MBA-holding Informatics Fellow's Portfolio: Revolutionizing Healthcare Through Plagiarism

I highlighted the MBA culture at least once before on this site, on April 16, 2010 at "Healthcare IT Corporate Ethics 101: 'A Strategy for Cerner Corporation to Address the HIT Stimulus Plan'", http://hcrenewal.blogspot.com/2010/04/healthcare-it-corporate-ethics-101.html.

In that post, I noted MBA candidates/Cerner employees happily conspiring in a paper at Duke's Fuqua School of Business towards combination in restraint of trade through "recommending that Cerner collaborate with other incumbent vendors to establish high regulatory standards, effectively creating a barrier to new firm entry. "

Combination in restraint of trade: An illegal compact between two or more persons to unjustly restrict competition and monopolize commerce in goods or services by controlling their production, distribution, and price or through other unlawful means. Such combinations are prohibited by the provisions of the Sherman Anti-Trust Act and other antitrust acts.

The paper was highlighted at  professor David Ridley's page "Duke University Fuqua School of Business: Past Papers" - that is, until a few days after my blog post went up and he was informed of it.   You can see cached copies of the paper and page at the post at link above.

Today, I've had another experience with an MBA holder who has decided to enter the field of Medical Informatics.

I received an unsolicited Cc: of an email, sent by a professional in my field I do not know at a university in Australia.  The email was directed at a postdoctoral fellow at a U.S. medical informatics program in the Midwest, advising the fellow that his 'Portfolio' brag page page was plagiarized directly almost verbatim from a personal essay I'd written ca. 1999 and now archived at my current Drexel site at http://cci.drexel.edu/faculty/ssilverstein/informaticsmd/infordef1.htm, and that plagiarism was bad for informatics careers:

Date: Tue, May 5, 2015 10:28 pm
To: [Name of recipient MBA-holding informatics fellow redacted - ed.]

I was disappointed to find the following three paragraphs on the homepage of your site ([URL redacted] - ed.)

"It became apparent to me and many informatics professionals that significant confusion and misconceptions exist in hospitals, industry, and the world at large about what medical informatics is, and what experts in medical informatics do (and are able to do if given the opportunity). Also, there is confusion as to what medical informatics is not.

"The available quantity of information in most subject areas ("domains") has grown rapidly in recent decades. Issues about information and its use have become quite complex, and the issues themselves have undergone scientific study. Informatics is information science. In other words, informatics is a scientific discipline that studies information and its use.

"Both theoretical and practical issues are studied. Examples of theoretical issues include terminology, semantics (term meaning), term relationships, and information mapping (translation). Practical issues include information capture, indexing, retrieval, interpretation, and dissemination. Medical informatics, an informatics subspecialty, is the scholarly study of these information issues in the domain of biomedicine."

This text is an almost perfect copy of the introduction to Scott Silverstein’s page (http://cci.drexel.edu/faculty/ssilverstein/informaticsmd/infordef1.htm).

Plagiarism has no place in Medical Informatics, and could harm your career. I would appreciate it if you could rewrite or remove this content on your site

Best Regards 

[Professor name redacted - ed.]

There was other copied material after these paragraphs as well; almost the entire page was my words and ideas.  The page shamelessly concluded with this:

Shamelessly copied from http://cci.drexel.edu/faculty/ssilverstein/informaticsmd/infordef1.htm#importance

I do not know how the Australian professor detected the plagiarism, if he had involvement with the fellow, or the context of the interaction.

This fellow had an MBA and the title of his "portfolio" page was about his passion for 'revolutionizing healthcare.'

It's clear he thought his stealing my words and ideas would never be noticed. In other words, exploiting my creativity for his own gain and image-enhancement was fine.

Obviously in our connected world, plagiarism is not a good idea. Perhaps not so obvious are the predatory values of the MBA degree and the damaging effects on all our healthcare when such individuals 'revolutionize' it.

I sent a demand for the material's immediate removal along with a polite suggestion of unpleasantness if he does not comply.

I am not naming the postdoc due to having bigger fish to fry.

-- SS

Update 5/6/2015: 

The fellow has removed about 3/4 of my material from the webpage in question, but a passage remains verbatim.

