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

In Nov. 2008 I wrote a post "Should The U.S. Call A Moratorium On Ambitious National Electronic Health Records Plans?"

The question was raised based on reports of serious difficulty experienced by the UK in their national program for electronic health records, Connecting for Health.

I commented on how the world financial crisis of 2008-09, combined with chronic project difficulties and mismanagement and profound clinician resistance 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 actual cancellation.

From the British press:

Bank bailout puts £12.7bn NHS computer project in jeopardy

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.

It is simply stunning that the UK might be "locked in" to a potential disaster by IT vendors. (How is this allowed to happen?)

I'd also commented on how the lack of true Medical Informatics education and expertise in the new UK CfH "head of informatics" (and predecessors, for that matter) was a symptom of a much larger disease in healthcare IT.

The disease is a paradoxical (especially for medicine) and turned-on-its-head leadership structure where "amateurs" reign. Amateurs, in the sense that my significant telecommunications experience and even licensure as a radio amateur (ham) extra class, a hobby, would not qualify me to, say, lead a national telecommunications projects for the British Armed Forces due to lack of professional telecommunications training and credentials.

Read my Nov. 2008 "Moratorium" post for details on the UK problems.

Since that time, there have been two remarkable events in the United States (when I wrote the above posting, I had no idea whatsoever that the following would occur):

In Dec. 2008, the Joint Commission (the organization that accredits healthcare organizations here) issued a Sentinel Event Alert on HIT recommending that significantly more caution be taken in its design and implementation due to risks posed by the technology. In "Joint Commission Sentinel Event Alert On Healthcare IT" I commended the JC for taking such a step, likely to be viewed with disdain by the business sector and those infatuated with HIT as a "magic bullet" panacea for healthcare.

Then, in Jan. 2009, the highest scientific authority in the U.S., the National Research Council (NRC) of the National Academies issued their report after a several-year study of HIT entitled "Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions," a rather innocuous sounding title for a potentially explosive report.

The National Academies perform an unparalleled public service by bringing together committees of experts in all areas of scientific and technological endeavor. These experts serve pro bono to address critical national issues and give advice to the federal government and the public.

Four organizations comprise the Academies: the National Academy of Sciences, the National Academy of Engineering, the Institute of Medicine and the National Research Council.

I believe the title of the Press Release about the NRC report summarizes the report more accurately than its native title. The Press Release title is: "National Research Council: Current Approaches to Health IT Insufficient."

I presented the release at the post "Current Approaches to Health IT Insufficient ... and Other Master of the Obvious News."

While I do not know if my work had any influence on this report, its conclusions parallel those of myself and a relatively small number of colleagues who've stuck to unpopular (with the industry, that is) contrarian views on the unquestioned goodness of HIT. It is likely a number of the authors of this report were aware of my work over the years, as a frequent poster in the American Medical Informatics Association listservs and frequent writer and speaker on these issues, including some outspoken comments made at AMIA when some of the authors were in attendance. I believe the report can be better summarized by the following quote:

"Healthcare IT, dominated by non-medical IT personnel who views these tools as IT systems that happen to involve clinicians, rather than clinical tools that happen to involve computers, have mismanaged HIT through their false assumptions, lack of knowledge and lack of insight for at least several decades." - Silverstein

The NRC report found that current efforts aimed at the nationwide deployment of health care IT are not sufficient to achieve medical leaders' vision of health care in the 21st century and may even set back the cause. This conclusion was reached based partially upon site visits to eight U.S. medical centers considered leaders in the field of health care IT.

It concluded that greater emphasis should be placed on information technology that provides health care workers and patients with cognitive support, such as assistance in decision-making and problem-solving , as opposed to its current "medicine as a business" paradigm providing clinicians with, essentially, an inventory system based on 19th century accounting theorem (the major critique of IT, in fact, by Peter Drucker in his latter years). As I observed in 1999:

Management expert Peter F. Drucker, one of the most respected names in modern management thinking, offers some highly relevant insights about information issues in his book "Management Challenges for the 21st Century" (HarperBusiness, 1999). These insights amplify the importance of medical information specialists (medical informaticists) taking leadership roles in healthcare organizations, and the problems with allowing MIS to predominate on medical information issues and clinical information tool development and evaluation.

Drucker writes that "the information revolution...is not happening in IT or MIS, and is not led by CIO's...what has triggered the [real] information revolutions and is driving them is the failure of the 'information industry' - the IT people, the MIS people, the CIO's - to provide information. For 50 years, information technology has centered on data...and technology [not useful information]."

