Tuesday, October 28, 2008

Do Healthcare Organizations Truly Want Electronic Health Records To Succeed?

As readers here know, I have written frequently about the seemingly paradoxical problems commonly experienced by healthcare organizations in their clinical IT (EHR, CPOE, Decision Support, etc.) projects, including at my academic site on this topic.

It seems as if organizations do not learn from and do not want to learn from one another, or from the wisdom of decades of experience of the informatics pioneers, in literature that is widely available to anyone with a computer and just a little sense of due diligence and/or curiosity. As I've written at this blog, organizations also seem to resist formal medical informatics expertise.

Simple, formulaic, well known "best practices" approaches (e.g., appointment of executive "champions", permitting enduser and stakeholder involvement at all phases, and other "sterile technique in surgery" commonsense platitudes) are inadequate for HIT management.

Many business IT personnel in healthcare settings have not quite figured out how to apply true best practices known from decades of medical informatics, social informatics and healthcare IT management research in the complex, poorly bounded, conflicted, highly variable, uncertain, and high tempo work domains (per Nemeth & Cook, pdf here) of clinical settings, and resist such wisdom for traditional MIS approaches suitable in traditional business. Yet, clinical IT and business IT appear to be distinct subspecialties of IT, requiring different approaches to system design, implementation and lifecycle.

Perhaps more importantly, those same business IT personnel often seem to lack knowledge about how to effectively manage what might be called "worst practices" of various stakeholders that nullify the benefits of any best practices that are employed.

Why do these "worst practices" misbehavior situations arise? (See the addendum for some examples that anyone working in HIT will find familiar.)

Further, in every account of health IT difficulty I've encountered, it seems the same "Keystone Kops" organizational players mismanage clinical IT projects at great expense - expense which healthcare organizations can ill afford.

The following question must be asked. Why is this so regarding a technology so highly touted and so purportedly desired by all?

Computers and EHR’s have been widely touted as being the key to a literal cornucopia of medical benefits: better and cheaper healthcare, reduced errors, evidence-based, genetically tailored medicine, and other cybernetic miracles.

Yet, many clinical information systems don't reflect the health care professional's hectic work environment, with its all too frequent interruptions from phone calls, pages, colleagues and patients. Instead, they are designed for people who work in calm and solitary environments, with resultant poor usability [1]. A leading computerized practitioner order entry (CPOE) system was found to actually facilitate medication error risks [2]. As implemented, EHR’s were not associated with better quality ambulatory care [3]. Expensive, clinician morale-damaging failure and de-installation of EHRs are not uncommon [4]. National EHR efforts such as in the UK have self-admittedly made serious errors and needlessly wasted billions of dollars [5]. The U.S. Office of the National Coordinator for Health IT (ONC) recognizes that a major barrier to wide adoption of this technology is a high failure rate for EHR implementations [6].

Finally, diffusion of EHR’s after 30-plus years of effort and billions of dollars spent remains limited. As per the 2008 statistics in the prestigious New England Journal of Medicine, just four percent of physicians in the U.S. reported having an extensive, fully functional electronic-records system, and just thirteen percent reported having a basic system. Most hospitals are also lacking the technology to any meaningful extent [7].

I have thought hard about what the large scale "metaproblems" for this seeming paradox might be, other than just mismanagement secondary to stupidity of the type that's put this country in some dire financial jeopardy recently. I also thought about a line I often tell my students (itself borrowed from somewhere) that there are no true paradoxes, just false assumptions.

As an example of yet another situation - actually a continuation of a situation - that brought a possible
new "meta-explanation" of Healthcare IT chaos to mind (which I disclose below), I present Act III of my own experience.

I then present my thoughts on an a possible explanation for the "paradox" of widespread HIT problems.


Drexel EHR Debacle, A Tale in Three Acts:

Some time ago I wrote at Healthcare Renewal here that at my own organization I was excluded from the EHR project of the Faculty Practice Plan after the original CIO left (I had only attended a few meetings at her invitation at that point). Let's call this "Drexel EHR Debacle, Act I."

Fast forward two years to Act II. Due to design failure of the E&M ('evaluation and management') component of the system, the component that was supposed to "reduce administrative costs" via helping automate and optimize billing functions -- but instead raised costs by a few million dollars to manually correct errors the E&M coder was creating! - the result was a multimillion dollar lawsuit (link to Civil Complaint PDF here ) by Drexel against the EHR vendor AllScripts and Allscript's partner Medicomp Systems. The latter advertised itself as a "corporation specializing in the development of point-of-care tools for Electronic Medical Records ... to help overcome physician resistance to adoption" (!). What was unfortunate is that I possibly might have prevented the problems had I been involved, as I had seen a similar issue at Yale years prior that actually did lead to a Justice Dept. investigation and fines for billing irregularities ( link ). My assistance was not sought, even after I volunteered to help Drexel in the lawsuit against the vendor.

Now, fast forward another two years to the current time, and what I call Act III of this debacle.

I have recently been informed of issues such as this: that the EMR allegedly cannot be used by senior executives to gauge the productivity of salaried physicians and that the senior people feel they do not have a quality system (yet who selected it in the first place?) The end users were apparently not utilized to make the decision nor to beta test or write user requirements, and in retrospect senior leaders are doubting the system was needed at all for ambulatory. No pilot was conducted. After go live the Compliance Officer apparently felt that the system as implemented did not meet federal guidelines and reversed some of the features.

