Wednesday, February 24, 2016

At least former ONC chair Blumenthal now says "health IT can [even] cause safety issues." Other than that, it's unicorns and fairies in the Harvard Business Review.

The truth about healthcare IT, that it is perilously insecure, and is causing clinician despair and patient harm, is increasingly becoming mainstream. 

For example, seen at the eclectic, widely read, multi-author website of Beauchamp Brogan Distinguished Professor of Law at the University if Tennessee Glenn Reynolds, Instapundit (

REMEMBER THE HEALTHCARE.GOV LAUNCH? Apparently so did some hackers:

“To improve the quality of our health care while lowering its cost, we will make the immediate investments necessary to ensure that, within five years, all of America’s medical records are computerized,” President Obama said. “This will cut waste, eliminate red tape and reduce the need to repeat expensive medical tests.”  While the shift Obama and many others pushed may have improved care, electronic medical records led to quite the unique hostage situation in Los Angeles this week. There, a hospital fell prey to a cyberattack — and the hospital has escaped its plight by paying hackers a $17,000 ransom.

Government mandates and electronic security don’t seem to be a very good mix.
Posted at by Stephen Green on Feb 18, 2016 at 7:31 am Link

and this:

MY USA TODAY COLUMN: Futuristic Data Security With A Pen And A Pad. “If I were running an intelligence agency, I’d have all my important stuff done in handwriting or on mechanical typewriters (the old kind that type over the same fabric ribbon multiple times) and distributed in sealed envelopes. If I were setting up a voting system, I’d use paper ballots instead of electronic voting machines. And if I were running a hospital, I’d seriously consider doing everything on paper."

Posted at by Glenn Reynolds on Feb 22, 2016 at 1:21 pm Link

and this:

YES. NEXT QUESTION: Are Mandatory Electronic Medical Records Causing Doctor Burnout?

Posted at by Sarah Hoyt on Dec 17, 2015 at 4:39 am Link

However, former ONC chair David Blumenthal (now president of the Commonwealth Fund) apparently hasn't received the message.  He and a colleague wrote the following in the Harvard Business Review.

Speeding Up the Digitization of American Health Care 
David Blumenthal
Aneesh Chopra
February 22, 2016

No more of those infuriating forms to fill out at doctors’ offices: the information is all in the computer. Doctors and hospitals don’t repeat tests you’ve had someplace else: they’re all in the computer. All your caretakers know exactly what medicines you’re on and what you’re allergic to: that’s in the computer. When your elderly mother moves from a hospital to a rehabilitation center, the nurses and doctors there know all about her before she arrives: all in the computer.

The usual utopian trope, and as usual it ignores the self-corrective effects of being asked to repeat information that would otherwise be taken as fact from a computer, which can and does propagate errors (which can and does have deadly effects).

These and many other feats of information management will soon be routine in the United States. Indeed, in some places they are already happening. Our health system is undergoing a digital revolution that will profoundly affect the health care of Americans.

"Soon" has been the mantra of the zealots since about 1950.  Further, the assumption in such articles is that the effects are all beneficent ("profoundly affect" means "in good ways only"), and the results are quite mixed on that score.

Many providers and policy-makers tend to see these issues as technical failings of the electronic records that have been recently been adopted with federal support. This has caused some critics to say that the federal investment – estimated at $31 billion over 10 years – is not paying off.

But this diagnosis is only partly correct. Underlying the challenges facing the digital health revolution are economic and social issues that must be addressed if the potential value of electronic records is to be realized.

Aside from the conflict of interest of such passages being written by a person who contributed to those tens of billions spent, in fact, the federal investment has largely been a huge waste for healthcare and a huge boon for the IT industry, disenfranchising the medical community (including physicians and nurses) and creating mayhem for patient care, e.g., and

I can also add that the "economic and social issues that must be addressed" were reasonably understood and needed to be addressed before the likes of Blumenthal and ONC put the cart before the horse, "ready, fire, aim"-style on nationsl rollout of health IT.  See my July 2010 post "Meaningful Use Final Rule: Have the Administration and ONC Put the Cart Before the Horse on Health IT?" , my Oct . 2010 post "Cart before the horse, again: IOM to study HIT patient safety for ONC; should HITECH be repealed?" and my June 5, 2012 post "Cart Before the Horse, Part 3: AHRQ's 'Health IT Hazard Manager'".

