More On Healthcare Management By Domain Neutral Generalists: CIO's Running Hospital Pharmacies and Home Healthcare Divisions?

Both Roy Poses and I have written on a plague of healthcare mismanagement and perhaps malfeasance in part due to leadership by domain amateurs, i.e., healthcare leadership profoundly lacking in biomedical education and experience.

Examples of recent posts about the risks posed by domain neutral biomedical leadership are:

"NY Times Proclaims Anyone Can Run a Health Care Organization with a Little Studying Up" (Poses)

"Health Care Leaders: Don't Know Much About Health Care" (Poses)

"On Optimal Expertise for Leadership in Biomedicine" (me)

"Informatics, or Infomagic? Health IT Cannot Flourish When Everybody is an Expert" (me)

and "Pfizer/Wyeth Merger And Sacrificing The Future: Laying Off Scientific Staff All Over The Place" (me).

I have also written of a cross-occupational invasion of healthcare by the IT profession, in the form of power and territorial grabs over clinicians with regard to the tools clinicians increasingly need in order to provide patient care.

These leadership inversions, where domain neutral personnel are viewed as best able to lead any endeavor as if the world consists of interchangeable, faceless resources following equally interchangeable processes, are due to attitudinal laxity and permissiveness on the part of medical leadership, a takeover of healthcare by those with primary pecuniary interests, and perhaps a lack of appreciation for the value of domain expertise as sign of a waning western culture.

In a recent hospital CIO interview, in this case of CIO Avery Cloud at New Hanover Regional Medical Center in Wilmington, NC, we see both of these elements - supportive views towards healthcare leadership by domain amateurs, and towards a cross-occupational invasion of healthcare by IT personnel - combined:

Q: Is that inherent in their background, though, when you’ve got a lot of folks who worked to move their way up through IT, which is the argument of “are you better off with someone who’s risen through the IT ranks”, or better off to get a visionary who just lets other people worry about the nuts and the bolts?

A: That’s an interesting debate. I’ll just tell you about me: I came up through the technical ranks. I hold an MBA, but more importantly, I have an affinity to business. When people ask me about me and my job, I tell them I’m a business person who just happens to know IT.

I’d like to think that I could run any of the departments in this hospital [wow - ed.] A good example is that nobody is surprised when the CFO runs the pharmacy department [i.e., nobody in this CIO's limited circles - ed.], or the CFO runs materials management. It should be no big surprise either that the CIO can do the same, or does the same [In fact, it likely would be a big surprise to many -ed.] A very good friend of mine in another hospital — he’s the CIO there — runs the pharmacy down there. Another friend of mine who’s a CIO runs the home care division [this is, in fact, stunning and should be a cause of great concern to healthcare regulators if true - ed.]

I'm sure CIO's would like to think that they could "run any of the departments in a hospital."

(How about: Legal? Risk management? Health Information Management a.k.a. Medical Records? Biomedical engineering? Nursing? Trauma? Diagnostic Imaging? Neurosurgery?)

The question is this: is this a realistic view? Or, is it an extreme form of hubris and the Dunning Kruger effect? Can they run complex departments far outside their core competencies optimally? Or will they more likely be running an area they know little about by the seat of their pants?

Further, do leadership roles in organizations such as NIH or the Centers for Disease Control call merely for an MBA and domain neutral backgrounds? If not, why not?

Why are hospitals exempt from a requirement for domain specific expertise in their leadership?

As to CIO's (and, for that matter, CFO's) running hospital pharmacies, let's show the knowledge gaps graphically by first exploring the prerequisite training of a typical Pharm.D. pharmacist:

Professional Degree (Pharm.D. Degree) Curriculum
Class of 2011, 2012, & 2013
(Admitted Fall 2007, 2008 & 2009)

First Year, Fall Semester

NBAN 301	Principles of Human Anatomy	3 credit hours
PSIO 743	Fundamentals of Physiology	5 credit hours
PHAR 700	Pharmacy as a Profession	1 credit hour
PHAR 701	Pharmaceutical Care Lab 1	2 credit hours
PHAR 702	Physical Pharmacy	3 credit hours
PHAR 703	Intro Pharmacy Practice Experiences 1	1 credit hour
PHAR 720	Patient Health Education	2 credit hours
	Total hours	17 hours

First Year, Spring Semester

BIOC 531	General Biochemistry	4 credit hours
PHAR 708	Pharmaceutics	3 credit hours
PHAR 709	Immunology and Biotechnology	2 credit hours
PHAR 710	Intro Pharmacy Practice Experiences 2	1 credit hour
PHAR 711	Chemical Properties of Drugs	2 credit hours
PHAR 712	Pharmaceutical Care Lab 2	2 credit hours
PHAR 737	Disease Prevention and Health Promotion	2 credit hours
	Elective	2-3 credit hours
	Total hours	18-19 hours

First Year, Late Spring – after spring term concludes

PHAR 714

Introductory Community Rotation (2 weeks)

2 credit hours

Second Year, Fall Semester

PCOL 743	Pharmacology 1	3 credit hours
PHAR 715	Pathophysiology & Therapeutics 1	4 credit hours
PHAR 716	Chemistry of Drug Action 1	3 credit hours
PHAR 717	Intro Pharmacy Practice Experiences 3	1 credit hour
PHAR 723	Pharmaceutical Care Lab 3	1 credit hour
PHAR 727	Medical Literature Evaluation	2 credit hours
	Elective	2-3 credit hours
	Total hours	16-17 hours

Second Year, Spring Semester

PCOL 744	Pharmacology 2	3 credit hours
PHAR 719	Intro Pharmacy Practice Experience 4	1 credit hour
PHAR 724	Pharmaceutical Care Lab 4	2 credit hours
PHAR 725	Pathophysiology & Therapeutics	4 credit hours
PHAR 726	Chemistry of Drug Action 2	2 credit hours
PHAR 728	Pharmacy Management	2 credit hours
	Elective	2-3 credit hours
	Total hours	16-17 hours

Second Year, Late Spring – after spring term concludes

PHAR 729

Introductory Institutional Rotation (2 weeks)

2 credit hours

Third Year, Fall Semester

PHAR 730	Pathophysiology & Therapeutics 3	4 credit hours
PHAR 731	Biopharmaceutics & Pharmacokinetics	3 credit hours
PHAR 732	Non-Prescription Drugs	3 credit hours
PHAR 733	Pharmacy Systems	2 credit hours
PHAR 735	Pharmaceutical Care Lab 5	1 credit hour
PHAR 742	Intro Pharmacy Practice Experiences 5	1 credit hour
	Elective	2-3 hours
	Total hours	16-17 hours

Third Year, Spring Semester

PHAR 734	Pharmacy Law and Ethics	3 credit hours
PHAR 736	Pharmaceutical Care Lab 6	1 credit hour
PHAR 738	Outcomes Assessment/Quality Improvement	2 credit hours
PHAR 739	Therapeutic Patient Monitoring	3 credit hours
PHAR 740	Pathophysiology & Therapeutics 4	4 credit hours
PHAR 741	Clinical Pharmacokinetics	3 credit hours
PHAR 746	Intro Pharmacy Practice Experiences 6	1 credit hour
	Elective	0-2 credit hours
	Total hours	17-19 hours

Fourth Year

Students complete eight five-week experiences beginning in the summer preceding their fourth year. Students will have required experiences, such as ambulatory care and acute care, and elective experiences.

