Saturday, January 14, 2006

Our Policy is to Always Blame the Computer: Will Healthcare Computing Incompetence Kill the Elderly?

Significant problems with the new Medicare prescription drug benefit program have, quite predictably, arisen. At least 19 states have had to step in to guarantee coverage for their low-income residents, so that these residents, often with multiple chronic diseases, can get their medicines.

This is a scandal of significant proportions.

Some examples of the problems?

In Arizona: Because of confusion over which part of Medicare should cover their drugs, transplant patients were being denied lifesaving antirejection medication since the drug plan was launched Jan. 1. Dialysis patients on AHCCCS also were being denied.

In Missouri: Pharmacist Richard Logan has been serving patients on the same block in Charleston, Mo., population 5,000, for more than 30 years. But he says nothing compares to the problems he's had with the new Medicare drug benefit ... Logan lives in a rural part of the state where incomes are low, so he serves a lot of patients who until Jan. 1 got their drugs through the Medicaid program. He says the transition to Medicare coverage has been particularly hard for them. He had one low-income patient with diabetes and emphysema, he says, "whose co-pays, after we discovered he was in the computer system somewhere, would have cost him $300 to walk out of the pharmacy with his medicine." Logan gave the man his pills for free until coverage was straightened out. Then there was the cancer patient, whose name showed up correctly in the computer, but whose prescription couldn't be approved. Logan tried repeatedly to call to get the problem straightened out, but "we could not talk to a person. Anytime we tried to call the phone lines were busy, they hung up on us, told us to call back after 7 o'clock at night or before 9 o'clock the morning. And we would start at 7 a.m. calling and get the same message. This went on for about four days."

In Maine: residents in Maine nursing homes were assigned to drug plans in other states. "If people who are in nursing homes have a guardian, a lot of time what's happened is they were assigning plans to people based on a guardian address," In some cases those guardians live in Pennsylvania or West Virginia, she says, and patients were assigned to plans there, "and there's no way that person can get a pharmacy in Maine to cover their prescription drug."

In California: Declaring an emergency, health officials announced that Medi-Cal will pay for prescription drugs for some low-income seniors and the disabled who have been unable to get needed medicine under Medicare's new drug plan. Two other states took similar steps Thursday, joining a rising tide of states that already have acted.

The common factor in the program's problems is the flow of information through computer systems:

Glitch continues to slow Medicare access to drugs

ST. PAUL - A computer glitch related to the new Medicare drug benefit is still hampering low-income people who are having trouble getting their prescriptions filled.

"The system is just plain not fixed yet," Jim Varpness, executive director of the Minnesota Board on Aging, said Monday. "Medicare said they'd fix it by Sunday, but here we still are. This is very difficult for some very frail people."

Some people have resorted to going to emergency rooms to get urgently needed drugs, including drugs for mental problems, while many pharmacists are filling prescriptions on faith, hoping that Medicare will reimburse them.

"This is very frustrating -- for us, for pharmacists and especially for beneficiaries who need their medicines now," Varpness said. "We're doing what we can, but we can't fix Medicare's problem. It's a federal problem with a very complex program that was put into place very quickly."

Affected are the thousands of poor older and disabled Americans who are on both Medicare and Medicaid. Last year, Medicaid covered drug costs for 95,000 people in Minnesota. Those costs were transferred Jan. 1 to the Medicare drug program, a network of federally subsidized private insurance plans.

Eligible people should be getting their drugs for between $1 and $3 per prescription. But the Medicare computer system wasn't confirming to pharmacists that those beneficiaries were eligible for the deep discount. Instead, it showed they were required to pay a $250 deductible plus the full discounted cost of drugs.

On Friday, Medicare officials said they expected to fix the glitch by the start of the week. As of Monday, they still hadn't.

Medicare spokesman Robert Herskovitz said Monday that "it might be the end of this week before pharmacists can count on getting accurate information."

