Thursday, November 13, 2008

Should The U.S. Call A Moratorium On Ambitious National Electronic Health Records Plans?

We are now engaged in a worldwide economic crisis, the likes of which have probably not been seen since the 1920's.

In "Bank Bailout Puts £12.7bn NHS Electronic Medical Record Project In Jeopardy" I commented on how the world financial crisis of 2008 combined with chronic project difficulties and mismanagement was creating such high levels of doubt about the UK's Connecting for Health (CfH) national program for electronic health records (EHR's), that the program was under consideration for cancellation.

From that post:

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.

More on Connelly, the "recently appointed head of informatics" later.

In the United States, we need to consider the implications of this towards our own ambitious plans for national health records.

Either we get it right, or we should not pursue it at all under the current economic downturn. There are millions of uninsured and underserved people in this country who would benefit far more tangibly from funding of healthcare services rather than funding of ambitious health records projects that transfer scarce capital from the healthcare to the IT sector. These are initiatives that are demonstrably fraught with peril (as in the UK), that healthcare organizations and clinicians may not truly want to succeed, and with unproven ROI and unclear quality improvement benefits (see "Do Healthcare Organizations Truly Want Electronic Health Records To Succeed?").

If we are going to stay on our present course and commit billions of dollars to ambitious IT projects that might be better spent on healthcare provision, we damn well better learn something from the UK experience. I am unfortunately doubtful of this.

As I state at my academic site on HIT difficulties (link), learning from others' mistakes - learning what not to do, aside from "best practices" - is important. However, one fundamental lesson to be learned of the highest importance is on leadership of HIT. Towards that end I provide additional material on the UK's national EMR difficulties.

At Healthcare Renewal, Roy Poses and I have often noted the lack of biomedical or healthcare credentials in the "C" level and board leadership of healthcare delivery and healthcare supporting organizations such as pharmaceuticals and medical devices and technology companies.

Here is more on the stunning UK CfH problems, followed by an interesting (and predictable!) finding on its new leadership.

From The Telegraph:

NHS IT system 'at a standstill'

By Kate Devlin, Medical Correspondent
Last Updated: 6:24PM GMT 28 Oct 2008

The roll-out of a flagship £12billion NHS IT system has come to a standstill in many parts of the country because of problems with the system, the NHS has admitted.
Ministers want the computer programme, one of the largest in the world, to eventually contain the medical records of every patient in the country. But NHS bosses in London have decided to halt the roll-out of the electronic care records to hospitals indefinitely, to sort out technical problems.

From E-Health Insider:

Political row over NPfIT: London on hold
28 Oct 2008

Opposition politicians have renewed their condemnation of the National Programme for IT in the NHS following press reports that the programme is “grinding to a halt.”

Conservative shadow health spokesman Stephen O’Brien said the reports confirmed that, with the “hugely expensive” programme “desperately behind schedule” suppliers were “deserting in droves” and “frontline professionals” were “voting with their feet and insisting on local solutions.”

Meanwhile, Liberal Democrat health spokesman Norman Lamb issued a statement saying that the “centralised project” had been “a shambles from the start” and it was “time for a re-think on how to proceed.”

The latest round of political attacks on the national programme follow the publication of an article in the Financial Times, arguing that progress on one aspect of the £12 billion project, the deployment of “strategic” care records systems, has stalled.

The article reviewed a number of recent stories that suggest this and questioned whether the programme would ever be completed.

... It noted that hospitals that have taken the London Release 1 version of Cerner’s Millennium care record service are experiencing problems with it and that further deployments that were scheduled for this year are showing no sign of going ahead.

And it noted that although health ministers promised that the much-delayed first installation of iSoft’s Lorenzo care record system would take place in Morecambe Bay this summer, the system has not gone live and neither the trust nor NHS Connecting for Health can give a date for go-live.

Jon Hoeksma, editor of E-Health Insider, was quoted as saying that while other parts of the programme continue to make progress, “this key part seems to be simply stuck. It has ground to a halt.”

