Found on the Web, With DNA: a Boy’s Father

Like many children whose mothers used an anonymous sperm donor, the 15-year-old boy longed for any shred of information about his biological father. But, uniquely, this resourceful teenager decided to try exploiting the latest in genetic technology and the sleuthing powers of the Internet in his quest.

By submitting a DNA sample to a commercial genetic database service designed to help people draw their family tree, the youth found a crucial clue that quickly enabled him to track down his long-sought parent.

“I was stunned,” said Wendy Kramer, whose online registry for children trying to find anonymous donors of sperm or egg helped lead the teenager to his father. “This had never been done before. No one knew you could get a DNA test and find your donor.”

While welcomed by advocates of children trying to locate anonymous donors, the case — apparently the first of its kind — has raised alarm among sperm banks and some medical ethicists. They are concerned it might start a trend that could violate the privacy of thousands of sperm donors and discourage future ones.

The case has also underscored how the growing number of genetic databases being established by governments, law enforcement agencies, private companies and research organizations could be used in unintended ways, potentially invading personal privacy and raising a thicket of social, ethical and legal questions.

“When you create these databases, you’re creating something that has a lot of power — far beyond what they were originally designed for,” said David M.J. Lazer, who studies the legal implications of genetic databases at Harvard University’s John F. Kennedy School of Government. “This seems like one of those scenarios.”

The database involved in the sperm donor case was set up by Family Tree DNA of Houston, a private company that has accumulated more than 45,000 DNA samples. For a fee, clients hoping to learn more about their heritage can have their DNA tested to see if it matches anyone in the database.

“We provide services for genealogists. That’s what we do,” company spokesman Max Blankfeld said. “We really didn’t have anything like this in mind.”

In this case, the teenager scraped some cells off the inside of his cheek last year and sent in the sample with $296 to see if his Y chromosome, which is passed down from father to son, matched anyone on file.

“At first he just wanted to get a little more information about his paternal side, like countries or origin. That kind of thing helps people who want to know: ‘Where am I from culturally? Where are my people from?’ Any bit of information is so welcomed,” Kramer said.

The youth has declined to be identified, revealing just the outlines of his case through Kramer’s registry to protect the identity of his newfound biological father. The case was first reported by the British magazine New Scientist.

About nine months after submitting his sample and agreeing to be contacted by other clients, the U.S. youth heard from two men with Y chromosomes that closely matched his, Kramer said. Neither man knew the other, but the analysis indicated there was about a 50 percent chance that all three had the same father, grandfather or great-grandfather, Kramer said. The men also had similar last names, spelled differently.

Because the youth’s mother had obtained the donor’s date of birth and birthplace from the sperm bank, he paid another online service, OmniTrace.com, to buy the name of every person born there on the same day, Kramer said. One man with the same last name appeared on the list, and within 10 days the youth contacted him, said Kramer, who declined to reveal details about the donor’s reaction.

“I think this kid would love to come out with his story, but for the time being those are the wishes of the donor,” Kramer said.

Since word of the case emerged, several other offspring registered on Kramer’s site,http://www.donorsiblingregistry.com/ , have clicked the link to the Family Tree DNA site (http://www.familytreedna.org/ ) in hopes of locating their biological father, she said.

“Given this case, more people will be putting their DNA in the pool so that potential connections can be made,” Kramer said. “Not everyone who puts their DNA in is going to find their biological father, but now we’ve seen this as a distinct possibility. The DNA databases are just going to grow and grow, and this is going to be more and more common.”

That scenario is likely to concern thousands of men who have donated sperm anonymously — often college students or other young men who saw it as an easy way to make money — according to sperm bank officials and ethicists. There are no reliable estimates of the number of Americans who have been born using donated sperm, but it could number in the hundreds of thousands.

“A fair number will be quite perturbed,” said R. Alta Charo, a University of Wisconsin bioethicist. “They well may be wondering, ‘Am I next?’ ”

Several experts said the relatively small number of people whose DNA is on file means the approach remains a long shot.

