A Primer On Why We Have Busywork Generators Masquerading as EMR's: Health IT Reality vs. the Bernard Madoff Version

As many have now observed, electronic medical records products on the market are clunky, fail to support the cognitive and workflow needs of clinicians, contribute to clinician cognitive overload and increased clerical work burden, and may be harming patients at a rate far higher than, say, VIOXX, which was summarily withdrawn from the market to be followed by billions of dollars of lawsuits.

Health IT can indeed improve healthcare quality, reduce costs and achieve other benefits claimed of it, but only if it's done well. There is tremendous underlying social and technical complexity underlying those two words "done well", and unfortunately in 2009 most health IT is simply not done well. Yet the technology is actually worshipped in what I see as a Bernard Madoff syndrome, an irrational exuberance in IT for reasons not entirely clear to me considering the existing objective evidence.

The motivation to learn how to truly "do HIT well" before embarking on a multi-billion dollar HIT adventure is sorely lacking -- our current approaches being inadequate per such authoritative sources as the National Research Council. In my transit authority safety officer-trained mind, I sense a train wreck approaching. Further, a federally pushed national HIT initiative using billions of dollars, dollars that might be better spent to prevent events like this hospital closure in an underserved area, is premature.

In regard to doing HIT well, usability and usefulness of EMR's have been largely stifled by traditional approaches to Health IT. Those approaches fail to adhere to "innovation" - innovation, that is, compared to traditional IT practices - that was called for by the pioneers beginning in the 1950's and 1960's. (Should I really use the term "innovation" if it's been called for now for over forty years?)

Dr. Don Lindberg in 1969:

"... computer engineering experts per se have virtually no idea of the real problems of medical or even hospital practice, and furthermore have consistently underestimated the complexity of the problems…in no cases can [building appropriate clinical information systems] be done, simply because they have not been defined with the physician as the continuing major contributor and user of the information" (Lindberg DAB: Computer Failures and Successes, Southern Medical Bulletin 1969;57:18-21).

Others such as Morris Collen, Octo Barnett, et al. published guidelines on how to best implement clinical IT that if followed would have alleviated many of the problems we have today. Sadly, they published their ideas starting in -- and perhaps even before -- the 1960's.

The recommendations of the pioneers are documented in "A History of Medical Informatics in the United States 1950-1990", by Morris Collen MD, section 3.4. For example, Octo Barnett's clinical IT "10 Commandments" (written in 1970) as reproduced in Collen's book on page 169, as well as 1960's and 70's material by Lindberg, Lamson, Collen, Davis, Baker, and numerous others address many of the substantial problems that plague health IT today.

What we largely have today are "busywork generators masquerading as EMR's."

I've only begun to illustrate some of the mission hostile user experiences presented by major vendor "CCHIT Certified" EHR's at this eight part series.

Below is a suggested reading list on the problems we have today.

Anyone contemplating policy work in health IT should be intimately familiar with these works, as they illustrate the true HIT environment in 2009, not the Bernard Madoff "unlimited returns no matter what" version.

What these articles do not illustrate is the common atmosphere of irrational exuberance and complacency now prevalent about HIT, with healthcare organizations and physicians now being pushed forcefully to adopt these technologies or suffer payment penalties they can ill afford:

Joint Commission: Sentinel Events Alert on HIT, Dec. 2008.

National Research Council report. Current Approaches to U.S. Healthcare Information Technology are Insufficient. Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions, Jan. 2009

The National Programme for IT in the NHS: Progress since 2006, Public Accounts Committee, January 2009. Summary points here.

Common Examples of Healthcare IT Difficulties (website). S. Silverstein, MD, Drexel University College of Information Science and Technology.

Health Care Information Technology Vendors' "Hold Harmless" Clause - Implications for Patients and Clinicians, Ross Koppel and David Kreda, Journal of the American Medical Association, 2009; 301(12):1276-1278

Finding a Cure: The Case for Regulation And Oversight of Electronic Health Records Systems, Hoffman and Podgurski, Harvard Journal of Law & Technology 2008 vol. 22, No. 1

Failure to Provide Clinicians Useful IT Systems: Opportunities to Leapfrog Current Technologies, Ball et al., Methods Inf Med 2008; 47: 4–7,

IT Vulnerabilities Highlighted by Errors, Malfunctions at Veterans’ Medical Centers, JAMA Mar. 4, 2009, p. 919-920.

Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System, Han et al., Pediatrics Vol. 116 No. 6 December 2005, pp. 1506-1512

Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors. Ross Koppel, PhD, et al, Journal of the American Medical Association, 2005;293:1197-1203

Hiding in Plain SIght: What Koppel et al. tell us about healthcare IT. Christopher Nemeth, Richard Cook. Journal of Biomedical Informatics. 38 (4): 262-3.

Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes and Threats to Patient Safety, Koppel, Wetterneck, Telles & Karsh, JAMIA 2008;15:408-423

The Computer Will See You Now, New York Times, Armstrong-Coben, March 5, 2009,

Health IT Project Success and Failure: Recommendations from Literature and an AMIA Workshop. Journal of the American Medical Informatics Association. Bonnie Kaplan and Kimberly D. Harris-Salamone (preprint, doi:10.1197/jamia.M2997)

Bad Health Informatics Can Kill. Working Group for Assessment of Health Information Systems of the European Federation for Medical Informatics (EFMI).

Electronic Health Record Use and the Quality of Ambulatory Care in the United States. Arch Intern Med. 2007;167:1400-1405

High Rates of Adverse Drug Events in a Highly Computerized Hospital, Nebeker at al., Arch Intern Med. 2005;165:1111-1116.

"Dutch nationwide EHR postponed: Are they in good company?", ICMCC.org, Jan. 24, 2009

“Avoiding EMR meltdown.” About a third of practices that buy electronic medical records systems stop using them within a year, AMA News, Dec. 2006.

"The failure rates of EMR implementations are also consistently high at close to 50%", from Proceedings of the 11th International Symposium on Health Information Management Research – iSHIMR 2006

"Industry experts estimate that failure rates of Electronic Medical Record (EMR) implementations range from 50–80%.", from A Commonsense Approach to EMRs, July 2006

Adverse Effects of Information Technology in Healthcare. This knowledge center presents a collection of information on the adverse effects of information technology in its application to healthcare. It also references sources of information on information security, and related media reports.

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

This is a short list, but if there were such articles about VIOXX or Phen-Fen and pharma or the government not just approved but demanded they be used, (figuratively) there would have been heads rolling.

There were outspoken people challenging the Bernard Madoff scheme ...

... Concerns about Madoff's business had surfaced as early as 1999, when financial analyst-whistleblower Harry Markopolos informed the SEC that he felt it was legally and mathematically impossible to achieve the gains Madoff claimed to deliver. Others felt it was inconceivable that his growing volume of accounts could be competently serviced by his documented accounting/auditing firm, a three-person firm with only one active accountant.

... but they were just disruptive, negative, bad people.

-- SS