy
director Andrew McCabe, former general counsel James Baker, and several
other top FBI officials have either resigned, retired, or been fired —
and some may soon be facing indictments themselves.

Setting aside whether resignations, retirements, or even firingsd under these circumstance indicate excessive zeal or criminal behaviore, and whether Hanson’s speculation about indictments are valid, he cited only a few cases to imply that investigation of Trump has been excessive.  So this is another case of reasoning from a small number of anecdotes, thus hasty generalization.

Base Rate Fallacy

Hanson went on to embellish his descriptions of the alleged misbehavior by a few Department of Justice personnel.  In particular, he noted

On 245 occasions in sworn testimony before Congress, Comey answered that
he either did not know the answers to questions or could not remember
the details of events. Had any private citizen tried such stonewalling
in an investigation, he or she would likely end up in jail.

He here was no longer citing one or a few anecdotes.  245 occasions seem to be a lot.  However, Hanson’s citation of it omits mentioning the numerator.  Setting aside again the notion that people may go to jail for responding to questions under oath by claiming faulty memory or lack of knowledge, Hanson failed to state either how many questions Comey was asked  Without knowing this, one cannot tell whether the Comey’s behavior was frequent or rare.  Thus, Hanson’s implication that Comey committed some sort of crime, and that doing so discredits his investigation of Trump, was based on the base rate fallacy.  He focused on the number of times an event occurred, while ignoring how many times it did not.

 Logical Fallacy: Incomplete Comparison

Consider again the two sentences written by Hanson above.  Not only did Hanson not establish the rate Hanson claimed faulty memory or ignorance, he did not address how often “private citizens” make such claims.  Thus, even if we knew the rate of Comey made these claims, we do not know the rate private citizens do so.  This thus appears to be an example of the logical fallacy of incomplete comparison, described as “an incomplete assertion that cannot possibly be refuted. This is popular in advertising.”   

Hanson’s Unsubstantiated Claims of Fact

I found the following relevant examples of claims about frequency or prevalence without any supporting data.

Half the country apparently believes Trump cannot be trusted.

everything he says and does is the object of pushback, opposition, and audit.

‘Fake news’ now abounds,

I found the following relevant examples of claims about causation without substantiation.

The sexual-abuse crises within the contemporary Catholic Church arose
from the de facto exemptions from the law given to priests.

Too many assumed that men of faith were exempt from prosecution because
as holy men they would be the last to violate the trust of minors

I found the following relevant unsubstantiated claims about peoples’ intent or state of mind.

They all apparently believed that their loud liberal credentials gave
them immunity from being held accountable for their harassment.

They apparently assumed that as supposed victims, they could not be viewed as being sympathetic to victimizers.

Journalists now see themselves as social-justice warriors who are immune from the scrutiny to which they subject others.

Weissmann apparently didn’t mind that the dossier was used by his
colleagues to deceive the Foreign Intelligence Surveillance Court into
granting a warrant to spy on an American citizen.

Credible Allegations of Trump’s and Cronies’ Conflicts of Interest and Corruption

While spinning his web of logical fallacies and unsubstantiated claims, Hanson ignored the rationale for the multitude of investigations of
President Trump and associates.  In fact, there is voluminous documentation of evidence
suggesting he has numerous conflicts of interest and he and his regime
are corrupt.  We summarized some of the most recent data here, in October, 2018.  As I said then, up to October, 2018…

In January, 2018, we first raised the question about how health care corruption could be pursued under a corrupt regime.  We noted sources that
summarized Trump’s. the Trump family’s, and the Trump administration’s
corruption..  These included a website, entitled “Tracking Trump’s Conflicts of Interest” published by the Sunlight Foundation, and two articles published in the Washington Monthly in January, 2018. “Commander-in-Thief,” categorized Mr Trump’s conflicted and corrupt behavior.  A Year in Trump Corruption,” was a catalog of the most salient cases in these categories in 2017.

In July, 2018, we addressed the Trump regime’s corruption again  By then, more summaries of Trump et al corruption had appeared.   In April, 2018, New York Magazine published “501 Days in Swampland,” a time-line of  starting just after the 2016 presidential election. In June, 2018, ProPublica reviewed
questionable spending amounting to $16.1 million since the beginning of
Trump’s candidacy for president at Trump properties by the US
government, and by Trump’s campaign, and by state and local governments. Meanwhile, Public Citizen released a report on money spent at Trump’s hospitality properties.

