Monday, February 09, 2009

"Triumph of Hope Over Experience" department: Healthcare IT as totalitarian tool?

Up on Drudge Report right now is this red banner:


It links to a story at today, mentioned by other commentators as well, such as Rush Limbaugh -- see my email to McCaughey and Limbaugh on how they missed the forest for the trees, below -- entitled "Ruin Your Health With the Obama Stimulus Plan: Betsy McCaughey."

The gist of McCaughey's article is that the Administration slipped HIT provisions into
H.R. 1 EH, a.k.a. the Economic Recovery Act of 2009, and is misleading the public on HIT, using it as a "backdoor" or Trojan Horse to help usher in socialized medicine. See Div. B Title IV, Health Information Technology (Word file extract) to review the Act's proposed text on HIT.

More on who is misleading who later...

First, health IT provisions may or may not constitute "economic stimulus" of the type needed for the country at this point in time. I will not address that issue here. I cannot do anything about their inclusion. The Act is what it is.

McCaughey pointed out by number of potentially ominous issues regarding H.R. 1 EH.

Ominous issues such as:

Senators should read these provisions and vote against them because they are dangerous to your health. (Page numbers refer to H.R. 1 EH, pdf version).

The bill’s health rules will affect “every individual in the United States” (445, 454, 479). Your medical treatments will be tracked electronically by a federal system. Having electronic medical records at your fingertips, easily transferred to a hospital, is beneficial. It will help avoid duplicate tests and errors.

But the bill goes further. One new bureaucracy, the National Coordinator of Health Information Technology, will monitor treatments to make sure your doctor is doing what the federal government deems appropriate and cost effective. The goal is to reduce costs and “guide” your doctor’s decisions (442, 446). These provisions in the stimulus bill are virtually identical to what Daschle prescribed in his 2008 book, “Critical: What We Can Do About the Health-Care Crisis.” According to Daschle, doctors have to give up autonomy and “learn to operate less like solo practitioners.”

Keeping doctors informed of the newest medical findings is important, but enforcing uniformity goes too far.

New Penalties

Hospitals and doctors that are not “meaningful users” of the new system will face penalties. “Meaningful user” isn’t defined in the bill. That will be left to the HHS secretary, who will be empowered to impose “more stringent measures of meaningful use over time” (511, 518, 540-541)

What penalties will deter your doctor from going beyond the electronically delivered protocols when your condition is atypical or you need an experimental treatment? The vagueness is intentional. In his book, Daschle proposed an appointed body with vast powers to make the “tough” decisions elected politicians won’t make.

Readers of HC Renewal will probably understand I have somewhat different concerns than HIT being used as a tool of control by government IT overlords.

I expressed them in the following letter to Ms. McCaughey, and forwarded to Rush Limbaugh as well:

From: MedInformaticsMD
Date: 02/09/2009 11:39PM
Subject: Re: National Coordinator of Health IT

Betsy, I am a clinical information technology professional (real deal - postdoctoral fellowship in same).

Yes, I looked over HR1 - title IV Health IT and am concerned by the heavy government hand I see being put on HIT, in a manner suggestive of Health IT becoming just a tool to accomplish turning docs into pecuniary slaves of Big Brother.

I should add the the Office of the National Coordinator was created in 2004 but was largely an advisory role, and toothless.

My major point, though, is that we probably need to worry more about putting $20 billion down the drain and deployment of unusable systems than Health IT turning doctors into slaves.

I have been writing for ten years on the severe mismanagement that goes on in health IT - poor design, chaotic implementation, lack of proper leadership by non clinical business computing personnel, and general mayhem when computer meets clinic. My website on HIT difficulty is here (

I've recently been joined in these warnings by higher authorities: the US Joint Commission for accreditation of hospitals, the National Research Council (NRC) and the UK House of Commons Accounts Committee!

Health IT (with a few exceptions) is largely a disaster area and I'm more concerned about mega-expensive "IT misadventure" than IT-empowered takeover of medicine!

See "Joint Commission Sentinel Event Alert" on HIT :

See the NRC Press Release " Current Approaches to U.S. Health Care Information Technology are Insufficient " at
Current Approaches to U.S. Health Care Information Technology are Insufficient

See the UK House of Commons report on major problems in their national Electronic Medical Records program (largely caused by US companies!) at
The National Programme for IT in the NHS: Progress since 2006 - Public Accounts Committee

Widespread health IT by 2014?


This bill may ruin our health, but not for the reasons stated ...