“The sperm bank involved in this case disclosed a lot more information than we do,” said William Jaeger of the Genetics and IVF Institute of Fairfax, one of the nation’s largest sperm banks. “In cases where the donor does not want to be identified, we do everything we can to protect them.”

Nevertheless, Jaeger and officials at several other of the nation’s largest sperm banks said the development is disturbing.

“Protecting the identify of our donors is paramount for us,” Jaeger said. “It would become a problem if it became common. It would really reduce the number of donors available, and I think you would be doing a disservice to people who want to use sperm donors.”

Many sperm banks offer donors the option to donate without anonymity and allow recipients to chose those donors. But those who opt to remain anonymous should be protected, officials said.

“I think it’s unethical. It’s an invasion of the donor’s privacy and a breach of contract,” said Cappy M. Rothman of the California Cryobank of Los Angeles, another large sperm bank. “If we were to expose our donors to being known, we would have many fewer donors.”

Some ethicists said the rights of offspring outweigh those of donors.

“I have no sympathy for someone who wants to have a child but doesn’t want the child to find out who their father is,” said George Annas of Boston University. “If you’re worried about it, you shouldn’t be selling your sperm.”

Other ethicists said the case illustrates the need to find ways to balance both interests.

“The overall issue is the importance of some offspring of donors to learn about their biologic parentage, which is a strong impulse in some children and needs to be taken seriously, with ways to accommodate that that are respectful of the privacy of the donors,” said John A. Robertson of the University of Texas School of Law.

“At the very least, we may now need to inform donors that we may no longer have a foolproof way to protect them,” Robertson said. “If the system is as porous as this case indicates, then at least we need to inform them that someone may track them down.”

Moreover, the case illustrates that when people put their DNA on a database, it provides information about more than themselves, several experts said.

“DNA is the ultimate identifier,” said Kathy Hudson, director of the Genetics and Public Policy Center at Johns Hopkins University. “I don’t know to what extent these databanks are taking their responsibility seriously to make sure people are aware of the possibility of these unintended disclosures.”

JCAHO board approves new policy on data mining

The Joint Commission on Accreditation of Healthcare Organizations said its board approved a policy under which the JCAHO would continue data mining “to measure and encourage quality improvement” but would no longer sell analyses of the data to third parties.

The board, which met this weekend, also affirmed the JCAHO’s “need to secure access to patient-level performance data” for accreditation-related work, a news release said.

The American Hospital Association has raised several issues regarding the request for patient-level data, and the Joint Commission said it would work with the AHA to resolve the issues. The new policy comes after the AHA and several other hospital organizations reacted with outrage to a contract by a JCAHO subsidiary to provide hospital-specific performance reports to several Blues plans. AHA spokesman Richard Wade said the JCAHO had “addressed the main issue about the sale of the data and that’s the beginning of the process of working on a data policy every one can support.”

Medical software from feds could benefit big health care

Some IT managers at large health care organizations are delighted that the federal government plans to offer its electronic health records (EHR) software to small and midsize physician practices at a low cost. The move is expected to be a significant boon to the efforts of big providers to computerize patient records, the IT managers say.

While many hospitals and large physician practices have deployed EHR software for their patient bases, the systems won’t be fully effective unless physicians in smaller medical groups who refer patients for treatment automate their records as well.

The Centers for Medicare and Medicaid Services (CMS) expects to announce the distribution plans for its Vista-Office EHR software this month. The announcement, which has already been widely publicized [QuickLink 55837], was due to take place last week but didn’t materialize. Vista-Office has been in use at Veterans Affairs hospitals and clinics for more than 20 years.

Encouraging Adoption

The CMS will allow physicians to license Vista-Office for less than $3,000 for a five-doctor practice, according to a CMS spokesman. The move is designed to address one of the biggest barriers to the Bush administration’s goal of computerizing all patient records over the next decade: the lagging adoption rate among smaller practices.