He continues, "The data available in business enterprises are still largely based on early 19th century accounting theorem. MIS has taken the data based on this theorem and computerized it. They are the data of the traditional accounting system. IT...collected the [accounting system's] data, manipulated them, analyzed them and presented them. On this rested, in large measure, the tremendous impact the new technology had on what cost accounting data were designed for: operations. But it also explains IT's near-zero impact on the management of business itself."

I'd also observed at that time that Medical Informatics and its teachings can thus be seen as a means to an end: the creation and dissemination of useful information that advances the practice, science and management of healthcare, not just facets of its operations.

In 2008 I wrote that:

... I believe the unimaginative, process over results, tightfisted control, bureacratic "data-processing" culture of the business IT (management information systems) world to be the lineal descendant of IBM's patchcord plug-panel programmed, card tabulating machines from which IBM made a large portion of their profit in the days before the electronic computer. You perhaps required such a culture when you were running huge businesses from stacks of tens of thousands of punched cards. However, such a model does not work well in meeting the information needs of clinical medicine.

... Medical informatics, a pioneering field, in many ways saw the electronic computer not as a card-based data processing machine but as a canvas for development of creative works to serve the needs of clinical medicine and its practitioners.

The National Research Council report in fact incarnates my contention that HIT is not a subspecies of MIS or management information system (i.e., business IT). I maintain that only the assumption that it is, combined with leadership by non clinicians, could result in outcomes such as this:

The report describes difficulties with data sharing and integration, deployment of new IT capabilities, and large-scale data management. Most importantly, current health care IT systems offer little cognitive support; clinicians spend a great deal of time sifting through large amounts of raw data (such as lab and other test results) and integrating it with their medical knowledge to form a whole picture of the patient. Many care providers told the committee that data entered into their IT systems was used mainly to comply with regulations or to defend against lawsuits, rather than to improve care. As a result, valuable time and energy is spent managing data as opposed to understanding the patient.

Provision of cognitive support for clinicians is perhaps an alien concept to those mired in data processing paradigms.

It seems critical that the National Research Council's recommendations for

"interdisciplinary research in biomedical informatics, computer science, social science, and health care engineering"

occur, in order to change current thinking and practices in HIT design, implementation and lifecycle. Further, this research must occur, and in a manner unbiased by industry interests, before more tens or hundreds of billions of dollars are sunk into yet more HIT systems that miss the mark.

Even the vaunted VistA system of the Veterans Administration has some problems:

Software hiccups cause drug, treatment errors at VA
Associated Press
Posted: January 14, 2009 - 5:59 am EDT

Patients at Veterans Affairs health centers around the country were given incorrect doses of drugs, had needed treatments delayed and may have been exposed to other medical errors because of software glitches that showed faulty displays of their electronic health records.

The glitches, which began in August 2008 and lingered until last month, were not disclosed by the Veterans Affairs Department to patients even though they sometimes involved prolonged infusions of drugs such as heparin, which in excessive doses can be life-threatening, according to internal documents obtained by the Associated Press under the Freedom of Information Act.

There is no evidence that any patients were harmed, even as the VA says it continues to review the situation. But the issue is more pressing as the federal government begins promoting universal use of EHRs. President-elect Barack Obama has made it a part of an additional $50 billion a year in spending for health IT programs that he has proposed.

The VA's recent glitches involved medical data—vital signs, laboratory results and active medications—that sometimes popped up under another patient's name on the computer screen. Records also failed to clearly display a doctor's stop order for a treatment, leading to reported cases of unnecessary doses of intravenous drugs such as blood-thinning heparin.

In a statement, the VA said there were nine reported cases where patients at the VA medical centers in Milwaukee, Durham, N.C., and Marion, Ind., were given incorrect doses—six of them involving heparin drips that were given for up to 11 hours longer than necessary. The other cases involved infusions of either sodium chloride or dextrose mixtures that were prolonged for up to 15 hours past the doctor's prescribed deadline.

This is a rather major "glitch", even more unnerving in that it was sporadic and geographically dispersed.

With these issues in mind, I again ask the question, backed up not just by my own relatively unknown and trivial work but by the national accrediting agency for healthcare in the U.S., and the highest scientific body here as well:

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

$50 billion a year is big money that might be better spent elsewhere - such as providing care for the poor and for disadvantaged children - until we know how to get HIT right.

I suggest it may be best not to go all-out for HIT under the current paradigm. It is my belief, in fact, based on the above issues plus a chronic influx of HIT difficulty and mismanagement stories I hear from colleagues, ex-colleagues, recruiters, etc., that healthcare organizations not contractually obligated should consider a postponement of plans to purchase clinical IT (i.e., systems for direct use by clinicians such as EHR's).

This postponement should last at least until the issues that lead to ineffective and counterproductive HIT can be better understood and corrections initiated in the industry.

-- SS