Students are required to complete at least 10 professional elective hours selected from an approved course list during their first, second, or third professional year and prior to fourth year experiential rotations. With the exception of Fall semester in the first professional year, one elective can be taken each semester of the didactic program. Electives are intended to complement the required curriculum and allow students to select courses based on professional interests. Students wishing to take electives during summer terms may do so after their first professional year on any of the campuses in the WVU system (Morgantown, Parkersburg, Potomac State, West Virginia Tech) provided the courses are selected from the list of professional electives or are deemed equivalent by the University. Students wishing to receive course credit for courses taken outside of the WVU system must have pre-approval by the Curriculum Committee.

Of course, even assuming no requirement for a Dissertation defense (which is a typical Ph.D. requirement), the candidate needs to take state and/or federal exams for licensure:

Licensure. A license to practice pharmacy is required in all States, the District of Columbia, and all U.S. territories. To obtain a license, a prospective pharmacist must graduate from a college of pharmacy that is accredited by the ACPE and pass a series of examinations. All States, U.S. territories, and the District of Columbia require the North American Pharmacist Licensure Exam (NAPLEX), which tests pharmacy skills and knowledge. Forty-four States and the District of Columbia also require the Multistate Pharmacy Jurisprudence Exam (MPJE), which tests pharmacy law. Both exams are administered by the National Association of Boards of Pharmacy (NABP). Each of the eight States and territories that do not require the MJPE has its own pharmacy law exam. In addition to the NAPLEX and MPJE, some States and territories require additional exams that are unique to their jurisdiction.

(I can add that the typical M.D. curriculum, such as at the medical school I attended, is even more rigorous. That is prior to the medical internship, residency, and postdoctoral fellowship(s) most physicians also must perform, where they become intimately familiar with the services of many hospital departments).

Now, let's explore the comparable pharmacy science/biomedical training of the typical hospital CIO or CFO (or CEO for that matter):


(This, of course, is the mathematical symbol for the null set.)

For comparison and contrast, see Roy Poses' post "What is Not Taught About Leadership in Healthcare" for the healthcare MBA curriculum at a prominent School of Management, namely Yale's. Dr. Poses observed:

... So what is missing? There seem to be two obvious areas that are not taught.

The first is health care. There are only two courses in this curriculum on "healthcare policy" and "healthcare management." ... The second area missing is ethics, particularly the business ethics of health care. There are simply no courses even remotely related.

In the first of my posts linked above I wrote:

... Those in charge [and who lack domain credentials -ed.] cannot see that which the domain specialist sees.

They cannot see because they lack the training, experience, and what is described as 'meta-competence' (in this brilliant article on competence [the Dunning-Kruger effect - ed.]) essential to seeing that which is obvious. Obvious, that is, to those who do not lack these characteristics. In addition, I've also observed that some lack the fundamental analytical abilities essential to understanding and managing the complexities of biomedical R&D.

Why those without domain expertise are in charge of organizations whose long term viability depends entirely on the most advanced and creative pursuit of biomedical 'miracles' [i.e., pharma - ed.] is another matter. I won't address this here, other than saying it reflects the adverse consequences of a bias that has evolved in management "science."

That bias is the belief that all the world consists of faceless labor resources performing easily definable processes upon interchangeable widgets, and that management can therefore be done by generic managers, exclusively. Some of the world is like that [i.e., fast food chains - ed.], but some isn't, such as biomedical R&D. [And clinical medicine as well - ed.]

Management in the absence of domain expertise in this industry is, in fact, mismanagement.

There is nothing here to spin, there is nothing to debate. There is nothing to discuss. This is a first principle.

Failure to accept this reality results in corporate failure.

These views apply to hospitals perhaps even more critically than to biomedical R&D. In hospitals, mistakes in judgment can result in great patient harm, and far more rapidly than in an R&D organization.

Finally, in the same CIO interview there's this:

Q: If you’re talking to your CIO peers, what would you tell them is the key to know that you need to have this done and the thoughts to entertain before they start?

A: I think, you know, customer’s king. The key is to evaluate the customer’s level of satisfaction with services being provided. You can’t do that without getting very involved and face to face with the customers. So that’s number one ... So I think that is really what IT leaders have got to strive for, the user viewpoint, the user view of the services that IT provides.

The fact that this "customer is king" advice seems to merit constant repetition among healthcare IT leadership circles, especially when the “customers” are clinicians with patient care obligations and responsibilities, should be a cause of deep reflection and introspection among those in HIT. At the very least, they need to ask themselves - and healthcare professionals need to ask them - "who are you, and what are your motives for stepping foot in our hospital?"

It is also such a fundamental first principal that its frequent repetition suggests typical hospital CIO's are not truly fit in 2009 to lead anything in healthcare where domain expertise and viewpoints are essential, healthcare IT included. Its need for frequent repitition - dating to many HIT publication I've seen since I entered the Medical Informatics field professionally in the early 1990's - suggests they don't truly recognize that the business of hospitals is taking care of patients, the clinicians being the enablers of that business, everyone else being facilitators. The known problems and failure rates of heath IT in hospitals is corroborative of that view.

Healthcare reform will certainly require healthcare leadership reform, and the first task of that reform should be a re-evaluation of expertise required to tamper with people's lives and well being in a hospital setting.

-- SS

Cross-occupational invasion of medicine by IT, exemplified

I have written on these pages about a cross-occupational invasion of medicine by IT personnel, wherein the IT personnel seem to forget that they are facilitators of healthcare, not enablers, with a primary purpose of serving the needs of clinicians.

The HISTalk site recently posted an attorney's views on the "hold harmless" and "defects nondisclosure" controversy first reported on by Koppel and Kreda in JAMA, and amplified in my letter to the editor in the same publication. The attorney's views at HISTalk (link below) are quite reasonable regarding such practices.

