$96m Medical IT System Down Under is Useless: Whistleblowers

The U.S. is about to embark on spending more money the the annual budget of NASA on health IT. If the experiences in other countries are an indication, I am afraid we will see more "Apollo 1's" than "Apollo 11's."

Here's a situation being experienced Down Under (I'd posted an insiders's view on the HIT situation there in late 2007 at this link):

The Age.com.AU
Nick Miller
April 17, 2009

$96m medical IT system useless: whistleblowers

A NEW $96 million computer system for Victorian hospitals that promised to cut down on dangerous medication errors will be almost useless when it goes "live" this year, insiders say.

Other new computer systems that handle finance and manage patient records are plagued with serious problems that take days, even weeks, to fix.

And in a further embarrassment for the years-overdue $360 million HealthSMART program, a hospital chosen by the Government to be a flagship "lead agency" — Ballarat Health System — has quit the project because it could not justify the expense.

An anonymous letter from "health-sector employees" sent to The Age says the Cerner clinical systems, intended to cut down on mistakes in doses or combinations of medicines, is being rushed into hospitals — with none of the medication functions working — so the Government will not be embarrassed before next year's election.

"The whole reason for this system was to introduce electronic medication," the letter says. "But next year is an election year and we must hit the agreed dates. This means the system will be almost useless when first live."

Documents released to The Age by the Department of Human Services under freedom of information, and the department's own website, confirm that when clinical systems go live at the first two hospitals late this year, they will not include its most significant functions.

These include ordering pathology tests or medical scans, medication management for emergency patients or inpatients, and "decision support" functions that cross-check drugs and doses.

Leaked reports show other new HealthSmart systems are highly unreliable.

In the last quarter of 2008, the reports showed serious problems with the "PCMS" system, which tracks patient records, books operating theatres and warns doctors of a patient's particular allergies or chronic health problems.

As of December, the system was used at five health services, including Northern, Frankston and Royal Women's hospitals.

Hospitals also reported major problems with the FMIS financial software that runs budgets, purchases, accounts and assets at seven hospitals, including Box Hill, Northern, Frankston, Monash and Peter Mac.

Ten hospitals were targeted for the Cerner clinical system, with Eastern Health, the Royal Victorian Eye and Ear Hospital and Ballarat Health Service as "lead agencies". The Age's FoI documents say Ballarat is "unlikely to proceed given costs included in business-case".

One hospital CEO told The Age he "will be very surprised if it stacks up", as the system cost hundreds of thousands of dollars to run each year.

Another senior Victorian health IT expert said most hospitals would never take up the software. "No one likes using it because it's s---," he said. "It's totally inflexible." [I guess I don't need to spell out the expletive - ed.]

A Health Department spokesman denied all the allegations, without giving any detail.

A spokesman for acting Health Minister Lisa Neville denied that hospitals were being pressured over HealthSMART to avoid embarrassment before the election.

Opposition health spokeswoman Helen Shardey said it was vital that Victoria's hospitals got a modern IT system, but the Government was failing to deliver one. "It's a massive cost to health services, and it seems the timing is being driven by the next election rather than the best clinical care," she said.

I can add little by way of commentary to this article. It speaks for itself and bodes poorly for our new Apollo project-in-postmodern-times challenge of "Reaching the Moon by Hot Air Balloon."

-- SS

A Software Engineer's Eloquence on Health IT

Here is an eloquent piece from the same software engineer/patient whose travails were covered at "A Most Interesting Patient Account of Misery by EHR."

If we had more people of this mindset in healthcare IT, we'd be much further along the diffusion curve and have far better, safer HIT:

From Unfortunate Issues for a National Health IT Network:

It would be wonderful if HIT could deliver President Obama's, or former PM Tony Blair's, vision. It would also be wonderful if HIT was about "saving lives". Tragically, the opposite is too often true. Poorly implemented HIT can do great harm ...

As IT professionals, we must resist the allure of wealth, prestige, and "solving big problems" when the cost of our exuberance is measurable in human lives. We must in the case of HIT proceed as trusted engineers, as builders of the great bridges over which our loved ones drive. We must rationally and soberly asses the HIT challenges we face before we start coding. If we are not up to this challenge, then we have a professional obligation to walk away from the fun and the money. While a national HIT network may someday deliver "life-saving" technology, achieving that vision will be a long, arduous, and expensive journey that requires of IT professionals a renewed emphasis on user interface design and data engineering fundamentals.