In October, we summarized the lengthy Tracking Corruption and Conflicts of Interest in the Trump Administration.
It broke down Trump and cronies’ behavior into the following four
categories: 1) US government payments to the Trump Organization; 2) use
of the power of the presidency to promote Trump brands; 3)    U.S.
government regulatory and policy decisions that benefit the business
interests of the Trump family and senior advisors; and 4) private and
foreign interests seeking to influence the Trump administration through
dealings with Trump businesses.  The lists of specific instances in
each category go on for pages, and have grown since October through
weekly updates.

Most recently, Citizens for Responsibility and Ethics in Washington (CREW) published a report that listed the following concerning Trump’s first two years in office:

CREW has identified 12 foreign governments that have made payments to Trump properties during his first two years in office, each of which is likely a violation of the Constitution’s foreign emoluments clause….

Instead of pushing back on President Trump’s refusal to divest from his business, allies in Congress have embraced the arrangement. 53 U.S. senators and representatives made more than 90 visits to Trump properties during his second year in office, up from 47 visits by 36 members the prior year, and similarly, at least 33 state-level government officials visited Trump properties, likely resulting in taxpayer funds going into Trump’s coffers.

More than 150 political committees, including campaigns and party committees, have spent nearly $5 million at Trump businesses since he became president. In Trump’s second year in office, CREW tracked 33 political events held at Trump properties—13 of which Trump himself attended, meeting and speaking with wealthy donors.

Special interests held at least 20 events at Trump properties during the president’s second year in office. Since Trump took office, at least 13 special interest groups have lobbied the White House, some for the first time, around the same time they patronized a Trump property, suggesting that making large payments to Trump’s businesses is viewed as a way to stay in his administration’s good graces.

Over the past year, President Trump made 118 visits to properties he still profits from in office, bringing his two-year total to 281 visits. CREW also identified 119 federal officials and employees who visited Trump properties over the past year, up from 70 the prior year.
In addition to making frequent visits to his properties, President Trump and other White House staff have promoted Trump businesses on at least 87 occasions. Trump himself mentioned or referred to his company 68 times during his second year in office, more than double the 33 times he did so the prior year.

Paying members at Trump’s resorts and clubs have received benefits beyond getting occasional face time with the President. Four Mar-a-Lago members have been considered for ambassadorships since his election, and three other members—with no federal government experience—acted as unelected, non-Senate-confirmed shadow officials in Trump’s Veterans Administration.

As an aside, in response to Hanson’s claim that few have ever given Trump “benefit of a doubt,” we discussed here all the credible allegations of misbehavior by Trump prior to his presidency that were investigated minimally, if at all, and which never led to any serious consequences for him.  Trump had been accused of lying to investigators about his Mafia connections; accepting kickbacks; violating fiduciary duties and at least two instances of fraud; failing to disclose he was under grand jury investigation in a casino license application; and perjury.  Also, his casino was found to have committed numerous violations of state regulations, and violating regulations regarding money laundering, but Trump paid no personal penalties.

Hanson ignored all that. 


So here is one example, one anecdote, showing, in my humble opinion, an extreme case of illogical, unsupported argumentation in defense of our current president against multiple credible allegations of conflicts of interest and corruption.  These allegations should concern anyone who cares about conflicts of interest and corruption in health care, because the presidency sets the tone for the whole country, and up to now, the executive branch of the US government provided the most and best resources for preventing and challenging conflicts of interest in health care.  Obviously, these allegations should also concern anyone who cares about the state or representative democracy in the US.

This case is notable because of the academic credentials of the person whose argumentation was so illogical and unsubstantiated.  Someone with such a prestigious academic position ought to know better, I think.

The case was also notable for how this widely published article seems to have inspired no criticism to date.  Of course, note that analyzing a short article filled with logical fallacies and unsubantiated claims likely takes much longer than writing said article.  Furthermore, note that the criticism takes much more space than the article itself.  This makes it hard to do criticism that is likely to be noticed much or have much effect.

So in conclusion let me take something I wrote about bad arguments in support of conflicts of interest in medicine in 2015, and edit it for a 2019 audience [additions in brackets]

it is most disappointing that conflicts of interest are now being
uncritically and illogically publicly defended by people in positions to
exert so much influence on health care [and the greater political economy, and all of society].