Our government is indeed, on this point, suffering from the illusion of hope over experience.

Put more directly, they are deluded about the true difficulty of making Health IT actually work on a large scale.

Health IT as Machiavellian ploy and Trojan Horse to achieve socialized medicine in the U.S.?

For the expenditure of a mere £12,656,200,000 the UK, which already has socialized medicine - repeat, ALREADY HAS SOCIALIZED MEDICINE - has not accomplished national health IT but instead has a quagmire. (The estimated cost of the national Health IT program at 31 March 2008 comes from the House of Commons Public Accounts Committee report, Jan. 2009, pg. 14, PDF here.)

Even so, the program's leaders unbelievably continue to lack formal biomedical and biomedical informatics credentials, helping assure the lack of real progress (ex-CIO of Cadbury Schweppes?) In the post where I made that observation (link) I also raised the question:

Can government really be the sponsor of ambitious health IT projects?

I'm not so sure.

I forgot to put in my letter to Betsy McCaughey issues in some other lands:

On January 22 after two months of serious discussion the Dutch health minister Dr. Ab Klink announced in the Dutch parliament that the implementation of a national EHR will be postponed . He did not mention a new target date.

it does not seem to be a Dutch-only problem. In Germany the introduction of the smart card has been seriously delayed, due to technical and security reasons. In the UK, one of the more advanced countries in the EU for implementation of a nationwide EHR system, serious safety and privacy issues are arising and the implementation has already a delay of over 2 years. The fact that on an almost regular basis electronic information is lost or stolen, doesn’t help either.

(Read the ICMCC story above in its entirety.)

I should also probably have included a link to my three part posting on how hospitals are an IT backwater here.

The new Economic Stimulus bill, to its great credit, does call for research on improving our understanding of designing and implementing health IT (e.g., Section 4202. RESEARCH AND DEVELOPMENT PROGRAMS):

(A) to generate innovative approaches to health care information enterprise integration by conducting cutting-edge, multidisciplinary research on the systems challenges to health care delivery; and

(B) the development and use of health information technologies and other complementary fields.

(4) RESEARCH AREAS- Research areas may include--

(A) interfaces between human information and communications technology systems; [I think they meant interfaces between humans and ICT systems - ed.]
(B) voice-recognition systems;
(C) software that improves interoperability and connectivity among health information systems;
(D) software dependability in systems critical to health care delivery;
(E) measurement of the impact of information technologies on the quality and productivity of health care;
(F) health information enterprise management;
(G) health information technology security and integrity; and
(H) relevant health information technology to reduce medical errors.

Amen to those points. Such research will take quite some time. (See "Predicting the Adoption of Electronic Health Records by Physicians: When Will Health Care be Paperless?" by Ford et al. I agree with the assessment of 2024, not 2014, for small practices.)

Hopefully the bulk of funds to conduct this needed research will not go to the "usual suspects" in the IT and management consulting industries, the same folks who rewarded the UK with such fine results. Let us hope actual health IT experts in the Biomedical Informatics domain get an appropriate "cut."

In any case, I think my letter to Betsy McCaughey speaks for itself and will not comment further except for the observation that if some of our government officials have a computer-facilitated medical power grab in their hearts, then I wish them luck. For they will need it.

Finally, who is misleading whom on HIT? HIT is a tool to facilitate clinical care, not a cybernetic miracle cure to "revolutionize" medicine. It seems the government has been thoroughly conned by the IT industry that this technology is worth throwing tens of billions of dollars at. The government has bought the "HIT is a Magic Bullet" exuberance hook, line and sinker.

-- SS


Anonymous said...

The reason that the IT system has not worked in UK is because of IT itself. If you want to look at the parallels, you can learn lessons from SAP, Oracle and others in the manufacturing world. I personally do not see the big deal about EMR (it is good to have) as its benefits are overstated.

So is the cost to achieve it. 20 billion dollars is a lot of money. If if was my business 1-2 billion max and in fact I would start with about 500 millions.

It is undoubtedly possible to design a implement a IT system that will work. With due modesty, I can get it done.

The total focus on healthcare solution in EHR is completely misplaced.


InformaticsMD said...

It is undoubtedly possible to design a implement a IT system that will work.

I agree. Many people can. It's not magic to create effective IT in biomedicine.

However, there are those who believe good intentions and slugging it our by trial and error are enough. Unfortunately, having good intentions is not enough.

Much like medicine itself, it takes the right education and awareness of relevant issues specific to healthcare.