Other national papers picked up the story, prompting an apparent admission that in London at least further deployments have been put on hold indefinitely.

This from Financial Times:

NHS records project grinds to halt
By Nicholas Timmins, Public Policy Editor
Monday Oct 27 2008 18:30

Progress on the £12bn computer programme designed to give doctors instant access to patients' records across the country has virtually ground to a halt, raising questions about whether the world's biggest civil information technology project will ever be finished.

Since [its launch in 2002], however, just one of the scores of acute care hospitals due to install the underlying administration system required in order for the patient record to work has done so. The hospital, Royal Free NHS Trust in London, continues to have difficulties getting it to operate properly.

... Health ministers originally promised the long-delayed first installation of patient record software in the north of England would finally take place in June at Morecambe Bay on the Lancashire/Cumbria border. But four months on, the system has still not gone live and neither Morecambe Bay nor Connecting for Health can give a date when it might.

CfH's most recent published plans for the next three months do not include a single installation of a patient administration system into any acute hospital trust.... Hospital chief executives, he said, did not want to take a new system "until they have seen it put in pretty flawlessly elsewhere".

And this from the Evening Standard (UK):

£12bn NHS computer system crashes at the first attempt
Anna Davis
Oct. 30, 2008

THE roll-out of a new computer system to every London hospital has been frozen after being installed in just one organisation.

IT experts have stopped setting up the software across the capital and have rushed to sort out problems caused by the system at the Royal Free Hampstead NHS trust the only acute hospital to have installed it so far.

It is the latest blow for the £12billion national programme, designed to give doctors access to patients' records wherever they are in the country.

The system has been beset with software glitches and design faults. One internal health service document said it could put seriously ill patients at risk of being inaccurately diagnosed.

According to the document, it is routinely crashing, intermittently losing patient information, and some staff are reverting to pen and paper.

It seems this UK program, which has already resulted in the expenditure of billions of dollars, is not at all meeting expectations. In fact, it may die.

This raises a few questions:

  • Could this CfH debacle have been prevented?
  • Could this scenario find itself repeated here in the United States?

I offer the opinion that the answer to both of these questions is a resounding "yes."

On the first question, the answer is related directly to the issue of leadership expertise as I explain in some detail at my academic teaching site "Sociotechnologic Issues in Clinical Computing: Common Examples of Healthcare IT Difficulties." At that site I wrote:

... diffusion of clinical information technology (IT specifically intended for use by clinicians in clinical care settings) after 30-plus years of effort and billions of dollars spent remains limited.

... This website is concerned with the reasons for this apparent paradox ... While clinical IT is now potentially capable of achieving many of the benefits long claimed for it such as improved medical quality and efficiency, reduced costs, better medical research and drugs, earlier disease detection, and so forth, there is a major caveat and essential precondition: the benefits will be realized only if clinical IT is done well. For if clinical IT is not done well, as often occurs in today’s environment of medical quick fixes and seemingly unquestioning exuberance about IT, the technology can be injurious to medical practice and biomedical R&D, and highly wasteful of scarce healthcare capital and resources.

Those two short words “done well” mask an underlying, profound, and, as yet, largely unrecognized (or ignored) complexity. This website is about the meaning of "done well" in the context of clinical computing, a computing subspecialty with issues and required expertise quite distinct from traditional MIS (management information systems, or business-related) computing.

Of note regarding leadership changes in the UK CfH electronic medical records program and its IT leadership:

Two senior management appointments for NHS National Programme for IT announced
12 August 2008

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. He has also held the positions of Group Applications Director in Corporate IT, and as Senior Responsible Officer for Information Management in the DWP Change Programme. He was previously a partner with KPMG Consulting in London, and has also worked in Reuters where his roles included Head of Real Time Technology and Director of News Products Development.

Cadbury Schweppes? The candy and Dr. Pepper/Snapple company? Gas and Power? Pension services? To lead a national health IT initiative?

The absence of biomedical, healthcare and medical informatics expertise in this "revised governance for handling informatics" is quite remarkable.

Can government really be the sponsor of ambitious health IT projects, I wonder? Should they?