Addendum- A reader at the AMIA clinical information systems workgroup points out that these words are truly worthy of the spirit of ACM.org's Engineer’s Code:

“Ethical tensions can best be addressed by thoughtful consideration of fundamental principles, rather than blind reliance on detailed regulations. These Principles should influence software engineers to consider broadly who is affected by their work; to examine if they and their colleagues are treating other human beings with due respect; to consider how the public, if reasonably well informed, would view their decisions; to analyze how the least empowered will be affected by their decisions; and to consider whether their acts would be judged worthy of the ideal professional working as a software engineer. In all these judgments concern for the health, safety and welfare of the public is primary; that is, the "Public Interest" is central to this Code.”

Now, if only such words could form the standard of practice, not the exception.

-- SS

Complacency and Healthcare IT: Who is Taken More Seriously on Risk, A CMIO or A Public Transit Authority Doctor?

In this post I make a very shameful comparison. Shameful to the healthcare industry, that is, and coming from an unusual perspective due to my diverse professional background.

I received quite interesting comments from a number of informatics colleagues regarding the linked patient's account of Health IT mayhem at "A Most Interesting Patient Account of Misery by EHR". The comments suggested that patient's account was not unusual.

Example:

Without being specific I can say from first hand information that this is not an isolated incident... the horrific experience is unfortunately in my direct experience typical.

and this:

... As you know, I’ve been in the HIT business, advocating for full integration of computing into clinical care, for more than three decades. The upshot, though, is that this country’s hospitals are not ready for wholesale automation of even the most rudimentary kind (such as using barcodes in clinical settings), much less a real EMR. I’d give it another 10-15 years ... before even considering advocacy for much in the way of EMRs. Not that there are EMRs we should advocate for now, in any case.

and this:

This hits home, I hope this gentleman keeps telling his story. He is one of the lucky ones that "lived to tell". These are the stories no one believes until it happens to them or a loved one ... He would be saving lives if he talks. I know the retaliation is hard to swallow. I lost my job, but walked out with dignity because I know that I did the right thing. This was such a traumatic event for him and he was one of the lucky ones who were coherent enough to know that something was wrong.

My colleagues are afraid of giving specifics largely due to fear of reprisal from their healthcare and health IT employers. Health IT chaos, though, is clearly more widespread than commonly reported.

Yet in the U.S. in 2009 we find ourselves poised to rapidly spend $20 billion, more than the annual budget of NASA (at $18.7 billion), on these unproven technologies.

Now, a little history from my heterogeneous past:

After a 1990 subway accident in Philadelphia that killed several people and injured hundreds, at a time when I was Medical Programs Manager [of preventive programs] and Medical Review Officer for the regional transit authority SEPTA (pre-informatics), I became sensitized to the potential outcomes of complacency. As I wrote here, some of the the factors contributing to the accident involved complacency and the ignoring of medical advice by non medical personnel.

Yet, the National Transportation Safety Board (NTSB) came in and investigated thoroughly. Improvements were made.

Has something similar ever occurred after an HIT failure?

It always puzzled me why my concerns about health IT problems, dating from my time as a hospital-based Chief Medical Informatics Officer (CMIO) in the 1990's, seemed to raise little concern among the IT and hospital administration and even among some of the hospital physicians themselves. It still puzzles me why my colleagues in active CMIO roles report the same problems in 2009.

It concerns me greatly that HIT is entirely unregulated as its devices become far more complex, and more intrusive in the "biochemical pathways-like" organizational complexities of healthcare. It concerns me that HIT vendors have the best environment of any healthcare vendor: freedom from liability and accountability, and freedom from defect disclosure. It concerns me that hospital executives have agreed to such terms, I believe violating both their Joint Commission safety standards obligations and their fiduciary responsibilities.

As a hospital CMIO observing profound HIT difficulties, it was as if I was supposed to simply acquiesce to the chaos in a medical ICU, in a cardiac catheterization lab, medical clinics, etc. caused by HIT design and implementation deficiencies. It was as if the reaction to my detailed accounts of issues putting patients at risk was that I was simply not a 'team player.' The complacency was palpable. The behaviors consistent with a belief that the IT personnel were wizards, exempt from the scrutiny afforded to mere mortals, was equally palpable.

It was jarring and bizarre. In fact, being a CMIO was more jarring than my earlier physician role in the Philadelphia transit authority, where I sometimes had to deal with very troubled vehicle operators with substance abuse problems and aggressive, sometimes abusive and very scary Philly union officials.

As an example of what I dealt with in that environment, I scanned a 1988 SEPTA transport workers union newsletter whose cover shows a drawing of an injured employee on crutches and a Donald Duck figure with a stethoscope representing the Medical Department physicians, holding a note telling the ostensibly crippled employee to return to work. The newsletter cover is at this link (jpg) and below.