“Vista is a good program, [and] if done correctly, there will be a level of ability to share records across regional health information organizations. It could prove to be a very effective tool for many of our small-practice, community-based M.D.s,” said John Hummel, CIO at Sutter Health in Sacramento, Calif. Sutter operates 27 hospitals in Northern California.

Any option that gets physicians to begin to computerize patient records is a good idea, said J. David Liss, vice president of government relations and strategic initiatives at NewYork-Presbyterian Healthcare System.

“Physicians who have rotated through VA hospitals love Vista — having all the patient data in one place is so compelling,” Liss said.

Hospitals and health systems could benefit from the government plan because historically, they capture the lion’s share of the benefits from EHRs: They get access to patient histories, while the physician practices that compile them bear most of the costs, said Eric Brown, an analyst at Forrester Research Inc.

As a result, large hospitals have a vested interest in making sure that all the physicians referring patients to them are using an EHR system, he said. Brown and others warned that the capital investment in electronic records often can be dwarfed by the training, implementation and configuration costs involved.

Vendors are ramping up to support physicians who will deploy Vista. In May, the not-for-profit organization WorldVista was awarded a contract by the CMS to provide training to vendors that will install the software.

Medsphere Systems Corp. in Aliso Viejo, Calif., will be offering Medsphere OpenVista, an open-source version of the government’s software that captures clinical, financial and administrative data. Medsphere will also be providing an ASP version of the software and services such as training, maintenance and support for Vista users, said Scott Shreeve, chief medical officer and co-founder of Medsphere.

Midland Memorial Hospital in Midland, Texas, will go live in December with its first clinical application based on Medsphere’s OpenVista. The hospital plans to use the technology to develop a comprehensive EHR system, said David Whiles, director of information systems at Midland.

“It is an extremely mature, very functionally rich electronic record,” he said. “It has been in place for 20-plus years, and it is not one of these new systems that vendors are offering, looking for alpha or beta partners.”

The OpenVista project will cost less than half of the upfront capital investment required for a commercial EHR product, Whiles said.

Privacy groups challenge HIPAA protections

Federal law aimed at ensuring electronic health information remains secure might not be strong enough to do the job, privacy and patient advocacy groups are arguing.

A primary goal of the Health Insurance Portability and Accountability Act of 1996 was to encourage electronic transactions among healthcare plans, doctors and hospitals while keeping patients’ medical records private, but based on the experiences of other businesses, where confidential information often has fallen prey to computer hackers, the groups worry the law’s protections may not be satisfactory.

“Simply put, we don’t think the legal protection under HIPAA is sufficient for the technological development planned — we’re not opposed to the technology, but we feel there should be more safeguards when (transmitting) some medical information,” Marc Rotenberg, executive director of the Electronic Privacy Information Center in Washington, D.C., told United Press International.

“There have been any number of security breaches in the financial services sector this year, and we know these problems are causing huge harm to consumers — as well as a huge cost to the economy,” Rotenberg said. “It’s clear from data about the rise in identity theft over the last five years that there are big privacy concerns.”

Another group already has sued the federal government over the issue. Citizens for Health — located in Minneapolis, but represented by Washington lawyer James Pyles — has a lawsuit pending in which they argue the new regulations could allow personal health information to be disclosed routinely without notice and without a patient’s consent.

“When the Bush administration first came into office. it agreed with the regulations to protect privacy, but less than a year later it reversed its position,” Jim Turner, the group’s chairman, told UPI. “In changing the regulations, the government allowed some 1.5 million people (to access) people’s medical records — a whole batch of health workers, insurance workers and suppliers were allowed … to read the records.”

The suit by Citizens for Health claims such open access is unconstitutional, based on the patient’s right to keep medical records private, Turner said.

“The trouble is that with the change in regulations, HIPAA has no teeth. If a person complains to the Department of Health and Human Services, nothing happens,” he said.

David Lynch, vice president of marketing at Apani, a network security software provider in Napa Valley, Calif., told UPI that hospitals seem unenthusiastic so far about implementing HIPAA. He also noted that the healthcare business faces its own unique set of problems where records privacy is concerned.

