Thursday, June 04, 2009

If The Military Can't Get Electronic Health Records Right, Why Would We Think Conflicted EHR Companies And IT-Backwater Hospitals Can?

The publication "The Machinery Behind Healthcare Reform: How an Industry Lobby Scored a Swift, Unexpected Victory by Channeling Billions to Electronic Records" on May 16 2009 in the Washington Post (my comments here) exposes a massive lobby that has grossly over-represented the benefits of healthcare IT, committed a cross-disciplinary invasion of medicine, and created a myth about HIT's supposed transformative powers in curing healthcare's ills.

Since its publication in the Post I have become concerned that the research literature that exists extolling healthcare IT may be tainted by corporate influence. The phenomenon of tainted biomedical literature is certainly familiar to readers of Healthcare Renewal and other medical blogs regarding pharmaceuticals and medical devices.

Electronic health records systems can facilitate, not revolutionize, medicine when led by competent experts cross-trained to a meaningful extent (i.e., graduate level or beyond) in both clinical medicine and information science and technology, e.g., biomedical informatics professionals. Even these professionals must often expend much effort in "managing the mismanagement" by incompetent and/or conflicted IT and hospital leadership. (An example of a tightly run and highly specialized project in a high risk medical subspecialty that did have tangible clinical and some financial returns, via identification of poorly performing medical devices -- not something the medical device industry cares for -- is here. This type of project is not easily portable.)

Making yet another case for how the concept of national electronic health records is probably a bad idea at this point in time with respect to our understanding of health IT and its social-technical interactions and challenges, it appears the military's EHR system AHLTA is simply a disaster. [Note: this is not to denigrate the military, and I am very thankful to all who serve and defend our country and freedoms. HIT problems seem unfortunately universal - ed.] All of the preventable elements I've written about are present: unreliability to due inadequate attention to resilience engineering, a mission hostile user experience, time-wasting, demoralization of clinicians, and a cornucopia of other predictable (to informatics experts) consequences when health IT is managed by anyone other than experts.

Just as our economy and culture are now falling apart at the seams as a result of decades of mismanagement and corruption, from micro to macro levels, in most domains (borrowing a phrase from Rev. Jeremiah Wright, "the chickens are coming home to roost"), so the wages of incompetence and corruption in healthcare and healthcare IT are rearing their ugly head. This is the situation in the setting of a relatively constrained patient population (primarily active military personnel and families):

U.S. Medicine - the Voice of Federal Medicine

May 2009

Electronic Records System Unreliable, Difficult to Use, Service Officials Tell Congress - By Sandra Basu

WASHINGTON—AHLTA, the Department of Defense’s $4 million [sic - that should be $4 billion - ed.] electronic medical record system, continues to be difficult for military physicians to use, according to top military health leaders who spoke at a House Armed Services subcommittee hearing at the end of March.

At a Congressional hearing titled “AHLTA is ‘Intolerable,’ Where do we go from here?” top Department of Defense and service leaders told members that medical personnel are hampered by an electronic medical record system that, among other issues, is slow, difficult to use, unreliable and frequently crashes.“Being the first service to vigorously support the fielding of AHLTA five years ago, we faced a near mutiny of our healthcare providers, our doctors, our nurse practitioners, physician assistants and others last summer,” Army Surgeon General Lt. Gen. Eric Schoomaker, MC, USA, told committee members at a joint hearing held by the Military Personnel Subcommittee and the Terrorism, Unconventional Threats and Capabilities Subcommittee.

Committee members also voiced concern about how the system was impacting provider morale and patient care. “The committee has heard from military doctors and nurses who use AHLTA that it is unreliable, difficult to use and has decreased the number of patients they can see each day. We have also heard that medical professionals leave the military because of their frustration with AHLTA,” said Rep. Joe Wilson, R.-S.C., ranking member of the Military Personnel Subcommittee of the House Armed Services Committee.

Difficult for physicians to use. Intolerable. Slow. Unreliable. Frequently crashes. Near mutiny. Morale. Affecting patient care, decreasing patient load. Can it get worse?


A Troubled System

AHLTA is currently deployed worldwide to 70 hospitals, 410 clinics and 6 dental clinics. In addition, the system is used in 14 theater hospitals and 208 forward resuscitative sites.

