Thursday, February 05, 2009

Will the U.S. spend the Economic Recovery Act's $20 billion for Healthcare IT more wisely than the UK?

The Congress is about to pledge more than $20 billion towards healthcare information technology as part of the Economic Recovery Plan.

As a Medical Informaticist, I could be a cheerleader, or simply remain silent, and benefit directly from this money.

... If I were an opportunist, that is, not an honest, critical thinking physician-computer scientist.

I have written multiple posts on Healthcare Renewal about the difficulties and even perils of healthcare IT. I suggested a possible moratorium on massive investment (here and here) until the issues are better understood, via robust research.

Healthcare IT is an experimental technology whose benefits are unclear, and about which varied organizations such as the National Research Council and the Joint Commission have recently issued less than stellar reports. See the Joint Commission Sentinel Event Alert on HIT and the National Research Council report "Current Approaches to U.S. Health Care Information Technology are Insufficient." This technology in 2009 is no magic bullet nor panacea.

In an editorial accompanying the very recent article "Clinical Information Technologies and Inpatient Outcomes", Archives of Internal Medicine 169(2), Jan. 26, 2009 (full text is available as of this writing at this link), it is observed that although the study is suggestive of clinical IT benefit, more research is needed. I also note that medical informatics expert David Bates, MD at Brigham & Women's Hospital, the editorial's author, pointed out:

"... organizations have been nervous about making large investments in technology that is difficult to implement , creates major issues with change management , carries a substantial risk of failure , and has uncertain benefits ." ... It is not sufficient just to have bought the technology—it has to be [implemented and] used effectively in a much broader quality structure. When it is not used effectively, it may even worsen performance ."

(This sounds remarkably like what I have been writing for the past ten years at great professional peril. I began such writing after observing firsthand as a CMIO that poorly conceived and implemented HIT, and poorly suited conceivers and implementors, wasted money, resources and time hospitals really don't have - and in one case put sick patients at great risk.)

So, as we are about to spend $20 billion for the technology that in the President's words will "improve healthcare quality and reduce costs...and save $80 billion per year", I present the UK National Health Service's progress since 2006 on their national HIT initiative. They are several years "ahead" of us, especially in terms of spending.

I won't comment on this summary futher, only saying that it speaks for itself. Will we repeat the same errors? A full report is also available (HTML version; and PDF version):

The National Programme for IT in the NHS: Progress since 2006 - Public Accounts Committee

14 Jan 2009

Conclusions and recommendations

1 Recent progress in deploying the new care records systems has been very disappointing, with just six deployments in total during the first five months of 2008-09. The completion date of 2014-15, four years later than originally planned, was forecast before the termination of Fujitsu's contract and must now be in doubt. The arrangements for the South have still not been resolved. The Department and the NHS are working with suppliers and should update the deployment timetables. Given the level of interest in the Programme, the Department should publish an annual report of progress against the timetables and revised forecasts. The report should include updates on actions to resolve the major technical problems with care records systems that are causing serious operational difficulties for Trusts.

2 By the end of 2008 the Lorenzo care records software had still not gone live throughout a single Acute Trust. Given the continuing delays and history of missed deadlines, there must be grounds for serious concern as to whether Lorenzo can be deployed in a reasonable timescale and in a form that brings demonstrable benefits to users and patients. Even so, pushing ahead with the implementation of Lorenzo before Trusts or the system are ready would only serve to damage the Programme. Future plans for deployment across the North, Midlands and East should therefore only follow successful deployment and testing in the three early adopter Trusts. This will mean that lessons can be learned before any decision is taken to begin a general roll-out.

3 The planned approach to deploy elements of the clinical functionality of Lorenzo (release 1) ahead of the patient administration system (release 2) is untested, and therefore poses a higher risk than previous deployments under the Programme. The Department and the NHS should undertake a thorough assessment of whether this approach to deployment will work in practice. No Trust other than the three early adopters should be invited to take the first release of Lorenzo until it is certain that release 1 and release 2 will work effectively together.

4 Of the four original Local Service Providers, two have left the Programme, and just two remain, both carrying large commitments. CSC is responsible for deploying care records systems to the whole of the North, Midlands and East after taking over Accenture's contracts. As well as deploying systems in London, BT is responsible for the N3 broadband network and the Spine. In the light of the experience of Accenture's and Fujitsu's departures from the Programme, it is vitally important that the Department assesses BT's and CSC's capacity and capability to continue to meet their substantial commitments. The assessment should consider the impact on the strength of the Department's position of having only two suppliers responsible for the Programme's major components.