For example, Lynch said, if a bank or credit-card company has a data breach and confidential information is lost, the customer will make his or her own decision whether to sever ties with that company, regardless of whether the government takes action against the firm.

“However, there is a difference in the healthcare world, there are less options,” he said. “If your doctor had a data breach, you are limited by your health insurance by which doctors and hospitals you can choose — it’s not like getting another credit card company.”

Lynch noted that so much information flows via the Internet — a public network — that even a casual observer could pick-up sensitive information. “You’ve got to protect the information, such as having it encrypted,” Lynch added.

National Consumer Health Privacy Survey 2005

In 1999, the California HealthCare Foundation (CHCF) released a groundbreaking study of Americans’ attitudes and behaviors concerning health privacy. The study found that nearly three out of four Americans had significant concerns about the privacy and confidentiality of their medical records. Now six years later, following implementation of national privacy protections under the Health Insurance Portability and Accountability Act (HIPAA), and the President’s push to adopt electronic medical records, a new CHCF survey plumbs consumers’ attitudes about the privacy of their health information.

Conducted by Forrester Research, the survey reveals that—despite federal protections under HIPAA—two in three Americans are concerned about the confidentiality of their personal health information and are largely unaware of their privacy rights.

In addition, one in eight patients reportedly engages in behavior to protect personal privacy, presenting a potential risk to their health. More than half (52 percent) of respondents are concerned that employers may use health information to limit job opportunities, highlighting the implications of the privacy issue.

Yet despite these concerns, consumers report a favorable view of new health technology, with a majority (59 percent) willing to share personal health information when it could result in better medical treatment.

As efforts to develop a nationwide health information network proceed, unaddressed concerns about personal privacy could have major implications.

The complete survey findings and an executive summary are available under Document Downloads below.

Survey Instrument

Executive Summary

Slide Presentation

Study Faults Follow-Up for Cancer Patients

With the help of powerful new drugs and surgical treatments, millions of Americans survive cancer, but doctors often ignore the patients’ needs after saving their lives, the National Academy of Sciences said on Monday.

The number of cancer survivors is growing rapidly, but their care is often haphazard and disjointed, so no one notices a recurrence of cancer or side effects that can occur months or years after treatment, the academy said in a new report.

One reason for the lack of appropriate follow-up care, it said, is that in many cases, insurance companies and health plans do not cover the necessary tests and examinations.

Dr. Sheldon Greenfield, chairman of a panel of 17 experts who conducted the study, said: “There are now 10 million Americans who have had cancer. Thanks to successes in cancer detection and treatment, as well as an aging population, their ranks are growing steadily.” But, Dr. Greenfield said, many survivors are lost in the health care system, “somewhere between active treatment and long-term follow-up.”

More than 6o percent of cancer survivors are 65 or older, so Medicare is “the primary payer of care for cancer survivors” in the United States, said the panel, established by the Institute of Medicine, an arm of the academy. It said government programs like Medicare, as well as insurance companies, should pay cancer specialists to prepare a comprehensive plan describing the follow-up care that ought to be provided to each person treated for cancer.

Cancer specialists should routinely provide such plans to internists and other primary care doctors, the panel said. At present, said Dr. Greenfield, a professor at the University of California, Irvine, “there is no organized system to link oncology care to primary care.”

Patricia Grullion, 46, of Los Angeles described what she experienced after being treated for breast cancer in 2001 and 2002.

“When my treatment ended,” Ms. Grullion said in an interview on Monday, “I was given a clean bill of health, but nobody gave me any real plan for the future, or any thoughts about what I could expect physically or emotionally. During the treatment, I focused on the task at hand, like a warrior. But after the treatment ended, I felt lost. I should have been elated, but I was scared, I was crying. Whenever I had a cold or an ache in my bones, I wondered, ‘Is the cancer coming back?’ “

The American Society of Clinical Oncology, which represents more than 20,000 cancer specialists, welcomed the academy’s recommendations and said it would try to carry them out. “The oncology community agrees” with the proposals, said Dr. Patricia A. Ganz, a breast cancer specialist who is on the society’s board and was a member of the panel that wrote the report.