I've sent another request backed by a screenshot and link to my material, and a rather more direct consequence of failure of complete removal.

Between the IT invasion of health IT and the MBA invasion, perhaps patients need to hire fulltime medical advocates for everything more serious then getting a boil lanced.

-- SS

Additional thought 5/7/2015:

I should add the misleading credentials exaggeration of minimal exposure to informatics (a seminar or AMIA short course at best) leading to a claim of a non-existent "American Medical Informatics Certification for Health Information Technology" by an erstwhile NextGen VP who also apparently holds a MBA with a concentration in Health Administration, see http://hcrenewal.blogspot.com/2009/02/nextgen-and-vendordoctor-dialog-yet.html.

8:11 AM

Honesty and Good Sense on Electronic Medical Records From Down Under

Australians seem to not be as seduced by the Siren Song of cybernetic miracles as health IT leaders in the United States.

It took an Australian computer scientist at U. Sydney to dissect and perform a detailed analysis of the internals of an American EHR system, the results of which were disturbing to say the least.  This was a task the American members of the American Medical Informatics Association (AMIA) should have taken on.  It's not as if they're unaware of clinical IT problems.

It also seems to take a group of Australian researchers at the Univ. of New South Wales, the Australian Patient Safety Foundation, and the University of South Australia to perform a forensic analysis on U.S. data in the FDA's Manufacturer and User Facility Device Experience (MAUDE) database, instead of Americans themselves. 

At least AMIA allowed the Australians the opportunuty to present their findings.

In "Patient Safety Problems Associated with Heathcare Information Technology: an Analysis of Adverse Events Reported to the US Food and Drug Administration" (free fulltext at this link), AMIA Annual Symposium Proceedings 2011;2011:853-7 the Australian researchers including Medical Informaticist and critical thinker Dr. Enrico Coiera (see here) analyzed healthcare information technology (HIT) events associated with patient harm submitted to the MAUDE database:

We downloaded all 899,768 reports that were submitted to MAUDE from January 2008 to July 2010 and searched for events using a broad definition of HIT as “hardware or software that is used to electronically create, maintain, analyse, store, receive, or otherwise aid in the diagnosis, cure, mitigation, treatment, or prevention of disease, and that is not an integral part of (1) an implantable device or (2) medical equipment.” We retrieved and classified 678 reports describing 436 unique events using a previously published methodology. Of the 436 HIT-related events that we examined, 11% (n=46) were associated with patient harm [this excludes the "near misses" - ed.] ... In this paper we specifically focus on examining the 46 events where HIT problems were associated with patient harm.

These submissions are voluntary, and due to systematic, severe impediments to submissions as below, this data likely represents a very small fraction ("tip of the iceberg" per FDA itself, link) of the true incidence of these events.  See the addendum to this post "Systematic impediments to voluntary reporting of health IT risks."

Summarizing the Australian researchers' findings (read the entire paper at the link above):

Medication problems represented 41% of the events of these types:

• Wrong patient
• Wrong dose or overdose
• Missed and delayed doses

Clinical process problems represented 33% of the events:

• Use errors in entering information ("use error" is an error due to poor and confusing design, as opposed to "user errors")
• Poor functionality of CPOE and PACS

Exposure to radiation occurred in 15% of the events

Surgery problems occurred in 11% of the events.

The authors recommended that "strategies to improve the safety of HIT should focus on designing safe user interfaces, integrated checks of key identifiers and decision support, and engineering safer clinical processes."

Unfortunately, that does not appear to be occurring in the U.S. to any significant degree.  "Certification" of health IT to meet government criteria for financial incentives is unrelated to such measures and is in my view symptomatic of industry regulatory capture (see here and here).  The IOM itself has instituted a "watch and wait" policy, a likely unique special accommodation in current regulation of medical devices (see here).

I reiterate this MAUDE data is voluntary and the impediments to its reporting systematic and severe.  See addendum to this post.

In the category of good sense on electronic medical records, I note the following articles:

Victoria aims for more open ICT strategy 

Pulse+IT Magazine
Kate McDonald
02 October 2012

The newly formed Victorian Information and Communications Technology Advisory Committee (VITAC) has released a draft strategy (PDF) describing how the state government should manage and use ICT to better provide government services.