While Army, Navy and Air Forcer medical leaders who testified all stressed the importance of an electronic medical record [perhaps due to lobby influence and myth-making? - ed.], they all expressed frustrations with AHLTA. Dr. Schoomaker told committee members that medical personnel, particularly specialists, often “spend as much or more time working around the system as they do with the system.” He said that the services are still not effectively able to seamlessly access complete data of patients from the battlefield between the military treatment facilities and the Department of Defense and the Veteran’s Administration.

Last year he said he knew he had a problem when he asked a physician who is a self-described “super user” of the system whether she was a “super fan” of the system and she responded that she was not. “When our best and most faithful users of AHLTA could not admit to being fans of the system, I knew we were really having serious problems,” Dr. Schoomaker said.

When the Army's Surgeon General observes that clinicians "spend as much or more time working around the system as they do with the system", and that the superusers are not enthusiastic about the system, and a Congressional hearing is held entitled "where do we go from here?" (it's clear to this author that they have no clue), one should start to very critically question basic assumptions about health IT. Who said it's a powerful tool to improve healthcare and reduce costs? Who said it's ready for national dissemination? What conflicts do such individuals have with the health IT industry?

He blamed the system’s failures on a lack of a clear-cut strategy for implementing AHLTA—a problem he believes still exists. “In my opinion, the failures of AHLTA can be attributed to the overall lack of a clear, actionable strategy and poor execution from its genesis. As a result of the MHS’s lack of an information management/information technology strategy up to this point, theArmy Medical Department has been largely frustrated by a number of obstacles that continue to impede the system’s capabilities and functionality,” he said.

He also said that the services should have a greater input in decision making regarding AHLTA. “Military health system information technology investments and solutions should be transparent to the services sitting here at the table and should be jointly governed, meaning that we with service input are treated as principal customer clients of the system and that we are heard and acted upon promptly,” he said.

As a faculty member in a College of Information Science and Technology where undergraduates and graduate students are taught the importance of information science and consideration of the needs of end users as a primary enabler of IT success, how can there be a "lack of an information management/information technology" strategy in this national health IT project? How can there have been a lack of input into decision making by the services in the development and deployment of AHLTA?

Leaders from the Navy and Air Force detailed the challenges that their personnel face in using AHLTA. “Almost all of the providers I spoke to relate to the system going down unexpectedly, recently at least once a week,” Navy Deputy Surgeon General Rear. Adm. Thomas R. Cullison, MC, USN, told committee members. He added that while no one would like to return to paper records, providers are “largely dissatisfied” with the system and that the system slows down their clinic time. “Most of our providers say they have to stay later in the afternoon to finish up notes simply because it slows down clinic time,” he said.

Air Force Deputy Surgeon General Maj. Gen. Charles Bruce Green, USAF, MC, told the committee that Air Force primary care physicians spend about 40 percent of their time working with AHLTA versus 60 percent of their time with patients. On the other hand, specialists are “working around the system trying to find new solutions,” since the system does not address the needs unique to their practices. In his written testimony, Dr. Green said that the problems associated with AHLTA have resulted in “low productivity and provider morale.”

Forty percent of clinician time spent tinkering with balky computers? This should be astonishing to any reader unfamiliar with these issues, and an eye opener to our governmental representatives not just regarding the military, but regarding the entire lobby-promoted scheme to force clinicians to adopt HIT by 2014 or suffer financial penalties.

Specialists "working around" the system (thus risking the dangers of workarounds of HIT deficiencies observed by Koppel and others) because it does not meet the needs of their subspecialties? No surprises here. After reading about issues in development of domain specific healthcare information systems for high risk subspecialties (such as here), it should be obvious that the business IT-dominated health IT industry as it currently exists cannot fill such needs.

More importantly, I feel the AHLTA project is an illustration of what will be reproduced, thousands or tens of thousands of times over, in hospitals and physician practices all over this country as we proceed in a national EHR initiative based on false premises borne of the health IT lobby.

The Problem

Then-Assistant Secretary of Defense for Health Affairs S. Ward Casscells, M.D., told committee members that many of the problems that AHLTA has suffered have been “self-inflicted wounds,” due to software contracts with vendors that were “poorly written.” “We have had, over the past decade, contracts that were poorly written from the standpoint of performance, they have loopholes in them that permitted delays. We have, in some instances, lax oversight of some of these contracts,” he said.