“Millions of patients are living with cancer as a chronic condition and need good long-term follow-up care,” said Dr. Ganz, a professor at U.C.L.A. “An internist or family doctor may send hundreds of patients for mammogramsand colonoscopies, but in many cases they know little about the treatment their patients receive for cancer.”

An explicit written plan for follow-up care could save lives by increasing the probability that primary care doctors will detect a recurrence of the original cancer, development of a new cancer or “chronic preventable conditions” that follow treatment, Dr. Ganz said.

Cancer survivors often experience psychological problems, including depression, persistent anxiety, debilitating fatigue and fear that cancer will return. Patients treated with surgery, radiation and chemotherapy may suffer infertility or impairment of sexual function, and have an elevated risk of developing osteoporosis, congestive heart failure and other heart problems, strokes and blood clots. In some cases, the panel said, chemotherapy may cause leukemia or bladder cancer.

Cancer survivors sometimes find that they are uninsurable. In many states, the panel said, insurance companies refuse to sell individual health insurance policies to people with a history of cancer, or charge them much higher premiums than are paid by other subscribers.

In addition, “a majority of cancer survivors who worked before their diagnosis return to work following their treatment” but often face discrimination from employers, sometimes even losing their jobs, the report said.

In some cases, the discrimination may violate federal or state laws. But Janlori Goldman, a research scholar at the Columbia University College of Physicians and Surgeons, said, “Federal law is not entirely clear about whether employers can discriminate against a person who currently has cancer, has had cancer in the past or has a genetic predisposition to it.”

Privacy advocates fight proposed medical-records network

Privacy advocates are battling moves in Congress to create an electronic network so physicians can obtain the medical histories of patients no matter where they are in the country.

The Department of Health and Human Services says that almost $87 billion could be saved each year if physicians were able to retrieve medical records easily. Proponents of such networks say that giving doctors the ability to retrieve standardized records electronically would avoid duplicative medical tests, reduce errors in prescribing medicine and give physicians a complete history of patients who fall sick while on vacation or on business trips.

But opponents say the plan will result in wider distribution of the most sensitive and personal records ever compiled on Americans, without adequate privacy protections and without giving patients the right to refuse to have records included in the system.

Marc Rotenberg, executive director of the Electronic Privacy Information Center, a Washington group that monitors electronic privacy issues, said there has to be stronger protections of electronic medical records given the epidemic of identity theft from computer data banks this year.

“We must not allow the most sensitive records that exist – our medical records – to go online without adequate privacy safeguards,” he said.

Scott Wallace, chairman of the Commission on Systemic Inoperability, a federal panel that examined the issue this year, accused privacy groups of scaremongering.

Wallace said that medical records stored electronically will actually be more secure than is the case with the current system, in which doctors have files of paper records stored in their offices.

“You have no idea who is looking at your paper records,” he said. Wallace said there is an electronic trail kept identifying each person who opens up an electronic record, which increases the confidentiality of medical records.

Wallace drew a parallel to the U.S. banking system, which has shifted from a paper-based system over the last decade to electronic banking. “Are there downsides and risks? There absolutely are. But like the banking system, they can be addressed and dealt with,” he said.

The federal commission last month issued a report that contended an electronic network would reduce the 98,000 U.S. deaths from medical errors each year by providing physicians with more information about a patient’s history and drug interactions. Information collected by the network could also help authorities track a disease or quickly spot patterns associated with terrorist attacks.

Rep. Nancy Johnson, R-Conn., introduced legislation in the House last month to set up a national system of electronic records and electronic prescriptions. Under terms of the measure, the federal rules would override any state privacy laws – a move Johnson said includes strong privacy protections.

Some experts caution that Americans are concerned that the government is already collecting too much information on them.

New York City’s health commissioner, Thomas Friedan, sparked a debate earlier this year by proposing that the city intervene in the medical care of New Yorkers by gathering medical test results from laboratories in order to identify those at risk for developing diabetes.

