Sunday, August 22, 2010

Are computers in medicine narcotic? "Why did the National Programme for IT fail?"

I noted an article Why did the National Programme for IT fail? by an "ex-IT person" at the site Smart Healthcare.com in a series entitled "Patient from Hell."

Aside from the intoxicant qualities of crisp bank notes, I am beginning to suspect that computers exert a narcotic effect, like Kool Aid laced with morphine or alcohol, on many in the population.

Many people who should know better of the challenges, dangers and myths surrounding these tools are drawn in to comparisons and analogies that I would charitably call magical thinking and puerile - and absurdist and stupid when not so charitable.

This article shows the muddled thinking behind the health IT mania. My observation: when you see the word "revolutionary" in the same paragraph as health IT you're dealing with hysterics.


The "patient from hell" asks:

Why is the road to electronic healthcare so much more rocky than computerising other bits of the economy? Other professions, including bankers, accountants and lawyers, have made the jump, some 30 years after the advent of personal computers. Even musicians, poets, journalists, artists, philosophers and MPs have got up to speed.

"Even?"

Yes, and you can train a dog to fetch a stick, therefore you can train a potato to dance.

Why is the road to HIT more rocky than the road to computer poetry or art?


Perhaps because the endeavors of clinicians are not like those of a musician or poet or lawyer or banker, but just a bit more informationally, operationally, cognitively, scientifically, and socially complex?


I was amazed at the time by the irresponsibility, primarily of the consultants [i.e., physicians - ed.], who were effectively opting out of the planning process. They showed no interest in playing a part in designing a new way of working – for themselves, for nurses and all others involved in the revolutionary changes which digitalisation would bring to their working practices.


In fact, they were showing responsibility - to patients - in not being so eager to "change to new ways of working" according to the diktats of computer geeks, government and other bureaucrats and myriad non-clinicians running around like drunks, hysterically screaming "revolution!"

I fear that communication between clinician and IT has now got so contaminated that crazy solutions will come out of the deliberations of the coalition government on the future of IT in the health service. All I ask is that clinicians and IT people talk to each other. Is that so hard?


If you have the right tools on your kitchen table, shouldn't it be easy to generate nuclear fission at home?

Due to factors such as the asymmetry in responsibilities, obligations and liabilities between the two fields, of differences in knowledge and expertise, and in mindset and qualifications to attain privileges to intervene in people's lives (who qualifies IT personnel to be involved in clinical affairs?), yes, idealistic "let's all play nice in the sandbox together" dreams are "so hard."

Unfortunately, these types of comparisons and sentiments are extremely common in the Healthcare-IT-industrial complex.

The reality is:

The NPfIT failed because its purveyors and promoters hadn't a clue about the complexities and wicked problems involved in such an endeavor, problems known and described in the Medical Informatics and Social Informatics literature, among others, for decades.

It also failed because of collective ignorance of these domains among its leaders, and among those who chose the leaders. For instance, as I wrote here:

The Department of Health has announced the two long-awaited senior management appointments for the National Programme for IT ... The Department announced in February that it was recruiting the two positions as part of a revised governance structure for handling informatics in the Department of Health.

Christine Connelly will be the first Chief Information Officer for Health and will focus on developing and delivering the Department's overall information strategy and integrating leadership across the NHS and associated bodies including NHS Connecting for Health and the NHS Information Centre for Health and Social Care.
Christine Connelly was previously Chief Information Officer at Cadbury Schweppes with direct control of all IT operations and projects. She also spent over 20 years at BP where her roles included Chief of Staff for Gas, Power and Renewables, and Head of IT for both the upstream and downstream business.

Martin Bellamy will be the Director of Programme and System Delivery. He will lead NHS Connecting for Health and focus on enhancing partnerships with and within the NHS. Martin Bellamy has worked for the Department for Work and Pensions since 2003. His main role has been as CIO of the Pension Service.

Excuse me. Cadbury Schweppes (candy and drink?) The Pension Service? As national leaders for healthcare IT?

Instead of sobriety, attitudes about health IT seem to universally be "sure, the experts think you shouldn’t ride a bicycle into the eye of a hurricane, but we have our own theories." (See here and here.)

The domain of health IT needs a very stiff period of detox and rock-solid sobriety before it can achieve the (non-revolutionary) benefits of which it is capable.

-- SS

18 comments:

Anonymous said...

HIT is a new religion, preached by fanatics who are not interested in a perspective other than their own. They have no idea of nor are they interested in the thought processes of the forced "converts". The NY Times recently published an Op-Ed on this topic.

Anonymous said...

“Just because you have a hammer, not ever thing becomes a nail.”

Steve Lucas

Anonymous said...

The NPfit failed due to the fact that the devices were not subjected to the regulatory authority of the MHRA, the UK equivalent of the FDA.