The strategy recommends that the government engage more closely with the ICT sector and move away from customised products in favour of existing market offerings.

... It recommends that the government engage with the ICT market early in the procurement lifecycle. “We will avoid being locked into single suppliers by favouring open standards and will be open to any qualified ICT provider regardless of size. Procurement of ICT services will be made more efficient.”

The strategy should also provide guidance to agencies to move away from customised major ICT developments and use existing market offerings with little or no customisation instead.

What this means is abandoning the approach of large, single-source (monolithic), proprietary clinical information systems from large health IT vendors that try to cover everything, in favor of smaller, open standards-based "best-of-breed" applications (from vendors of all sizes) that can be woven together to meet users' needs:

The subsequent fallout from the Ombudsman's report led to the Victorian government cancelling several programs, including the $323 million HealthSMART program, an ambitious project to roll out common eHealth infrastructure throughout Victoria's public health services.

This included implementing iSOFT's (now CSC) i.PM patient administration system and Cerner's clinical information system in its hospitals, as well as InterSystems' TrakCare platform for community health agencies.

I note that another article in eHealth Insider mentions the same strategy in the UK, "Winchester switches off Cerner in ED":

The Royal Hampshire County Hospital in Winchester has switched off Cerner Millennium in A&E and moved to Patient First.  The electronic patient record system will also be switched off for theatres and order communications at the old Winchester and Eastleigh Healthcare NHS Trust ... Basingstoke and North Hampshire was pursuing an alternative IT strategy, built around a 'best of breed' approach to building on its existing systems.

The U.S. has yet to learn these lessons, and will likely repeat the same mistakes at the cost of hundreds of billions of dollars.

Unfortunately, I have no answers.  I see no way to avoid it, considering the HITECH momentum that favors the large-vendor monolithic product model.

-- SS

--------------------------------------

Addendum.  Systematic impediments to voluntary reporting of health IT risks:

From the 2010 FDA internal memo on health IT risks:

Limitations of the MAUDE search and final subset of MDRs include the following:

1.  Not all H-IT safety issue MDRs can be captured due to limitations of reporting practices including:

... (a) Vast number of H-IT systems that interface with multiple medical devices currently assigned to multiple procodes making it difficult to identify specific procodes for H-IT safety issues;
... (b) Procode assignments are also affected by the ability of the reporter/contractor to correctly identify the event as a H-IT safety issue;
... (c) Correct identification by the reporter of the suspect device brand name is challenged by difficulties discerning the actual H-IT system versus the device it supports.

2.  Due to incomplete information in the MDRs, it is difficult to unduplicate similar reports, potentially resulting in a higher number of reports than actual events.

3.  Reported death and injury events may only be associated with the reported device but not necessarily attributed to the device.

4.  Correct identification by the reporter of the manufacturer name is convoluted by the inability to discern the manufacturer of the actual H-IT system versus the device it supports.

5.  The volume of MDR reporting to MAUDE may be impacted by a lack of understanding the reportability of H-IT safety issues and enforcement of such reporting.

From the 2012 IOM report on health IT safety:

... While some studies suggest improvements in patient safety can be made, others have found no effect. Instances of health IT–associated harm have been reported. However, little published evidence could be found quantifying the magnitude of the risk.

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.

… “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.

More worrisome, some case reports suggest that poorly designed health IT can create new hazards in the already complex delivery of care. Although the magnitude of the risk associated with health IT is not known, some examples illustrate the concerns. Dosing errors, failure to detect life-threatening illnesses, and delaying treatment due to poor human–computer interactions or loss of data have led to serious injury and death.”

Not knowing the magnitude of the risks is an effect of the impediments, and does not represent a good environment for national implementation in my view.

I also add "fear of medical malpractice litigation" to the lists above.

-- SS

6:34 AM

Massive Health IT Outage: But, Of Course, Patient Safety Was Not Compromised

Having been 'Down Under' in Sydney addressing the Health Informatics Society of Australia on the need to slow down their national health IT program - and on the need to think critically about HIT seller public relations exaggerations and hubris - and being very busy, I missed this quite stunning story of a major health IT outage.