5 The termination of Fujitsu's contract has caused uncertainty among Trusts in the South and new deployments have stopped. One option being considered for new deployments is for Trusts to have a choice of either Lorenzo provided through CSC or the [Cerner] Millennium system provided through BT. There are, however, considerable problems with existing deployments of [Cerner] Millennium and serious concerns about the prospects for future deployments of Lorenzo. Before the new arrangements for the South are finalised, the Department should assess whether it would be wise for Trusts in the South to adopt these systems. Should either of the Local Service Providers take on additional commitments relating to the South, the Department should take particular care to assess the implications of the extra workload for the quality of services to Trusts in the Local Service Providers' existing areas of responsibility.

6 The Programme is not providing value for money at present because there have been few successful deployments of the [Cerner] Millennium system and none of Lorenzo in any Acute Trust. Trusts cannot be expected to take on the burden of deploying care records systems that do not work effectively. Unless the position on care records system deployments improves appreciably in the very near future (i.e. within the next six months), the Department should assess the financial case for allowing Trusts to put forward applications for central funding for alternative systems compatible with the objectives of the Programme.

7 Despite our previous recommendation, the estimate of £3.6 billion for the Programme's local costs remains unreliable. The Department intends to collect some better data as part of the process of producing the next benefits statement for the Programme. In the light of that exercise, the Department should publish a revised, more accurate estimate for local costs and, thereby, for the cost of the Programme as a whole.

8 The Department hopes that the Programme will deliver benefits in the form of both financial savings and improvements in patient care and safety. In March 2008, the Department published the first benefits statement for the Programme, for 2006-07, predicting total benefits over 10 years of over £1 billion. There is, however, a lot of work to do within the NHS to realise and measure the benefits. Convincing NHS staff of the benefits will be key to securing their support for the Programme, and the credibility of the figures in the benefits statement would be considerably enhanced if they were audited. We consider future benefits statements should be subject to audit by the Comptroller and Auditor General. The Department should also review achievements under the Programme so that lessons can be identified and shared where products and services are working well.

9 Little clinical functionality has been deployed to date, with the result that the expectations of clinical staff have not been met. Deploying systems that offer good clinical functionality and clear benefits is essential if the support of NHS staff is to be secured. For all care records systems offered under the Programme, the Department and the NHS should set out clearly to NHS staff which elements of clinical functionality are included in existing releases of the software, which ones will be incorporated in the next planned releases and by what date, and which will be delivered over a longer timescale.

10 The Department has taken action to engage clinicians and other NHS staff but there remains some way to go in securing their support for the Programme. To assess and demonstrate the impact of its efforts to secure support for the Programme, the Department should repeat its surveys of NHS staff at regular intervals (at least every year) and publish the results.

11 Patients and doctors have understandable concerns about data security. However extensive the Care Record Guarantee and other security provisions being put in place are, ultimately data security and confidentiality rely on the actions of individual members of NHS staff in handling care records and other patient data. To help provide assurance, the Department and the NHS should set out clearly the disciplinary sanctions that will apply in the event that staff breach security procedures, and they should report on their enforcement of them.

12 The Department does not have a full picture of data security across the NHS as Trusts and Strategic Health Authorities are required to report only the most serious incidents to the Department. The Department's view is that it is not practical for it to collect details of all security breaches but at present it can offer little reassurance about the nature and extent of lower-level breaches that may be taking place. Given the importance of data security to the success and reputation of the Programme, the Department should consider how greater assurance might be provided through regular reporting. The Department should also report annually on the level of 'serious untoward incidents', on any penalties that have been imposed on suppliers for security breaches, and on the steps being taken to keep patient data secure.

13 Confidentiality agreements that the Department made with CSC in respect of two reviews of the delivery arrangements for Lorenzo are unacceptable because they obstruct parliamentary scrutiny of the Department's expenditure. The Department made open-ended confidentiality agreements in respect of these reviews, with the result that information will not be disclosed even after commercial confidentiality has lapsed with the passage of time. We believe this is improper. The Department should desist from entering into agreements of this kind.

Does the word "quagmire" apply, I ask?

Via what magic will we in the U.S. do better if pushed to achieve widespread EHR by 2014, just five years from now, I ask?

Why will we spend the $20 billion more wisely than the UK (especially when several of the major HIT contractors there were American HIT companies such as Cerner and IDX and management consultants CSC and Accenture?)

Helloo-oooooo, U.S. Congress. Anyone paying attention?

Probably not, I am afraid.

I note this rather inappropriate analogy from Sen. Sheldon Whitehouse of Rhode Island:

Just look at what private technology and innovation have already done with the internet. Google, eBay, Amazon, YouTube, Facebook. Whose life has not been changed? Now imagine what can happen in health care. Wonderful opportunities beckon, both in the near term, because funding this infrastructure will create jobs in the information technology sector, and in the long term, to help us bring down the spiraling health care costs that threatens to engulf our economy.

Reminds me of former Intel chief Craig Barrett lamenting that his 45 horses had EHR's, so why not 300+ million humans?

Anything you don't understand must be easy to accomplish, in effect.

How hard could it be, if you have all the right tools, after all, to accomplish nuclear fission on your kitchen table?