Why would doctors subject their patients to devices that are of unknown safety and efficacy? The Brits did what the US doctors have failed to do.

paulboal said...

Working with people who are ignorant of (and who choose to ignore) the "wicked complexities" of an industry obviously leads to failure. The benefit of having ignorant parties involved in problem solving, though, is that (if they're good) they can question the status quo and help separate the inherent complexities of the industry and the unnecessary ones that the industry has contrived over time. Revolution is the opportunity to throw off old assumptions and self-imposed constraints that aren't really necessary.

Good to remember: "You can automate a bad process and get it done faster... it's still a bad process!"

MedInformaticsMD said...

I do not agree. Ignorance does not if ever provide innovative or magical perspectives. There must be some level of rigorous domain knowledge for valuable contributions to be made in a field this complex.

MedInformaticsMD said...

I also add that no work (even 'processes', whatever that means in a clinical context as opposed to an assebly line of widgets) can be automated well with poorly done IT. Before IT personnel talk about 'bad process' in medicine, they desperately need to look introspectively at themselves.

Anonymous said...

I would say - please continue your stone age thinking and medical practice, blinded in the vehement opposition of Healthcare IT.

Your patients will make their decisions about where they want their care from - your stone age practice or from someone who has adapted technology, and makes it easy to share and access their information with other docs.

At some point, I do hope that you do come to the realization that the world is indeed inhabited by other "qualified", "intelligent" and "knowledgeable" people who know more about IT and how to make it work better than you Medical education qualifies you to.

And before you jump into another of your diatribes, let me clarify that the previous para did not assume that IT people knew more than you about medical practice. Only about how to go about introducing technology so that clinical information is easily stored, retrieved, used for decision making and shared better than paper based processes.

Olivia Reeves said...

The way I see it is like this that the clinical profession people are more busy then the other people from creative field... who can get some free time to engage in the computers... but the clinical people rarely get time for themselves to use the computers.

Anonymous said...

"someone who has adapted technology, and makes it easy to share and access their information with other docs"

Where is the person who has actually accomplished this, Anonymous? I'm very angry that they aren't sharing their ingenuity and know how with the rest of us. [/sarc]

Roy M. Poses MD said...

Re the comment by Anonymous from 22 August, 5:46 PM -

Ah, we have provoked another ad hominem attack, devoid of anything substantive about the considerable risks of adverse effects due to health care IT that MedInformaticsMD has tirelessly explored.

If you cannot produce either logic or evidence, and aren't even willing to identify yourself, why should we believe you?

American Journal of Medicine said...

The growth of IT has been a boon to humankind, but IT cannot solve all of our problems-- despite with techies and programmers tell us.

In our Journal, physicians and medical students repeatedly have lamented how technology is changing or has changed medical care and medical education.

We have published articles about the efficiency of bedside, handheld diagnostic tools (January 2010), but we also have published commentaries decrying decaying physical exam skills among US medical students.

An article in our June 2010 issue reveals how electronic "copy and paste" errors creep into electronic health records. In our January 2010 issue, we published a research study that reported electronic medical record-keeping as currently practiced in the US doesn't really save money.

IT is a useful tool in health care, but the research shows us that IT is not a silver bullet which will cure the ills of the system.

Pamela J. Powers, MPH
AJM Managing Editor

Anonymous said...

Dear Dr. Roy and Dr. Mediformatics,

If by your reasoning (about errors and psychotism of computers in Healthcare) we should stop using computers, it would behoove us to banish the entire field of medical practice itself going by medical error rates that are prevalent in the US alone.

http://www.answer-my-health-question.info/medical-error-statistics.html

Or maybe you choose to ignore the concept of statistics - that there is nothing that is a hundred percent. There are errors in flying which risks lives, there are errors in driving that also risk lives, there are adverse reactions to even the most common drugs in some people, and I could go on and on and on. We cannot rely on individual incidents to make decisions for the entire field. That is not how decisions get made.

So while the incidents of harm due to computers are real and we need to continuously strive to reduce them, it is illogical to ignore the prevalence of errors and harm that are avoidable by the use of computers.

MedInformaticsMD said...

American Journal of Medicine said...

IT is a useful tool in health care, but the research shows us that IT is not a silver bullet which will cure the ills of the system.

Pamela,

That is the sober view. IT is a tool that can effect improvements in healthcare - but only if done well.

Doing HIT "well" is a massively complex undertaking, however.

When you read an article about health IT that uses the word "revolutionize" or similar concepts, or hear a speaker using such terms, I suggest the writer/speaker is a hysteric and/or someone with strong pecuniary interests.

The culture of IT in 2010 seems increasingly histrionic, with laser focus on the supposed beneficence of IT in all spheres (business, education, medicine...) and scant attention to downsides.

