Are EMR's More Secure and Trustworthy Than Paper Records?

Contrary to utopian praise of EMR's as more secure than paper records:

Routine complication from surgery turns fatal
Lance Williams, Chronicle Staff Writer
Monday, August 10, 2009

A hospital patient suffers excruciating pain from what turns out to be a routine complication from elective surgery.

As her condition deteriorates, she and her family plead to see the doctor. But no doctor examines her until the next morning, when she goes into shock, is rushed into intensive care and dies.

Then, after her death, the hospital deletes portions of the woman's medical file in what the woman's family says is an attempt to cover up its horrendous mistakes.

Is this possible? Read on:

The allegations, contained in a lawsuit filed in Santa Clara County Superior Court, describe events that seemingly could occur only at an institution that provides medical care at its worst. Instead, the claims concern a 2007 fatality at what is regarded as one of the best hospitals on the West Coast - Stanford University Medical Center in Palo Alto.

The case of Diane Stewart, 70, who died of a bowel obstruction after knee replacement surgery, shows that bad mistakes and worst-case outcomes are possible even at world-renowned hospitals, said her family's lawyer, Christopher Dolan of San Francisco.

Medical errors occur because "we have corporatized medicine and marginalized the professional's role," Dolan said. "We took the same principles used in automation, to do the job cheaper and faster, and applied it to medicine."

Healthcare IT notwithstanding, I believe those observations are accurate. However, a more serious issue is the role of HIT in marginalizing the medical professional with respect to the IT professional, in what I've called (in this blog and elsewhere) a cross-occupational invasion of medicine by the IT profession.

"I believe Stanford is making a concerted effort to obstruct our family from learning the truth about what happened to our mom," he wrote in a complaint to the state Medical Board. In 2008, investigators from the state Department of Public Health found that "relevant" portions of Diane Stewart's computer file had been deleted after her death and that a supervisor instructed a nurse to make postmortem "late entries" to describe her care.

This may be a case where the CIO and other IT leaders need to be called to the stand to testify, possibly on criminal charges, since some cooperation from such personnel would be required if there is merit to allegations of post-death EMR alterations/erasures.

In a written statement, the hospital said that only temporary notes that were never intended to become part of Diane Stewart's permanent record had been discarded.

Never intended to become part of her medical record?

This "Watergate 18 minute gap"-reminiscent explanation raises a number of questions:

• How did these "Temporary Notes" come to be discarded?
• What was temporary about them?
  
• Does Stanford's EHR have a "Discard Temporary Notes" button?
• What authority and authentication is required in order for "Temporary Notes" to be discarded?
• What is Stanford's definition of a "Temporary Note" in an EHR?
• What might such notes contain?
• Who might they have been written by, and for what purpose(s)?
  
• If they involve decisions made in healthcare, why are they considered "temporary?"
• Are there notes made in a paper record that are considered "temporary" that can legitimately be discarded after a suspicious patient death?
• Are there backups that contain these notes, or were they erased too?
• Was such backup erasure initiated manually (e.g., by a human) or automatically?

Since these notes were discarded (erased), of course, we may never know what they contained.

Electronic records leave no erasure marks, and with collusion of the appropriate personnel, reality can be whatever one wants it to be in the electronic world. This represents yet another sociotechnical obstacle standing in the way of achieving a computer-based utopia in healthcare.

-- SS

Walmart to Become the Healthcare IT Punching Bag?

At "Wal-Mart to market Electronic Medical Records? Has Medicine Gone Bananas?" I noted the entry of Walmart into the healthcare IT fray.

As I observed here in early 2005, HIT is a field where angels fear to tread. Or should fear to tread.

Walmart is not exactly popular in numerous circles, so let me state I buy from them (most recently my Acer Netbook, clothing and various Christmas gifts) and am neutral on most of the issues that create the opposition. My father ran a business, after all.

However, he at least stuck to his core expertise, pharmacy. Walmart is trying to market EMR's, a product far beyond their core competencies. The HIT market and "ecosystem" is also far beyond their competencies, and it's not hard to predict they are going to have a rapid and quite unpleasant learning experience about the dark corners of this industry.

Felix Fulmer, a correspondent with longstanding expertise in academic and pharmaceutical research environments conveyed to me the following observations about this arrangement:

Deficient as its products often are, the HIT industry was built up by entrepreneurs over many years and by much hard work. They are now being challenged by a very large and very powerful entity. The entry of Walmart into EMR represents a tremendous threat to the HIT industry status quo.

This initiative is likely to help doctors and patients at the very least by reducing the cost of EMR (even if not improving the performance), putting downward price pressure on the entire industry. It is also likely to change the marketing and consulting practices in the HIT industry as well, driving wages down among other factors.

If successful, Walmart's initiative could in fact cause the extinction of the current monopolistic and parasitical HIT establishment. [In my estimate, a 33% - 50% reduction in companies, revenues and personnel in three or four years would not be an unreasonable figure - not that I would be sad to see some of them go - ed.]

Mr. Fulmer continues:

The HIT industry must realize this and, based on Walmart's history of capturing other markets and putting smaller competitors out of business, the captains of this industry must be quaking in their boots. These entrepreneurs will fiercely act to defend their territory, using every trick in the book [knowing the industry as well as I do, I cannot fail to agree with that assessment - ed.]

Walmart is going to be severely punished. The pushback from the HIT establishment will likely consist of three phases: subversion, obstruction, and agitation for litigation (in a collusive manner) to challenge the newcomer. There will be technical, administrative and political angles.

The first phase, subversion, will be the establishment's attempt to try to keep the Walmart arrangement from happening. It may occur through the press and through political means. Antitrust complaints, and a negative campaign of badmouthing and panning may occur. It will be insinuated or stated that Walmart doesn't have the required expertise, that they don't know what they're doing, among other claims to discredit, diminish and minimize the initiative.

The second phase will likely be obstruction. HIT products Walmart will carry will be sabotaged by other vendors in terms of passive aggressive measures to complicate or prevent data interoperability. There may be issues such as constant "breakdowns" of interfaces, inexplicable technical glitches blamed on Walmart and its supplier, of course. Walmart's HIT products and services will be scrutinized under a microscope and deficiencies highlighted through the media and printed competitive materials.

There may also be attempts to intimidate and misdirect physicians not to go with this product through the medical leadership, through back room paid sponsorship of "influential thought leaders" (as in pharma), through "detail people" (e.g., sales reps as in pharma) and other means. Hospital administrations and CIO's may also be influenced by various means to steer physicians away from this offering, perhaps to the level of marginalizing users or refusing to support this product.

Finally, there will be litigation, especially regarding the inevitable medical errors that occur when this technology is pushed into small town physicians offices unused to technology of this complexity. Walmart may be shocked to find the "learned intermediary" principle suddenly and mysteriously not be applied. Why would this be a surprise, considering their immensely deep pockets and the disdain of the the left-leaning, anti-big business judiciary system?

Mr. Fulmer concludes with this thought:

Walmart may think of their entry into the HIT marketplace as a great business plan, but their executives may need to partake of their own medical clinics to deal with the stress the HIT industry pushback will cause.