However, the user comments thread reveals some attitudes exemplifying the "invasion" of which I've written. Both the attorney's post and the responses by a poster under the nom-de-blog "Programmer" to others' concerns can be read at this link.

Read it all. The attitudes of "Programmer" (assuming they are genuine, which is likely) are remarkable.

-- SS

The Machinery Behind Healthcare Reform: How the HIT Lobby is Pushing Experimental and Unsafe Technology on Unconsented Patients and Clinicians

(To those who linked here from "The Health Care Blog", see my footnote at the end of this post. Also, I suggest readers at least peek at each and every hyperlink I've placed in this essay. It takes time, but it's illuminating - ed.)

In many past posts on Healthcare Renewal I have commented on a bewildering healthcare and IT industry blindness to a growing body of literature and experiences of those "in the trenches" that throw doubts upon Utopian views of health IT as a panacea for healthcare's problems. Those responsible for this literature advise caution and the highest levels of scientific rigor in the large scale adoption of clinical information technology if that technology is to actually improve healthcare, myself included. We know the difficulties and risks. Bad healthcare informatics wastes money and distracts clinicians. Bad healthcare informatics can kill. "Primum non nocerum" is a critical ideology in health IT.

I first wrote about these observations a decade ago and was merely standing on the shoulders of those who preceded me with their own critical thoughts and observations regarding cybernetic miracles in medicine.

I've also been puzzled about the sudden lurch by the current administration to commit tens of billions of dollars to national HIT, along with eventual penalties for resistance, within the ridiculously short time frame of 2014 and with little public discussion. The provisions seemed to simply "appear" in H.R. 1 EH, a.k.a. the Economic Recovery Act of 2009. I wrote about this here.

Finally, I was curious about the timing of a remarkable set of reports from highly respected U.S. organizations on HIT issues, such as a Dec. 2008 Sentinel Events Alert from the Joint Commission and a Jan. 2009 report from the U.S. National Research Council. What motivated their release?

The answers to these questions have become bit clearer via a remarkable article from the Washington Post. It reveals an administration heavily influenced by - no surprise - powerful industry lobbyists. (I thought this administration had pledged a different mode of government conduct, but as has been said, campaigning is done with poetry, and governing is done with prose.)

Here is an interesting explanation of how medicine has been cross-occupationally invaded by the IT industry, probably ten or more years before that industry really has the depth of understanding, depth of talent and capabilities to make useful, usable, safe, and cost effective national health IT a reality:

The Machinery Behind Health-Care Reform
How an Industry Lobby Scored a Swift, Unexpected Victory by Channeling Billions to Electronic Records

By Robert O'Harrow Jr.
Washington Post Staff Writer
Saturday, May 16, 2009

When President Obama won approval for his $787 billion stimulus package in February, large sections of the 407-page bill focused on a push for new technology that would not stimulate the economy for years.

The inclusion of as much as $36.5 billion in spending to create a nationwide network of electronic health records fulfilled one of Obama's key campaign promises -- to launch the reform of America's costly health-care system.

But it was more than a political victory for the new administration. It also represented a triumph for an influential trade group whose members now stand to gain billions in taxpayer dollars.

A Washington Post review found that the trade group, the Healthcare Information and Management Systems Society (HIMSS), had worked closely with technology vendors, researchers and other allies in a sophisticated, decade-long [lobbying] campaign to shape public opinion and win over Washington's political machinery ... At the center of those efforts is the Healthcare Information and Management Systems Society. Started a half-century ago, it represents 350 companies and about 20,000 members. Corporate members include government contractors such as Lockheed Martin and Northrop Grumman, health-care technology giants such as McKesson, Ingenix and GE Healthcare, and drug industry leaders, including the Pharmaceutical Research and Manufacturers of America.

With financial backing from the industry, they started advocacy groups, generated research to show the potential for massive savings and met routinely with lawmakers and other government officials.

A lot of voices were left out of that trade group's lobbying, including the open source EHR proponents following the traditions of the VistA effort, as one can learn about in the book "Medical Informatics 20/20" by VA pioneers Goldstein, Groen et al. These traditions are largely alien to the commercial IT sector as evidenced by the mission hostile clinical IT products they put out (see my series on that issue starting here) and even known grossly defective software for use on live patients.

The HIMSS trade group's massive conflicts of interest also seem to have blinded it to the longstanding concerns of many experts in medical informatics, social science and related fields that current approaches to health IT are insufficient and may impair healthcare quality initiatives (let's be frank about what that really means - it means patient harm).

The creation of advocacy groups backed by industry financing also seems eerily similar to many stories on HC Renewal and other blogs about the pharmaceutical industry, as does "generated research." That "research" may also have been industry funded, and it is my belief the impartiality and soundness of such research needs to be critically and impartially re-examined.

Their proposals made little headway in Congress, in part because of the complexity of the issues and questions about whether the technology and federal subsidies would work as billed.

In other words, Congress was doing its job regarding lobbying by proponents of an experimental technology in which they had a major financial stake. Until...

As the downturn worsened last year, advocates helped persuade Obama's advisers to dust off [i.e., uncritically accept lock, stock and barrel - ed.] electronic records legislation that had stalled in Congress -- legislation that the advocates had a hand in writing, the Post review found.

Their sudden success shows how the economic crisis created a remarkable opening for a political and financial windfall: the enactment of a sweeping new policy with no bureaucratic delays and virtually no public debate about an initiative aimed at transforming a sector that accounts for more than a sixth of the American economy.

Let me add that while the advocates "had a hand" in writing the legislation [i.e., they wrote the legislation - ed.], researchers and critical thinkers regarding the downsides of health IT industry in its present state seem to have had little voice in this legislation.

"It was perhaps a once-in-a-generation opportunity to make something happen," said H. Stephen Lieber, the trade group's president. Obama "identified the vehicle that he could use to move his policy agenda forward without the crippling policy debate."

I find this simply outrageous. The reason for policy debates in healthcare and especially healthcare IT is to avoid crippling or killing patients.

Lieber is not a clinician. Who is he to cheer (and perhaps to have spearheaded) the short circuiting of "policy debate" on health IT? According to his bio, he holds an MA from the School of Social Service Administration at the University of Chicago, a BA in Psychology from the University of Arkansas, and has completed additional course work at the graduate schools of business at both universities and at the Keller Graduate School of Management.

... Many technology advocates, including health policy specialists, say that networked electronic patient records that can be transmitted instantly would make health care more efficient and provide valuable insights about costs and care.... Some advocates also say the savings could amount to tens of billions of dollars each year from reduced paperwork, faster communication and the prevention of harmful drug interactions. An equally important benefit, they say, could be to enable researchers to determine the most effective procedures for an ailment. Such an approach would rely on unprecedented data-mining into medical records and the practices of doctors, a kind of surveillance that also would enable insurers to cut costs by controlling more precisely the care that patients receive [Leading to rationing to increase profits? - ed.]