Sadly, many in IT seem to lack the liberal arts education to understand concept such as cultural manias in which I believe they find themselves.

-- SS

MedInformaticsMD said...

Anonymous August 22, 2010 5:46:00 PM EDT wrote:

please continue your stone age thinking and medical practice, blinded in the vehement opposition of Healthcare IT.

This anonymous poster has misrepresented my views on health IT, my educational background regarding IT, and patent's wishes for the best care as backed by evidence as to the efficacy of treatments and tools (including IT) utilized in that care.

The opinions expressed are unresearched, unpolished, and risible.

Roy M. Poses MD said...

Anonymous of 23 August, 9:27 PM (and presumably also the Anonymous of 22 August, 5:46 PM) -

You seem to be getting ready to go through the catalog of logical fallacies. If MedInformaticsMD and I really were hostile to computers, then why would we be blogging on the internet?

Computers are tools,or devices information technology is a set of devices. Tools and devices can be well or badly designed, reliable or unreliable, very safe or very dangerous, and appropriate or inappropriate for a task.

To criticize the design, reliability, safety, or appropriateness of a particular device in a particular setting is obviously not the same as being a complete Luddite.

What you have employed is a crude version of a slippery slope argument.

If you read any of my writing, you would realize I am obviously well aware of probability and statistics, and that the benefits and harms of tests and treatments must be weighed against each other. Obviously, the benefits and harms of health care IT need to be reasonably assessed, too.

However, just because drugs and devices all have downsides does not mean that the downsides of health care IT are trivial.

Your implication that the problems with health care IT ought to be excused by the problems of drugs and devices is a crude version of an appeal to common practice.

http://www.nizkor.org/features/fallacies/appeal-to-common-practice.html

Finally, have you got good evidence (e.g., from controled trials) that the errors avoided by using some specific software or hardware would be more consequential than those caused by them? Or more broadly, do you have good evidence that the benefits of specific health care IT practices outweight their harms in the clinical setting?

MedInformaticsMD said...

Roy, thanks for pointing out logical fallacies to the writer of the above comment. I can add a few more comments:

Anonymous August 23, 2010 9:27:00 PM EDT writes:

If by your reasoning (about errors and psychotism of computers in Healthcare) we should stop using computers, it would behoove us to banish the entire field of medical practice itself going by medical error rates that are prevalent in the US alone.

Actually, by my reasoning we need to improve health IT and stop being hysterical about its supposed benefits.

Extraordinary claims require extraordinary proof, and so far what I've seen is either inadequate to support extraordinary claims, or unsupportive of such claims.

Or maybe you choose to ignore the concept of statistics - that there is nothing that is a hundred percent. There are errors in flying which risks lives, there are errors in driving that also risk lives, there are adverse reactions to even the most common drugs in some people, and I could go on and on and on. We cannot rely on individual incidents to make decisions for the entire field. That is not how decisions get made.

I agree. However, the research and studies such as the subset from 2009 I collated here demonstrate the problems are beyond "anecdotes."

So while the incidents of harm due to computers are real and we need to continuously strive to reduce them, it is illogical to ignore the prevalence of errors and harm that are avoidable by the use of computers.

The magnitude of the former is unclear. Medical experimentation under these conditions, especially without explicit patient consent and robust research protections, is unethical.

-- SS

MedInformaticsMD said...

Note to anonymous posters:

Read the material at http://www.nizkor.org/features/fallacies before posting again.

Please make sure your comments are not in violation of these simple principles.

You waste our time and yours if they are.

Thank you.

-- SS

MedInformaticsMD said...

Another though occurs about the comments of various posters who choose to remain anonymous, such as this:

Or maybe you choose to ignore the concept of statistics - that there is nothing that is a hundred percent. There are errors in flying which risks lives, there are errors in driving that also risk lives, there are adverse reactions to even the most common drugs in some people, and I could go on and on and on. We cannot rely on individual incidents to make decisions for the entire field. That is not how decisions get made. So while the incidents of harm due to computers are real and we need to continuously strive to reduce them, it is illogical to ignore the prevalence of errors and harm that are avoidable by the use of computers.

By the patterns of the writing, it is likely the writer is an IT professional who lacks clinical skills and experience.

The issue is this:

Through what dysfunction do such personnel deem to stick their necks into serious clinical, social and ethical affairs in which they are novices?

How do they deem themselves fit to pronounce to clinicians what the latter should be doing, in any way, shape of form, IT or otherwise?

This was a question I asked myself upon exposure to hospital IT personnel twenty years ago, in critical care settings such as ICU's and invasive cardiology units, and I have still not received a satisfactory answer.

However, I have theorized that computers attract those of an authoritarian or even totalitarian demeanor.

-- SS