-- SS

Waste Feared in Digitizing Patient Records: Wall Street Journal

In today's Wall Street Journal an article appeared entitled "Waste Feared in Digitizing Patient Records" by Jacob Goldstein and Jane Zhang.

I would certainly call this title an understatement. Readers of the HC Renewal blog can probably understand why from my many postings on the challenges and the (largely unrealized as of 2009) potential of well done healthcare IT.

President Barack Obama has pledged to "wield technology's wonders to raise health care's quality and lower its cost," but many in the field warn that rushing the process of digitizing patients' records could lead to wasteful spending.

Both President Obama and former President George W. Bush have endorsed the goal of having electronic health records in widespread use by 2014. But the degree of difficulty promises to be high.

A study published last year in the New England Journal of Medicine found that only 4% of U.S. physicians were using "fully functional" electronic health-records systems. What's more, simply installing new IT systems in doctors' offices isn't enough. The systems have to be able to talk to each other, so doctors and hospitals can share information. And doctors and nurses have to learn how to use the systems in ways that help patients.

I would differ from the statement in the article that "many in the field warn that rushing the process of digitizing patients' records could lead to wasteful spending" [i.e., on systems that don't work, require massive remediation, are rejected, fail, etc. - ed.]

I have been writing on these issues for over ten years, and in that time I've only seen a handful of people writing such things publicly. They usually received scorn or were labeled as naysayers - much as economic forecasters and stock market experts the past few years who warned of potential trouble due to risky loans bundled into even riskier government backed securities.

In fact, my own site "Common Examples of Healthcare IT Difficulties" remains nearly unique on the Web in covering health IT problems at a very granular level. (It was originally entitled "Common Examples of Healthcare IT Failure" but I changed the name due to comments from some in the field that the title was too "negative.")

Last week, House Democrats unveiled a fiscal-stimulus bill that includes $20 billion for health-care information technology.

"In some ways I am thrilled, because IT will need federal help," said John Glaser, chief information officer for Partners HealthCare, a large nonprofit hospital system in Boston. "But you can bring in too much money too fast and not only waste it, but set us back."

In what may be a first, a non medical non biomedical informatics-trained (to my knowledge) CIO echoes the sentiments that a relatively small group of informed biomedical informatics, sociology, and other specialists have been saying for years. In fact, Glaser did participate in a site visit by the National Research Council Health IT Report team to Partners Healthcare. The Press Release summary of the NRC report itself entitled "Current Approaches to U.S Healthcare Information Technology are Insufficient" states:

... Current efforts aimed at the nationwide deployment of health care information technology (IT) will not be sufficient to achieve medical leaders' vision of health care in the 21st century and may even set back the cause, says a new report from the National Research Council. The report, based partially on site visits to eight U.S. medical centers considered leaders in the field of health care IT, concludes that greater emphasis should be placed on information technology that provides health care workers and patients with cognitive support [as opposed to just an 'inventory system' of medical information - ed.], such as assistance in decision-making and problem-solving.

Most IT personnel in the healthcare space have spent the past few decades waxing ecstatic about how healthcare IT was a cybernetic miracle to cure healthcare's ills as if by magic, physician and nurse complaints about how the technology slowed them down or created cognitive overload be damned. Unfortunately, it's an unfiltered diet of this propaganda I fear has been ingested by government officials over the past few decades that's led to the pronouncements that billions spent on health IT in 2009 is a sure bet that will, as the President stated, raise healthcare quality and reduce its costs.

What has been missing is a genuine, "political correctness be damned" rationale for why this technology has been disappointing in diffusion and performance even after 40+ years of research and efforts. Then we have this:

The Democrats' bill attempts to address many of the potential pitfalls associated with the rollout, spelling out plans to increase privacy protections, fund regional electronic networks, train technicians and give doctors financial incentives to use electronic records in ways that are likely to benefit patients.

A Republican congressional aide says the minority supports the goal of digitizing health records, but doesn't support spending money on technology that isn't yet developed. The aide adds that Republicans plan to draft amendments to make sure money won't be wasted on a piecemeal system.

I agree with the latter assessment. HIT is still a largely experimental technology. The IT industry uses hospitals, doctor offices and patients as alpha and beta test sites and subjects, unregulated by the FDA or other agency. When HIT fails, there is no central agency to report the failures to, only the vendor. Fixes go into a "queue" for remediation, with priority level decided by the vendor.

The major pitfalls of an attempted large scale national "rollout" can't be addressed when those major pitfalls are rarely found in the literature. Yes, privacy, interoperability and incentives are important. However, IT that causes error, slows clinicians down, confuses and insults them, and is really not useful to them in improving their ability to care for their patients are the most fundamental pitfalls that have impaired this technology's diffusion and acceptance.

The national HIT project in the UK is a quagmire in part for just these reasons (see here).

"If it's too hasty, you can create so many bad experiences that people say...'My data's a mess and my patients are angry,'" Mr. Glaser says.

I would say the major complaint is more akin to "the IT is a mess", not "my data's a mess."

What is at the root of these difficulties?

False assumptions, for starters.

If you attempt to travel to the moon in a hot air balloon under the assumption that since the moon is up and the balloon goes up, therefore the balloon is a viable solution to earth-moon transit, you will just not see Neil Armstrong's footprints in the Sea of Tranquility.

To the moon in a hot air balloon!

The major false assumption in HIT has been that HIT is just a specialized type of MIS (management information system), as opposed to it own subspecialized domain in the IT space.

This assumption and its corollary, that HIT is an MIS that just happens to involve clinicians (as opposed to the reality that HIT is a virtual clinical tool that just happens to involve computers) is at the root of HIT's difficulties. This assumption leads directly to errors in leadership, management, design and implementation of health IT. It leads to strategic, tactical and operational errors. IT personnel should not be leading design, deployment and management of clinical tools, either material or virtual, simply because those tools involve computers.

Let me illustrate by analogy. The recent Airbus that lost engine power due to collision with birds in New York was designed as a fly-by-wire aircraft. The control inputs from the pilots are mediated by computers that in turn control the active aircraft flight surfaces, as opposed to direct electric or hydraulic actuators. These computer systems also provide detailed information and decision support to the pilots. It has been claimed that those automated systems also prevented this NY aircraft from stalling or going out of control through programmed "artificial intelligence."

If this were health IT, the computer personnel would be put in charge of aircraft design, since the computers are now essential to aircraft operation and flight safety, and have the aeronautical engineers and other aeronautical domain experts report to them. The latter would be asked to perform their roles in accordance with what is convenient for the IT personnel, and blamed when they reject poorly conceived and implemented IT that could confuse and overwhelm pilots and cause air accidents.

Yes, this does sound bizarre, but this is what largely goes on in health IT.