On the second question, could the UK scenario find itself repeated in the United States, the answer is most definitely 'yes.'

While there are informatics professionals at high levels within the HHS/ONC-led national initiative (not yet a formal program), the clinical IT initiatives of rank and file healthcare organization are still largely under the model of leadership by non-medical IT personnel.

Amateurs in health IT are running heath IT.
One impact is a high failure rate for EHR implementations [1]. By analogy, in the field of Amateur (“ham”) Radio, I am among an uncommon group of physicians who hold high-level radio telecommunications licenses from the FCC, the Extra class, obtained after a series of examinations. I have built, operated and repaired sophisticated and powerful radio transmitters, receivers and other equipment. I can set up an emergency station with local, regional and international coverage in a very short time and communicate readily with others if needed.

Even with this background, I would not for a moment believe I should be telling commercial broadcasters, emergency services, and the military how they should be implementing and operating their wireless technologies, or managing those functions. I do not have the level of training and experience necessary. In radio, I am an amateur, not a professional.

In Electronic Health Records (EHR’s) and related clinical IT, however, a wide variety of “amateurs”, including technologists, clinicians and politicians, are telling medicine - as a field - how to implement and operate this modern and increasingly important tool of the profession.

Those IT professionals with success in the business computing field, or clinicians with some knowledge (often self taught) about information technology, are not best equipped to manage the issues in health IT. These personnel are, consistent with my amateur radio analogy above, “amateurs” in such settings, if one is truly honest about it.

As in radio, this label is not meant in a pejorative way. It is simply reality. However, the results of such a leadership model are predictable.

In effect, every HIT delay, failure, or difficulty is simply a transfer of wealth from the healthcare sector to the technology sector with one root cause being an unlikely leadership model.

"Irrational exuberance" for any technology or innovation can create - as we have learned - massive unexpected problems. This is certainly the case in IT.

Considering the uncertain ROI and QI data about healthcare IT, questionable leadership models, current financial turmoil, local clinical IT problems paralleling the more widespread problems in the UK CfH program, and the many uninsured and medically underserved communities in the U.S., I wonder if national EMR's may be an unwise pursuit in the U.S. at this time. Perhaps a moratorium on large scale healthcare IT efforts in the U.S. is warranted.

Such a move might also allow time to objectively and scientifically resolve some of the above issues.

This will certainly be an issue for the new U.S. administration.

Billions of dollars that might be spent on IT misadventure in a time of unprecedented national financial challenges and hardships might perhaps be better spent for the time being on delivery of needed medical services, health insurance and other "safety net" interventions.

-- SS


[1] Market Barriers and Challenges to Widespread Adoption of Health Information Technology. U.S. Office of the National Coordinator for Health Information Technology (accessed Nov. 13, 2008).


Anonymous said...

We certainly need to question the use of a national EMR when we have security issues appearing today without such a service in place. The Nov. 14 WSJ article by David Armstrong highlights Unions Say CVS Pushed Costly Drug To Doctors. The article highlights how Merck, through CVS, has been urging doctors to add Januvia to specific patients treatments, even though this drug cost as much as eight times other treatments.

There is a great deal of politically correct talk of patient information and education. The bottom line here is someone accessed specific patient information in order to run this promotion. We have also seen recent court cases where information mining of prescription habits of doctors has been questioned.

I recently had an opportunity to speak with a laid off drug rep. His first statement to me was that the drug companies have no ethics. He then spoke about how this business outlook was finding it's way into the everyday decisions made in a medical practice. He stated the drug business was the same business he entered into 13 years ago or the business his father spent 35 years in.

Merck has come under fire for it's promotion of Gardasil as a mandated drug for school admission. Problematic is the age requirements do not correspond to the original sample group. Unfortunately a comment by a Merck stockholder that all Merck stockholders should support this mandate has been removed from the WSJ Health Bog's coverage of this topic. (November 11, 2008, 2:11 pm Making Gardasil Vaccination Mandatory Would Be Unwise, Academics Say Posted by Jonathan D. Rockoff )

I am not trying to pick on Merck, as I feel all drug companies suffer from the same lack of ethics, but we see a pattern to enrich the company with no consideration for personal privacy. Presented with such a large database I do not see how pharma could resist mining it to maximize profits at patient expense. Ultimately we all pay in higher premiums for expensive drugs and test. Drugs and test that may be unnecessary or for which there are cheaper alternatives.