Nationally, the disease costs an estimated $5 billion a year to treat. Friedan’s aim is to ensure that those at risk for developing diabetes be notified and encouraged to take drugs to stay healthy.

James Pyles, a Washington attorney who represents health-care groups concerned with privacy, said Friedan’s plan may be well-meaning, but it’s not a government responsibility.

Pyles said some Americans are already declining to seek medical care because they are concerned that their privacy will be invaded.

“There’s a long tradition in this country beginning with the Bill of Rights that law-abiding citizens have a right to be left alone,” he said. He said there are also obvious health benefits for every male over 40 getting prostate tests, but there’s no government responsibility to order men to get them.

Pyles warned that establishing a government database of individual medical data would only result in people resorting to a “black market” of physicians, who would agree to treat them for embarrassing or work-disabling diseases without entering the information into a database. And with medicine about to enter the genetic age, Pyles noted, many people are concerned that information on their genetic makeup could affect the lives of their children or grandchildren.

An underground system of medicine “would be an ironic result, and an unintended result,” he said.

Although many Americans are unaware of it, federal rules that went into effect in 2003 permit physicians to share medical histories with insurers and their business associates without notifying the patients.


(Contact Lance Gay at GayL@SHNS.com. Distributed by Scripps Howard News Service,http://www.shns.com/)

Lessons for NPfIT from ‘wild ride’ to US failure

A study of the ‘wild ride’ towards a failed implementation of a new electronic medical record system found a ‘transient climate of conflict’ associated with the adoption of the new way of working.

The qualitative study, reported in the British Medical Journal, was completed during an implementation by Kaiser Permanente, the US’ largest non-profit healthcare system which is regarded as a model for cost-effective care and is watched closely by the NHS.

The study carried out in Kaiser Permanente’s facilities in Hawaii made seven key findings on its observation of staff as they used the new system:

Users perceived the decision to adopt the EMR as flawed;

Software design problems increased resistance;

The system reduced doctors’ productivity, especially during initial implementation , which fuelled resistance;

The system required clarification of roles and responsibilities which was traumatic for some individuals;

A cooperative culture created trade offs at various times in the implementation;

No single leadership style was optimal a consensus building may lead to m ore effective adoption decisions, whereas decisive leadership could help resolve barriers and resistance during implementation;

The process fostered a counter climate of conflict which was resolved by the withdrawal of the initial system.

Authors of the study say it has “notable implications for health service providers contemplating adopting an EMR.”

Implementation started in 1999 when two systems were examined EpiCare by Epic Systems and the Clinical Information System (CIS) developed by Kaiser Permanente with IBM.

The report says that, after a 12 month delay related to the operating system, the first site started using the CIS in October 2000. In 2002 Kaiser hired a new chief executive who initiated a review of system choice and concluded that EpiCare had matured beyond the CIS. All Kaiser Permanente regions halted implementation of the CIS and began planning for EpiCare.

At that time, the BMJ paper says, a third of the company’s Hawaiian sites had implemented CIS fully and the rest had read only access, some with order entry functionality.

“For many,” say the authors, “the 28 month experience had been, to use a Hawaiian surfing metaphor, truly a ‘wild ride’.”

A clinician quoted in the research said: “What got docs here frustrated was nobody really seemed to listen. And they had to compromise their values and ethics to help the system work. That’s where I saw very amiable, nice quiet, people starting to talk stink behind the scenes.”

The researchers concluded: “Implementation involved several critical components, including perceptions of the system selection, early testing, adaptation of the system to the larger organisation, and adaptation of the organisation to the new electronic environment. Throughout, organisational factors such as leadership, culture, and professional ideals played complex roles, each facilitating and hindering implementation at various points.”

In a commentary on the paper, Sheila Teasdale, strategic director of Primis+, the support service for NHS primary care information, praises the bravery of the authors in reporting a failure. She notes the lessons for the National Programme for IT and says the reasons for failure will come as no surprise for those working in health informatics.