True … reform requires
such substantive reform of the financial arrangements among corporations  … and others who make decisions about patients’ or the public’s
health [and about the health of the political economy and the greater society].  To decide how to
accomplish such reform, we need a better discussion informed by logic
and evidence, sans logical fallacies. Those who lead health care [the political economy, and the greater society] ought
to be able to participate in this discussion under these conditions.

Musical Interlude

To lighten things up a bit, here is a 1978 video of Elvis Costello live performing Watching the Detectives

MDS Resources to Prepare for Fall 2019

To: Federally Certified Skilled Nursing Facilities Administrators, Directors of Nursing, MDS Coordinators, Billing and Coding Personnel, Licensed Nursing Facilities Administrators

From: The Education and Technical Assistance (ETA) Branch of the Health Facilities and Emergency Medical Services Division (HFEMSD)

On October 1, 2019, CMS will transition from using the Resource Utilization Group (RUG) reimbursement scale to the Patient-Driven Payment Model (PDPM). New information from CMS is available:

Additional information on the current MDS 3.0 version 1.16.1 is also available:
Classes starting in March on specific MDS topics are available in Denver and Craig as listed on Facilities that wish to host trainings are encouraged to schedule now.

To see additional session details and register for on-site attendance for one of these offerings:

  1. Go to:

  2. Log in to your existing CO.TRAIN account, or new users click “Create an Account”.
  3. Once you’ve logged in, or created an account, Search (top right) for the appropriate Course ID. (See above for desired training)

  4. Click link for desired course. Note open session options.

  5. Click the “Register” button for the session you wish to attend.

  6. Remember to register separately for each desired course.

Detailed Instructions for Using (if needed)

Questions?: Please email:

Reminder – Assisted Living Advisory Committee meeting on Thursday, January 24, 2019

To: Assisted Living Residence Providers and Stakeholders 

From: Dee Reda, Community Services Section Manager

The next Assisted Living Advisory Committee meeting is on Thursday, January 24, 2019 from 12:00 p.m. – 2:00 p.m. in Building A, Sabin/Cleere Room.

For meeting agendas, handouts, etc. please go to Click on the folder labeled “2019 Meetings” and find the corresponding meeting date. We recommend that you return to this site on the day of the meeting to check for additional or revised meeting materials. 

To participate via Web using Zoom Meetings: 
Join from PC, Mac, Linux, iOS or Android: 

Meeting ID: 675 245 553

Step #1: Go to .
The Zoom meeting screen will appear entitled “Assisted Living Advisory Committee”
Step #2: For sound, choose Phone Call or Computer Audio.
Step #3: You will now be in the Virtual Meeting Room.

If you have never attended a Zoom meeting before:
Get a quick overview: 

To participate by telephone:
Step #1: Dial (for higher quality, dial a number based on your current location): US: +1 408 638 0968 or +1 646 876 9923 or +1 669 900 6833
Step #2: When prompted, enter the Meeting ID: 675 245 553
Step #3: You will be on hold until a few moments before the meeting.

If you have any questions, please contact Michelle Topkoff at or call 303-692-2848 at least a business day in advance of the meeting. 

Meeting information

At the Colorado Department of Public Health and Environment, we work hard to protect and promote your health and the environment. If you’re planning a visit to our campus and want to ride your bike here, we won’t take a second look at your helmet head, and if the bus you’re taking is running a little late, we won’t worry. We want you to be your healthiest you, and we appreciate your efforts to reduce pollution.
If you’re coming to our campus: Our campus is located at 4300 Cherry Creek Drive South, Denver, 80246.
If you’re riding your bike: Our campus is located just south of the Cherry Creek bike trail. Bicycle parking is available at multiple locations on the main campus. Covered bicycle parking also is available at several locations, as well as on the ground floor of the parking structure on Birch Street, which is just east of the main campus 
If you’re riding the bus: RTD’s Trip Planner is a great way to find the fastest route.
If you’re driving: Visitor parking is conveniently located in front of all of our buildings. Please check in with security in Building A so you can get a visitor badge.
You might also want to know:
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We are located just east of Glendale’s City Set, where there are several restaurants.
Lactation Rooms are available on the first floors of buildings A and B. 

Chapter 7 Assisted Living Regulation Updates and Resources:

Updates on the Chapter 7 Assisted Living Regulations can be found on the Assisted Living News & Resources web page at

It is our hope that this resource will provide you with up-to-date and relevant tools, training, and information, as we move forward with implementing the new regulations under 6CCR 1011-1, Chapter 7 Assisted Living Regulations. Current features of the newsletter include on “What’s New”, “Important Dates,” “Training,” “Blog,” “FAQs”, “Help” and “Advisory Committee”. Our goal is to provide you with a clear understanding of the new portions of the regulation as well as training to help you comply. 