Unbelievable. Hospitals sign HIT contracts putting all liability for system defects on clinicians, and that gag them from disclosing defects outside their organizations. The military's HIT contracts apparently had additional flaws that are probably pervasive in the commercial sector as well.

... In moving forward to rectify AHLTA problems, DoD has adopted a Unified Strategy Regional Distribtion Approach, a three-phased plan for reshaping the electronic health system. In written testimony, Dr. Casscells explained this strategy seeks to “improve provider satisfaction, improve reliability and strengthen data sharing throughout DoD and Department of Veterans Affairs healthcare delivery continuum and with private healthcare providers.” The first phase of the approach will focus on “stabilizing performance, reliability and the core infrastructure,” of the system according to Casscell’s written testimony.

"I want to be wary of overpromising. We have done that in the past [indeed, the entire HIT industry has massively overpromised for decades - ed.], but I am excited about this. I think there is a chance here that we can once again be leaders for the nation in electronic health records, as was the case several decades ago. I would like to think that a year or two from now, you will agree with me that AHLTA has gone from intolerable to indispensible,” Dr. Casscells told committee members.

Tommy J. Morris, acting director in DoD’s office of the Deputy Assistant Secretary of Defense for Force Health Protection and Readiness Programs, said that the only service that nonconcurred with their proposed blueprint to overhaul AHLTA was the Army [not exactly an unimportant stakeholder - ed.]

Dr. Schoomaker, on his part, challenged the notion that there was actually a “strategy” in place for rectifying AHLTA. “Mr. Morris has got a plan, he does not have a strategy. We asked for a strategy. A plan is just one element of a larger strategy. We asked for a strategy and our involvement in that strategy, so with respect, that is what we in a sense partially nonconcurred with,” Dr. Schoomaker said.

"I've got a plan." How familiar a refrain that is in a time of mass societal mismanagement.

If I were a politician examining health IT, I'd really start looking into how our government became convinced health IT was not only a worthwhile investment, but an "economic stimulus." As with our friends up north, it seems to be primarily a stimulus for poseurs and dyscompetents to come out of the woodwork, disrupt healthcare providers, and then collect massive fees for the "favor."

In consideration of the above, I ask:

If the military, with its internal discipline and ability to take over entire modern countries with just a few thousand soldiers lost, and its constrained patient population (active military personnel and families generally free of complex and chronic illnesses) can't get electronic health records right, why would anyone think inept and sometimes corrupt EHR companies, dyscompetent hospital IT departments, and reckless and cavalier hospital executives can?

I reiterate my concerns that the "AHLTA experience" will become all too familiar to hospitals and physician practices throughout this country, unless sanity and rationality is restored to our thinking about health IT.

-- SS


Beyond-The-Spectrum said...

I believe that electronic storage of medical records CAN work, if the powers-that-be are willing tomake it a priority. I'm sure some enterprising capitalist will be willing to turn a buck on the notion if its willing to return a profit, and potential profit is more than enough incentive for working out the bugs in any such system

InformaticsMD said...

Beyond The Political Spectrum said...

I believe that electronic storage of medical records CAN work...potential profit is more than enough incentive for working out the bugs in any such system

I also believe they can work, and in fact have made them work.

The problem is your use of the term "bugs in the system." Many others make this same false assumption that the major issue is "bugs" in the information technology.

Try reading the following essay (as an example) to learn why "bugs in the system" is so vast an oversimplification of the problems impeding HIT diffusion and success that the phrase is actually harmful to progress in health IT:

Learning from Social Informatics - Kling, U. Indiana

(This essay was later expanded into a book.)

Most "enterprising capitalists" don't want to be burdened by such messy stuff, cannot understand it, or deny its importance, and that is one reason why we have the debacles in health IT that we have.

It will take an enterprising capitalist who is also incredibly competent to manage these issues properly, and such creatures are rare as hens teeth.

Finally, it's not as if the information on how to make HIT work is Top Secret. The problem is pervasive false assumptions about HIT and underestimations of the complexities, and a stubborn resistance to these issues.

One way to describe this is a belief in "technological determinism", but I like the term I coined better: "the syndrome of inappropriate overconfidence in computers."

This suggests that while many enterprising capitalists already on the HIT scene think they're smart, in reality they're not that smart.

-- SS