Healthcare IT Failure and The Arrogance of the IT Industry

In the Wall Street Journal healthcare blog post "Safety Guru: ‘Health IT Is Harder Than It Looks’" here, reporter Jacob Goldstein reports on UC San Francisco hospitalist Bob Wachter's commentary that:

... recent experience has confirmed that health IT is harder than it looks … Several major installations of vendor-produced systems have failed, and many safety hazards caused by faulty health IT systems have been reported.

I would differ with Dr. Wachter only in that the "experience that health IT is harder than it looks" goes far beyond "recent", e.g., as in the wisdom of the Medical Informatics pioneers from the 1960's-1970's and earlier as in my post "Medical Informatics, Pharma, Health IT, and Golden Advice That Sits Sadly Unused" here.

One comment to the WSJ posting, however, caught my eye. It is a common refrain heard from the IT industry and from health IT amateurs (a term I use in the same sense that I am a radio amateur) unaware of decades of research in the sociotechnical aspects of computerization, i.e., medical informatics, social informatics [1], human computer interaction, etc.:

Commenter: "I have seen very few health IT products that actually harness the power of the computer. Bob is right about “implementation without changing processes” - we need companies to stop asking docs and hospitals how they can duplicate the paper chart and instead work with docs and hospitals to make things work better than the old way."

I take the opposite view.

In reality, handwriting issues aside, there is little wrong with "the old medical chart" from an information science perspective. It evolved over a century or longer to serve the needs of its users. It is a simple document in terms of organization, containing sometimes complex information but in an easy to find form (when maintained by humans properly) and in a presentation style that recognizes human cognitive limitations in very busy, complex social environments such as patient care settings.

Its quasi-duplication in electronic form would serve medicine well.

Instead, like the OS bloat that has now left room for newcomers such as Google Chrome OS to demonstrate the virtues of simplicity, we have markedly complicated EHR's with a large number of screens, subscreens, widgets, controls, scroll bars, alerts, navigation aids, and other "bloatware" that bog the clinician down. (A paper chart and pen do not require a 500+ page user manual as do some EHR's).

The "power of the computer" and its programmers to create complexity is what slows physician down and creates myriad opportunities for unexpected adverse consequences, often through the mission hostile user experience presented to clinical users [2]. This is not to minimize the issues of implementation debacles and upheavals [3,4], bugs, errors, unpredicted dependencies and interactions (e.g., per Koppel's articles on CPOE [5] and barcoding [6]), and other problems unavoidable in any massively complex computer information system [7].

In fact, politically speaking, health IT can be viewed as a cross-occupational invasion of healthcare by the IT industry. (Other invaders are at work also, but I am only considering the IT industry here.)

The latter industry is largely healthcare-dyscompetent or incompetent [8] while simultaneously highly arrogant, perhaps as a result of the acculturation common in the field [9].

I ask:

What right do the domain-dyscompetent occupants have to tell the occupees, the latter rigorously trained in clinical medicine through years of both classroom and grueling practical experience, and in the record keeping paradigms developed over centuries, how to maintain their records and perform their processes?

What arrogance is it that drives the the occupants to tell the occupees to stop complaining about the terms of the occupation - seriously deficient experimental health IT applications - and get in line with the methodologies and preferences of the occupants?

The pace of articles showing the lack of return on investment of health IT is accelerating (see, for example, "2009: A Pivotal Year in Health IT" here). The reasons for this failure can be explained by a simple triad:

• Health IT is an experimental technology.

• The vendors promote it as a well tested, validated, tried and true healthcare "cure."

• Reality is a harsh master.

Until the arrogance of the IT industry is recognized and countered - even if it comes to, in a quasi-comical suggestion, the doctors arming themselves with scalpels and cutting every network cable in sight - and it is recognized that experiments conducted under false assumptions are doomed to fail - our approaches to health IT, per the National Research Council, will remain insufficent [10].

The latter organization recommended that health IT success will depend upon accelerating interdisciplinary research in biomedical informatics, computer science, social science, and health care engineering.

This research will be a long time in coming if we as a society are still at the level of arguing about whether "health IT is harder than it looks" and about the unproven and arrogant assertion, made with a straight face by process re-engineering analysts and consultants seeing money to be made and with little consideration of unforeseen side effects, that the computer will achieve miracles only when we "change medical processes" [i.e., adjust medicine, the occupee, for the convenience of medicine's occupiers, the IT industry].

-- SS

Notes:

(numbers hyperlink to source)

[1] Understanding And Communicating Social Informatics. Kling, Rosenbaum & Sawyer. Information Today Press, 2005.

[2] Are Health IT Designers, Testers and Purchasers Trying to Harm Patients? S. Silverstein MD. Healthcare Renewal Blog, eight-part series, http://tinyurl.com/hostileuserexper

[3] H.I.T. or Miss: Lessons Learned from Health Information Technology Implementations. AHIMA Press (2009), ISBN: 9781584262404. (Disclosure - I am an associate editor of this book).

[4] A Critical Essay on the Deployment of an ED Clinical Information System - Systemic Failure or Bad Luck, version 6. Prof. Jon Patrick, Health Information Technologies Research Laboratory, University of Sydney, Australia, Dec. 2009.

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

[6] Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety. J Am Med Inform Assoc. 2008;15:408-423

[7] 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.

[8] Hiding in plain sight: What Koppel et al. tell us about healthcare IT. Christopher Nemeth, Richard Cook, J Biomed Inform. 2005 Aug;38(4):262-3

[9] Defensive climate in the computer science classroom. Barker et al. ACM SIGCSE Bulletin, Volume 34 , Issue 1 (March 2002)

[10] Current Approaches to U.S. Health Care Information Technology are Insufficient. The National Academies, Jan. 9, 2009.