These assertions have never been proven in a scientifically robust manner. Further, there is a growing body of literature expressing significant doubts about these predictions of cybernetic miracles from health IT (see short partial lists of examples here and here) that has largely been ignored - in the worst traditions of pseudoscience and scientific fraud - by the industry and its lobbyists. In fact, the latter assertion - comparative effectiveness research based on EHR data - may have moved from scientific possibility (e.g., better detection of major adverse drug and therapy events) to anti-scientific pipe dream, as in my essay "Have we suffered a complete breakdown in the scientific method with regard to EHR and clinical IT?" I am not even considering massive potential for abuses created by online national health records.

"Finally, we're going to have access to millions and millions of patient records online," said Blackford Middleton, a physician, Harvard professor and chairman of the Center for Information Technology Leadership, whose studies have concluded the health-care system could save $77.8 billion each year through the universal use of information technology networks. "This is the biggest step for health-care information technology in this country's history."

But others said the case was far from being so clear. Some observers said the projected savings are overly optimistic and that launching such vast computer networks under tight deadlines is risky, a lesson learned by the Bush administration when it botched a variety of homeland security systems rushed into place after the Sept. 11 terrorist attacks.

While I respect Blackford Middleton as a former leader of the EHR company from which I selected the EHR for Christiana Care Health System in the late 1990's, I also respect those "others" who say the case is far from clear. It is through science and an open political process that such debates need to be resolved, not through lobbying and utopianism. The potential for adverse, unexpected consequences in such a major social re-engineering effort are simply too great for cavalier attitudes or utopianism. We are already seeing adverse consequences - just the most recent examples are here and here.

Industry "roll out HIT no matter what, patient and clinician informed consent be damned" attitudes also teeter on the precipice of human rights violation. In fact, the corporatization of health IT and the treatment of health IT as if it were any other IT not involving third parties with special rights (i.e., patients) may have already resulted in serious breaches of hospital executive fiduciary responsibilities towards safety and (in the U.S.) of their Joint Commission safety standards obligations as well; see my essay here.

Some proponents said they worry that an over-reliance on technology as a solution could distract the health-care system from difficult questions about quality of care. They said efforts to find a quick technological fix will likely run up against complex cultural challenges.

The latter quote sounds like me, stating the obvious. Allow me to translate the applied, real world meaning of "cultural challenges." It means increased political infighting between stakeholders, power grabs, distractions and chaos on the medical floor and in the medical office, and other social and political upheavals within medicine that will likely distract from the ability of already harried clinicians to provide care.

"I would like to believe that the effective use of technology to augment health care will lead to substantial savings and improvements in the quality of care," said Mark Frisse, a physician and professor of biomedical informatics at Vanderbilt University, who leads an electronic health record program in Nashville. "But the evidence does not consistently bear this out."

Dr. Frisse is quite correct, although I would add that the evidence that does not bear out these beliefs is many, many times stronger than that which, say, caused VIOXX to be pulled off the market.

"HIMSS has a very effective grass roots advocacy program that reaches all levels of government," Dave Roberts, a senior executive, said in the group's literature... HIMSS has a "strategic alliance" with the Center for Information Technology Leadership, a nonprofit that produces research reports -- which HIMSS prints and distributes to Congress and elsewhere.

I agree with that description. Missing from the description, and one I would not add, is a "scientific organization."

After volunteering on John Kerry's presidential campaign in 2004, [now-chairman of the board of HIMSS and their ally, the Center for Information Technology Leadership] Middleton said he was recruited as an Obama volunteer last year and provided information about electronic records to the candidate's health-care policy group. Middleton said he worked with several campaign officials, including David Blumenthal, a colleague at Partners HealthCare and a Harvard professor, who was Obama's health-care adviser and is now the administration's national coordinator for health technology.

"We didn't have to go very far to get our information," said one senior Obama adviser, who was not authorized to speak publicly and discussed the campaign on the condition of anonymity. Blumenthal "taught all the rest of us everything we know."

He may have taught them "everything they know", but he apparently did not teach them everything that is important to know. Obama's team has seemingly thrown a significant body of literature on HIT drawbacks and risks under the bus. This is the essence of scientific naïveté and quackery.

Middleton said he provided many of those details.

"I sent them a LOT of stuff, many papers and most of the reports. I probably spoke or communicated with David Blumenthal, David Cutler (the health economist on the team), or Dora Hughes about every other week during the heat of the campaign," Middleton said in an e-mail.

While Blumenthal goes on in the article to minimize Middleton's influence, I can only wonder if any of the HIT industry lobbyists sent "this stuff" to the campaign.

The stimulus bill suggests that the government will recoup about a third of the spending allocated for electronic health records over the next decade, an assumption that some health-care observers question, in part because of a critical analysis by the Congressional Budget Office last year.

The CBO, then led by Orszag, examined the industry-funded study behind the $77.8 billion assertion, among other things, and concluded that it relied on "overly optimistic" assumptions and said much is unknown about the potential impact of health information technology.

I can add that not only is there much unknown about the potential, but there is much unknown about the true difficulties of making it all actually work as promised. See this seminal short article on why this is so.

This is a spectacularly poor way to run major national initiatives costing tens of billions of dollars and upon which patient wellbeing rides. Blindly.

Joseph Antos, a health-care policy specialist who has examined the legislation, said the risks of the technology plan are high because of the haste with which it is being implemented and the special interests seeking to profit from it.

"This is the real way things get done [and the "real" way true disasters such as our recent world wide financial chaos get initiated - ed.]," said Antos, of the American Enterprise Institute, a Washington think tank. "The stimulus bill looked like a bonanza to an awful lot of people." [I tend to take "awful lot of people" quite literally in this case.]

Haste is an understatement. A more reasonable timeframe might have been 2024, not 2014.

I can add that if this initiative blows up as it has in the UK, then the only triumph will be the financial triumph of the trade group and its apparatchiks. The losers will be the administration, patients, clinicians, and everyone else in the healthcare system. [6/29/09 addendum: it's worse than I thought. The UK's NPfIT in the NHS was suspected to have been doomed from the start, but proceeded anyway; see "16 key points in Gateway Reviews on NHS IT scheme" and the Gateway Reviews themselves, released under a UK FOI request - ed.]

In all seriousness, and with recognition of the harshness of this observation, I add that the patients who might die as a result of hastily and poorly designed and implemented health IT under this rushed "real way" initiative, will have in effect been murdered by this lobby.