In much more detail, the errors that follow from the assumption that "HIT is MIS" include:

• A striking lack in the HIT industry of the scientific rigor of medicine
  
• An HIT track record of success, or lack thereof, at best similar to MIS. See, for example:

Statistics on IT Project Failure Rates. The surveys referenced here provide statistical data regarding IT project failure rates. This topic is not often discussed in the mainstream IT literature. Health care IT failure rates may be even higher due to its greater sociotechnical complexity compared to traditional business IT. link

Pessimism, Computer Failure, and Information Systems Development in the Public Sector. (Public Administration Review 67;5:917-929, Sept/Oct. 2007, Shaun Goldfinch, University of Otago, New Zealand). Cautionary article on IT that should be read by every healthcare executive documenting the widespread nature of IT difficulties and failure, the lack of attention to the issues responsible, and recommending much more critical attitudes towards IT. link to pdf

• HIT that does not meet clinician needs, slows clinicians down, cognitively overloads them, necessitates ad hoc workarounds that make clinicians' work more complex, and promotes rather than prevents informational errors.
• Unbacked, often IT marketing driven claims that HIT will ipso facto reduce healthcare costs, reduce FTE's and improve care quality. The latter claims are problematic when scientifically tested, e.g., Electronic Health Record Use and the Quality of Ambulatory Care in the United States” (Arch Intern Med. 2007;167:1400-1405, link to abstract here).
• Use of tightly controlled and mechanistic approaches and methodologies of MIS more suitable to developing business IT such as accounting and financial systems, but profoundly unsuitable to creating IT that meets the needs of clinicians in actual medical settings due to lack of methodological imagination and agility. In fact, MIS encourages what J. Paul Getty once described as "bureaucratic corpulence, the trap of sterile formalism and unproductive ritual."
  
• Paradoxical leadership. Non medical personnel of a technology and/or business focus in charge of HIT design, acquisition, deployment and life cycle, leading to technology modeled after what they know best, and therefore poorly supporting what they know least (clinical medicine and its "hiding in plain sight" complexities).
• Over reliance on "process" to make up for this deficiency, although a thousand generic workers will always be outperformed by one domain expert who actually knows what they're doing.
• Paradoxical and intensely dysfunctional reporting of healthcare enablers to healthcare facilitators, such as postdoctoral trained clinician-informatics experts reporting to non-medical, non-science business IT CIO's or other IT personnel with bachelor's level training, and the latter evaluating the performance of the former.
  
• Creation of an HIT industry that has created and promotes the myth of HIT cybernetic miracles out of its own interests.
• Spectacular, expensive, multi-football field sized annual trade shows promoting this technology (e.g., HIMSS).
• "Cross disciplinary piracy" - a dubious pretense to biomedical leadership qualification and insight by all manner of IT and IT facilitator personnel over seasoned clinicians.
• Lack of clinician input, and blame placed on hapless clinicians when they reject suboptimal HIT designs.
• Lack of adequate biomedical informatics input from true informatics experts. Such personnel are often used as "internal consultants" who may or may not be listened to. Common in hospitals is the "Director of Informatics" or "Chief Medical Informatics Officer" role, which usually translates to "Director of Nothing" or "Chief of Nothing" with little or no direct control of resources or personnel. Often used as 'internal salesmen of suboptimal HIT' to other clinicians.
  
• Too much input from "medical instamaticists", people who've managed to convince others that doing something with a computer in medicine qualifies them to play critical roles in major HIT projects. Often, these personnel know just enough to be dangerous and disruptive to those who actually know what they're doing.
• Legions of expensive consultants with the same assumptions.
• Suppression of reports of HIT difficulties that could - and should - be shared by other organizations as "lessons learned" due to self interest of the involved vendors, consultants and IT personnel.
• Focus on doing too much at once; e.g., simultaneous or near simultaneous implementation of EHR, CPOE, financial and other ancillary systems that provide little benefit to clinician end users and that drain healthcare's limited resources to the IT sector. This is as opposed to an incremental approach that starts with EHR support for clinicians and highly customized systems for high risk, high revenue areas, to be followed in stages by more comprehensive, integrated IT systems that if done well might have an ROI to the hospital business side.
• "Big bang" rollouts that attempt massive cultural change in an entire organization instead of incremental change, beginning with a pilot area or areas, then advancing unit by unit, specialty by speciality, subspecialty by subspeciality, learning as one goes to avoid costly errors.
  

If money is to be massively spent, it would be better spent initially on true R&D. This R&D would strive to end false assumptions and develop well grounded leadership structures, development methods for effective HIT, and ensure proper engagement of experts and end users to facilitate this technology in attaining its true capabilities.

-- SS

National Research Council: Current Approaches to Health IT Insufficient ... and Other "Master of the Obvious" News

The National Research Council has issued a remarkable press release about a new report on HIT. The press release is at this link:

Current Approaches to U.S. Health Care Information Technology are Insufficient

(Jan 12 addendum: a prepublication pdf of the report itself is here.)

I reproduce the press release below, but please do read my polemic before reviewing it.

My early mentor, cardiothoracic surgery pioneer Victor P. Satinsky, M.D., used to become irritated when people or organizations presented views that qualified them as "Masters of the Obvious." I believe the following release by the highest scientific authorities in the land qualifies for such a categorization.

Sadly, the release by the National Research Council outlines the "what" (what is wrong), but not the "why." Perhaps that will be found in the full report, although many of the "whys" (that is, why these health IT problems exist at all, and why the Joint Commission and NRC reports are even necessary, after 40+ years of Biomedical Informatics, IT-sociology and other research) can be found right here on Healthcare Renewal.

On the positive side for clinicians, life as a typical hospital CIO or other non-medical executive may have just become substantially more aligned towards serving the needs of clinicians, via being compelled by this report and its aftermath to make major changes in the way HIT is pursued. These changes would replace the familiar pursuit of building self-serving IT empires.

In fact, if you're a CIO who is accustomed to doing typical deals with HIT vendors, hires typical business IT staff unknowledgeable and untried in anything medical to work in clinical IT, along with lots of ham-fisted but hats-in-hand consultants who then try to clean up the mess the IT staff make, and who bullies and brands with a scarlet letter anyone who challenges the status quo (such as Medical Informaticists and other cross-disciplinary specialists who actually know what they're doing in HIT) while the latter actually try to protect the "customers" also known as "patients", your life has just become a bit more challenging.

I'd thought the December 2008 Joint Commission Sentinel Event Alert on Health IT, on the risks posed by improperly designed and implemented Health IT had been a one-up. I thought it might have been a fluke, written and released by some young disgruntled employee like Justen Deal who would be fired. I thought the Joint Commission Alert would be ignored by the players in the highly lucrative and often exploitative (of clinician ignorance and learned helplessness, that is) HIT ecosystem.

I may have been mistaken. The NRC report may change that.

Significantly, the NRC report was about a number of the best medical organizations in this country, not about the smaller less experienced hospitals where things are far worse.

Finally, the report is not news to me, others who objectively observe HIT (especially those without financial or other conflicts of interest), or to readers of this blog. In the words of abducted-by-aliens, ignored-by-the-experts pilot Russell Casse after several cities are destroyed by the aliens:

"I've been sayin' it, I've been sayin' it, ain't I been sayin' it?"

Read the whole Press Release below.