OASIS D Classes *FREE*

To: Federally Certified Skilled Home Health Facilities Administrators, Directors of Nursing, OASIS Coordinators, Billing and Coding Personnel, Licensed Home Health Facilities Administrators

From: The Education and Technical Assistance (ETA) Branch of the Health Facilities and Emergency Medical Services Division (HFEMSD)

ETA will offer classes on specific OASIS topics in Denver, La Junta, Grand Junction, Boulder and Craig featuring OASIS D items and guidance. You may choose to take sessions all at once or individually as your interest and needs dictate. All registration is first-come, first-served, even for sessions within a specific facility.

ETA reserves the right to cancel classes with low registration. This is a possibility for some Denver sessions. Early registration is helpful.

OASIS D Basics (One Session): Course ID 1082008
This beginning three-hour class is how to get started with OASIS D.

OASIS D Item-by-Item (2 Sessions): Course ID 1082009
This practical application class reviews item-by-item data set completion. We will follow Mrs. Green’s assessment, which will require two sessions to complete. Attendance at both sessions is required to complete this class.

OASIS Quality Measures (One Session): Course ID 1066910
This course assumes familiarity with the OASIS D Item Set, covering more advanced content and application.

To see additional session details and register for on-site attendance for one of these offerings:
1. Go to 
2. Log in to your existing TRAIN account, or new users click “Create an Account”
3. Once you’ve logged in, or created an account, Search (top right) for the appropriate Course ID. (See above for desired training)
4. Click link for desired course.
5. Click the “Registration” tab.
6. Click the “Register” button for the session you wish to attend.
7. Remember to register separately for each desired course.

A detailed example of the above process (if needed)

Questions?: Please email

More Than Just Dander

First, a sort of meta-comment in the form of a shout-out to HCRenewal’s intrepid editor, Dr. Roy Poses, for his just-published analysis of what we might call “blogging: rise and fall.” He sees decline reflected in publications long  devoted to health and health policy, yet now flaking off.

Methinks, however, despite the usefulness of his overview of recent decades, Dr. P need not fret excessively. Water spilling out of the barrel’s lip will slow down once folks come along and punch a whole bunch of little mid-section tweet-holes in it. Information still flows. (Sort of.)  In any case, surely there’s overlap between blogs’ and tweets’ readerships. Surely well-researched and -reasoned long form still has its place. Unfortunately, hard to know for sure: it’s hard to measure. Nobody’s polling these folks and to my knowledge information scientists haven’t published much–a quick search inside Google Scholar bears this out–that’s of a quantitative nature.

So we’re left with admittedly rather unsatisfactory anecdotal reports on people who need blogs like ours and find their way to it. Congressional staffers you know who you are. Rightly or wrongly, I’m hopeful. Maybe we shade this a little by the suspicion that many younger social media users share with me a short attention span. Hence they come to rely more and more on quick hits. In any case, let’s hope this is evolution and diversification, not just entropy and a race to the bottom.

Now to my theme of the day. Yet again the dander hath risen for I’ve lost count how many times around what ails our health delivery systems. And so is my lunch: the gorge, too, hath risen. The miscreants’ very relentlessness is nauseating. More, then, on two of them that keep cropping up here like those small burrowing insectivores in this tedious yet oddly riveting game of Whack-A-Mole.

A. Chicanery at the VA: looking back and looking forward.

On balance, and despite its many flaws, VA health’s operation in all its enormity is not itself a miscreant. Different story for those folks trying to destroy it from within, on the dubious premise that lest we privatize it it’s irredeemable. Search this blog on “VA Cetona” for detail on such matters.

Why does this even happen? We’ve described the VA’s Shadow Rulers (search here on that as well) in these pages. The SR’s fall in the 0.1%. Why do they need or want the headache of trying, in what’s fated to be a futile effort, to upend and hollow out the health lifeline extended for nearly a century to patriots returning from the military?

When the left gets power it tries to expand and improve government. (Of course the efforts can unfortunately go awry, viz. Hillarycare in the 1990s, and cast shade on future attempts.) When the right gets power, at least in the two generations since an actor became president in 1980, government is seen as “not the solution but the problem.” The response may be to try to rejigger and downsize. “Drown the baby in the bath.” Or, perhaps far more likely, something else now happening in the VA and throughout the Trump kakistocracy.

