Monday, November 24, 2008

Open letter to Sen. Baucus on Health IT

Dear Sen. Baucus,

I respectfully offer you the following information in the hope that it will improve your efforts towards healthcare reform, enabling better healthcare for all.

From the WSJ, Nov. 24, 2008:

SEN. BAUCUS: Everybody talks about health IT. We all know we need it. It hasn't happened. Why? Partly because we're America. We're not a single-payer system like the UK, which can say, you hospitals, you have to put this in because we're paying your bills.

Indeed, that was said to the UK's hospitals. It has worked out to date - to put it politely - poorly.

The UK's results to date, after the expenditure of billions of dollars ...

(and an ironic dependence on an American health IT company, Cerner; see "Big Problems Hit Royal Free's Cerner Records Roll-out" and "Milton Keynes' Care Records System Caused Near Meltdown" as examples of how that's been working out)

... are at this healthcare renewal posting and include the following results. This is recommended reading for you, Senator Baucus, and our Congress as well:

Bank bailout puts £12.7bn NHS computer project in jeopardy

John Carvel, social affairs editor
The Guardian, Wednesday October 29 2008

The future of the NHS's £12.7bn computer programme was in doubt last night after its managers acknowledged further delays in introducing a system for the electronic storage and transmission of patients' records.

Connecting for Health, the NHS agency responsible for the world's biggest civil IT project, said it was no longer possible to give a date when hospitals in England will start using the sophisticated software that is required to keep track of patients' medical files.

Christine Connelly, the Department of Health's recently appointed head of informatics, is understood to be reviewing whether the programme is a cost-effective way of improving the quality and safety of patient care.

She will have to find compelling arguments to stop the Treasury earmarking health service IT as a candidate for cuts to compensate for the billions spent on the bailout of the banks. However, the high cost of cancelling contracts with IT suppliers may be a factor saving the programme from cancellation.

In May the National Audit Office said the project was running at least four years late, but still appeared to be feasible. It has since been beset by a series of further setbacks.

The agency fired Fujitsu, the contractor responsible for building the patient record system in the south of England. It asked BT to take over the work, but has not yet agreed a price.

In London, attempts to install the system at the Royal Free hospital and Barts caused weeks of confusion and disruption. Other trusts that were next in line were so alarmed that they pleaded for postponement.

In the north, the first installation of the Lorenzo version of the software at Morecambe Bay was repeatedly delayed.

Sanator Baucus, if health IT is "easier" in the UK due to their being single payer, then heaven help the U.S. in such efforts.

You might also read my post "Should The U.S. Call A Moratorium On Ambitious National Electronic Health Records Plans?" for much more on this issue.

Back to the WSJ quoting you:

SEN. BAUCUS: But we're America. We're going to find our solution. We need to work with appropriate bodies to develop interoperable standards, then give incentives to providers so they can put the IT systems in.

I dearly wish it were that easy to "put the IT systems in." I dearly wish that standards and incentives were the sole missing links. Unfortunately, the reality is far different, as thirty-plus years of informatics research has shown.

Sen. Baucus, I invite you and your staff to increase your awareness of Biomedical Informatics. In doing so you will learn that the call for "interoperability" of health IT may be setting our sights impractically high, and that what's more needed and attainable is aggregatability of intelligently selected data elements into a national repository.

The repository can then be used as an "executive radar" and is far easier to accomplish (and already has precedents on a smaller scale) then full interoperability among a menagerie of competing HIT products from myriad strong-minded "our way is best" vendors.

As to "incentives", you will also learn from sites such as "Common Examples of Healthcare IT Difficulties" and courses such as "Organizational and Sociological Issues in Health IT" (Word file) that standards and incentives and the fact that we have a heterogeneous healthcare environment are not the major impediments to HIT diffusion.

People issues and leadership by HIT "amateurs" (those lacking formal education and credentials in the subspecialty of clinical computing) trump all other issues, as in any area of technology. You might review the article "Electronic Medical Records - Not for Amateurs" starting on page 21 of the PDF file here.

I fear, however, that Congress subscribes to the procrustean, reactionary, IT industry-enriching, Intel-Craig Barrett "if it works for my horses it will work great for people" belief that clinical computing is just another brand of business computing, and that it's fine to further burden primary care physicians in their fifteen minutes per patient with hard-to-use IT where user interaction design was an afterthought.