Perhaps we as a profession should feel for patients who were denied care due to lack of funds while the IT industry diverted capital out of healthcare for "insufficient" HIT, or were denied good care through malfunctioning HIT or non-functioning HIT, or who suffered outcomes that good HIT could have prevented (i.e., the cost of lost opportunity - my own father died from malpractice as a result of informational confusion a good EHR might have prevented). All while the society's gatekeepers ignored the Distant Early Warning Line of the HIT pioneers that all was not well. (Anyone know of other sectors that crashed this past year where such warnings were ignored?)

The Press Release should be read in its entirety. I will not comment on it here further, other than to say that HC Renewal can be searched on the term "Medical Informatics", "EMR" or similar for much more material on these issues.

Emphases in boldface are mine.

The National Academies

Date: Jan. 9, 2009

FOR IMMEDIATE RELEASE

CURRENT APPROACHES TO U.S. HEALTH CARE INFORMATION TECHNOLOGY ARE INSUFFICIENT

WASHINGTON -- Current efforts aimed at the nationwide deployment of health care information technology (IT) will not be sufficient to achieve medical leaders' vision of health care in the 21st century and may even set back the cause, says a new report from the National Research Council. The report, based partially on site visits to eight U.S. medical centers considered leaders in the field of health care IT, concludes that greater emphasis should be placed on information technology that provides health care workers and patients with cognitive support, such as assistance in decision-making and problem-solving.

In 2001, the Institute of Medicine -- which with the Research Council, National Academy of Sciences, and National Academy of Engineering make up the National Academies -- laid out a vision of 21st century health care that involves care which is safe, effective, patient-centered, timely, efficient, and equitable. Many aspects of this vision involve information technology, such as having access to comprehensive data on patients, tools to integrate evidence into practice, and the ability to highlight problems as they arise. To see how leaders in U.S. health care use computing and information management in providing care, the committee that wrote the new report visited eight medical centers -- University of Pittsburgh Medical Center; Veterans Affairs Medical Center in Washington, D.C.; HCA TriStar and the Vanderbilt University Medical Center, both in Nashville, Tenn.; Partners HealthCare System in Boston; Intermountain Healthcare in Salt Lake City; University of California-San Francisco Medical Center; and Palo Alto Medical Foundation in California.

Although the institutions showed a strong commitment to delivering quality health care, the IT systems seen by the committee fall short of what will be needed to realize IOM's vision. The report describes difficulties with data sharing and integration, deployment of new IT capabilities, and large-scale data management. Most importantly, current health care IT systems offer little cognitive support; clinicians spend a great deal of time sifting through large amounts of raw data (such as lab and other test results) and integrating it with their medical knowledge to form a whole picture of the patient. Many care providers told the committee that data entered into their IT systems was used mainly to comply with regulations or to defend against lawsuits, rather than to improve care. As a result, valuable time and energy is spent managing data as opposed to understanding the patient.

Ideally, IT systems would place raw data into context with current medical knowledge to provide clinicians with computer models, "virtual patients," that depict the health status of the patient, including information on how different organ systems are interacting, epidemiological insight into the local prevalence of disease, and potential patient-specific treatment regimens. Although health care workers could still have access to the raw data if they needed it, clinicians would be able to work with models without drowning in data. This cognitive support would help clinicians more efficiently and effectively determine a course of action through improved understanding of a patient's status, says the report.

The report identifies several principles for improving health care IT. In the short term, government, health care providers, and health care IT vendors should embrace measurable improvements in quality of care as the driving rationale for adopting health care IT, and should avoid programs that focus on adoption of specific clinical applications. In the long term, success will depend upon accelerating interdisciplinary research in biomedical informatics, computer science, social science, and health care engineering.

This report was sponsored by the U.S. National Library of Medicine, National Institutes of Health, U.S. National Science Foundation, Partners HealthCare System, Vanderbilt University Medical Center , the Commonwealth Fund, and the Robert Wood Johnson Foundation. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine , and National Research Council are private, nonprofit institutions that provide science, technology, and health policy advice under a congressional charter. The Research Council is the principal operating agency of the National Academy of Sciences and the National Academy of Engineering. A committee roster follows.

Copies of COMPUTATIONAL TECHNOLOGY FOR EFFECTIVE HEALTH CARE: IMMEDIATE STEPS AND STRATEGIC DIRECTIONS are available from the National Academies Press; tel. 202-334-3313 or 1-800-624-6242 or on the Internet at HTTP://WWW.NAP.EDU. Reporters may obtain a copy from the Office of News and Public Information (contacts listed above).

# # #

[ This news release and report are available at HTTP://NATIONAL-ACADEMIES.ORG ]

NATIONAL RESEARCH COUNCIL
Division on Engineering and Physical Sciences
Computer Science and Telecommunications Board

COMMITTEE ON ENGAGING THE COMPUTER SCIENCE RESEARCH COMMUNITY IN HEALTH CARE INFORMATICS

WILLIAM W. STEAD ¹ (CHAIR)
McKesson Foundation Professor of Medicine and Biomedical
Informatics, and
Associate Vice Chancellor for Strategy and Transformation
Vanderbilt University
Nashville , Tenn.

G. OCTO BARNETT ¹
Professor of Medicine
Harvard Medical School , and
Senior Scientific Director
Laboratory of Computer Science
Massachusetts General Hospital
Boston

SUSAN B. DAVIDSON
Weiss Professor and Chair
Computer and Information Science
University of Pennsylvania
Philadelphia

ERIC DISHMAN
General Manager and Global Director
Intel Corp.
Hillsboro , Ore.

DEBORAH L. ESTRIN
Professor of Computer Science, and
Director
Center for Embedded Networked Sensing
Department of Computer Science
University of California
Los Angeles

ALON HALEVY
Research Scientist
Department of Engineering
Google Inc.
Seattle

DONALD A. NORMAN
Co-Founder
Neilsen Norman Group
Northbrook , Ill.

IDA SIM
Associate Professor of Medicine
Department of Medicine
School of Medicine
University of California
San Francisco

ALFRED Z. SPECTOR ²
Vice President of Research and Special Initiatives
Google Inc.
New York City

PETER SZOLOVITS ¹
Head
Clinical Decision-Making Group
Computer Science and Artificial Intelligence Laboratory, and
Professor of Computer Science and Engineering
Massachusetts Institute of Technology
Cambridge

ANDRIES VAN DAM ²
University Professor of Technology and Education and
Professor of Computer Science
Brown University
Providence , R.I.

GIO WIEDERHOLD
Professor Emeritus
Department of Computer Science
Stanford University
Stanford , Calif.

RESEARCH COUNCIL STAFF

HERB LIN
Study Director

1 Member, Institute of Medicine
2 Member, National Academy of Engineering

Supplementary points: sometimes saying "I told you so" to those who place the scarlet letters upon those not afflicted with HIT irrational exuberance is appropriate. This is one of those times.

To patients harmed or killed by the clouded vision and/or conflicts of interest of the pundits, I hereby apologize for the learned helplessness of the healthcare community in not taking charge of this situation sooner.

-- SS

Should The U.S. Call A Moratorium On Ambitious National Electronic Health Records Plans?

We are now engaged in a worldwide economic crisis, the likes of which have probably not been seen since the 1920's.