Just a typical "glitch":

Some lessons from a major outage
Posted on July 31, 2012
By Tony Collins

Last week Cerner had a major outage across the US. Its international customers might also have been affected.

InformationWeek Healthcare reported that Cerner’s remote hosting service went down for about six hours on Monday, 23 July. It hit “hospital and physician practice clients all over the country”. Information Week said the unusual outage “reportedly took down the vendor’s entire network” and raised “new questions about the reliability of cloud-based hosting services”.

A Cerner spokesperson Kelli Christman told Information Week,

“Cerner’s remote-hosted clients experienced unscheduled downtime this week. Our clients all have downtime procedures in place to ensure patient safety.  [Meaning, for the most part, blank paper - ed.] The issue has been resolved and clients are back up and running. A human error caused the outage.  [I don't think they mean human error as in poor disaster recovery and business continuity engineering - ed.]  As a result, we are reviewing our training protocol and documented work instructions for any improvements that can be made.”

Christman did not respond to a question about how many Cerner clients were affected. HIStalk, a popular health IT blog, reported that hospital staff resorted to paper [if that was true, that paper was OK in an unplanned workflow disruption of major proportions, then why do we need to spend billions on health IT, one might ask? - ed.] but it is unclear whether they would have had access to the most recent information on patients.

One Tweet by @UhVeeNesh said “Thank you Cerner for being down all day. Just how I like to start my week…with the computer system crashing for all of NorCal [Northern California].”

Tony Collins is a commentator for ComputerWorldUK.com.  He's quoted me, as I wrote in my May 2011 post Key lesson from the NPfIT - The Tony Collins Blog.

This incident brings to life longstanding concerns about hospitals outsourcing their crucial functions to IT companies.  

Quite simply, I think it's insane, at least in the foreseeable future, as this example shows.

It also brings to mind the concerns that health IT, as an unregulated technology, causes dangers in hospitals with inadequate internal disaster and business continuity functions aside from fresh sheets of paper.  Such capabilities would likely be mandatory if health IT were meaningfully regulated.

The Joint Commission, for example, likely issued its stamp of approval for the affected hospitals, hospitals who had outsourced their crucial medical records functions to an outside party that sometimes went mute.  If someone was injured or died due to this outage, they would not care very much about the supposed advantages.

There's this in the article:

... “Issue appears to have something to do with DNS entries being deleted across RHO network and possible Active Directory corruption. Outage was across all North America clients as well as some international clients.”

Of course, patient safety was not compromised.

Finally:

Imagine being a patient, perhaps with a complex history, in extremis at the time of this outage.  

I, for one, do not want my own medical care nor that of my relatives and friends subject to cybernetic recordkeeping unreliability and incompetence like this, and the risk it creates.

-- SS

Aug. 8, 2012 addendum:

The Los Angeles Times covered this outage in a story aptly entitled "Patient data outage exposes risks of electronic medical records."

They write:

Dozens of hospitals across the country lost access to crucial electronic medical records for about five hours during a major computer outage last week, raising fresh concerns about whether poorly designed technology can compromise patient care.

My only comment is that the answer to this question is rather axiomatic.

They also quote Jacob Reider, acting chief medical officer at the federal Office of the National Coordinator for Health Information Technology, who said:

"These types of outages are quite rare and there's no way to completely eliminate human error"

This is precisely the type of political spin and misdirection I cautioned the Australian health authorities to evaluate critically.

Paper, unless there is a mass outbreak of use of disappearing ink, or locally hosted clinical IT, do not go blank en masse across multiple states and countries for any length of time, raising risk across multiple hospitals greatly, acutely and simultaneously.  (Locally hosted IT outages only cause "local" mayhem; see my further thoughts on this issue here).

-- SS

11:08 PM

Forbes: Obamacare Billionaire: What One Entrepreneur's Rise Says About The Future Of Medicine

An article in Forbes appeared today (4/18/12) entitled "Obamacare Billionaire: What One Entrepreneur's Rise Says About The Future Of Medicine" by Matthew Herper.