I have often said that what is lacking in HIT is the rigor of medicine itself. It is not an area that should be learned by trial and error.

-- SS

Anonymous said...

I posted the Following response to her article, maybe a littl ebug picture thinkning is needed here:

"Yesterday Bloomberg published (and the Drudge Report featured) an op-ed on healthcare and the stimulus package by former lieutenant governor of New York Beth McCaughey. McCaughey, famous for her existential lashing of the Clinton Healthcare Plan in an article titled, No Exit, continued her support of the healthcare status quo in her critique of some of the ideas currently being put forth on how to mitigate the rising cost of healthcare in this country. Instead of recognizing how the current healthcare crisis is hurting us and our future, McCaughey instead chose to fan the flames of ideology, enticing us to once again believe that the problem is in the other – not how healthcare’s rising cost impacts us all.

Her critique was largely centered on current efforts to better integrate the healthcare system by eliminating waste and encouraging best practices through the establishment of a National Coordinator of Health Information Technology, a provision of Obama’s stimulus package. She cites the aim of the office is:

“…to reduce costs and “guide” your doctor’s decisions...”

While she attempts to paint this as the federal government commanding your doctor’s decisions, in actuality the office would use information technology to empower your doctor to avoid unnecessary or erroneous treatments by giving them access to the opinions of other providers and even your own medical records.

Her opposition, grounded in the potential for reduced autonomy, choice and excessive regulation has its merits, but her argument is clouded by her flawed logic and belief that it is better to just leave everything just the way it is (please see Future at Risk if you find yourself in agreement).

She goes on to disparage measures that seek to:

“...slow the development and use of new medications and technologies because they are driving up costs…Medicare now pays for treatments deemed safe and effective. The stimulus bill would change that and apply a cost - effectiveness standard…using a formula that divides the cost of the treatment by the number of years the patient is likely to benefit…”

According to a CBO report done under George Herbert Walker Bush’s administration, much of the rising cost of healthcare can be attributed to usage of new and costly procedures that are made available to American providers at a speed unheard of on other industrialized nations. At current, procedures and treatments are approved as soon as they are proven safe and effective. There is no consideration for how costs may affect the overall quality of life of the patient. Meanwhile, Medicare and in turn taxpayers are expected to foot the bill, eventhough there are currently no mechanisms of accountability for these costly procedures and their actual health benefits.

Not surprisingly with the exponential proliferation of new drugs and tecnologies in recent decades, Medicare expenditures have increased over 5800% since 1970 and the Medicare trust fund is expected to be insolvent by 2019 without a significant increase in taxes or a major decrease in spending. Moreover, between 1992 and 1996, average annual healthcare expenditures for individuals aged 65 and older were $7,365, but grew to $37,581 during their last year of life. Yet, McCaughey rails against the idea of creating a body to examine new and experimental treatments and their “cost-effectiveness” in cases where a procedure may be clinically effective but still do little to help (and may even hinder) a patient’s quality of life. This stance is unacceptable given consequences of such unsustainable healtcare spending for our nation both now and in the future.

The ethical dilemmas surrounding healthcare resources, their usage and end of life issues are complex, but if anything now is not the time for complacency. These issues have been ignored for far too long and it is high time that we encourage rather than discourage our leaders to have a vigorous debate about the current approach rather than continuing to embrace the unsustainable dogma that more healthcare consumption is always better.

McCaughey concludes with:

“The health-care industry is the largest employer in the U.S. It produces almost 17 percent of the nation’s gross domestic product. Yet the bill treats health care the way European governments do: as a cost problem instead of a growth industry.”

Well as much as the healthcare system does to aid employment in this country, it doesn’t mean there are also ways that the status quo is hurting us as well: the solvency of our government, the competitiveness of our businesses and the ability of all Americans to afford access to name a few. In fact, just think of how many more well paying jobs could be created by other industries currently bogged down by healthcare costs. Clearly healthcare is a cost problem in this country and the growth in that cost is threatening the health and stability of Americans both today and tomorrow.

Going off the quote above, perhaps she is still stuck in the time when the public healthcare debate seemed to bounce only between being for 100% nationalization or 100% privatization. Of course it was never that simple and it’s apparent that it still isn’t. There is neither a single cause nor a single victim of today’s healthcare crisis and in order to realize the comprehensive healthcare reform we need, it will take the collaboration and support of all stakeholders, government, businesses and individuals alike. Let the work begin."