Steve Lucas

Anonymous said...

The Call to Action/Health Care Reform 2009 proposal released 11/13/08
( by Senator Max Baucus is a disaster.
The Baucus plan is an expansion and continuation of the status-quo
mixture of a government subsidized ineffective private health
maintenance insurance industry operating parallel to and within Medicare

7 Specific Reasons Why the Baucus Health Reform 2009 Plan Fails.....

1) The Baucus plan fails to enroll all Americans in a single payer
National Health Insurance such as the most efficient health insurance
plan (Medicare) which is already contracted with most doctors,
hospitals and clinics in the Country. Medicare has the lowest operating
expenses and the best morbidity (sickness rates) and mortality (death
rates) compared to all other insurance companies. The Baucus plan will
therefore divert $700 Billion to $1 Trillion per year away from
patients, hospitals, doctors, clinics, nurses, pharmaceuticals,
therapist and researchers into the overhead pockets of health private
insurance company administrators and executives.

2) The Baucus plan fails to technologically upgrade, integrate and
centralize medical billing and records systems in order to optimize
examination of clinical outcomes, pharmaceutical efficacies and monitor
fraud and abuse. In addition, by failing to centralize and
technologically upgrade billing and records systems within a single
National Health Insurance plan, America will be unable to instantly
monitor disease outbreaks and instantly respond to natural and man made
disasters or bio-nuclear terrorism..

3) The Baucus plan fails to control drug costs by failing to allow a
single efficient national health insurance company such as Medicare to
bid on pharmaceuticals. In addition, the Baucus plan by failing to put
all Americans on a National Health Insurance Plan such as Medicare does
little to shrink the 'risk pool' of insured, thereby failing to decrease
insurance premium expenses for all Americans.

4) The Baucus plan fails to provide funding for scientific, clinical and
epidemiological research and development by allowing private private
insurance companies to divert funds from medical research and
development to instead support their massive and profitable
administrative and executive bureaucratic overheads.

5) The Baucus plan fails to provide physicians with the same legal
protection from malpractice lawsuits which have been established for
commercial health insurance corporations during the last 3 decades.

6) The Baucus plan fails to explain where to find the 1.5 million new
health care workers which will be needed once 100 million new Americans
obtain health care insurance. Health care workers can be found easily by
shutting down the wasteful and inefficient private health insurance
companies, putting all Americans on National Health Insurance such as
Medicare. The 1.5 million former private insurance company bureaucrats
can then be remployed to actually deliver health care in hospitals,
clinics, nursing homes, assisted living facilities, pharmacies and home
health services such as Alzheimer family assistance.

7) The Baucus Plan fails to address this problem of disenfranchised
physicians. Many physicians in this country have left the practice of
medicine, or downsized their practices due to private insurance company
abuses, malpractice threats and direct pharmaceutical marketing. A
recent national poll of physicians based on the AMA database
demonstrated that 60% of physicians support a single payer National
Health Insurance such as Medicare. A continuation and technological
upgrading of our most fair Medicare Health Insurance for all based on
the concepts outlined above, would undoubtedly motivate those
disenfranchised physicians to return to the profession and bright
younger physicians to invigorate the field.

The Baucus plan is wasteful, inefficient, fragmented, creates a new
redundant bureaucracy and will continue to provide no potential future
health improvements for America. Only an efficient National Health
Insurance carrier such as a technologically upgraded Medicare Insurance
company will be able to provide low cost health insurance and pharmaceuticals
for all Americans while maintaining the quality of private physician practices and Hospitals.


Anonymous said...

Nurses do not have time to wedge their care giving into templates generated by absentee electronic healthcare records experts.