Sunday, April 27, 2014

From a physician and former USAF air traffic controller/pilot on the state of healthcare IT

From a colleague, a physician and blogger and fellow AMIA member with an eclectic background, on the state of healthcare information technology.  Reposted with his permission.

Emphases in bold are mine:

To restate the old joke, the nice things about medical informatics standards, are their are so many of them too chose from… don’t think we necessarily need to invest even more time and energy on ever more sophisticated data models or ever more exhaustive standards (which are then largely ignored). 

The fact of the matter is that the EMR remains in the United States a tool for maximization of reimbursement and as such is not a  technological destination but rather a technological dead end. The driver for proliferation of this ‘dead end’ is the government being willing to fund its expansion with their fervent hope that it will be their magic bullet for finding the cheats and cheaters of Medicare. 

When I was in the USAF, I was trained to be a software and systems engineer at their great expense and at my great pleasure. Additionally, I was for several years prior to my medical school career a USAF Air Traffic Controller and so I was intimately familiar with perhaps the most perfect of all known systems engineering efforts the Worldwide Air Traffic Control System, and most remarkably (from the wellsprings of my fading memories) I have 50 hours of stick time in the F-16. 

The flying environment of the F-16 which is ‘eyes outside the cockpit’ was made possible by advanced human engineering efforts that resulted in Heads Up Displays of both intense rational and aesthetic beauty that made the machine a joy to fly. 

Fast forward 20 years and what am I given as a clinician to work with…. to keep my head out of the cockpit…… spreadsheets…… designed by engineers who like spreadsheets and think in spread sheets…..  and who don’t even take the 30 minutes it takes to articulate the logic of presentation of clinical data, i.e., present the serum salts together with the BUN/Creatinine, present the RDW with the RBC indices and the hematocrit and hemoglobin … present the last 3 d’s worth of data together aggregated by type rather than alphabetized and homogenized and distributed in clinically illogical boxes. 

The F-16 was designed by engineers, but pilots oversaw its development and the display of its information systems were always the results of intense end user interaction with the design teams. This type of intense physician interaction and veto power of poor information design efforts does not exist in [the health IT] industry. Their goal is feature proliferation and uniqueness (not commonality) of function as a market differentiation tool and to avoid suits for ‘look and feel’ viz a viz the Apple vs Microsoft suits of the 80’s. 

The reality is the train has left, those of us addicted to patient care watch in dismayed horror as our productivity plunges and we struggle to restructure not our workflows but our clinical thought processes to badly designed, logically flawed, and obscenely overpriced documentation tools that distract the expert clinician from a high quality clinical encounter. 

Quite honestly gentleman and gentlewomen of the jury, I don’t give a ‘rats a**’ about superior documentation, I am obsessed with superior outcomes, and as somebody who actually has to work with this junk, it all sucks………. and will continue to suck until such time as real world clinicians have veto power over the efforts of systems design teams with respect to their information design efforts…. What information design efforts?  My point precisely……. 

As always Acerbically Yours, 

frnk m (Frank Meissner)

“I am not a pessimist, I am an optimist who has not arrived’ 
                                                                      Mark Twain

My reply back was:

Frank, on a related note, I was at a fleamarket yesterday looking for radio & electronics stuff (my hobby) and came across a man selling copies of "Aviation Week" from 1960.  He had the entire year's set.

I looked through them and was STUNNED.

The engineering prowess described in not just the articles but in the advertisements as well - bearings, servos, instrumentation, etc. for aircraft and spacecraft was stunning.  There was even an ad for a desktop computer, a Packard Bell PB-250 with "microsecond add time, 350 transistors and 46 (or so) instructions" for a mere $30,000.

What you are describing - and what I have been trying to describe for over a decade and a half - is an intellectually impoverished industry that ignores our specialty [Medical Informatics] and good engineering practices in general.

That AMIA has made itself appear comfortable with that status quo has been a disappointment to say the least.  What you just wrote should have come from the leadership, and years ago, not from the grass roots.

If physicians could refuse use of clinical IT without sanction, I believe in 2014 that most would walk away.

The fact that this technology is now forced on clinicians is not what the pioneers in informatics intended, I am confident; our medical leadership, furthermore, should be ashamed of this set of affairs. As a former medical manager for the Southeastern PA Transportation Authority, even bus drivers and porters in public transit had more rights to determine what equipment they would or would not use in their work, and its configuration, than physicians have in theirs.

-- SS


Steve Lucas said...

The FAA has known since the Clinton Administration that the pilots Third Class Medical serves no purpose. So what to do, they add DUI’s to the count and still can not come up with a statistically significant number.

Next step, add an all electronic reporting system. The result is to cut out doctors who do only a few exams a year as the cost of the system outweighs the benefit. The FAA also gains access to a persons health records so that a doctor who up codes and marks a prescription never given creates an excuse for the FAA to investigate.

Today experienced Medical Examiners are speaking out about the waste in this system. The government itself has a report showing the system is a total and complete disaster.

The solution, keep the system in place.

Then add to this fewer pilots, flying fewer hours, in fewer aircraft and by 2020 private aircraft are suppose to have date in and data out capability, at a cost yet to be determined. Today a simple transponder shows the location, altitude, and through the use of a code, the intention of the aircraft. Not good enough when we can add more technology.

Talking on the radio and eyes out of the cockpit are no substitute for technology, or at least that is what a politician feels when a company comes calling with a donation.

All of general aviation uses less than one half of one percent of all of the gas sold in the US, yet we face constant suits from groups petitioning the EPA over our emissions. This can all of course be solved with more technology.

The logical fallacies abound and this is only one small part of my life. The drive for technology, and some how the belief that any person can access any record, of any type, for any reason is simply absurd. Those records are only as good as the original information, and the people inputting that information have their own agendas.

EMR’s are only an extension of the concept that new and more expensive is always better. The supply of funds in the private sector is unlimited, and costs always come down. Failure is always do to lack of faith in the idea, and of course nobody is ever hurt.

Steve Lucas

Anonymous said...

****The reality is the train has left, those of us addicted to patient care watch in dismayed horror as our productivity plunges and we struggle to restructure not our workflows but our clinical thought processes to badly designed, logically flawed, and obscenely overpriced documentation tools that distract the expert clinician from a high quality clinical encounter.****

Said another way, the care governed by these unapproved CPOE and EHR devices has been radically altered to the negative due to their toxicity.
They represent an emerging disease that should be epidemiologically studied.

Hey,that deSalvo likes these population type studies