The article is largely a hagiography of Cerner founder Neal Patterson:

North Kansas City is an unlikely place to launch a revolution in American health care. Yet here, amid the dilapidated grain elevators, fast food joints and vast green plains, the dream of using computers to keep you alive at a reasonable cost is battling onward. In a bunkerlike building built to withstand a direct hit by a category five tornado, 22,000 servers handle 150 million health care transactions a day, roughly one-third of the patient data for the entire U.S. Records of your blood pressure, cholesterol, lab test results, that gallbladder surgery last year—and how much you paid for it—may sit there right now. Armed guards stand watch.

This is a data center at the headquarters of Cerner, the world’s largest stand-alone maker of health IT systems—and company number 1,621 on FORBES’ Global 2000 list—where the blood-and-guts realities of medicine meet the ­sterile speed and exactitude of the computer revolution.

Omitted are some pertinent negative accounts, such as Cerner's role in the failed £12.7bn ($20bn U.S.) National Programme for IT in the NHS (NPfIT), as described here and here.

Patterson is quoted with the standard industry bellicose grandiosity and hysterics about computers "revolutionizing" (as opposed to facilitating) medicine:

... In 1999 a report from the prestigious Institute of Medicine gave Patterson hope that the rest of medicine was ready to follow in Mayo’s footsteps. Titled “To Err Is Human,” the report detailed how between 44,000 and 98,000 people die every year in hospitals from preventable mistakes, like getting the wrong medicine or the wrong dose of the right one. The ­report specifically prescribed better computer systems as a way to prevent these deadly mistakes. Patterson cites that study as the moment when health IT entered the mainstream. But it was still slow going, and that drove him nuts. His customers at that time were more worried about the Y2K bug than they were about revolutionizing health care.

I first heard him and other HIT CEO's uttering the "revolution" line at a Microsoft Healthcare Users Group meeting ca. 1997 and attended largely by IT technicians. I was probably the only Medical Informatics-trained professional in attendance, and perhaps the only physician there.

When I then asked those in the room how many had healthcare experience or had even read the Merck Manual, few hands went up. The CEO's could not then satisfactorily explain how medicine would be "revolutionized" by such a crowd. (One of those CEO's, of erstwhile HIT vendor HBOC, was later found to be seriously cooking the books after acquisition by McKesson. See "Former McKesson HBOC Chairman Convicted of Securities Fraud; Defrauded Investors Lost in Excess of $8 Billion" at FBI.gov. Some revolution...)

Unfortunately, most medical errors have little to do with documentation, either paper or electronic, as I wrote in Dec. 2010 at "Is Healthcare IT a Solution to the Wrong Problem?". The latter, however, has introduced many new errors modes and other social-technical problems, permitted massive security breaches (it's very hard to haul away 10,000 paper charts without being noticed) and opportunities for medical records evidence spoliation simply not possible with paper.

There are a few Ddulite-ish quotes from Eric Topol and David Bates in an article with a clear tone of exalting health IT.

I am quoted in the Forbes article in about the only comment critical of health IT, and the only comment concerning the ethics of human subjects experimentation conducted with this technology, as it exists in 2012:

... the Hippocratic oath says nothing about breaking eggs to make omelets. “We’re kind of headed in the wrong direction,” says Scot Silverstein, a health IT expert at Drexel University who believes that the current systems are too prone to randomly losing data [I had cited this study - ed.] and complicating doctors’ lives.

While the "breaking eggs to make omelets" metaphor was not mine, it reminded me that I just carried out my final earthly duty for my mother, injured in mid 2010 by a health IT-related error and deceased since June 2011. I filed her final IRS tax return yesterday, the due date.

I just hope my mother is enjoying her omelet in the Pearly Gates Diner. Scrambled eggs were about all she could eat well after the health IT accident.

As a result of that experience, my new business card (phone # redacted):

(Click to enlarge)

I no longer merely write about health IT risks. I find past involvement with attorneys early in my medical career, as Manager of Medical Programs and Medical Review Officer (drug testing officer) for one of the largest public transit authorities in the United States, quite helpful in this new role.