She says the paper from Hawaii adds weight to that existing knowledge and says it is important to reinforce its messages.

“There are now encouraging signs of increasing involvement of clinicians proficient in information technology within the National Programme for IT and an increasing level of informed and constructive debate, which is being listened to by NHS Connecting for Health.

“This is a positive and welcome development and one which must be fostered throughout the NHS; we simply cannot afford for this implementation to fail.”

© 2005 E-HEALTH-MEDIA LTD. ALL RIGHTS RESERVED.

Court backs privacy of rape accusers’ mental health files

The Utah Supreme Court on Friday moved to protect the confidentiality of rape victims’ mental health records.

Defendants now must give their accusers notice when they attempt to subpoena such protected records, which cannot be disclosed without approval from a judge.

The ruling came in the appeal of Arthur Anthony Gonzales, who is serving four years to life in prison for attempted rape and forcible sexual abuse. Defense attorney Ed Montgomery subpoenaed – and received – the victim’s private records from the University of Utah Neuropsychiatric Institute.

Montgomery examined the records before asking the trial judge to review them and decide whether he could use them. The records were supposed to be sent directly to the judge, rather than the attorney. Questioning Montgomery’s ethics, 3rd District Judge Sheila McCleve ruled the records could not be used at trial and reprimanded Montgomery, who then quit the case.

The justices upheld McCleve on Friday, saying defense attorneys in rape and other criminal cases involving protected records must send copies of their subpoenas to prosecutors.

“When a victim’s confidential records are reviewed before she even knows they are subpoenaed, she cannot choose to protect them,” wrote Justice Ronald E. Nehring for the high court.

The justices also upheld rulings by 3rd District Judge Joseph Fratto denying Gonzales the right to question two witnesses at trial about their juvenile shoplifting records. The high court rejected a claim that Gonzales was denied the attorney of his choice, saying Montgomery voluntarily withdrew from the case.

Gonzales also had claimed he deserved a new trial because his second attorney was ineffective. At the end of his trial, the attorney asked for a mistrial, admitting she had made an error.

She had asked her client on the witness stand if he had ever been “accused” of other sexual assaults, rather than charged or convicted.

That question prompted prosecutors to question Gonzales about prior assault accusations, with permission from Fratto.

The justices said Friday the question would not have changed the outcome of the case.

In an October 2004 letter to The Salt Lake Tribune, Gonzales insisted he has been wrongly accused.

Gonzales was engaged to his 16-year-old victim’s mother, and claimed the girl had a previous history of psychiatric problems that included hallucinations.

Kaiser Permanente’s experience of implementing an electronic medical record: a qualitative study

Objective To examine users’ attitudes to implementation of an electronic medical record system in Kaiser Permanente Hawaii.

Design Qualitative study based on semistructured interviews.

Setting Four primary healthcare teams in four clinics, and four specialty departments in one hospital, on Oahu, Hawaii. Shortly before the interviews, Kaiser Permanente stopped implementation of the initial system in favour of a competing one.

Participants Twenty six senior clinicians, managers, and project team members.

Results Seven key findings emerged: users perceived the decision to adopt the electronic medical record system as flawed; software design problems increased resistance; the system reduced doctors’ productivity, especially during initial implementation, which fuelled resistance; the system required clarification of clinical roles and responsibilities, which was traumatic for some individuals; a cooperative culture created trade-offs at varying points in the implementation; no single leadership style was optimal–a participatory, consensus-building style may lead to more effectiveadoption decisions, whereas decisive leadership could help resolve barriers and resistance during implementation; the process fostered a counter climate of conflict, which was resolved by withdrawalof the initial system.

Conclusions Implementation involved severalcritical components, including perceptions of the system selection, early testing, adaptation of the system to the larger organisation, and adaptation of the organisation to the new electronic environment.Throughout, organisational factors such as leadership, culture, and professional ideals played complex roles, each facilitating and hindering implementation at various points. A transient climate of conflict was associated with adoption of the system.