The very same IT that may then cause - through overly simplistic, biased or defective P4P formulas and metrics - the diversion of hard-earned money from clinicians' pockets to the payers' purse.

In which case, good luck with a national efforts at HIT.

You and the rest of Congress would need it, as physicians would rightly apply active and passive aggression and other measures to sabotage and sink ill conceived and poorly implemented HIT initiatives led by amateurs.

And if the leadership for a U.S. national health IT initiative remains typical of other flavors of IT, with its high rates of difficulty and failure, I could not condemn U.S. physicians in that regard.

Worse, Sen. Baucus, as per the European Federation for Medical Informatics (EFMI) Working Group for Assessment of Health Information Systems, you should be aware that bad informatics can kill.

Finally, everyone on your staff and in Congress should read this article from Down Under:

Pessimism, Computer Failure, and Information Systems Development in the Public Sector. (Public Administration Review 67;5:917-929, Sept/Oct. 2007, Shaun Goldfinch, University of Otago, New Zealand).

Cautionary article on IT that should be read by every healthcare executive documenting the widespread nature of IT difficulties and failure, the lack of attention to the issues responsible, and recommending much more critical attitudes towards IT. link to pdf

It tells a cautionary tale to counterbalance the irrational exuberance over IT that seems to have taken hold in our society, indeed paradoxically accelerating after the great dot-com crash of the early 2000's. (My statement on the exuberance issue is webcast at Government Health IT here.)

Senator, I hope this information is useful and enlightening to you, and helps steer a more informed approach to health IT, so that health IT can succeed in its mission to improve healthcare.

It seems self evident that a defective healthcare system cannot itself be reformed or improved via defective health IT.

-- SS


Anonymous said...

Good letter, Scot. Hope it falls on other than deaf ears.


MedInformaticsMD said...

Good letter, Scot. Hope it falls on other than deaf ears.

I spoke with and then emailed it to a staff fellow, Andrew Hu, at House Energy & Commerce to whom I was directed by Sen. Baucus' Washington Office.

So, my post is not just floating in cyberspace.

Readers might add their own comments to:

-- SS

MedInformaticsMD said...

I am reposting a message from a reader, sans the ad hominem:

... I essentially agree with most everything you are saying.

I have been involved in HIE discussions recently that have clearly lacked input from clinical IT specialists, and that shortcoming is a fatal flaw to the effort. Any and all ideas or suggestions are passively or aggressively resisted as you say.

I am interested in what non-business-centric alternatives exist for the application of IT processes to the clinical setting. How would you encourage buy-in from physicians and other practitioners? Is there a documented recommendation for technology implementation put forth by clinical IT specialists that is being ignored by the mainstream? I would love to advocate for your plan in our region. What is your plan?

I am so tired of coming to the table with ill-informed ideas and having them righteously shot down. We need informed persons to come participate in these discussions and I want to be better informed of the clinical perspective to be more valuable to the effort.

By backbeatcat

MedInformaticsMD said...

Backbeatcat wrote:

I am interested in what non-business-centric alternatives exist for the application of IT processes to the clinical setting.

I believe this cannot be explained in a blog comment.

At its most fundamental, the answer is that health IT projects should be thought of as medical projects in complex, unforgiving clinical settings that happen to involve computers, not as IT projects that happen to involve clinicians.

The long answer is not as simple. I believe it takes much more than reading short essays to become truly fluent in these issues, such as graduate or post graduate education in biomedical informatics, social informatics, and related fields.

It takes biomedical informaticists 4 years of med school, 4 years of postgraduate medical education, 2 years of postdoctoral fellowship, and years of applied experience before we become fluent in the issues.

The answer is "education." Specific education is expected of all practicing clinical medicine, nursing etc. Why it is not expected of those in medical facilitation positions such as IT, I cannot find a reasonable answer.

That is why I find exclusion of those with biomedical informatics expertise from leadership roles in health IT so patently cavalier and, in fact, cavalier and anti-science. The very opposite of medicine.

For those without the time for extensive education or even an online certificate program, a good start at achieving basic fluency is in some of the myriad references I quote in this post (to which these comments are attached) and others, such as this one.

Explore them, especially the textbooks in the latter post.

The answers are there.