In order to process an encounter a physician cannot just check that they treated the patient for certain conditions; they must also check that they "did not treat" the following conditions. A total of over 70 clicks on a single page. Attendings are having to do this at night at home. Complaints are ignored. The mobile notebooks do not work properly and the system allegedly goes down frequently. Local IT support is minimal since the system is apparently an ASP model. Change management processes were not fully vetted and a plan was not executed and no one knows the right channel for getting problems addressed.

And on and on it goes.

I once again volunteered my help, and received initial interest and an invitation to a lunch meeting with the project leads. However, once I reminded that I am now an adjunct, and no longer an Asst. Professor FTE (by my own choice due to dysfunction) and therefore I would be charging a consulting fee, interest stopped. The lunch meeting was paradoxically cancelled by an AA with an indefinite statement about it being rescheduled at some time in the future. That was a few weeks ago.

(Sadly, one of the reasons I resigned my asst. professor position after only two years and voluntarily remained as a non tenure track adjunct is that without a hospital -- Drexel has no hospital of its own; Hahnemann is Tenet-managed and has not done well financially in the competitive Philadelphia medical environment and is not a fertile place for informatics research -- and with the medical college EMR project I'd hoped to use as the backbone for funded research basically brain damaged and clinician confidence affected, perhaps irreparably, I saw little chance at winning increasingly competitive NIH funding for research, and therefore no chance to secure tenure. Better to be in a non tenure track position in such an environment, I felt.)


Now as to the "meta issues" that might be playing out, here and elsewhere:

I've recently read the following online somewhere regarding discussion of the media and its biases:

I learned a long time ago that when people or institutions begin to behave in a matter that seems to be entirely against their own interests, it’s because we don’t understand what their motives really are .

I have always assumed that, at least organizationally speaking, healthcare organizations
wanted their EHR projects to succeed. While I have encountered individuals who seemed to want specific projects to fail, usually due to territorial or other fairly obvious political issues, I always thought a reasonable assumption about HC organizations is that they want clinical IT projects to succeed.

What if that is a false assumption?

What if there are a critical mass of people in many healthcare organizations who, while afraid to express it openly, are in opposition to the inconveniences, costs, political battles, loss of power, fear of loss of ability to conceal substandard performance (a fear both at the practitioner level and the management level), etc., such that on balance what the organizational motives "really are" are
to cause EHR to fail?

This could explain the prevalence of the "large scale problems" noted, and explain resistance regarding hiring of the most qualified in clinical IT (i.e., formally trained medical informatics experts), who might actually be correctly perceived as the best people to
make this technology work.

Finally, the national push to EHR that started a few years ago with ONC and the "2014 goal" should have had the effect of a large increase in the desirability of people with formal informatics training. However, if the assumption that organizations want EHR to succeed is not correct, then a federal mandate might only increase the resistance to the best talent in empowered operational roles, out of resentment towards the mandate at the very least.

So, my question is: do healthcare organizations really want clinical IT to succeed, and are many of the "problems" seen that are often identified as "sociotechnical complexities" in reality the outcome of simmering opposition to EHR's and other clinical IT, and the often nasty issues they create for everyone in a healthcare organization?

I am myself skeptical about this possibility, but again, there are no paradoxes, only false assumptions.

If the assumption about organizations wanting clinical IT success is even in part false, then those pressuring the healthcare industry to computerize as a means to save costs and improve quality may be barking up the wrong tree.

-- SS


[1] Most hospitals don't use latest ordering technology. Oregon Health & Science University, http://www.eurekalert.org/pub_releases/2003-11/ohs-mhd112403.php (accessed Oct. 25, 2008)

[2] 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

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

[4] Medical Records Institute, as reported in Modern Healthcare, October 30, 2007. http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20071030/FREE
/310300002/0/FRONTPAGE (accessed Oct. 25, 2008)

[5] Granger [UK] says he is 'ashamed' of some systems provided. E-Health Insider, 10 Jul 2007, http://www.e-health-insider.com/news/item.cfm?ID=2854 (accessed Oct. 25, 2008)

[6] Current Market Barriers and Challenges to Widespread Adoption of Health Information Technology. U.S. Office of the National Coordinator for Health Information Technology (ONC), http://www.os.dhhs.gov/healthit/barrierAdpt.html (accessed Oct. 25, 2008).

[7] "Electronic Health Records in Ambulatory Care - A National Survey of Physicians", NEJM 359:50-60


In summarizing these issues, blog founder Roy Poses made an astute observation:

MedInformaticsMD came up with a novel hypothesis about why the EMR, and other health care IT applications, often seem so jinxed. Perhaps many (presumably thoughtful and intelligent) people within health care organizations are very skeptical of these applications because of problems such as security flaws, user unfriendliness, conflicts with work flow, etc, etc. However, since it is politically incorrect to express their skepticism openly and frankly, they resort to passive aggressive opposition.

A review of the manifestations of passive aggressive behavior is quite interesting in that regard:

Common signs

There are certain behaviors that help identify passive-aggressive behavior.

These behaviors are quite familiar to those working in healthcare informatics.

-- SS

1 comment:

Maggie said...

FYI there's a discussion going on about these issues now (Oct 27-Nov 3) at:
www.thenationaldialogue.org. Today is the last day, so don't miss your chance to add your comments.

It's called the National Dialogue on Health IT & Privacy. On the site, you can contribute ideas, and read and rate others' ideas. Watch in real time as the best ideas "rise to the top."

** The results of this online dialogue are being compiled into a report to the Federal CIO Council, Office of Management and Budget, and the incoming Administration by the National Academy of Public Administrators. **

Hope to see you there.
Maggie, The National Dialogue