-- SS

Footnote:

It is interesting to watch the "circling of the wagons" that is starting over the WaPO story. It is in fact predictable that ad hominem, distortion of views, etc. will follow. For example, Matthew Holt of The Health Care Blog, who writes (emphases mine):

I draw your attention to a troika of articles, all of which show how things can be slightly misinterpreted.

First, who knew that Blackford Middleton was either the most influential health policy wonk out there, or single-handedly responsible for the Haliburtonization of health IT? If you read the WaPo article about it, it looks as though there was some kind of terrible conspiracy to impose an evil fraud in terms of unnecessary health IT spending on the taxpayer. And for example MedinfomaticsMD over at Health Care Renewal (who appears to have jumped from the position that some health IT installations have real problems to the less tenable one that all EMRs kill) is just one going loopy about it.

"Loopy?"

Merriam-Webster:

Loopy:

1 : having or characterized by loops
2 : crazy, bizarre

— loop·i·ly \-pə-lē\ adverb

— loop·i·ness \-pē-nəs\ noun

Ad hominem (link) is no substitute for a logical argument, in fact it is a logical fallacy. Further, an over the top statement that I've "jumped to a less tenable position that all EMR's kill" is quite disappointing from someone who clearly has the intellect to know how amateurishly political an attack that is on a physician-informaticist in this field for almost two decades. One who is trying to take a strong pro-patient, ethical stance while balancing the need to develop safe and effective health IT along more reasonable timelines, and without the behind-the-scenes corporate influence we write about at Healthcare Renewal.

-- SS

Was Google lobbying Washington for HIPAA exclusion of their PHR effort?

At "Should Google Seek the Resignations of Those Responsible for This Healthcare IT Debacle?" I expressed great concern about what I term the cross occupational intrusion of the IT industry into healthcare.

My major concern in that post was how the information technologists at Google, even with nearly unlimited access to capital (and therefore to the world's informatics expertise) badly mismanaged a Personal Health Records (PHR) project through commission of a most fundamental biomedical information science blunder (quite distinct from IT; most IT technologists and MIS personnel really stink at biomedical information science). They tried to map relatively ungranular, imprecise, and often misused billing codes back to enduser-viewable diagnoses, resulting in easily predictable patient panic and mayhem.

As usual in HIT: it's possibly even worse.

I am quite concerned about a letter from the consumer education and advocacy organization Consumer Watchdog.org and their allegations that Google has been lobbying Congress to be excluded from HIPAA provisions on privacy and forbidding sales of medical records. The letter, dated April 22, is here (http://www.consumerwatchdog.org/resources/LtrSchmidt042209.pdf).

Considering that Google is heavily into the PHR space, and even worse, considering they made an Informatics 101 error in attempting to map billing codes into user-viewable diagnostic data, I would (and I'm sure others would as well) view such attempts if they indeed occurred as ominous, a true heavy handed intrusion of the IT industry not only into the affairs of medicine but into what really is another human rights issue. (I'd pointed out another potential HIT-related human rights issue at the post "UPMC as Proving Ground for IT Tests On Children".)

I would be interested in additional information on the Google lobbying issue, especially from those at Harvard and other academic centers who have been involved in the Google PHR initiative.

I have shared these concerns with the American Medical Informatics Association (AMIA) clinical information systems workgroup (cis-wg) and the people & organizational issues workgroup (poi-wg) as well.

I hope the Consumer Watchdog allegations are not accurate, because if they are valid, the implications of national EHR grow increasingly unsettling.

UPMC as "Proving Ground" for IT Tests On Children: Pioneers in Health IT, or Pioneers in Ignoring the Past?

Hospitals as a "Proving Ground" for tests of unproven health IT - upon children?

At my post "BusinessWeek on Health IT: The Dubious Promise of Digital Medicine" I began to discuss the responses made by health IT vendors and organizations regarding HIT problems and defects, raised in a very serious April 23, 2009 BusinessWeek article on these issues.

In this post I address the following claims regarding UMPC and a controversial Dec. 2005 article by a UPMC physician in the journal Pediatrics ("Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System", Yong Y. Han et al. -- my comments on this paper at that time were at this link).

BusinessWeek wrote:

... [HIT vendor Cerner] faced more questions over its technology at the University of Pittsburgh Medical Center (UPMC). In 2005 researchers there [i.e., Han et al. - ed.] found that at the university's Children's Hospital [note that this is a Children's Hospital - ed.], patient deaths more than doubled, to 6.6% of intensive-care admissions, in the five months following the installation of a computerized order-entry system. The research on child patient deaths at the University of Pittsburgh found a "direct association between [computerized records] and increased mortality," according to an article published in December 2005 in the medical journal Pediatrics. Digital technology slowed treatment in several ways, the researchers concluded. One example: Doctors and nurses in the intensive-care unit were accustomed to ordering medications and tests while a sick child was en route to the hospital.

The Cerner system required that orders be submitted only when the patient arrived, costing crucial time. The authors of the Pediatrics article acknowledged that their work clashed with other studies showing that digitization decreases errors and shortens hospital stays [but also is consistent with another body of literature (examples here) that Health IT vendors and others with conflicts of interest simply ignore, as per my numerous HC Renewal posts on the issue. Pharma should only have it as good - ed.]

G. Daniel Martich, chief medical information officer at UPMC, says the Pediatrics study was flawed. Factors other than the installation of computers, such as the centralization of pharmacy services, also disrupted care, he emphasizes. The problems identified in the 2005 paper have all been resolved, Martich adds. "There were workflow issues," he says. "We learned the hard way because we were pioneers." Over the long run, he says, technology has helped decrease mortality rates and cut medication errors in half at Children's Hospital since 2003 .

Again, I emphasize we are considering the healthcare of children in this matter.

Here are my observations and questions:

• Why is the 2005 paper simply being dismissed? This is not a scientific approach to the peer reviewed literature, especially where the deaths of children are concerned. I believed in 2005 and believe now that the red flags raised by this paper may have been "brushed under the carpet" too rapidly. See my 2005 post on the matter.

• The implication that the Cerner CPOE was uninvolved in the increased mortality would itself require a very careful observational study to ferret out the exact contributions of its deficits and that of the "centralization" of pharmacy services and other factors. Has such a study been performed and peer reviewed, and has a rebuttal been posted by the original study's authors? Can such a prospective study even be performed after the fact?
  

• While CMIO G. Daniel Martich claims "the problems in the 2005 paper have all been resolved" [wait - I thought the paper was flawed, yet it illustrated problems now resolved? - ed.], how can patients be assured of this? Where are the studies that show the issues have all been resolved?