Many pharmacists are giving beneficiaries their prescriptions and charging the correct co-pays without the proper confirmation, "hoping that Medicare will make everything right," Varpness said.

Computers, however, are machines that, unless malfunctioning due to a defect in their hardware (rare), do not make mistakes.

They cannot and do not, however, rectify problems caused by garbage: garbage programming, garbage systems planning, garbage leadership by people whose understanding of the complexities of healthcare are garbage, garbage assumptions and underestimations, garbage conflicts of interest, and garbage accountability and penalties for screw ups of this magnitude.

Tge metaphor "garbage in, garbage out" but scratches the surface of the garbage that pervades healthcare computing.

Who, exactly, were the government computing "experts", private contractors, private payor IT personnel, the IS "let's outsource-this-to-India-to-save-a-few-bucks" leaders, and other "healthcare information technology experts" responsible for this debacle? How many sweetheart deals with vendors with poor track records were done? How much participation was there from the people most affected by this debacle, i.e., clinicians, pharmacists, and patients? Who is going to be held accountable? Why do these debacles go on and on, such as this Veterans Administration deposit of nearly $500 million directly to the garbage can, without much of an apparent learning curve?

Roy Poses has argued that there is an "anechoic effect" which keeps localized healthcare scandals from hitting the national media.

I append that idea to include healthcare computing, where debacles as documented at such places as here and here, of a national and international nature, receive little press. Even when they do, the root causes of the problems are glossed over. Healthcare IT gets a pass.

The inevitable Congressional investigation that will result will focus on the symptoms of the problem, but not on the disease itself: the assumption that healthcare computing and merchant computing are one and the same.

Would a situation of the frail elderly dying due to prescription delays spur a "Flexner report" on the healthcare IT industry, which is nearly completely unregulated? Would it spur attention to my commentary on this issue, published in JAMA ("Barriers to Computerized Prescribing") in the late 1990's and the NEJM a few years ago, and of others?


In an accompanying editorial, Robert L. Wears, M.D., M.S., of the University of Florida, Jacksonville, and Marc Berg, M.A., M.D., Ph.D., of Erasmus University, Rotterdam, the Netherlands, discuss the findings by Koppel et al and a review article in this issue by Garg et al which examined computerized clinical decision support systems.

"These results are disappointing but should not be surprising. There is a long-standing, rich, and abundant literature on the problems associated with the introduction of computer technology into complex work in other domains, as well as occasional notes in health care. Clearly, there is no reason to expect health care, which is from an organizational standpoint probably the most complex enterprise in modern society, to be immune to them. Taken together, these 2 studies suggest that important lessons about introducing new technologies into complex work seem to have been missed."

"For a small but important example, it has been long established in software engineering that systems cannot be adequately evaluated by their developers, a principle that seems to be commonly overlooked in health care. Since roughly 75 percent of all large IT projects in health care fail, inattention to these lessons is, at best, wasteful of time and resources and, at worst, harmful to patients and clinicians.

"To begin to move forward, it is necessary to dispense with the commonly held notion that these problems are simply bits of bad programming or poor implementation that can easily be excised or avoided the next time around," the authors write. "In short, rather than framing the problem as 'not developing the systems right,' these failures demonstrate 'not developing the right systems' due to widespread but misleading theories about both technology and clinical work."

"... an information technology in and of itself cannot do anything, and when the patterns of its use are not tailored to the workers and their environment to yield high-quality care, the technological interventions will not be productive. This implies that any IT acquisition or implementation trajectory should, first and foremost, be an organizational change trajectory. This is true at both the organizational level and the national level; a national health IT infrastructure without a clear logic about how health care organizations will become engaged in this infrastructure is bound to fail," the authors write. (JAMA. 2005;293:1261-1263.

Unfortunately, I doubt this latest round of "Healthcare Computing Failure 101" will spur meaningful examination and change, or spur the healthcare IT industry from its current self-congratulatory mode of inquiry to a dialectical, self-critical one.

The healthcare computing circus must go on.

-- SS

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