Unfortunately, quite hard, as I’m afraid those with naïve views about healthcare IT are about to discover, at taxpayer expense.

-- SS


steve said...

We are living in an unprecedented social experiment.

Never so much technology has been available to everyone.
From a very young age, children start with a computer connected to the Internet then graduate very quickly in the name of parent security with mobile phones, they are the new generation of connected kids.
For these kids social interactivity is happening through emails, SMS and of course what it is called “Social” sites with the likes of Facebook and others.

didier grossemy

Anonymous said...

SS- Having read a couple of years worth of your posts on the subject I wonder if perhaps the professional peril that your efforts have earned might not be because of your points which I believe have been well made.

Instead, I believe that you have been a little too divisive in setting the business IT crowd up as an antagonist to the clinical informaticists such as yourself. I agree that your profession's role should be central to organizing and implementing solutions. I further believe that the rhetoric that you use has been at times abrasive and exclusionary...implying, whatever your intention, that there shouldn't be any role in health care implementations whatsoever for IT generalists. Perhaps I am wrong, but I believe that your tone of discussion is the single greatest impediment to people receiving and welcoming your generally well-founded criticisms.

My point here truly isn't to attack your ideas or approach but to offer an observation.

MedInformaticsMD said...

I am puzzled by the above comment about this post, which presents official UK government material, quotes the US National Research Council, US Joint Commission and an informatics expert at B&W hospital, and then asks questions about how the US will do better than the UK. Nothing about "generic IT" personnel at all.

Yet "Anonymous" feels my posts are too "divisive" against generic IT workers, which I presume means management information systems personnel.

I shall respond:

The world economy is in an utter shambles due to fraud and incompetence, people being laid off worldwide, biomedicine included.

The Bernie Madoffs of the world scammed people out of their life's savings. Worse, he apparently claimed to utilize advanced computer algorithms for trading, feeding off investors' massive overconfidence in computing magic.

Biomedicine is subject to corrupt, incompetent "generalist" leadership and conflicts of interest that have severely damaged the public's confidence in its practitioners and in its drug and device producers. Patients have died as a result.

I've seen IT departments hamper R&D and drug adverse events surveillance efforts for multinational pharmas, in fact, usually when led by IT generalists or worse, non-IT personnel,on a belief in domain neutrality for leadership.

The IT industry in healthcare does not seem to know what it's doing, resulting in mass chaos and waste in national programs such as the UK quagmire as I reproduce from their own report. My inbox receives a stream of stories of HIT waste and mismanagement (not by clinicians, who usually are not empowered in meaningful ways), some of which I post on my website in anonymized form. These are massive wastes of capital that can be better spent on taking care of needy patients.

In that setting, anonymous writes "you have been a little too divisive in setting the business IT crowd up as an antagonist."

Thanks for the observation, Mr. Chamberlain. I'm sorry if physicians are starting to rebel against the "learned helplessness" that causes them to make nice with cross-occupational pirates in various sectors stealing their profession from them.

Anonymous also writes "...implying, whatever your intention, that there shouldn't be any role in health care implementations whatsoever for IT generalists."

"Any role whatsoever?"

You need to read what is actually written about leadership vs. facilitation in HIT before you arrive at hysterical interpretations of well reasoned argument.

I teach such IT generalists, by the way, at the graduate level, in preparing them for stronger roles in health IT.

On wonders if "anonymous" has done same as have the ambitious and intelligent IT professionals in my university's social-issues-aware information science/IT programs.

I also suggest anonymous search my writings on my early mentor "Victor P. Satinsky." Dr Satinsky never lost a complex cardiothoracic surgery patient for his critical thinking. Not a one.

Finally, if people entrusted with the well being of patients cannot use a "divisive" tone in speaking out against intrusions into the profession by overextended IT leaders, then who can?

-- SS

Anonymous said...

Let me paraphrase the comments from "Anonymous" above. He is trying to say, "Lighten up dude."

MedInformaticsMD said...


Let me paraphrase my comments:

Patients', and more globally our society's well being has been put at risk by those with an attitude of "lighten up, dude."

Perhaps we should "lighten up" about issues such as this?

When Doctors and Nurses Can’t Do the Right Thing

Medicine is serious business. Perhaps those with lighter temperaments would be better off reading "lighter" materials such as here.

Anonymous said...

Why, in the original report from the Public Accounts Committee of the House of Commons, do you suppose the name of the manufacturer of "Millennium" device is redacted (omitted)? Are the purchasers and government suppliers required to sign a non-disparagement agreement with the device manufacturer? If such is the case, might this explain the conspiracy of silence about medical, privacy, and economic dangers of these experimental patient care record devices?

MedInformaticsMD said...

Why, in the original report from the Public Accounts Committee of the House of Commons, do you suppose the name of the manufacturer of "Millennium" device is redacted (omitted)?

I don't know, but I also found it interesting.

Perhaps someone knows the answer?