(click to enlarge)

Note the text about the medical department and the duck cartoon on the right depicting the doctors ("quack, quack").

In retrospect, I felt far less uncomfortable as a physician in the mass transit environment than I did as a CMIO at a major hospital. I did not expect much in the way of rigor and science from a transit agency and transit union leaders.

Remarkably, though, I also never feared retaliation or being fired for pointing out potential safety problems. Doing so, in fact, was taken quite seriously, by the Medical Director, the GM's office, Industrial Relations, the system Safety Officer, even the unions when presented the cold, hard facts. Never as Medical Programs Manager and Medical Review Officer was I ignored, as I was as a hospital CMIO.

I felt less comfortable as a hospital CMIO than in the mass transit authority, as I expected a lot more from hospital leadership ... and still do.

On the other hand, I respected the union leaders' directness and unabashed defense of their membership.

Physicians can learn something from them in regards to defense of patient care, and defense of their own profession.

My writing style has, in part, certainly been informed by past interactions with TWU, UTU, BLET, BRS and other transit union leaders and members.

-- SS

Addendum Apr. 18:

Although the causality of this terrible accident just one day after my post above is yet to be determined, I am often reminded of the public safety aspects of my prior line of work in ensuring fitness for duty of public servants in safety sensitive roles:

Sat, Apr. 18, 2009
Man struck, killed by SEPTA bus

By DAVID GAMBACORTA
Philadelphia Daily News

Milton Boneta cheated death seven months ago when he was struck by a SEPTA bus in his wheelchair at 8th Street and Girard Avenue. Fate revisited him in cruel fashion at the same intersection yesterday. This time, he was not as lucky.

Police said the Route 47 bus crushed Boneta, 61, as he crossed 8th Street in his motorized wheelchair at about 4:15 p.m. Based on the reactions of witnesses and the grisly scene, there was no chance he could have survived this accident ...

"The operator told me to check for a pulse or to see if he was breathing," [a witness] said, adding that his body clearly was too badly mangled for any lifesaving efforts.

Remembering what I used to do in public transit vs. the inability to perform a similar function as a CMIO in hospitals brings into focus the absurdity of allowing IT personnel to have a veto on issues that concern patient care and safety. (As the head of the Division of Biostatistics and Bioinformatics of a major medical center who had his staff review my HIT site recently wrote me, he "could not imagine any reasonable individual" - i.e., hospital executive - allowing that situation to occur, and found it "downright scary.")

Hospitals can cover up and bury their mistakes, especially when related to the relatively esoteric issues of HIT dysfunction, so perhaps their attitudes can be more cavalier than in the transit industry.

-- 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

A Most Interesting Patient Account of Misery by EHR

As I have written many times, health IT can achieve many of its touted benefits, but only if done well. "Done well" is not as easy at it might seem in the complex world of healthcare.

I am providing a link to a fascinating story by a patient, Joe Bugajski, who is a professional in enterprise architecture, data access strategies, application engineering, information integration and quality, technology standards, and other related domains, with impressive big-industry expertise.

The story is here:

Tuesday, March 17th, 2009 | Joe Bugajski
The Data Model That Nearly Killed Me

It is worth reading in its entirety. It illustrates many of the points I've made on HC Renewal about healthcare IT difficulties in the real world (as opposed to the Bernie Madoff world of "unlimited returns, no matter what.")

Here is an excerpt:

... Medical personnel at urgent care and the hospital who interacted with me all used a version of the same electronic health information system (the “system”). It became clear that everyone was fighting that system. Indeed, they wasted between 40% and 60% of their time making the system do something useful for them. The system kept everyone from fulfilling their duties - the health information system did not help medical professionals perform their duties.

Since my hospital stay, I confirmed that electronic health information systems are mostly broken. I interviewed medical professionals, healthcare IT experts, and my allergist. They confirmed my sickbed analysis. Indeed, several experts said that they longed for handwritten charts once more hanging from the foot of every patient’s bed. (Again, please read Prof. Dr. Armstrong-Coben’s Op-Ed article.) My analysis argues for careful analysis of strengths, weaknesses, opportunities, and threats (SWOT) associated with building a national health information network. If the nation simply accepts the President’s vision while healthcare IT vendors collect some of the $20 billion stimulus bounty, individuals and businesses will pay higher medical costs, patients will receive inferior care, and medical professionals will lose precious time fighting IT systems instead of delivering better care.

