Friday, October 22, 2010

JAMIA: Health information technology: fallacies and sober realities

A superb, well-researched, and I believe watershed position paper in JAMIA was just published. I will briefly cover its major points due to current time limitations (ironically, I have an elderly health IT-injured relative to tend to). However I did want to make readers aware of the paper.

The paper nukes the health IT industry myths, memes and cavalier business practices that I find so disappointing.

The article organizes many of the themes around HIT myths, irrational exuberances and marketing memes into one coherent position paper (unfortunately, free fulltext is not yet available online that I can locate, but if you can obtain the article, it is a must-read):

J Am Med Inform Assoc. 2010 Nov 1;17(6):617-23.

Health information technology: fallacies and sober realities (link)

Karsh BT, Weinger MB, Abbott PA, Wears RL.

Department of Industrial and Systems Engineering and Systems Engineering Initiative for Patient Safety, University of Wisconsin, Madison, Wisconsin, USA.

Abstract

Current research suggests that the rate of adoption of health information technology (HIT) is low, and that HIT may not have the touted beneficial effects on quality of care or costs. The twin issues of the failure of HIT adoption and of HIT efficacy stem primarily from a series of fallacies about HIT. [Not discussed are the origins and maintenance vectors of those fallacies, a topic for significant research itself - ed.] We discuss 12 HIT fallacies and their implications for design and implementation. These fallacies must be understood and addressed for HIT to yield better results. Foundational cognitive and human factors engineering research and development are essential to better inform HIT development, deployment, and use.

PMID: 20962121 [PubMed - in process]

The article presents a series of HIT "fallacies" akin to the logical fallacies lists often referenced at this blog including:

THE ‘RISK FREE HIT’ FALLACY
THE ‘HIT IS NOT A DEVICE’ FALLACY
THE ‘LEARNED INTERMEDIARY’ FALLACY
THE ‘BAD APPLE’ FALLACY'
THE ‘USE EQUALS SUCCESS’ FALLACY
THE ‘MESSY DESK’ FALLACY (i.e., the fallacy that medicine is neat and linear)
THE ‘FATHER KNOWS BEST’ FALLACY
THE ‘FIELD OF DREAMS’ FALLACY
THE ‘ONE SIZE FITS ALL’ FALLACY
THE ‘WE COMPUTERIZED THE PAPER, SO WE CAN GO PAPERLESS’ FALLACY

I will write more about the paper in a future posting. However, readers of this blog, where I've covered these issues, can probably ascertain the meanings of these fallacies regarding health IT without further explanation.

Addendum 10/29: This is not just a "what is wrong with health IT" paper. The paper points out that insufficient contextual research has been conducted to support effective commercial HIT design and implementation despite decades of exemplary research on these topics, and suggests a path to remediation.

At the most fundamental level, HIT must be focused on transforming care and improving patient outcomes and must be designed to support the needs of clinicians and their patients. For example:

  • The needs of users and the complexities of clinical work must be analyzed first, followed by evaluation of the entire scope of potential solutions, rather than examining the current array of available products and characterizing the needs that they might meet.
  • Appropriate metrics for HIT success should not be adoption or usage, but rather impact on health.
  • The ‘comparative effectiveness’ perspective must also be applied to HIT - what is the return-on-investment of each HIT initiative compared with alternative uses of these funds?
  • There must be substantive collaboration with those who can contribute unique and important expertise such as human factors engineers, applied psychologists, medical sociologists, communication scientists, cognitive scientists, and interaction designers.
  • During HIT development, vendors and healthcare organizations must focus on more meaningful measures of design success: clinician and patient ease of learning, time to find information, time to solve relevant clinical problems, use errors, accuracy of found information, changes in task and information flow, workload, situation awareness, communication and coordination effectiveness, and patient and clinician
    satisfaction.
  • We must also consider the likely undesirable consequences of current policies and regulations on HIT advancement, e.g., hold harmless clauses.

If you have access to JAMIA via a library, I recommend downloading the article and reading it.

What will be interesting is the healthcare IT industry and government response, and the response of those with financial interests in pushing for rapid HIT diffusion along HITECH timelines (the "Bullet train out of the station with only a quarter mile of track" fallacy...)