The "eggs that get broken", as in a well known old nursery rhyme from the early 1800's, cannot be reassembled. Those injured or killed in the unregulated, thoughtless, cavalier journey to some mystical medical cybernetic utopia deserve justice, and the eggheads responsible for their harms have earned the privilege of explaining themselves in the courtroom and being properly penalized where appropriate.

The future of medicine - if it is to not become a nightmare ignoring the lessons of history, repeating the mistakes of the past - belongs to those willing to take an ethical stand in defense of medicine's core values, and in defense of patients.

-- SS

7:23 PM

Physicians Down Under Get Direct About Danger of Bad HIT

Too often, physicians acquiese to demands by hospital executives that they adjust to and use health IT, even if that health IT is flawed. This is despite the fact that liability for patient care resides with the physicians, not the HIT vendor or executives.

Several physicians Down Under have had enough:

Doctors issue deadly warning
Daily Examiner, Grafton, Australia
David Bancroft | 23rd July 2009

It seems incredible that a patient record system that aims to improve treatment could kill people [not so incredible to the informed - e.g., see "Bad Informatics Can Kill" - ed.], but that is a claim being made about a new system that is almost certainly going to be introduced into the Grafton Base Hospital next week.

Earlier this month, leading health officials from the Lismore Base Hospital wrote to the North Coast Area Health Service (NCAHS) claiming a new Surginet electronic medical record system that had been operating in the hospital for several months would 'inevitably' lead to the death of patients.

But the health service said changes had been made to the Surginet electronic medical record (EMR) system since the concerns were raised by the four senior clinicians on July 2, and the system had been operating 'satisfactorily' in Sydney without patient concerns being raised. ["Without concerns raised" does not mean they do not exist - ed.]

In their letter to NCAHS chief executive officer Chris Crawford, which was copied to the Minister for Health John Della Bosca, the four medical specialists said there had been recurring problems over several months and 'these have not improved'.

“This has resulted in unnecessary compromise of patient safety,” they wrote.

“There have been repeated well demonstrated cases of near miss disasters due to these problems. [Will patients be as lucky the next time? - ed.]

“We believe that negative patient outcomes, including death, will inevitably result from the continuing use of this system.

“Surginet is fundamentally flawed.

“New technology should: improve the quality of our work; help us to be more efficient, and; make routine tasks easier.

“EMR Surginet does none of these; in fact it has had the opposite effect.

“We believe that the Surginet EMR system is unsafe and will result in patient morbidity and mortality.”

Surginet was to be implemented at the Grafton Base Hospital yesterday, but after concerns were raised with the area health service, implementation was delayed until next Wednesday.

A health service spokesman said the implementation had been delayed so the software producers, Cerner [an American company behind the HIT products that caused difficulty in the UK - see the UK House of Commons report here, esp. points 5 and 6 - ed.], could speak with Grafton surgeons and anaesthetists prior to the implementation about any concerns they may have.

“NCAHS takes any concerns raised about patient safety seriously and is addressing these,” the spokesman said.

“It should be emphasised that Surginet is operating satisfactorily in Sydney hospitals without patient safety concerns being raised. [Again, that does not mean they do not exist; clinicians may be afraid to speak out and working furiously to establish workarounds to problems - ed.]

“It is a system used worldwide that can be adapted to accommodate local work practices in NSW hospitals. ["Can be adapted" - anything "can be adapted". But has this application actually been adapted to the culture in NSW hospitals? - ed.]

“Arrangements are being made for discussions to be held with the department heads by representatives of the EMR project team and Cerner.”

The spokesman said Surginet had recently been introduced at the Maclean Hospital and there had been no complaints and the NCAHS had actually received a letter of thanks from the hospital. [A letter of thanks from whom at the hospital, exactly, and based on what substantive claims? - ed.]

Such discrepancies between one hospital and the next regarding HIT require critical evaluation - erring on the side of patient safety, not IT vendor convenience. Considering the aforementioned UK House of Commons report and the "near miss disasters" mentioned by the Australian physicians, such due diligence is mandatory in my opinion.

Further, American physicians can probably learn from these Australian counterparts in being vocal about HIT problems.

-- SS

7:41 AM