• Does the damning commentary by the UK's former NHS HIT Director Richard Granger, stories such as patients going untreated for months at a time related to Cerner Millennium Care Records Service ("If NPfiT were a jumbo jet heaven help 747 flyers"), an equally damning report in Jan. 2009 on Cerner's EHR products (i.e., "Millenium") as reported by the UK House of Commons Public Accounts Committee, and the impact on the UK's £12.7 billion national Health IT project suggest a systemic problem needing investigation?

Martich also makes the fantastic claim that "we learned the hard way because we were pioneers."

Pioneers?

Pioneers in what, exactly?

As a former NIH informatics fellow and then former CMIO myself more than a decade ago, it seems more likely UPHS (as well as the children and their parents, and the pediatricians who held the ultimate responsibility per Koppel and Kreda's Hold Harmless paper in JAMA) learned the "hard way" because the organization ignored the work of the pioneers.

There is literature going back fifty years on the challenges of health IT as mentioned in my many posts at HC Renewal, such as here.

I began my informatics postdoc in 1992-4 working on CPOE implementation at Yale-New Haven Hospital. I'd learned lessons from the writings of others who'd experienced CPOE difficulties years before that, such as (emphases mine):

Massaro TA. Introducing physician order entry at a major academic medical center. I: Impact on organizational culture and behavior. Acad Med 1993;68:20–5. [PubMed]

Summary: In 1988 the University of Virginia Medical Center began implementation of a medical information system based on mandatory physician order entry. The implementation process was much more difficult than expected. The program experienced considerable delays, and cost much more than was originally estimated. Although there were some legitimate questions concerning the user-friendliness of the new technology, these were less significant than the cultural and behavioral problems encountered. The new system challenged basic institutional assumptions; it disturbed traditional patterns of conduct and forced people to modify established practice routines ... The author describes the problems that occurred and the organizational behaviors on which they were based, analyzes the lessons learned, documents the progress that has been achieved, and outlines the challenges that remain. The center's experience provides insight into the issue of technology-driven organizational transformation in academic medical centers. Recommendations for successful introduction of similar agents of institutional change are presented.

and

Massaro TA. Introducing physician order entry at a major academic medical center: II. Impact on medical education. Acad Med 1993;68:25–30. [PubMed]:

Summary: The introduction [in 1988] of an information technology (IT) system that mandates order entry by physicians had significant and often unexpected effects on medical education at the University of Virginia Medical Center. The system was deactivated briefly after the introduction of laboratory ordering, and frustration with the pharmacy ordering pathways provoked a major confrontation between the residents and medical center management. Changes in responsibilities, patterns, and priorities of work introduced by the system also contributed significantly to the general dissatisfaction. These issues had not been thoroughly considered in the planning stage, but it was only after accommodation was made to these changes that integration of the technology into routine practice could proceed. The author emphasizes the importance of extensive involvement and leadership of attending physicians in the planning and implementation of such a system. He presents a set of recommendations to those considering similar IT initiatives and wishing to reduce the disruptions that may accompany their introduction. With time and experience, however, the housestaff have adjusted to the system and developed facility in using it. Much of the dissatisfaction was derived from the perception that "doctors spend too much time on the computer." In fact, less than 10% of the physicians spent more than an hour each day. However, a small group of residents on call for the busier services were sometimes at the computer for more than four hours each day.

The entire thirty year old field of Social Informatics spells out the dangers of unintended consequences, and books such as Lorenzi and Riley's "Managing Technological Change: Organizational Aspects of Health Informatics", which contains enough information to have allowed avoidance of the issues in the 2005 paper, was first published in 1994.

My website on HIT difficulties would have helped avoid these issues as well, and it has been online and nearly unique (and the top hit on queries on 'healthcare IT failure' - click here - and similar) for a decade. Did anyone in this CPOE project do such a search, read it, and perhaps query its author about the material [of course not - ed.] before spending tens of millions of dollars and putting patients at risk?

In other words, was true due diligence performed? Considering this was a Children's Hospital, one would have expected extraordinary levels of due diligence.

Pioneers learning the hard way? No. It seems this medical center was a pioneer in ignoring the lessons of the past. I believe a simpler explanation of the difficulties in this CPOE project might be that, like many HIT projects, the project was mismanaged.

Perhaps Dr. Martich meant UPMC were pioneers in this particular new CPOE system. As in this article in the Pittsburgh Tribune:

The University of Pittsburgh Medical Center is taking another step in a quest to commercialize new medical technology.

UPMC on Monday signed a three-year deal with health care information technology provider Cerner Corp. to develop and market medicine-related technological advances. Both parties will contribute $10 million in cash, services and intellectual property to the effort.

The deal is a smaller version of an April 2005 deal between UPMC and information technology behemoth IBM.

As is the case in the IBM deal, UPMC will serve as a built-in proving ground for jointly developed technologies and products, with Cerner marketing the products and UPMC awarded a share of profits.

"Proving ground?"

I cannot believe I am reading such a claim. A hospital and patients, as I have written before, are not a learning lab for HIT vendors. The appropriate "proving ground" for new medical technology is the controlled clinical trial where participants (in this case, patients and healthcare professionals alike) have freedom of choice whether or not to participate, and a chance to give (or deny) consent after being fully informed of potential risk.

Were patients or their parents asked to give consent to the use of HIT (such as here)? Were they even aware they were serving as subjects of a "proving ground?" Likewise for clinicians?

It should be kept in mind that in this "proving ground" (i.e., experimental) situation we are dealing with children. Using a hospital as a "proving ground" for unproven HIT on unconsented or coerced subjects (e.g., children, their parents, and the doctors themselves) probably amounts to battery at the very least, is consistent with violations of fiduciary and Joint Commission safety standards, and I am concerned about it representing human rights violations as well.

In view of the recent Koppel and Kreda paper in JAMA on "hold HIT vendors harmless" and "defects gag" clauses, this entire arrangement seems incredibly disturbing at the very least.

I also believe the conflict of interest represented by a healthcare organization partnering with a vendor to "commercialize new medical technology" on unconsented subjects while sharing profits is a horrendous development, for as I stated, the appropriate settings for such practices are properly conducted, impartial clinical trials. The potential for abuses in the current arrangement seems uncomfortably high.

My sentiments seem aligned with IOM's recommendation 4.1 and others on Conflict of Interest as pointed out by fellow HC Renewal blogger Bernard Carroll at this post:

Academic medical centers and other research institutions should establish a policy that individuals generally may not conduct research with human participants if they have a significant financial interest in an existing or potential product or a company that could be affected by the outcome of the research. Exceptions to the policy should be made public and should be permitted only if the conflict of interest committee (a) determines that an individual’s participation is essential for the conduct of the research and (b) establishes an effective mechanism for managing the conflict and protecting the integrity of the research…” (page S-14).