A SWOT analysis is a good idea. Unfortunately, such an analysis is difficult in face of HIT contractual gag clauses, lack of cross-institutional knowledge sharing, and a societal meme that "health IT is all plug and play goodness and apple pie, always and forever" that got inserted into the national psyche.

This meme somehow short-circuited the critical approaches necessary towards perfecting and proving an experimental technology (which was how many if not most informatics professionals viewed HIT when I started my fellowship in the early 1990's). I believe this meme arose and was propagated largely through efforts of the marketing arms of vendors, trade associations and pundits.

I agree with Mr. Bugajski's conclusions, which parallel my own writings over the past few years:

A national health information network, while a laudable vision, will require massive data integration engineering at a scale never before undertaken by the IT industry ... Mr. President, don’t be fooled by IT vendors telling (false) tales of munificent and magnificent skills with their heath information system development. Rather, ask them to depart immediately. Instead call upon our nation’s best system and data architects to report for duty. [As I've noted over the years, Medical Informatics experts have that expertise with respect to HIT - ed.]

... The national health information network envisioned by President Barak Obama is a pipedream. That is, unless and until information technology (IT) professionals [ideally with leadership and input from Medical Informatics professionals --ed.] learn how to build systems and data models that meet end-user requirements (read, useful to medical professionals). My recent experience with an urgent care clinic and a major tertiary care hospital convinced me that the United States will require a long time before there is a consistent data model capable of recording a patient’s health information, let alone a data model capable of accurately and reliably transmitting that information from one healthcare institution to another. Much of the groundwork required to achieve the vision needs to be done. The $20 billion allocated by the American Recovery and Reinvestment Act for a health information network will be squandered by IT vendors and hospital administrators [as I opined in my recent WSJ letter to the editor - ed.] long before the nation has a viable network unless and until the administration acts rationally to establish a program of development that is free of vendor and administrative greed. Take it from a guy who recently found breathing very difficult, do not hold your breath waiting for a national health information network to appear.

I fear (from over a decades' experience), unfortunately, that due to arrogance, greed, irrational exuberance, inappropriate overconfidence in computing, and other forms of stupidity, many in HIT and government will receive these well-engineered words no differently than as depicted in this medieval illustration:




-- SS

Should Google Seek the Resignations of Those Responsible for This Healthcare IT Debacle?

Simply amazing. One of the richest and most "leading edge" IT companies in the world with almost unlimited resources and access to expertise commits one of the most fundamental biomedical information science (a.k.a. informatics) blunders, as in the taxonomy in my post here, at the level of "likely to cause patient harm in short term if uncorrected."

I have repeatedly written over at least the past ten years that applying the leadership and methodologies of business IT to clinical computing is both ill conceived and dangerous, as business computing and clinical computing are two very different computing subspecialties, the latter requiring quite specialized leadership and approaches.

I've written it at academic sites, in magazines, in newspapers, and other venues.

Yet, as we have observed at HC Renewal regarding other flavors of healthcare mismanagement and malfeasance, these words seem to suffer an anechoic fate.

Here we go again with another example of what appears to be gross mismanagement of clinical IT by business IT personnel and organizations. The following type of debacle is sooner or later going to kill patients and must end, immediately:

Boston Globe
Electronic health records raise doubt
Google service's inaccuracies may hold wide lesson ["may?" - ed.]
By Lisa Wangsness, Globe Staff
April 13, 2009

WASHINGTON - When Dave deBronkart, a tech-savvy kidney cancer survivor, tried to transfer his medical records from Beth Israel Deaconess Medical Center to Google Health, a new free service that lets patients keep all their health records in one place and easily share them with new doctors, he was stunned at what he found.

Google said his cancer had spread to either his brain or spine - a frightening diagnosis deBronkart had never gotten from his doctors - and listed an array of other conditions that he never had, as far as he knew, like chronic lung disease and aortic aneurysm. A warning announced his blood pressure medication required "immediate attention."

"I wondered, 'What are they talking about?' " said deBronkart, who is 59 and lives in Nashua.

DeBronkart eventually discovered the problem: Some of the information in his Google Health record was drawn from billing records, which sometimes reflect imprecise information plugged into codes required by insurers. Google Health and others in the fast-growing personal health record business say they are offering a revolutionary tool to help patients navigate a fragmented healthcare system, but some doctors fear that inaccurate information from billing data could lead to improper treatment.

(Addendum April 19: a first hand account of this problem is at e-patients.net here.)

What manner of amateurs made and approved the decision to map semantically and often medically imprecise, and often deliberately overstated or misused billing codes to diagnoses, and then display the diagnostic terms to a user - ANY user, patient or "learned intermediary" - in an electronic health record?