In "Bank Bailout Puts £12.7bn NHS Electronic Medical Record Project In Jeopardy" I commented on how the world financial crisis of 2008 combined with chronic project difficulties and mismanagement was creating such high levels of doubt about the UK's Connecting for Health (CfH) national program for electronic health records (EHR's), that the program was under consideration for cancellation.

From that post:

Christine Connelly, the Department of Health's recently appointed head of informatics, is understood to be reviewing whether the programme is a cost-effective way of improving the quality and safety of patient care.

She will have to find compelling arguments to stop the Treasury earmarking health service IT as a candidate for cuts to compensate for the billions spent on the bailout of the banks. However, the high cost of cancelling contracts with IT suppliers may be a factor saving the programme from cancellation.

More on Connelly, the "recently appointed head of informatics" later.

In the United States, we need to consider the implications of this towards our own ambitious plans for national health records.

Either we get it right, or we should not pursue it at all under the current economic downturn. There are millions of uninsured and underserved people in this country who would benefit far more tangibly from funding of healthcare services rather than funding of ambitious health records projects that transfer scarce capital from the healthcare to the IT sector. These are initiatives that are demonstrably fraught with peril (as in the UK), that healthcare organizations and clinicians may not truly want to succeed, and with unproven ROI and unclear quality improvement benefits (see "Do Healthcare Organizations Truly Want Electronic Health Records To Succeed?").

If we are going to stay on our present course and commit billions of dollars to ambitious IT projects that might be better spent on healthcare provision, we damn well better learn something from the UK experience. I am unfortunately doubtful of this.

As I state at my academic site on HIT difficulties (link), learning from others' mistakes - learning what not to do, aside from "best practices" - is important. However, one fundamental lesson to be learned of the highest importance is on leadership of HIT. Towards that end I provide additional material on the UK's national EMR difficulties.

At Healthcare Renewal, Roy Poses and I have often noted the lack of biomedical or healthcare credentials in the "C" level and board leadership of healthcare delivery and healthcare supporting organizations such as pharmaceuticals and medical devices and technology companies.

Here is more on the stunning UK CfH problems, followed by an interesting (and predictable!) finding on its new leadership.

From The Telegraph:

NHS IT system 'at a standstill'

By Kate Devlin, Medical Correspondent Last Updated: 6:24PM GMT 28 Oct 2008

The roll-out of a flagship £12billion NHS IT system has come to a standstill in many parts of the country because of problems with the system, the NHS has admitted. Ministers want the computer programme, one of the largest in the world, to eventually contain the medical records of every patient in the country. But NHS bosses in London have decided to halt the roll-out of the electronic care records to hospitals indefinitely, to sort out technical problems.

From E-Health Insider:

Political row over NPfIT: London on hold
28 Oct 2008

Opposition politicians have renewed their condemnation of the National Programme for IT in the NHS following press reports that the programme is “grinding to a halt.”

Conservative shadow health spokesman Stephen O’Brien said the reports confirmed that, with the “hugely expensive” programme “desperately behind schedule” suppliers were “deserting in droves” and “frontline professionals” were “voting with their feet and insisting on local solutions.”

Meanwhile, Liberal Democrat health spokesman Norman Lamb issued a statement saying that the “centralised project” had been “a shambles from the start” and it was “time for a re-think on how to proceed.”

The latest round of political attacks on the national programme follow the publication of an article in the Financial Times, arguing that progress on one aspect of the £12 billion project, the deployment of “strategic” care records systems, has stalled.

The article reviewed a number of recent stories that suggest this and questioned whether the programme would ever be completed.

... It noted that hospitals that have taken the London Release 1 version of Cerner’s Millennium care record service are experiencing problems with it and that further deployments that were scheduled for this year are showing no sign of going ahead.

And it noted that although health ministers promised that the much-delayed first installation of iSoft’s Lorenzo care record system would take place in Morecambe Bay this summer, the system has not gone live and neither the trust nor NHS Connecting for Health can give a date for go-live.

Jon Hoeksma, editor of E-Health Insider, was quoted as saying that while other parts of the programme continue to make progress, “this key part seems to be simply stuck. It has ground to a halt.”

Other national papers picked up the story, prompting an apparent admission that in London at least further deployments have been put on hold indefinitely.

This from Financial Times:

NHS records project grinds to halt
By Nicholas Timmins, Public Policy Editor
Monday Oct 27 2008 18:30

Progress on the £12bn computer programme designed to give doctors instant access to patients' records across the country has virtually ground to a halt, raising questions about whether the world's biggest civil information technology project will ever be finished.

Since [its launch in 2002], however, just one of the scores of acute care hospitals due to install the underlying administration system required in order for the patient record to work has done so. The hospital, Royal Free NHS Trust in London, continues to have difficulties getting it to operate properly.

... Health ministers originally promised the long-delayed first installation of patient record software in the north of England would finally take place in June at Morecambe Bay on the Lancashire/Cumbria border. But four months on, the system has still not gone live and neither Morecambe Bay nor Connecting for Health can give a date when it might.

CfH's most recent published plans for the next three months do not include a single installation of a patient administration system into any acute hospital trust.... Hospital chief executives, he said, did not want to take a new system "until they have seen it put in pretty flawlessly elsewhere".

And this from the Evening Standard (UK):

£12bn NHS computer system crashes at the first attempt
Anna Davis
Oct. 30, 2008

THE roll-out of a new computer system to every London hospital has been frozen after being installed in just one organisation.

IT experts have stopped setting up the software across the capital and have rushed to sort out problems caused by the system at the Royal Free Hampstead NHS trust the only acute hospital to have installed it so far.

It is the latest blow for the £12billion national programme, designed to give doctors access to patients' records wherever they are in the country.

The system has been beset with software glitches and design faults. One internal health service document said it could put seriously ill patients at risk of being inaccurately diagnosed.

According to the document, it is routinely crashing, intermittently losing patient information, and some staff are reverting to pen and paper.

It seems this UK program, which has already resulted in the expenditure of billions of dollars, is not at all meeting expectations. In fact, it may die.

This raises a few questions:

• Could this CfH debacle have been prevented?

• Could this scenario find itself repeated here in the United States?

I offer the opinion that the answer to both of these questions is a resounding "yes."

On the first question, the answer is related directly to the issue of leadership expertise as I explain in some detail at my academic teaching site "Sociotechnologic Issues in Clinical Computing: Common Examples of Healthcare IT Difficulties." At that site I wrote:

... diffusion of clinical information technology (IT specifically intended for use by clinicians in clinical care settings) after 30-plus years of effort and billions of dollars spent remains limited.

... This website is concerned with the reasons for this apparent paradox ... While clinical IT is now potentially capable of achieving many of the benefits long claimed for it such as improved medical quality and efficiency, reduced costs, better medical research and drugs, earlier disease detection, and so forth, there is a major caveat and essential precondition: the benefits will be realized only if clinical IT is done well. For if clinical IT is not done well, as often occurs in today’s environment of medical quick fixes and seemingly unquestioning exuberance about IT, the technology can be injurious to medical practice and biomedical R&D, and highly wasteful of scarce healthcare capital and resources.