Namely, don’t seize power to return it to the people. Seize it in order to use it in a third-dimensional play to drain resources. As for the first two dimensions, don’t even try to improve–David Shulkin’s mistake (see below)–or eliminate (despite Mick Mulvaney’s baby drowning proclivities, hugely unpopular) care provided by the VA. Not when there’s a third way: divert those resources. In fact, from the earliest instances of frontier exploitation to the newest frontier we have–our heretofore private personal information–despoliation has been the watchword, the core motive, the secret sauce: don’t ameliorate. Don’t eliminate. (Honestly: viz., Shrub’s expansion of guvmint.) Despoliate.

It is, as Shrub used to say (maybe), one of our country’s most basic pieces of strategery.

Such a strategy was discussed (and surely it’s as old as the hills) by Times tech reporter Steve Lohr in a recent piece on, of all things, artificial intelligence. (“Elixir of prosperity [or] job killer”?) Lohr makes clear that what’s old is new again, linking the asset of private data to all the other assets that’ve been strip-mined. “In the American model,” notes Lohr, “coming from Silicon Valley in California, a handful of Internet companies become big winners and society is treated as a data-generating resource to be strip mined.”

As Buffy the Vampire Slayer once said, “can you spell ‘duh’?”

Strip mining started with the earliest settlers, and now … data, the final frontier. Same deal, though. The American model, and economic maldistribution, and so much of our plight is bound up with this baked-in trait, which seems to’ve seeped into society’s DNA. Or else originated there. Find a mine. Strip it. Let others pick up the pieces.

But let’s go back to that last credible VA Secretary. How do we know that Shulkin pissed off the strip-miners? Why, just read what he himself wrote in a scholarly publication just a few months ago in the prestigious New England Journal. In a piece entitled “why the VA needs more competition,” he and closely-associated Michigan colleague Kyle Sheetz first declared, unequivocally and repetitiously, competition: good!!! Emphasis in the original through repetition. Clever. After reassuring their audience how much they liked competition they let the cat out of the bag in the final paragraph of a long-ish article: “Privatizing the VA by offering unregulated access to private-sector providers is probably not feasible, necessary, or the best way to care for veterans.”

That’s exactly what the quietly-undermining, unelected Trumpsters pushing for strip-mining veterans’ health care didn’t want to hear. We know (see below) how that came out.

Similar in emphasis is a piece just out (January 2019) in the equally prestigious Annals of Internal Medicine, by (no pun intended) veteran federal health official Carolyn Clancy and her own VA/AHRQ colleagues. I’m perplexed at the way Clancy herself has hung in there (and yet she persisted) at the federal agencies to which she’s contributed greatly over recent decades. I’m perplexed about how, within these agencies,she’s been bounced around, most recently landing as the VA’s “Deputy Under Secretary for Discovery, Education and Affiliate Networks.” (That top’s spinning so fast what I just wrote may already be superannuated news.)

In any case Clancy et al. put their shoulders to Shulkin’s wheel extolling the May 2018 federal MISSION legislation streamlining VA and non-VA care, and the ostensible role their new Center for Innovation might play in such an effort. They pointed out all the right innovation-cum-research caveats about the need for adequate data: “paying for value could backfire without accurate measurement of costs and outcomes.” In this case they were certainly correct: privatizers in this particular world aren’t interested in evidence-based anything. They’re profiteers. (See: “Department of Education.” See: “Department of the Interior.” See: Environmental Protection Agency.)

Shulkin’s words saw the light of day about a month after the MISSION legislation, in the final days of June, 2018. But here’s why I put Shulkin having “liked competition” in the past tense. By the time his NEJM piece appeared Shulkin, also accused of what I still deem to’ve been truly flimsy ethics violations, was already gone from his organization. By the end of March the Orange Man had already fired him. As a personal fiasco this was unseemly, since the VA secretary was a rare bird who both consented to be a hold-over from early administrations, yet managed early on to be a current POTUS favorite. Surprising? In this White House?

In none of these events was there ever put forward any really compelling justification either for privatizing VA care or for starting with the assumptions that outside “leaders” and outside doctors could do a better job than–what with all their flaws–VA medical staff. Suzanne Gordon, a distinguished journalist and author, admittedly parti pris as a fellow of the Oakland-based 501(c)3 Veterans Healthcare Policy Institute, has just published an American Prospect piece on “Trump’s under-the-radar push to dismantle veterans’ health care.” Her central thesis is worth quoting in extenso.