Not to mention how poorly conceived and implemented many of the HIT billing systems themselves are, making billing data even less trustworthy...

Injecting humor into a most somber post,
Homer succinctly summarizes the situation.

It is common knowledge to any competent person in healthcare informatics that doing what was done by Google Health is prone to create exactly the kind of situation that occurred.

Insurance data, by contrast, is already computerized and far easier and cheaper to download. But it is also prone to inaccuracies, partly because of the clunky diagnostic coding language used for medical billing, or because doctors sometimes label a test with the disease they hope to rule out, medical technology specialists say.

One does not have to be much of a "specialist" to make this realization. Almost anyone who's ever practiced medicine could probably have told Google's designers, developers and programmers this. This raises a number of questions, which also do not require a specialist to raise:

• What were the designers, implementers and management of this project thinking?
  
• Who was leading the project?
  
• What were there backgrounds?
  
• Who made the decision to implement in this manner?

Danny Sands raises the obvious:

"The problem is this kind of information should never be used clinically, especially if you don't have starting or ending dates" attached to each problem, said deBronkart's primary care doctor, Daniel Z. Sands, who is also the director of medical informatics at Cisco Systems.

Indeed.

Personal health records, such as those offered by Google Health, are a promising tool for patients' empowerment - but inaccuracies could be "a huge problem," ["could be?" - ed.] said Dr. Paul Tang, the chief medical information officer for the Palo Alto Medical Foundation, who chairs a health technology panel for the National Quality Forum.

For example, he said, an inaccurate diagnosis of gastrointestinal bleeding on a heart attack patient's personal health record could stop an emergency room doctor from administering a life-saving drug.

And when such an event occurs and a patient is harmed or killed, who then is held accountable - and who is held harmless? (Oh wait ... we know the answer to that question thanks to Koppel and Kreda...)

This "billing data" issue and other EHR issues like it are not rocket science, they are Medical Informatics 101.

I've seen such issues before, such as at "AOL kerfuffle: information technology vs. information science, a distinction lost at industry's peril" and at "On Intel's and Walmart's prescription for Healthcare IT."

I summed the problem up like this at the post "A Biomedical Informatics Manifesto":

Biomedical Informatics as a specialty might as well be invisible. Amateurs** rule HIT.

(** Amateur in the sense that I am a radio amateur, not a telecommunications professional and would not deem myself appropriate to design and run a critical telecommunications project).

Perhaps, though, I should have added "amateurs rule HIT, and even worse are too often managed by incompetents."

I believe Google should conduct a top to bottom investigation of the management chain and the decision making process that led to such a fiasco, which can only further erode public confidence in electronic health records at a time of national distrust in Big Business and Big Medicine.

Those who made such design and implementation decisions without appropriate input from those who know better, or worse, those who might have overridden or ignored such counsel, should be dealt with appropriately. (If it were me, I'd ask for their resignation, but that's my opinion.)

Clinical medicine, Electronic Health Records and patients' well being are not an information technologists' learning lab.

Also of concern to me, this is the type of data our government seems to be touting for use in Comparative Effectiveness Research. (It is also of concern to me in this regard that our new Secretary of HHS was the former Kansas commissioner for insurance from 1994 to 2002, and such billing data is likely where the majority of her experience with medical datasets resides.)

Finally, like the financial schemes of the past decade, I can only wonder when the computational House of Cards that is being built in healthcare as a result of the quasi-religious Syndrome of Inappropriate Overconfidence in Computing, and worship of its priests, the IT Whiz Kids and consultants to whom domain expertise is optional, will come crashing down.

-- SS

Addendum:

A physician correspondent who wishes to remain anonymous writes (emphases mine):

[The Boston Globe article] could not have come at a better time.

Just today, a spouse had his "home grown" PHR for his wife who was hospitalized with multiple medical problems, including advanced metastic breast cancer and complex vascular disease. He has an elaborate PHR with history, treatments, allergies, medication lists, etc.

It was so impressive that when this 80ish year old patient was admitted, he gave the medication list from the computer to the physicians and nurses. It appeared so reliable that not one health care professional bothered to question it or reconcile it with the labels on the bottles (everyone is so busy nowadays clicking and scrolling the computer silos for information).

As it turns out, he left out a decimal point on a dose of a potent medication that should have been 2.5 mg. The computer printed a legible list (with other errors too) stating the dose of this med was 25 mg per day (10 times too much). It was ordered that way by the doctors. It got to the pharmacy, but somewhere in this complex chain, a non physician non nurse individual got the dose to the patient correctly as 2.5 mg [fortunately, the error was caught, this time. What about next time? - ed.]