Those two short words “done well” mask an underlying, profound, and, as yet, largely unrecognized (or ignored) complexity. This website is about the meaning of "done well" in the context of clinical computing, a computing subspecialty with issues and required expertise quite distinct from traditional MIS (management information systems, or business-related) computing.

Of note regarding leadership changes in the UK CfH electronic medical records program and its IT leadership:

Two senior management appointments for NHS National Programme for IT announced
12 August 2008

The Department of Health has announced the two long-awaited senior management appointments for the National Programme for IT ... The Department announced in February that it was recruiting the two positions as part of a revised governance structure for handling informatics in the Department of Health.

Christine Connelly will be the first Chief Information Officer for Health and will focus on developing and delivering the Department's overall information strategy and integrating leadership across the NHS and associated bodies including NHS Connecting for Health and the NHS Information Centre for Health and Social Care.

Christine Connelly was previously Chief Information Officer at Cadbury Schweppes with direct control of all IT operations and projects. She also spent over 20 years at BP where her roles included Chief of Staff for Gas, Power and Renewables, and Head of IT for both the upstream and downstream business.

Martin Bellamy will be the Director of Programme and System Delivery. He will lead NHS Connecting for Health and focus on enhancing partnerships with and within the NHS. Martin Bellamy has worked for the Department for Work and Pensions since 2003. His main role has been as CIO of the Pension Service. He has also held the positions of Group Applications Director in Corporate IT, and as Senior Responsible Officer for Information Management in the DWP Change Programme. He was previously a partner with KPMG Consulting in London, and has also worked in Reuters where his roles included Head of Real Time Technology and Director of News Products Development.

Cadbury Schweppes? The candy and Dr. Pepper/Snapple company? Gas and Power? Pension services? To lead a national health IT initiative?

The absence of biomedical, healthcare and medical informatics expertise in this "revised governance for handling informatics" is quite remarkable.

Can government really be the sponsor of ambitious health IT projects, I wonder? Should they?

On the second question, could the UK scenario find itself repeated in the United States, the answer is most definitely 'yes.'

While there are informatics professionals at high levels within the HHS/ONC-led national initiative (not yet a formal program), the clinical IT initiatives of rank and file healthcare organization are still largely under the model of leadership by non-medical IT personnel.

Amateurs in health IT are running heath IT. One impact is a high failure rate for EHR implementations [1]. By analogy, in the field of Amateur (“ham”) Radio, I am among an uncommon group of physicians who hold high-level radio telecommunications licenses from the FCC, the Extra class, obtained after a series of examinations. I have built, operated and repaired sophisticated and powerful radio transmitters, receivers and other equipment. I can set up an emergency station with local, regional and international coverage in a very short time and communicate readily with others if needed.

Even with this background, I would not for a moment believe I should be telling commercial broadcasters, emergency services, and the military how they should be implementing and operating their wireless technologies, or managing those functions. I do not have the level of training and experience necessary. In radio, I am an amateur, not a professional.

In Electronic Health Records (EHR’s) and related clinical IT, however, a wide variety of “amateurs”, including technologists, clinicians and politicians, are telling medicine - as a field - how to implement and operate this modern and increasingly important tool of the profession.

Those IT professionals with success in the business computing field, or clinicians with some knowledge (often self taught) about information technology, are not best equipped to manage the issues in health IT. These personnel are, consistent with my amateur radio analogy above, “amateurs” in such settings, if one is truly honest about it.

As in radio, this label is not meant in a pejorative way. It is simply reality. However, the results of such a leadership model are predictable.

In effect, every HIT delay, failure, or difficulty is simply a transfer of wealth from the healthcare sector to the technology sector with one root cause being an unlikely leadership model.

"Irrational exuberance" for any technology or innovation can create - as we have learned - massive unexpected problems. This is certainly the case in IT.

Considering the uncertain ROI and QI data about healthcare IT, questionable leadership models, current financial turmoil, local clinical IT problems paralleling the more widespread problems in the UK CfH program, and the many uninsured and medically underserved communities in the U.S., I wonder if national EMR's may be an unwise pursuit in the U.S. at this time. Perhaps a moratorium on large scale healthcare IT efforts in the U.S. is warranted.

Such a move might also allow time to objectively and scientifically resolve some of the above issues.

This will certainly be an issue for the new U.S. administration.

Billions of dollars that might be spent on IT misadventure in a time of unprecedented national financial challenges and hardships might perhaps be better spent for the time being on delivery of needed medical services, health insurance and other "safety net" interventions.

-- SS

Note:

[1] Market Barriers and Challenges to Widespread Adoption of Health Information Technology. U.S. Office of the National Coordinator for Health Information Technology (accessed Nov. 13, 2008).

SEEDIE, the Society for Exorbitantly Expensive and Difficult to Implement EHR’s, and commercialized VistA, the possible Linux of Health IT

While I have nothing to do with the following sites, they contain in a dark-humor sort of way a lot of truths about the current state of the commercial EMR vendor marketplace:

SEEDIE, the Society for Exorbitantly Expensive and Difficult to Implement EHR’s

also see

EXTORMITY, the first Seedie-certified EMR from the electronic health records mega-corporation dedicated to offering highly proprietary, difficult to customize and prohibitively expensive healthcare IT solutions.

I became aware of these sites when I presented this week at the 2nd WorldVistA Educational Conference at Robert Morris University in Pittsburgh. VistA is the VA's home-grown (over a few decades) EMR system, and is EMR the way EMR would have gone if the "medical industrial IT complex" had not intervened. VistA's source code is free, as it was developed via taxpayer dollars, and is being modified for commercial environments. WorldVistA's version is already in use in a number of sites in the US and in other countries and is perhaps the 1994-phase "Linux" of the HIT world.

WorldVistA was formed to extend and collaboratively improve the VistA electronic health record and health information system for use outside of its original setting. The system was originally developed by the U.S. Department of Veterans Affairs (VA) for use in its veterans hospitals, outpatient clinics, and nursing homes. WorldVistA has a number of development efforts aimed at adding new software modules such as pediatrics, obstetrics, and other functions not used in the veterans' healthcare setting.

A functional demo of VistA's Computerized Patient Record System (CPRS) is available, courtesy of the U.S. government here (PC only, unfortunately).

I consider this growing open-source HIT movement fascinating. I believe that growing problems and dissatisfaction with commerical EMR's and more importantly, business IT culture as parodied in the Seedie/Extormity links above may seriously delay the spread of effective clinical IT, or even kill current enthusiasm for clinical IT altogether.

I also believe the unimaginative, process over results, tightfisted control, bureacratic "data-processing" culture of the business IT (management information systems) world to be the lineal descendant of IBM's patchcord plug-panel programmed, card tabulating machines from which IBM made a large portion of their profit in the days before the electronic computer. You perhaps required such a culture when you were running huge businesses from stacks of tens of thousands of punched cards. However, such a model does not work well in meeting the information needs of clinical medicine.