Further -

Some history on the issue of risk (this blog has a long memory):

Mr. Blumenthal, Feb. 22, 2016, in the new HBR article:

"... some electronic health records are complex and difficult to use. This is frustrating for doctors and nurses, slows them down, and can even cause safety issues."

Mr. Blumenthal, April 30, 2010:

... Blumenthal said that although an advisory committee concluded that more information was necessary, he called the evidence of the reports “anecdotal and fragmented” at best ... [Blumenthal's] department is confident that its mission remains unchanged in trying to push all healthcare establishments to adopt EMRs as a standard practice. "The [ONC] committee [investigating FDA reports of HIT endangerment] said that nothing it had found would give them any pause that a policy of introducing EMR's could impede patient safety," he said.

(Ironically and tragically, just weeks later, on May 19, 2010 my mother was severely injured and later died as a result of a dangerously faulty EHR.)

Mr. Blumenthal's views on risk of 2010 as ONC chair represent either deliberate mistruths or ignorance.  Both of those traits tend to be long term, so why should any physician believe the views he expresses in the Harvard Business Review in 2016?

I grant that the views of 2016 in the new article are somewhat more in line with reality, but with significant faults including but not limited to:

1) Since the magnitude of the "safety issues" that health IT can "even" cause are unknown (best estimates are from the ECRI Deep Dive study, which are alarming as at, it is reckless at best to promote the continued rapid expansion of this technology.

2) On causality, Mr. Blumenthal's views are either erroneous or deliberately misdirect to blame the "health care markets":

"If health care markets functioned well in the U.S, HITECH would have been unnecessary. The industry would have wired itself like our financial, travel, and retail sectors."

Mr. Blumenthal fails to realize, still, the primary reason why healthcare practitioners have resisted computerization: bad health IT.

Bad Health IT ("BHIT") is defined as IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy, promotes evidentiary non-trustworthiness, or otherwise demonstrates suboptimal design and/or implementation. 

The Jan. 2015 letter to HHS from about 40 medical societies was clear on these issues:

The health IT industry needs to provide worthwhile products before they are shoved down physicians' and patient's throats.

Not to mention the outright peril such systems place patients under:

Feb. 18, 2016
Hollywood Presbyterian Medical Center: Negligent hospital IT leaders allow hacker invasion that cripples EHRs, disrupts clinicians ... but patient safety and confidentiality not compromised
Forbes Feb. 23, 2016:
White Hat Hackers Hit 12 American Hospitals To Prove Patient Life 'Extremely Vulnerable'

Then this statement is made:

Patients tend to be loyal to doctors and hospitals at least in part because that’s where they’re known – that’s where their records reside. If that information can travel to another hospital or doctor at the push of a button, patients can more easily leave current providers behind. That’s not good for business.

That's risible.  Patients don't hang around care they don't like because they can't "push a button" to transfer their records.  In fact, if anything, it's an impediment to cost-cutters that it's not easy for bureaucrats to force patients to go to the cheapest "provider" due to records "stuck" at one office or organization. 

Clinicians have very clearly stated their reasons for hating health IT.  See the Medical Societies letter linked above, for example.  There's no need to make up nonsensical reasons, such as doctors and hospitals holding patients "captive" through their records.

And as for vendors, if you can move information from one vendor system to another, providers can switch out or build upon records more easily in search of a better product. That’s lost revenue for the company.

On that point I am in agreement.

But technical fixes and better records won’t be enough. We need incentives that reward quality and safety improvement and cost reduction.

Not mentioned is reasonable regulation regarding compromised safety, for which "incentives" alone are insufficient.

And we need penalties for providers and vendors that slow-walk the digital revolution to protect their economic interests.