-- SS

10/31/10 addendum

For a pro-industry alternate view on the importance and credibility of this article, see the Review posted on the HisTALK site by its owner at Monday Morning Update 11/1/10, approximately at the halfway mark.

My major concern with the review is not just on its internal logic and anti-academic, academics-automatically-hate-business bias (having been employed in academia, the healthcare IT industry and in Big Pharma myself, I see multiple perspectives).

... The authors of this paper are academics. I like their objectivity, but I’m left with the feeling that they are disillusioned about this fact that is distasteful to them: both healthcare and healthcare IT are businesses that, rightly or wrongly, make decisions based on their own self-preservation, not high-minded academic ideals. [Such as the Hippocratic oath - ed.]

My other concern is the review's taking on the JAMIA article in isolation, ignoring the increasing body of other literature up to the National Reseaarch Council (quoted at the beginning of the Karsh article) shedding doubt on HIT beneficence, effectiveness and ROI, and the statements of the Healthcare IT industry itself such as:

HIMSS's former Chairman of the Board Barry Chaiken admitting the technology remains experimental:

... We’re still learning, in healthcare, about that user interface. We’re still learning about how to put the applications together in a clinical workflow that’s going to be valuable to the patients and to the people who are providing care. Let’s be patient. Let’s give them a chance to figure out the right way to do this. Let’s give the application providers an opportunity to make this better;

and a HIMSS task force itself admitting in this 2009 PDF report that:

"Electronic medical record (EMR)!adoption rates have been slower than expected in the United States, especially in comparison to other industry sectors and other developed countries. A key reason, aside from initial costs and lost productivity during EMR implementation, is lack of efficiency and usability of EMRs currently available";

It seems that from the ethical point of view, when industry leaders themselves express doubts in their own products, the responsible position is to err on the side of caution.

-- SS

8 comments:

Anonymous said...

This paper provides accurate and descriptive language depicting the horrific reality for doctors who have been forced to participate in this experiment.

Not only are the defenseless patients guinea pigs for the HIT vendors, but the doctors and nurses have been USED by the HIT vendors as guinea pigs, and free consultants as well.

Scot M Silverstein MD said...

Not only are the defenseless patients guinea pigs for the HIT vendors, but the doctors and nurses have been USED by the HIT vendors as guinea pigs, and free consultants as well.

I agree. What's even more significant is that after 30+ years, the commercial HIT vendors still can't get it right; in fact they are so far from the mark that the National Research Council in 2009 opined that:

Current efforts aimed at the nationwide deployment of health care IT will not be sufficient to achieve the vision of 21st-century health care, and may even set back the cause if these efforts continue
wholly without change from their present course. Specifically, success in this regard will require greater emphasis on providing cognitive support for health care providers and for patients and family caregivers. This point is the central conclusion of this report.


As James Bond said in the opening of Goldfinger, "shocking - simply shocking."

There has been ample literature on how to avoid and/or remediate these problems. The new JAMIA article by Karsh et. al "Health information technology: fallacies and sober realities" is one of the best.

-- SS

Michael Kirsch, M.D. said...

It is clear that EMR is driven by IT folks, who have forged ahead without input and guidance from those of us who will be at Ground Zero - physicians. It makes great sense to coders and billers, who don't have a clue why we physicians are hostile to 'point and click' medicine.

Anonymous said...

Indeed a sobering commentary, yet the show goes on, enriching the sellers of snake oil. Hey, wasn't it due to snake oil sales that the FDA was established?

Anonymous said...

I'm surprised that more docs don't join in on single payor socialized medicine simply to get rid of the coders and billers etc etc etc.

Scot M Silverstein MD said...

The UK has socialized medicine, yet failed in its national health IT project miserably.

The answer's not the medical system structure or ideology. The answer is reform of the manner in which health IT is led, designed, produced, evaluated and maintained.

-- SS

Health Information said...

I completely agree with you, this paper ha opened the reality for doctors who have been forced to participate in this experiment.

BobbyG said...

I would sure love to read this article. It would help me further refine my views on HIT (I work in Adoption Support for a REC, but I am no Pollyanna cheerleader. See http://regionalextensioncenter.blogspot.com)

Not sure if I wanna pay 30 bucks for a one-day pass, though.