Being a detective with an eye for detail and a stickler for accuracy, I happened to notice the error when the spouse was showing off his PHR to me.

Again, this is one case with potentially dangerous consequences of a pervasive error generated in the PHR by flawed data entry. It was not a Google or Health Vault device, but I cannot believe that these companies have garbage filters on their devices to prevent the "garbage in, garbage out" syndrome. Good medical care is being subverted by these experimental devices.

Upon scratching the surface of PHR, EMR, and CPOE devices' functional impact on the administration of medical care, the dangers are widespread. This toxicity is covered up from scrutiny by the "non-disclosures" and "hold harmless" contractual obligations described in the Koppel and Kreda report.

One wonders how many incidents like this happen every day and are being concealed by the HIT industry and the pundits profiting handsomely from selling defective HIT devices. I am quite concerned that nobody really knows. This is not science.

On a final sobering note, as the "hold harmless" and "defects gag" clauses are purged from HIT contracting, which they will most certainly be, I would suggest the many amateurs in HIT obtain some very solid liability insurance covering patient harm related to their systems and their advice.

For they may just find themselves as defendants answering questions on the witness stand in front of a hungry plaintiff's attorney, a jury of average citizens, bereaved relatives of patients who were harmed via IT misadventure, and questions composed by people of my background. These questions will place the true nature of their expertise and qualifications to be tooling around with medical care under severe scrutiny.

That will likely not be very pretty.

-- SS

April 22 addendum:

In comment #15 to this post Matthew Holt issued this filled with absolutes ad hominem comment ...

Seriously, MedInformaticsMD, you are so pissed off with everyone in IT [everyone? - ed.] that you're now part of the problem [problem of vendors creating bad IT? - ed.] Do you seriously think that the people at BIDMC, Google and everyone else in health IT (even Cerner) just dont give a shit? [I cannot read minds. I can only see results - ed.] Or do you think that they might be trying to figure out how to solve these problems [of course they're trying to solve problems, but good intentions without requisite ability and expertise are inadequate in healthcare - ed.], and perhaps could you some constructive help. Rather than a barrage of attacks on anything they try to do. [Anything? You mean, such as in this post praising Google in areas where they do leverage their expertise properly? -ed.]

Perhaps my direct Chairman of Medicine-after-patient-mishap tone in offering the most constructive of criticism - i.e., don't embark on medical projects in which you are over your head, find people who do know the domain and let them lead, don't release anything in medicine without appropriate, rigorous premarket trials - upset him. In addition to the inserts above, in the comments section I replied:

I'm sorry you feel that way.

I'm not sure what "problem" you're referring to, but if it's harming patients due to badly implemented HIT, I'm certainly not part of that problem.

As just one example, my website on HIT difficulties serves as a resource read internationally on how to best avoid HIT errors, has been online for a decade, and is quoted in one of the newest and best books on HIT, specifically "Medical Informatics 20/20."

Did anyone at BIDMC, Google or Cerner ever read it? Did you ever read it? If not, why not? It is in fact the first link that comes up on a google search on "healthcare IT failure", for example. Do they take it seriously? If not, why not?

I believe they were negligent on this project. This suggests they need to give a bit more of a s--- about their work, expecially since real, live patients are involved and the mistake made was so fundamental.

Finally, see my post "A Software Engineer's Eloquence on Health IT" for what I consider an attitude of someone who really does give a s--- about such matters.

Finally, I see no links to my decade-old academic website on HIT difficulties over at Matthew's blog. One wonders why. It may have to do with a tension between the statement that "the Health Care Blog (THCB) has acquired a reputation as one of the most respected independent voices in the healthcare industry" and the post "A Shout out to our sponsors."

Healthcare Renewal has no sponsors and does not take advertising. We report, you decide.

-- SS

Hedge Fund U, Version 2

We have posted frequently on the governance and leadership of academic medical organizations. While one would think that health care organizations, and especially academic health care organizations ought to be held to a particularly high standard of governance, we have noted how their governance is often unrepresentative of key constituencies, opaque, unaccountable, unsupportive of the academic and health care mission, and not subject to codes of ethics. How the governance of organizations with such exemplary missions and sterling repuations got this way has been unclear.