From The Tabulating Machine Company to IBM: [Census tabulating pioneer Herman] Hollerith's company, the Tabulating Machine Company, rented out machines to other customers both government (Austria, Canada, France, Russia) and private (New York Central RR, Marshall Fields, Penn Steel). The company was profitable but due to its policy of renting instead of selling machines, it had cash flow problems. The Tabulating Machine Company merged in 1911 with 3 other companies, International Time Recording Co, Bundy Manufacturing, and Computing Scale of America to become Computing Tabulating Recording Company. In 1924 its name was changed to International Business Machines - IBM.

Hollerith Type III Tabulator with its control panel exposed. Photo: MNRAS, Vol.92, No.7 (1932). Click to enlarge.

(These machines also help explain why the ENIAC, the behemoth characterized as the first fully electronic computer, was programmed with patchcords. The paradigms of the electromechanical tabulators were reproduced with the much faster vaccuum tube technology. )

Medical informatics, a pioneering field, in many ways saw the electronic computer not as a card-based data processing machine but as a canvas for development of creative works to serve the needs of clinical medicine and its practitioners.

Severe delays in or abandonment of current HIT efforts due to expensive failures and lack of ROI would be a shame, because clinical IT at this point in time has finally attained the capability to provide the many benefits that have been promised about it for the past few decades - but only if done well -- and the definition of "well" in this context is a very long essay in itself.

At best while not a panacea, at worst clinical IT can and does impair the quality of care if done poorly, and wastes significant capital and expense that healthcare can ill afford.

Finally, my presentation at the WorldVista meeting entitled "Open Source and an End to Vendor Hegemony: Why This is Essential to HIT Success" is here (zipped Powerpoint).

-- SS

"I hope that some day you get your wish"

The HISTalk site, a popular, vendor-supported health IT "gossip" site, has a different standard for its reader comments than HC Renewal, allowing anonymous ad hominem and other forms of hysterical or irrational argumentation to be posted without refutation by the site owner.

In a way, this is good, because such posts may reveal sentiments held by a number of people but rarely expressed, except in an anonymous forum.

With regard to the thread I mentioned in my HC Renewal post "Physician Stereotypes and the Failure of Health IT", there have been some very interesting followup comments made. The following raised my eyebrows:

Followup from "Preston", who alleges "I have a music education degree and a Master of Healthcare Administration and I serve as an IT director for a health plan", and who as I mentioned in the earlier post paternalistically "values my medical staff for the value they bring":

... the “wisdom” that pervades your posts is a sense of victimhood…that the high failure rates in IT (please acknowledge that medicine has a 100% failure rate at keeping people alive for their desired lifespan) are due to the mystical idea that physicians have been forced to depend on IT experts to assist them with IT issues.

So, physicians and others who speak out on HIT issues in the interest of patient care are merely expressing "victimhood" (this does not seem to reflect very good reasoning), and the other statement about medicine's 'failure rates' is at best some odd, irrelevant comparison (akin to "a hundred dollars is a good price for a toaster, compared to buying a Ferrari.") I cannot even parse the meaning of the final passage in the comment.

In another comment a poster "TraynorMD" (I somehow find it doubtful this person is actually an MD) offers this hysterical, anti-intellectual, ad hominem laden comment:

Hmm - a non-practicing MD who, despite a long list of what he deems essential but unfairly ignored industry credentials, can’t seem to hold a job for very long? He’s not doing informatics physicians any favors with his whining diatribes that always end up congratulating himself for his own wonderfulness. I’m sure that’s why he can’t stand the idea of a CIO getting and holding a job based on accomplishment instead of argumentative resume-brandishing. We should be hearing from those out there getting the work done, not loudmouth bystanders.

Ironically, in the very same blog which generated the discussion thread is a link to the story of the New Zealand hospital whose IT debacle nearly killed people and caused a senior physician there to tell the press the hospital "could not guarantee patient safety."

While I sincerely hope the views I reposted above are a minority in the health IT world, they are reminiscent of feedback people who write about HIT problems receive, and not always anonymously (e.g., Ross Koppel's study on CPOE being called "disingenuous" by those with industry interests). They are certainly consistent with views I saw displayed as a CMIO myself by some MIS department staff, often in behind-closed-doors chatter by people who forgot that "in hospitals, the walls have ears."

Someone should please tell me why clinicians would want people of such anti-intellectual views and/or poor reasoning skills to be anywhere near systems upon which patient care depends.

At least the first poster admits this:

We get it. You would like for clinical IT specialists to be escalated to positions of leadership. That sounds great and I hope that some day you get your wish.

"We", I imagine, refers to non-clinicians in HIT, and I can only imagine this statement was made without much enthusiasm.

Finally, I want to make the point that I find the resistance in IT circles towards leadership of clinical IT by qualified biomedical informatics professionals quite puzzling. It's not as if the latter want to run the entire IT shop including business IT, just provide leadship in clinical IT.

It's a true win-win situation, after all. CIO's and other IT personnel get reduced job stress and perhaps longer tenures due to the expertise and presence of a cross-disciplinary intermediary between clinicians and IT (it's been said that in healthcare, CIO="career is over", as average job tenure is just a few years). Biomedical informatics professionals get to leverage their expertise and the sacrifices they made in pursuing additional training. The healthcare system benefits from improved HIT and less costly HIT errors, difficulties and failures.

And last (but certainly not least), patients benefit.

-- SS

On the Pitfalls of Going Electronic: Should Physicians Reject Hospital EMRs?

Yes, I believe they should, and with a spine, especially when they're lousy and their design and implementation have been led by people with superficial "certification" and/or no clinical credentials whatsoever. And sometimes no discernible IT credentials, either, unless you consider the "school of hard knocks" a credential.

(More on the credentials issue below. Also see my website "Common Examples of Healthcare IT Difficulties" for more on these issues.)

A viewpoint article was just published in the NEJM by Harvard physicians Pamela Hartzband, M.D. and Jerome Groopman, M.D. entitled "Off the Record — Avoiding the Pitfalls of Going Electronic" (NEJM 358:1656-1658, April 17, 2008).

The authors note:

... The ultimate goal of the electronic medical record — a technological solution being championed by the Bush administration, the presidential candidates, and New York Mayor Michael Bloomberg, as well as Google, Microsoft, and many insurance companies — is to make all patient information immediately accessible and easily transferable and to allow its essential elements to be held by both physician and patient. The history, physical exam findings, medications, laboratory
results, and all physicians' opinions will be collected in one place and available at a single keystroke. And there is no doubt that these records offer many benefits. We worry, however, that they are being touted as a panacea for nearly all the ills of modern medicine. Before blindly embracing electronic records, we should consider their current limitations and potential downsides.

As we have increasingly used electronic medical records in our hospital and received them from other institutions, we've noticed several serious problems with the way in which notes and letters are crafted. Many times, physicians have clearly cut and pasted large blocks of text, or even complete notes, from other physicians; we have seen portions of our own notes inserted verbatim into another doctor's note. This is, in essence, a form of clinical plagiarism with potentially deleterious consequences for the patient.