One wonders if the individuals involved in the CPOE project had unreported conflicts of interest with the HIT industry. Perhaps, as in pharma, this needs to be explored.

Han's 2005 article in Pediatrics suggesting children died as a result of the "experiment" should probably be further explored on the basis of the issues I raise above. I also note Han is no longer at UPMC; perhaps his treatment after publication of this article should also be investigated.

In Dec. 2005 on this blog I wrote:

... This study is dealing with children, of course, and is perhaps a flag that much more detailed study of these systems, especially in socially-sensitive environments such as pediatrics, need to be performed.

For if this study's findings are not just due to serendipity and do reflect some underlying causation, the medical, ethical and legal issues could be enormous.

I stand by that assessment.

Finally, putting the camera to my statement that medicine is suffering a cross occupational invasion by the IT industry, in Business Week the picture below appeared of a handsome and proud physician in his office:

Cerner CEO Neal Patterson

Oh, wait...

That person is not a physician nor does he have any medical experience of which I am aware. He is the CEO of the Cerner HIT company.

This picture is the future face of medicine, and it will not be the brightest of futures if this cross occupational invasion continues unopposed by those of a scientific and biomedical mindset much longer.

I really do believe it is the time for a Congressional investigation of these issues, and strong consideration of FDA regulation of health IT, a precedent set long ago in the pharmaceutical industry.

-- SS

Addendum: I note in Dr. Martich's bio an impressive list of medical credentials; however I find formal Biomedical Informatics and/or computer science training lacking. This is not to attack the person, but the culture of HIT, as this scenario is common in HIT and represents what I refer to as "amateurs" running health IT.

I use the term "amateur" not derisively, but in the same sense that I am a radio amateur (albeit licensed after examination at the Extra class and in the "old days", when 20 WPM morse code proficiency was also required). I am not a telecommunications professional. While I have excellent skills in telecommunications theory, hardware, antennas, and operations, I would not consider myself even remotely qualified to, say, run a strategic telecommunications project for a large organization.

In medicine, I always believed education was critical. I may have been mistaken.

Everyone's An Expert in Healthcare and Health IT? (PARODY WARNING)

(Note: be aware the "story" about Amazon.com below is a parody.)

At "Informatics, or Infomagic? Health IT Cannot Flourish When Everybody is an Expert" I lamented that those lacking biomedical and healthcare informatics experience were growing bolder in their cross-occupational invasion of medicine, and were deluded about their own lack of knowledge in a very specialized domain. The IT specialties appear the most intrusive, followed by anyone who's made money with computers.

I've written many times on a critical first principle: health IT applications are medical devices for complex clinical environments that happen to involve computers. However, consistent with the diminution of critical thinking skills that bought us our currently economically and culturally depressed society, the prevailing model of health IT is that they are management information systems that happen to involve doctors and nurses.

This latter belief manifests itself frequently in the news, and will only increase thanks to the $20+ billion to be thrown at the problem via the ARRA. This is more than the annual budget of NASA (which, ironically, if forced to retire the Space Shuttle without a replacement project of equal scope, will idle tens of thousands of aerospace professionals whose innovations have profoundly influenced miracles of modern technology - including computers).

An example of cross occupational boundary confusion is below, where it is seemingly wished by a hospital CIO that an online merchant selling "electronics, apparel, computers, book, DVD's & more" would become involved and offer deep insights into medical devices and the needs of clinicians.

Written as a spoof or parody (which, I am sorry to admit I originally thought was real), is this apparently fictional tale of Amazon's Jeff Bezos joining the EHR bandwagon:

*** NOTE: THE FOLLOWING IS A PARODY, NOT REAL ***

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Amazon.com announced today that it will develop a new Electronic Health Record based upon the same user interface experience and underlying information technology that it uses to support its global ecommerce business.

Said Amazon braintrust, Jeff Bezos, “Our experience with user interfaces and high performance computing are ideally suited to help healthcare. [Ideally suited to healthcare? Really? - ed.] We nudge people’s decision making and behavior with the gentle push of data. When you buy a book on Amazon.com, your user interface is different than my user interface when buying the exact same book. Amazon generates the user interface based on the analytics of the broader context of the customer’s profile, purchasing history, geographic location, and other similar customers’ profiles. The parallels in healthcare are numerous and obvious. [Obvious to whom? - ed.]
--------------------------------------------------------------------

*** NOTE: THE PRECEDING IS A PARODY, NOT REAL ***

The spoof was revealed by this sentence in the middle of the essay:

The Amazon story is a spoof, though I wish it weren't. :-)

I understand the intentions, but that fact might have been made a bit more obvious. I was fooled on first read. (In fact, I first believed the author was pointing out weaknesses with this scheme.) Such web based stories, especially with names of prominent people and companies, can propagate internationally via seach engines, automated aggregators, finance boards and other services and mislead. Further, those who are not native English speakers or who read it in computerized translation might also be misled. Et cetera. We have enough rumors on the internet, thank you very much. And yes, perhaps I'm being oversensitive after being taken in.

That said, and while I am laughing at myself for being fooled, at the content I am not laughing. To the original author of the spoof, a CIO at a prominent hospital system and data warehousing expert (but not a clinician), I would ask the following:

The biomedical training and experience of Mr. Bezos is what, exactly? Might such training and experience be important?

Do physicians need more variation in the presentation of information and the user interfaces they deal with, or less?

You opine that you wish Mr. Bezos joins Google's PHR experts, Intel's Craig Barrett and others in espousing what's best for a field in which they are amateurs. Why?

Don't we hear enough stories like this that could benefit from more highly domain specific expertise, not less?

Here's my humor for the evening:

When first principles are ignored, anybody is a medical expert and can inform the design of medical devices. Next, will you wish Crazy Drinking Straw company will offer wisdom on catheters used in angiography, and M&M Mars will offer profound insights into the manufacture of medicinal pills? (After all, M&M's and pills are very similar, so why not?)

M&M's and pills are very similar in many ways.
Perhaps Mars Candy Co. should go into the generics business?

However, my stating in detail why I see an "Amazon EHR" to be as strange as the examples above and why I believe the parody author's logic is flawed would likely be ill received, so I'll leave it at that.

My most fervent wish is that business folks would stick to selling books and chotchkas, designing microprocessors, and other goods and services where their expertise is valid.

And others stop "wishing" for cybernetic miracles by the unqualified.

Finally, my apologies to Mr. Bezos for an initial version of this post attributing the parody's ideas to him.

