Throwing The National Research Council Report On Health IT Under The Bus, Part 1: MedStar Health

I wrote about the just-released National Research Council report on HIT at the post "Current Approaches to Health IT Insufficient ... and Other Master of the Obvious News."

Critiques on the National Research Council report are to be expected. It will likely have a major impact on the HIT industry and those with special interests in that industry. There will be critique, I expect, to a significant degree, unfortunately up to and including in today's political climate ad hominem attacks on its authors, I'm afraid. (I am definitely not implying the latter is the case below, however.)

The following critique, seen at the HISTalk industry-sponsored gossip site here, has me scratching my head a bit.

I'm scratching my head at the following commentary on HIT and the NRC report by an official at MedStar Health, Peter Basch, MD, Medical Director of Ambulatory Clinical Systems.

Points that leave me wanting are as follows:

... in spite of this clear support for funding and continued development of HIT, some media headlines have painted this report as harshly critical of the potential of HIT in general and EHRs in particular. This media misinterpretation resulted primarily from two faults inherent to the report:

(1) the NRC’s mislabeling of their recommendations as a change from what health IT leaders are advocating for; and

(2) the NRC’s inappropriate assignment of blame to EHRs as being the cause of dysfunction rather than their understanding that EHR functionality and implementation deficits are a result of a dysfunctional reimbursement system, which is based on volume of episodic care and verbosity of documentation.

My comments:

Did the NRC mislabel their recommendations for improving HIT as a "change" from what health IT leaders advocate? For example, I haven't heard many industry based health IT leaders advocating for -- or generally supporting with money - studies of interdisciplinary research in biomedical informatics, social science, or healthcare engineering, for example.

In fact, at the Government Health IT Conference & Exhibition 2008 in Washington, the plenary session leaders and many attendees, including the "experts" from large HIT management consulting organizations, seemed to have little idea what I was talking about when I mentioned the study of social factors. They largely blamed doctors for HIT's ills, until I gave some examples where that was decidedly not the case, and the plenary members then agreed there might be other "unknown" issues at play. Interestingly, the attendees from the VHA knew precisely what I was talking about.

I believe the NRC recommendations are indeed "change we can believe in" compared to the usual and customary HIT industry chatter. I also believe the media reported accurately on the current state and potential of HIT under its current design and management paradigms (note the latter point; I am an HIT advocate, but only if done right.)

Did the NRC "blame" EHR's as the cause of dysfunction, or as a symptom of some deeper issues? The latter seems the case.

Are implementation and functionality deficits a sole result of the reimbursement system? Doubtful, see below regarding HIT in the UK and Australia. While I agree we have a dysfunctional reimbursement system here in the U.S. that makes quality HIT harder to achieve (my own organization had to sue AllScripts over a malfunctioning E&M module, for example, see civil complaint PDF here), I believe there are far more fundamental issues at play in HIT failure.

Another point made in the HISTalk posting:

... While it is true many early adopter systems believed (at the time) that merely switching off paper medical records to EHRs would lead to improved and safer care , nobody has believed that, or has advocated that position in years

My comments:

"Nobody has advocated EHRs would lead to improved and safer care in years?" ... What about the statement "To improve the quality of our health care while lowering its costs, we will make the immediate investments necessary to ensure that within five years, all of America's medical records are computerized" by the President-elect on Jan. 8, 2009 as just one example?

That's an ambitious timeline indeed for a technology our National Research Council tells us is not yet ready to provide such benefits without significant rethinking and rework. It certainly send a clear message to the public that HIT in 2009 is a magic bullet, a panacea towards better healthcare quality. It suggests the new administration has absorbed that view through ill informed HIT industry and pundit wishful thinking, and perhaps purposeful disinformation.

I can easily find myriad quotes expressing the same point of view, that EMR ipso facto equals better healthcare quality, on a google search "EMR improves care" or similar search engine query. I think those in informatics should be educating on the dangers in that view, not denying it exists.

A third point in the HISTalk posting:

... The NRC faults current EHR build as not supporting the cognitive support necessary to optimize care. This deficiency is obvious and abundantly clear to veteran EHR and HIT users – many of whom work on their own or with vendors on new and better functioning clinical decision support. However, let’s be fair as to the root cause of this deficiency. It is neither lack of vendor vision nor limitation of IT technology; it is lack of a market.

My comments:

"The root cause" of misdesign of HIT, its glaring deficiencies towards its users' needs after 40+ years of trying, is simply - market forces?

Are any of the sociotechnical ("people and their interactions with technology") issues at my website here or at other sites by those studying social-IT issues and misalignment of the business IT paradigm towards clinical computing relevant? Or, should such issues simply be thrown under the bus since under government stimulus a better market will magically appear?

Is the entire discipline of social informatics (the study of information and communication technologies in social, cultural and institutional contexts) irrelevant?

What about the problems with the UK's massively government funded national HIT program (see here), and the problems in Australia (see here)? Were the reimbursement system and the market a cause of the problems there? Doubtful. Here's what the UK national program's former leader Richard Granger had to say:

"Sometimes we put in stuff that I'm just ashamed of ... Some of the stuff that Cerner has put in recently is appalling ... Cerner and prime contractor Fujitsu had not listened to end users ... Failed marriages and co-dependency with subcontractors ... A string of problems ranging from missing appointment records, to inability to report on wait times ... Almost a dozen cancelled go-live dates ... Stupid or evil people ... Stockholm syndrome - identifying with suppliers' interests rather than your own ... A little coterie of people out there who are "alleged experts" who were dismissed for reasons of non-performance."

How familiar to Medical Informatics experts that all is.

In summary, are the market and the reimbursement system the major causes of HIT's disappointing track record as claimed in the critique? Hardly.

Perhaps there are other far more fundamental "root causes" for HIT dysfunction that this critique of the NRC report is leaving out, including the issues above as well as additional factors mentioned in my posting here.

We as clinicians, especially those who are biomedical informatics professionals, cannot improve the situation by making ill informed, wishy-washy excuses for the HIT vendors. While the latter, as in pharma, might treat us, as well as CIO's and IT hospital personnel to nice perks, promote us in speaking engagements as key opinion leaders (KOL's), give grants, etc., they have produced mediocre to very poor products for the most part for decades. This wastes resources that healthcare can ill afford, ultimately harms or at best does not help patients, and needless to say makes reports such as the NRC report and Joint Commission Sentinel Event Alert necessary.

I am aghast at the stories I hear even today of HIT products such as EHR's and CPOE's with cryptic user interaction design that inundate, confound and insult clinicians, force clinicians to "drink information from a firehose", or have other issues that waste time and create new opportunities for error.

To be quite frank, the IT industry spends exponentially more time and expense on design and debate over trivial and arcane features in computer operating systems (to ensure a "better user experience", the fluffy marketing-ish industry buzzword du jour for what used to be called "efficient interaction") than on HIT.

As in medicine itself, we cannot cure this situation by failing to recognize or by ignoring the symptoms, signs and features which are right before our eyes.

Ironic note - While I do not know the author of the critique, a few of the case studies of HIT dysfunction and difficulty at the above referenced sociotechnical issues website here involved a high level person now at MedStar. I can assure readers that the issues then had nothing to do with "reimbursement" and "lack of a market" and very much to do with "lack of vendor vision" as well as "lack of hospital management and IS department vision" in the prior organization.

-- SS