[The Republican] strategy will not only erase what has been the most successful American experiment in government-delivered health care, but will also send veterans out into a private system that is more expensive, less accountable, and unable to meet their particular needs. The key notion underpinning the Mission Act, that the private sector can offer comparable care to the VHA, is deeply flawed. Study after study (after study) has found that the VHA generally outperforms the private sector on key quality metrics, and that private providers are woefully unprepared to treat the often unique and difficult veteran patient population. The most recent evidence came in a Dartmouth College study published in December, which compared performance between VHA and private hospitals in 121 regions across the country. The results: In 14 out of 15 measures, government care fared “significantly better” than private hospitals.

Gordon also has a new book out on this subject, as most supporters of the traditional VA system already know. Worth a look. Meanwhile the Senate and White House and those advising them clearly never really cared about quaint ideas such as “studies,” “evidence,” or “data.” They cherry-pick a few quotes about the brusqueness of some VA care, which often is admittedly more bureaucratic than today’s “consumer-facing” and endlessly-polling private-care organizations. You can find those quotes as well as I can–any search engine known to man will do the trick.

Recent events on the larger political canvas make it abundantly clear, in the meantime. It’s not about quality. It never was. It’s about callously starting with a dismissive attitude toward government workers, then back-solving from there. Having worked for years at the VA, I can vouch for its quality as well as its struggle to assist the really needy patients who depend upon it. In fact, this new study shows quite rigorously that the VA was already dramatically reducing wait-times within multiple VA installations, right down to private-sector levels. So this branch of government has listened and successfully striven to achieve a performance level that’s not just high-science but also high-touch, as medicine’s “customers” (yechhh) have come to expect.

The present furlough of federal employees proves the point. If you can dismiss someone as human collateral-damage, you don’t start first by examining the good things they’ve done for you. You’re an elephant poacher. Take the spoils and leave the carcass to rot.

B. More on the Opiate Eaters Who Eat Very Well.

Speaking of despoliators, Dr. Poses and I both wrote here recently on how, in the world of dangerous narcotics, this single family of mostly physicians, the Sacklers, garnered a much more grand market share than they like to let on. Time to add to that and earlier reporting with a few updates.

When, in a different venue than the VA I was providing front line medical care to privately-insured patients, I noticed an arresting change. I saw more and more folks arrive in my office in shop-till-you-drop mode seeing opiate renewals. Always OxyContin, Percocet or Vicodin. If I didn’t provide the “fill” they’d go next door. The demand built and built. The drug makers kept assuring they were safe and effective. At free dinners they paid an army of fellow physicians to regale us with the same message.

Then those patients started to die on me. OD courtesy of “safe” Purdue (and others’) product.

Then in the past very few years, and I honestly should’ve seen it coming but didn’t, the crisis spilled over from doctors’ exam rooms into the political arena. It’s actually something, unlike the VA, that’s garnering a certain timid degree of nonpartisan interest in finding practical solutions, call it consensus even, starting with decriminalizing measures. But I find it gorge-raising to see the usual suspects continuously fighting the notion that as a society, we blew it with opiates. We blew it. With their help.

I’ve spent a fair amount of time looking at similar medico-legal crises, including the far-reaching tobacco and environmental lead poisoning matters, as well as narrower ones such as evolving surgical and pharmacological approaches to certain diseases. In every case our tort system, combined with the deep pockets of those who are (allegedly) truly guilty, conspire to perpetuate Bleak House-style court battles over culpability. Strip miners seem to believe–or want us to swallow whole the absurdist notion–that they leave the world a better place. In the case of Purdue, this false consciousness is undoubtedly propped up by the Sacklers’ prowess as culturati: one can hardly turn around, as I recently did at the Met in New York, without finding their name plastered on this gallery or that institution of higher learning. But the motive, be it within the strip miners’ organization or that of a cultural organization, comes down to the same thing: “we need the money.” Allegedly.

Recent disclosures from “sources,” including internal Purdue emails, clarify all this. Fortunately for us it turns out the founder’s (Raymond’s) son Richard was an early adopter–relatively so–of email. Both were physicians, but Richard was of the first generation to be granted an American MD. Email was barely used at all in 1995 when Microsoft first added a TCP/IP stack to its operating system, with the introduction of Windows 95. Then email really took off, by 2001 having a fair amount of penetration in the business world. So maybe we shouldn’t be so surprised that Purdue Pharma was squirreling away some of Richard’s pronouncements in an archival time capsule for our delectation nearly a generation later.