-- SS

Health IT Vendor Blames HIT Problems on Those Damn Doctors, Since HIT is Perfect, Like Mother and Apple Pie

Seen on the HisTALK blog:

http://histalk2.com/2009/04/16/news-41609/#comment-3996

Mythoughts Exactly Says:

In my experience with EMR implementations, the big reason they are unsuccessful is because as Pete Potomus says “Drs are busy people” [busy with patient care activities and responsibilities - ed.], they want it to be flexible enough to conform to their individual standards and the customer doesn’t take ownership of the process of implementation and customization to the individual physician needs. It’s not that many of the EMRs don’t have the flexibility - it’s that the medical profession is too “busy” to take the time to learn the application [sure, doctors have all the time in the world to learn how to use tools like this - ed.], take advantage of all the functionality available and standardize their practice. Like any new “instrument” used in the practice of medicine, EMR take a lot of work to learn, tailor to the individual practice and become efficient.

I cannot fathom the remarkable arrogance and insensitivity above to the turmoil most physicians now find themselves in, squeezed from all sides - political, financial, legal, regulatory - in trying to render patient care.

This commenter's profile links to a Health IT vendor, Informatics Corporation of America. I find the comment "Like any new 'instrument' used in the practice of medicine, EMR take a lot of work to learn, tailor to the individual practice and become efficient" quite interesting.

I find it of interest in that, unlike other new instruments used in the practice of medicine, Health IT is entirely unregulated, and the vendors unaccountable.

Also, why does it take so much work to learn? Why is that rarely asked by the pundits and those who make money from HIT? Could it be due to the poor user experience HIT too often presents?

HIT is also not as infinitely malleable as the writer suggests, especially in areas such as workflow customization, clinical content, cognitive support and other areas. Further, in may large HC organizations, bureaucracy often prevents full use of customization features even as they exist.

Doctors and other clinicians then suffer.

One wonders if this vendor has ever considered that physicians’ reluctance to “standardize their practices" [i.e., alter their practices to conform to the IT designer's beliefs about medicine - ed.] might in fact be the best stance relative to patient safety in 2009? Or do they have absolute faith in HIT?

One wonders if this vendor merely believes the National Research Council's report on widespread inadequacies of HIT (the highest scientific body in the land), including the recommendation that "in the long term, [HIT] success will depend upon accelerating interdisciplinary research in biomedical informatics, computer science, social science, and health care engineering [to improve HIT]" is merely senseless prattle?

There is a reason I write about a cross-occupational invasion, piracy if you will, of medicine by IT. Physicians and other clinicians are being taken hostage - they either comply with the IT industry's demands for compliance to the cesspool all too often created by health IT (and the demands of its enforcers, a.k.a. government in 2009), or else.

Health IT failure is, after all, entirely doctors' fault. Right?

Wrong.

This canard has to stop. Now.

I've heard it for years (since at least the mid 1990's), and I for one, am tired of hearing it.

Who are IT personnel of any stripe to be telling physicians what to do? What, exactly, are their qualifications to render such judgments? (When physicians and other clinicians hear this type of "advice" they should ask this question. Loudly.)

The problems with HIT are that HIT is largely experimental and often substandard or defective, its purveyors conflicted and arrogant. Worse, many have grown imperious due to physicians' learned helplessness and vendors' shielding from liability.

We complain about dishonesty, dangerous products and conflicts of interest in pharma? Health IT seems significantly worse.

Apparently, this HIT company has found solutions to all the problems in the corpus below:

Joint Commission: Sentinel Events Alert on HIT, Dec. 2008.

National Research Council report. Current Approaches to U.S. Healthcare Information Technology are Insufficient. Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions, Jan. 2009

The National Programme for IT in the NHS: Progress since 2006, Public Accounts Committee, January 2009. Summary points here.

Common Examples of Healthcare IT Difficulties (website). S. Silverstein, MD, Drexel University College of Information Science and Technology.

Health Care Information Technology Vendors' "Hold Harmless" Clause - Implications for Patients and Clinicians, Ross Koppel and David Kreda, Journal of the American Medical Association, 2009; 301(12):1276-1278

Finding a Cure: The Case for Regulation And Oversight of Electronic Health Records Systems, Hoffman and Podgurski, Harvard Journal of Law & Technology 2008 vol. 22, No. 1

Failure to Provide Clinicians Useful IT Systems: Opportunities to Leapfrog Current Technologies, Ball et al., Methods Inf Med 2008; 47: 4–7,

IT Vulnerabilities Highlighted by Errors, Malfunctions at Veterans’ Medical Centers, JAMA Mar. 4, 2009, p. 919-920.

Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System, Han et al., Pediatrics Vol. 116 No. 6 December 2005, pp. 1506-1512

Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors. Ross Koppel, PhD, et al, Journal of the American Medical Association, 2005;293:1197-1203

Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes and Threats to Patient Safety, Koppel, Wetterneck, Telles & Karsh, JAMIA 2008;15:408-423

The Computer Will See You Now, New York Times, Armstrong-Coben, March 5, 2009,

Health IT Project Success and Failure: Recommendations from Literature and an AMIA Workshop. Journal of the American Medical Informatics Association. Bonnie Kaplan and Kimberly D. Harris-Salamone (preprint, doi:10.1197/jamia.M2997)

Bad Health Informatics Can Kill. Working Group for Assessment of Health Information Systems of the European Federation for Medical Informatics (EFMI).

Electronic Health Record Use and the Quality of Ambulatory Care in the United States. Arch Intern Med. 2007;167:1400-1405

High Rates of Adverse Drug Events in a Highly Computerized Hospital, Nebeker at al., Arch Intern Med. 2005;165:1111-1116.

"Dutch nationwide EHR postponed: Are they in good company?", ICMCC.org, Jan. 24, 2009

“Avoiding EMR meltdown.” About a third of practices that buy electronic medical records systems stop using them within a year, AMA News, Dec. 2006.

"The failure rates of EMR implementations are also consistently high at close to 50%", from Proceedings of the 11th International Symposium on Health Information Management Research – iSHIMR 2006

"Industry experts estimate that failure rates of Electronic Medical Record (EMR) implementations range from 50–80%.", from A Commonsense Approach to EMRs, July 2006

Adverse Effects of Information Technology in Healthcare. This knowledge center presents a collection of information on the adverse effects of information technology in its application to healthcare. It also references sources of information on information security, and related media reports.

Pessimism, Computer Failure, and Information Systems Development in the Public Sector. Shaun Goldfinch, University of Otago, New Zealand, Public Administration Review 67;5:917-929, Sept/Oct. 2007

-- SS