Residents, rushing to complete numerous tasks for large numbers of patients, have sometimes pasted in the medical history and the history of the present illness from someone else's note even before the patient arrives at the clinic. Efficient? Yes. Useful? No. This capacity to manipulate the electronic record makes it far too easy for trainees to avoid taking their own histories and coming to their own conclusions about what might be wrong. Senior physicians also cut and paste from their own notes, filling each note with the identical medical history, family history, social history, and review of systems. Though it may be appropriate to repeat certain information, often the primary motivation for such blanket copying is to pass scrutiny for billing. Unfortunately, these kinds of repetitive notes dull the reader, hiding the important new data.

Writing in a personal and independent way forces us to think and formulate our ideas. Notes that are meant to be focused and selective have become voluminous and templated, distracting from the key cognitive work of providing care. Such charts may satisfy the demands of third-party payers, but they are the product of a word processor, not of physicians' thoughtful review and analysis. They may be "efficient" for the purpose of documentation but not for creative clinical thinking.

In effect, the doctors have keenly observed that not only do EMR's impair documentation and thinking by seasoned professionals, especially those pressed for time, but the use of these technologies impairs the training of the next generation of physicians. I benefited much through learning how to properly document medical observations, findings, differential diagnoses, treatment plans, and other high level cognitive processes. IT designed by non clinicians with the maintenance of payor profit as a principal motivator may be, in effect, causing a further dilution in the quality of medical training. Social informatics predicts such unexpected adverse outcomes of any new information and communications technology (ICT).

However, the current environment of irrational exuberance over Health IT, as well as the potential for capital transfer from the healthcare to the IT and payer sectors and the motivators and conflicts this generates among hospital management, consultants, regulators and others, has had a marked blinding effect.

The NEJM authors also note:

Similarly, electronic medical records can reproduce all of a patient's laboratory results, often dropping them in automatically. There is no selectivity, because it takes human effort to wade through all the data and isolate the information that is pertinent to the patient's current problems. Although the intent may be to ensure thoroughness, in the new electronic sea of results, it becomes difficult to find those that are truly relevant.

A colleague at a major cancer center that recently switched to electronic medical records said that chart review during rounds has become nearly worthless. He bemoaned the vain search through meaningless repetition in multiple notes for the single line that represented a new development. "It's like `Where's Waldo?'" he said bitterly. Ironically, he has started to handwrite a list of new developments on index cards so that he can refer to them at the bedside.

...The worst kind of electronic medical record requires filling in boxes with little room for free text. Although completing such templates may help physicians survive a report-card review, it directs them to ask restrictive questions rather than engaging in a narrative-based, open-ended dialogue. Such dialogue can be key to making the correct diagnosis and to understanding which treatment best fits a patient's beliefs and needs.

... These problems, we believe, will only worsen, for even as we are pressed to see more patients per hour and to work with greater "efficiency," we must respond to demands for detailed documentation to justify our billing and protect ourselves from lawsuits. Though the electronic medical record serves these exigencies, it simultaneously risks compromising care by fostering a generic approach to diagnosis and treatment.

I agree with these assessments, especially for hospital based enterprise EMR's forced on doctors by management.

Physician leadership of HIT projects would be of great benefit. However, here's what typical healthcare organizational leaders have to say about physician leadership of HIT initiatives, in this case Denis Baker, the CIO of Sarasota Memorial Hospital, a major medical center on the Gulf Coast of Florida in an interview here:

I think that physicians bring a certain aspect to the job, but I don’t think they necessarily know how a hospital works. I think they know how their practice works and how they interact with the hospital, but I don’t think they absolutely know what nursing does, or any of the ancillary departments, and what they do.

Worse, as far as I can tell, the CIO making that statement appears to lack formal education in medicine, information systems, information technology and biomedical information science i.e., informatics. (I was unable to find any such credentials but will correct this if mistaken.)

Stereotypes of physicians do not come any more patronizing than that.

Oh, wait ... yes they do.

His statement is little different than a decade ago when I wrote this essay about stereotypes and observed others in influential positions holding marginalizing views of physicians - and indeed of professional education of any kind:

Several healthcare MIS Recruitment firms have published interesting views on healthcare MIS leadership, views that most clinicians will not identify with. " I don't think a degree gets you anything ," says healthcare recruiter Lion Goodman, president of the Goodman Group in San Rafael, California about CIO's and other healthcare MIS staffers.

Healthcare MIS recruiter Betsy Hersher of Hersher Associates , Northbrook, Illinois, agreed, stating " There's nothing like the school of Hard Knocks ." (Who's Growing CIO's, Healthcare Informatics, Nov. 1998, p. 88).

In seeking out CIO talent, recruiter Lion Goodman " doesn't think clinical experience yields [hospital] IT people who have broad enough perspective . Physicians in particular make poor choices for CIOs. They don't think of the business issues at hand because they're consumed with patient care issues ," according to Goodman.

It appears there's been little change in ten years.

Oh, wait ... yes there has been "change."

"Specialists" and "managers" in HIT projects now undergo certification by vendor-centric groups such as the Health Information Management Systems Society HIMSS.

Here's a description of the value of certication as a HIMSS Certified Professional in Healthcare Information and Management Systems (CPHIMS):

CPHIMS status provides both internal and external rewards. As a Certified Professional in Healthcare Information and Management Systems, you:

• Distinguish yourself from your peers as certified in healthcare information and management systems;
• Expand your career opportunities;
• Signal that you have mastered proven, broad-based concepts through successful completion of the Certified Professional in Healthcare Information and Management Systems Examination;
• Provide yourself with skills and tools to help you make a difference in your career, your organization, and your community;
• Enjoy the pride of recognition of knowing that you are among the elite in a critical field of healthcare; and
• Have a premier credential based on a sound assessment to distinguish yourself in an increasingly competitive marketplace.

Wow! "You are among the elite" after taking this exam!

Here are the eligibility standards:

Baccalaureate degree plus five (5) years of associated information and management systems experience*, three (3) of those years in healthcare.

Graduate degree plus three (3) years of associated information and management systems experience*, two (2) of those years in healthcare.

*Associated information and management systems experience includes experience in the following functional areas: administration/management, clinical information systems, e-health, information systems, or management engineering.

And now, the certification instrument:

The CPHIMS credential is awarded to individuals who demonstrate eligibility for the Certification Program and who successfully complete a qualifying examination. The examination consists of 115 multiple-choice test items, presented during a 2-hour session. Scoring is based on 100 items pre-selected for desirable psychometric characteristics. The additional 15 test items are included as pretest items. Performance on pretest items does not affect a candidate’s score.

That is the certification that will be used to hire more "experts" in HIT.

This is pathetic. My exams to become a licensed ham radio operator were more challenging. I consider such a credential unmeritorious at best, fraudulent at worst. (I haven't even inquired as to costs.)

However, medical credentialing exams are just a bit more thorough.

By several orders of magnitude, that is.

In conclusion, medicine is in very sad shape when in an era of out of control technology costs ($100 million for an EMR?), unclear benefit and irrational exuberance over HIT it's demanded of physicians that they use tools designed by business IT personnel, processes and methodologies best known for failure, produced by an industry rife with conflicts, whose leaders often lack substantive credentials, patronize those who do, produce ill-conceived and/or shoddy products whose use is mandated by non-clinician hospital managers and that as the NEJM writers note, impair medical practice and education.

-- SS