In 2007, we reported on one famous institution which had a more representative, transparent, and accountable form of governance. Let me provide a summary of the background from FIRE, the Foundation for Individual Rights in Education,

For over a century, Dartmouth College provided alumni with an avenue for direct participation in selecting leadership, with eight of the 18 members of Dartmouth's Board of Trustees coming from popular vote (the other ten were appointed by the Board). Starting in 2004, petition candidates—those who had to gather alumni signatures to be nominated—challenged those selected by the Association of Alumni in the annual trustee elections. Alumni responded in kind: over the next four years, four petition candidates were elected to the Board of Trustees.

These trustees spoke out when they perceived their alma mater as not living up to its mission, and Dartmouth students benefited. In May 2005, the college repealed its speech code, and it immediately moved from FIRE's "red-light" rating and became a 'green-light' institution.

These developments did not please everyone, however. Some campus officials viewed the propensity of petition candidates to voice their opinions on illiberal policies as detrimental to the school's image. The Wall Street Journal profiled T.J. Rodgers, a petition-nominated trustee, who explained the criticisms leveled at the 'divisive dissidents.'

>> If 'divisive' means there are issues and we debate the issues and move forward according to a consensus, then divisive equals democracy, and democracy is good. The alternative, which I fear is what the administration and [Board of Trustees Chairman] Ed Haldeman are after right now, is a politburo-one-party rule. <<

As the petition candidates grew in numbers (including George Mason Law Professor Todd Zywicki), so too did the official criticism. After Zywicki expressed disagreement with Dartmouth's leadership, the Board's chairman responded.

Haldeman and his cohorts wrote in a statement on the board's Web site that Zywicki 'violated his responsibilities as a trustee of Dartmouth College, which includes acting in the best overall interests of Dartmouth and representing Dartmouth positively in words and deeds.'

It was clear that a frank discussion of the issues at Dartmouth was not welcome on the governing board. The Trustees thus moved to alter the playing field. In September 2008, the Board declared that it would add five new positions—all hand-picked by current Trustees. The century-long tradition of parity between alumni-elected Trustees and the self-perpetuating Board members was erased. It came as no surprise when the Association of Alumni announced in January that the 2009 election would feature no petition candidates.

In 2007, what really got our attention was the stated rationale for this push towards less representative and accountable governance. Mr Haldeman, the chairman of the board of trustees, announced a smaller proportion of elected trustees would ensure that the board "has the broad range of backgrounds, skills, expertise, and fundraising capabilities needed," and that the board members would possess "even more diverse backgrounds." Yet when we examined the backgrounds of the current charter trustees, we found that they exhibited little diversity. Remarkably, three-quarters (6/8) were in leaders of the finance sector. In 2007, they seemed not very diverse, but why the majority should be in the financial sector, and what implications that had, was then obscure.

Things have changed. In the fall of 2008, the world economy descended into an unprecedented financial collapse. Many concluded that the global economic collapse was caused by arrogance, greed, and corruption within the financial sector.

This suggested that leadership of academia, and academic medicine in particular, by leaders of the finance sector might not, in retrospect, have been a such a good idea. Furthermore, when we had other occasions to look, we found that Dartmouth College was not an isolated case.

We noted that half of the Fellows of Harvard, the university's equivalent of a board of trustees, were from finance, and two were affiliated with corporations at the center of the global financial collapse. We recently found that almost 40% of the board of Yeshiva University were from finance as of the end of 2008. One former board member was Bernie Madoff, now in jail for running a giant Ponzi scheme disguised as an unregistered hedge fund. Yeshiva lost $110 million of its investments with Madoff. Another former member was indicted, accused of fraudulently abetting Madoff's operations. One current member runs a hedge fund that had to pay $180 million to settle other fraud allegations.

So we raised the hypothesis that some of the problems of academia, and particularly the problems of medical academia, may have been at least enabled by leadership more used to working in an increasingly amoral marketplace than to upholding the academic mission. Simultaneously, a commentary in the Chronicle of Higher Education put it this way,

Most college and university boards are composed largely of wealthy people, usually from the worlds of finance, law, and private enterprise. They are sometimes alumni but are often selected for their personal capacity to give, their links to other people who might give, or their historical record of having given.

Many trustees today have in fact been part of the elite sectors of finance, law, and enterprise that have proven improvident, shortsighted, and badly governed. Can they be seen as the wisest of our wise who will bring both generosity and wisdom to the academy?

News items from last week, some generated by release of financial disclosure forms from new members of the current US administration, add insight into what now appears to be a pervasive web of entanglements among academia and the finance sector.