According to a new court filing recently revealed in the NY Times, Richard Sackler said some, um, fairly incriminating things to say in these internal emails. Still earning his spurs as head of daddy’s (and Uncle Mortimer’s) company after a couple of years or so in the saddle, and undoubtedly aware of the dramatic uptick in addiction issues that I saw in my own clinic in those turn-of-the-century years, he allegedly blasted everyone else in sight–except, of course, his own ever-so-cultured family.

“[T]he launch of OxyContin tablets will be followed by a blizzard of prescriptions that will bury the competition. The prescription blizzard will be so deep, dense, and white….” said Sackler fils. Based on no evidence reps were told to claim a “less than one percent” risk of addiction. As for that small subset of patients who did find themselves hopelessly addicted, the claim was to be made that “We have to hammer on abusers in every way possible…. They are the culprits and the problem. They are reckless criminals.”

Now, hot off the press in 2019, the Guardian reports how this overall attitude has been replicated within the lobbyist-influenced government of Messrs. Trump and Azar. Since 2015 (pre-Trump! pre-Azar!) chair of the FDA’s own Anesthetic and Analgesic Drug Products Advisory Committee, Kentucky anesthesiology professor Raeford Brown has bravely characterized the rift that now mires down the FDA in tackling this crisis seriously. Admittedly with cover from many in Congress, Brown said this to interviewers.

I think that the FDA has learned nothing. The modus operandi of the agency is that they talk a good game and then nothing happens. Working directly with the agency for the last five years, as I sit and listen to them in meetings, all I can think about is the clock ticking and how many people are dying every moment that they’re not doing anything. The lack of insight that continues to be exhibited by the agency is in many ways a willful blindness that borders on the criminal.

Scott Gottlieb, who’s tying your hands? Is it this guy? The FDA seems to be replete with such interlocking-directorate staff, all trying to assure  the “level playing field.” And what is that playing field? Who are the players? We can answer this. Talk to the drug reps (I have). Except of course those who wake up and see what they’re really doing, burn out and bail out. Talk to the lobbyists and the investors (I have). The watchword is not “safe and effective.” It’s blame-the-victim and lucrative. Let’s get our motives straight here. You can do that just fine without listening to us at Health Care Renewal. Just listen to Richard Sackler in a time capsule from 2001.

Ever wonder why the strip-miners need so much of our patients’ loot? Well, take a little trip to Davos, Switzerland, where the rich and rich go to rub shoulders and tell each other how smart they are: YouTube offers a hint here.

B’bye–too much dander, got to go take a bath.

Join NHSN Colorado Group Monthly Webinar on 2/6/2019

The Colorado Department of Public Health and Environment is hosting a monthly NHSN Colorado user group webinar to provide updates and training related to NSHN. The purpose of the monthly webinar is to provide updates and training on various topics to the licensed facilities in Colorado who report in NHSN. Immediately following the webinar, CDPHE staff will be available to assist new users in NHSN set-up, enrollment and other facility specific questions. 

The monthly webinar will be held on the first Wednesday of every month from 1p.m. – 2 p.m. (MST). 

Please join us at our next monthly webinar on February 6, 2019. Click here to register for the webinar.
– Updates and announcements
– NHSN Patient Safety Component Annual Survey
– Q&A

For questions, please contact Lynda Saignaphone at 303-692-2923,

Experts declare physician burnout ‘a public health crisis’ – and health IT a significant pathogen

I’m certain when the information technology hyperenthusiasts and
non-clinical management information systems “experts” and pundits get the technology
all figured out, this burnout crisis will end.

It will be about the same
time as Zefram Cochrane invents the warp drive in Bozeman, Montana just
prior to first contact by the Vulcans. That is in 2063 or so.

Experts declare physician burnout ‘a public health crisis’
January 22, 2019

Experts from leading U.S. health organizations deemed physician burnout “a public health crisis” in a recent report.

Physician burnout has received some attention in recent years, but not enough. As a result, it is both poorly understood and getting worse,” Andrew R. Iliff, MA, JD, lead writer and program manager at Harvard Global Health Institute, told Healio Psychiatry.