These words are totalitarian.  Responses to glaringly obvious adverse consequences, such as protecting patients from cybernetic harm and the ability to practice good medicine without distraction and burnout don't seem to count.  All that matters is the "revolution."

If we make the market for good health care work, a lot of our current [wicked (, intractable - ed.] technical problems will melt away as providers and vendors compete to make service and care better for their customers: the nation’s patients.

My comment about this statement, that massive healthcare IT sociotechnical problems will simply "melt away" is best summarized in a picture of a land where that can plausibly occur:

Mr, Blumenthal seems unaware of the domain of Social Informatics, "the interdisciplinary study of the design, uses and consequences of information technologies that takes into account their interaction with institutional and cultural contexts" (see  Problems in fields as wickedly complex as at the intersection of healthcare and IT do not and will not "melt away."  However, they need to be managed.  What we have now is mismanagement of those problems, with imposition of painfully inappropriate mandates and lack of meaningful regulation and safety surveillance, among other defects.

"Speeding up" healthcare digitization as a national plan in 2016?  No. 

National implementation needs to be seriously rethought in 2016, and massively scaled back and slowed down until we have more of a handle on how to manage change correctly. 

Anything else is reckless.

End note: the grandiose term "revolution" with respect to health IT is a hyper-enthusiast's or zealot's term, is hyperbolic, hackneyed and no longer believed except by the most seriously deluded, and needs to be promptly abandoned.  Leave "revolutions" to the Lenins and Trotskys of the world.

-- SS


Trevor3130 said...

Scot, I think I know why you are suspicious of programs/projects labelled "revolutionary". The authors of such are more likely to be ignorant of history, and that's sufficient defect to be wary.
Would you prefer a descriptor like "renewal" instead? I wouldn't since it implies the same destructive "re-creation".
How about "transformation" as in our Digital Transformation Office?
Did you see This is Why People Fear the ‘Internet of Things’?

afraid said...

The HiTech disaster is much like the disaster, both of which we continue to suffer from. Policies that ignore the primary motivation of self interest are bound to create opportunities to be turned on their heads to yield results exactly opposite of the policy's intent.

Politically correct Pollyannas make poor leaders because of this. They live in the world of unicorns and magical forests depicted in your post.

InformaticsMD said...


We're not dealing with politically correct polyannas. We're dealing with cybernetic extremists, to whom the computer has more rights than the patients.

Such people are also heartless bastards. For instance, from "ONC safety center still up in the air", Politico, ARTHUR ALLEN 6/17/15 regarding a toothless "health IT safety center" as opposed to more traditional healthcare device regulation:

... There was a high degree of consensus on the 30-member RTI panel, [ONC’s chief officer of clinical quality and safety Andy] Gettinger noted. When asked, in a recent interview, whether the group’s composition affected its decision to shy from a more investigative center, he said he would have loved to have the participation of health IT expert and longtime critic Scot Silverstein, who blames an EHR error on a severe injury his mother suffered in a hospital in 2010.

“He may have heard what we were intending and been able to step back from specific things relative to his mother’s care and gotten to a space to see that this initiative has the potential of making real change in the EHRs used throughout the country,” Gettinger said.

Silverstein said he was never invited to be on the panel. Gettinger’s comment, he said, “is insulting on the basis of minimizing my mother’s death which is the poster example of what’s wrong with these systems, not a one-off thing.”

In other words, ONC's Gettinger implies I might understand how great a toothless IT safety center would be - if only I'd put my maimed-and-died-by-EHR mother aside.

That's apparently what passes for reasoned discussion and ethics among the cybernetic extremists.

-- SS

InformaticsMD said...

Trevor3130 wrote:

Would you prefer a descriptor like "renewal" instead? I wouldn't since it implies the same destructive "re-creation".
How about "transformation" as in our Digital Transformation Office?

I prefer not to use bombastic terms at all. There is no "renewal" nor "revolution." Ideally, clinicians can be assisted by clinical IT. So, the term I would use is simply "IT adoption in medicine."

See for instance my post at

-- SS

afraid said...

The Pollyannas who really believe that their simplistic ideas that depend on corporate altruism.