One set of stories was about Lawrence Summers, now chief economic advisor to the US President, but president of Harvard University from 2001-2006. Just after resigning as president, and while still a professor at the university's Kennedy School of Government, Mr Summers suddenly began lucrative relationships with multiple players in the financial sector. Per the New York Times, Mr Summers assumed an amazingly well-paid part-time position at a hedge fund,

Mr. Summers, the former Treasury secretary and Harvard president who is now the chief economic adviser to President Obama, earned nearly $5.2 million in just the last of his two years at one of the world’s largest funds, according to financial records released Friday by the White House.

Impressive as that might sound, it is all the more considering that Mr. Summers worked there just one day a week.

Much is known about Mr. Summers’s days in Washington and Cambridge, but little attention has been paid to his two years in New York, from late 2006 to late 2008, advising an elite corps of math wizards and scientists devising investment strategies for D. E. Shaw & Company.

Mr Summers also collected prodigious speaking fees from many financial corporations, some of which subsequently failed or had to be bailed, out, as per the Washington Post, he

was paid more than $2.7 million in speaking fees by several troubled Wall Street firms and other organizations.

Financial institutions including JP Morgan Chase, Citigroup, Goldman Sachs, Lehman Brothers and Merrill Lynch paid Summers for speaking appearances in 2008. Fees ranged from $45,000 for a Nov. 12 Merrill Lynch appearance to $135,000 for an April 16 visit to Goldman Sachs, according to his disclosure form. Summers reported donating two fees totaling $70,000, including the payment from Merrill Lynch, to charity.

Summers received all this money why he was still a faculty member at Harvard. As noted by the Washington Post, he did not leave his faculty position there until 2009.

Although there is no evidence that Summers had financial relationships with corporations in the finance sector while president of Harvard, his sudden and very lucrative jump into that sector after leaving the presidency, and while nominally a full-time faculty member, suggests at least a major alignment of interests. Some commentators have made this point more forcefully, for example, Robert Scheer in the Nation,

Not surprisingly, Lawrence Summers is convinced that he deserved every penny of the $8 million that Wall Street firms paid him last year. And why shouldn't he be cut in on the loot from the loopholes in the toxic derivatives market that he pushed into law when he was Bill Clinton's treasury secretary? No one has been more persistently effective in paving the way for the financial swindles that enriched the titans of finance while impoverishing the rest of the world than the man who is now the top economic adviser to President Obama.

Perhaps this alignment was related to charges that while president of Harvard, Summers helped stifle someone who tried to blow the whistle on excessively risky investment practices involving financial derivatives at the Harvard Management Company. Per the Harvard Crimson,

After a year-long stint at a European investment bank and another at Enron, Iris M. Mack signed on to be a quantitative analyst for Harvard Management Company in early 2002, hoping, she says, to find job security and distance from the risky trading and accounting practices that forced her last employer into bankruptcy in the company charged with managing Harvard’s endowment.

But only a few months later, Mack says she was fired after she raised concerns to University officials about managers’ qualifications and possibly irresponsible usage of financial instruments that could have contributed to the recent and sudden decline in Harvard’s endowment.

In an e-mail sent May 30, 2002 to Marne Levine, chief of staff for then-Harvard President Lawrence H. Summers, Mack detailed her concerns regarding what she deemed HMC’s 'frightening' usage of derivatives and statistical modeling techniques, as well as the Company’s lack of a timely and portfolio-wide risk management system, high employee turnover rate, and low level of productivity in the workplace, specifically among managers.

According to documents and e-mail records, all provided by Mack, Levine had initially assured Mack that their correspondence would remain confidential. But on July 1, HMC chief Jack R. Meyer called Mack into a meeting, in which she was presented with copies of her e-mails, according to a letter sent to Levine and Summers by Mack’s attorney.

The next day, Meyer dismissed Mack, pointing to 'these baseless allegations against HMC [that you sent] to individuals outside of HMC,' the letter says.

Ultimately, Mack says she reached an out-of-court settlement with Harvard over her firing because her lawyers felt that the University did not want to attract media attention from the dismissal....

Now, with the economy in an unprecedented slump in part due to the widespread and unregulated use of derivative contracts, Mack says she feels 'vindicated' but also sad.

'I’m not trying to pretend I’m omniscient or anything, but a lot of people who were quantitative traders, in the back of our minds, we knew a lot of these models were just that: guestimates,' Mack says. 'I have mixed feelings, on the one hand, I wasn’t crazy, I knew what I was talking about. But maybe if more and more people had spoken up, the economy wouldn’t be the way it is now.'

So now we wonder whether the poor governance practices, and resultant poor leadership of many academic health care institutions may have resulted from the increasing dominance of the governance of these organizations by people from the "improvident, shortsighted, and badly governed" finance sector?