“Like the blind man describing an elephant, people have described the
challenges in front of them, including unhelpful electronic health
records and a looming physician shortage,” he continued. “We believe it
is important to frame this as a systems problem, requiring systemic
solutions in order to avoid further adding to ballooning health care
costs and undermining the provision of care.”

In their paper, experts from Harvard T.H. Chan School of Public
Health, the Harvard Global Health Institute, the Massachusetts Medical
Society and the Massachusetts Health and Hospital Association
recommended ways to address the prevalence of burnout among physicians
and other health care providers. Recommendations included:

  • appointing an executive-level chief wellness officer (CWO) at every major health care organization;
  • providing support for those experiencing burnout; and
  • improving the efficiency of EHRs.

More on that third Pavlovian, formulaic, hackneyed, health IT amateur-proffered bullet point in a moment.

… The usability of EHRs must be addressed through reform of certification
standards by the federal government; improved interoperability; use of
application programming interfaces by vendors; and increased physician
engagement in the records’ design, implementation and customization,
according to the report.

“Certification” standards are useless towards the stated ends.  Interoperability via API’s is not the major issue, either; fundamental operability and, ultimately, clinician burden is.

It is also far too late in the game for “physician
engagement” to make any difference.   People in my specialty, myself included dating back to the 1990’s – and me on this blog starting ca. 2004 – had been calling for clinician (and especially Medical Informatics) leadership (not merely “engagement”) of health IT. 

I note that the original title for my health IT academic site, still residing here, was “Preventing Medical Errors: Medical Informatics and Leadership of Clinical Computing.”  The original ca. 1999 site is partially archived at

Little has changed, and the worst predictions I’d been making about the healthcare IT bubble/experiment (see query search seem to be reaching unfortunate fruition.

Regarding the “efficiency” bullet point above:  quite seriously, from the perspective of this
trained-by-the-pioneers Medical Informatics specialist, the “efficiency
of EHRs” can only marginally be “improved.”  This is due to both technical and political reasons.  The systems are far too complex, with far too many templates, widgets, options, “tricks”, “gotchas” etc.  (with user manuals hundreds of pages long for each, that cause even my eyes to glaze over), too embedded, too protected by the industry, especially those involving legacy code, and too entrenched by politics – to name just some of the issues making major reform of the systems themselves impractical.

The situation should never have gotten this far, predicted as far back as 1969 by EHR pioneer Dr. Donald A.B. Lindberg (,
who wrote that an effect of the “over sell” even occurring then has
been “the feeling that logic compels us to build total hospital
information systems like military command-and-control systems … and
other grotesque concepts too numerous to mention.”


Lindberg in 1969.  From Collen, “A History of Medical Informatics in the United States: 1950 to 1990”

What is needed is a significant downgrading of required clinician
(physician/nurse) interaction with these “command-and-control systems”, including data entry, and the use of clericals to perform those
functions.  See my August 2016 essay “More on uncoupling clinicians from EHR clerical oppression” at

More generally, see my numerous posts on this issue at

One last quote from the Healio article:

… Burnout not only causes physicians suffering, it also can adversely impact patients. Prior research has shown that burnout may does increase the risk for medical errors.  [Fixed the academic equivocation – ed.]

Put more simply, physician and nurse burnout can kill you.

If a healthcare organization cannot afford the appropriate clerical help to avoid clinician burnout, then they cannot afford an EHR.


Can I now say “I told you so?” without the health IT industry sockpuppets coming out of the woodwork? (

— SS

TB Update and Skin Testing Practicum for Health Care Providers

To: Medical Directors and Directors of Nursing

From: The Denver Metro TB Clinic and CDPHE Tuberculosis Program 


The Denver Metro TB Clinic invite nurses and other health care providers from home health agencies, clinics, and long-term care facilities to attend a tuberculosis update and skin testing practicum on Thursday, March 28th, 2019 from 12:30pm – 5:00pm in the Public Health Auditorium, 2nd floor at Denver Public Health (605 Bannock Street, Denver). 

Course Objectives are: 
– Express an increased and updated knowledge of TB infection and TB disease
– Demonstrate their skill in placing and reading the TST

Who Should attend?: Health care providers working in hospitals, home health care agencies, jails and other long-term care facilities, occupation health, Civil Surgeon’s offices, and local public health agencies.

For more details and a link to register go to: 

Registration cost is $60 
Space is very limited so please register early. 

For more information please contact Carolyn Bargman at 303-602-7243 with any questions. 

Practicum Flyer