Friday, November 19, 2010

Avatar fails. (No, not the Cameron movie, but yet another lousy EMR system implemented by amateurs.)

A story "Designed for Efficiency, New Computer Software at Health Dept. Misfires" by The Bay Citizen senior writer Katharine Mieszkowski appeared in the New York Times today regarding San Francisco's Dept. of Public Health.


That's a mild term indeed. In the realm of incendiary comments in the interest of patient care:

In this story, mental health and social workers, and the disadvantaged people suffering mental illness, drug addiction, etc. that these professionals attempt to raise up from misery one difficult step at a time, are being used as unconsenting experimental subjects and free software debuggers and beta testers:

This story follows a script very familiar to Medical Informatics professionals:

  • Poorly designed and implemented healthcare IT causes clinical and other chaos;
  • Vendor and implementation leaders claims "glitches" and "teething pains" and blame the users for inexperience and/or incompetence;
  • Vendor promises relief in the "next version";
  • These principals hope it all "goes away" until the system implodes on itself and needs replacement, starting the cycle anew, and/or-
  • The principals hope newspapers stop paying attention to the chaos caused by the IT and the users simply surrender, and let the information systems control them, rather than the other way around.

Considering the patient population involved here, one might wonder if the project leaders have any more compassion than the machines they proffer:

New York Times
Designed for Efficiency, New Computer Software at Health Dept. Misfires
November 18, 2010 (from the Bay Citizen)

In July, the San Francisco Department of Public Health started using an $11.2 million electronic medical records system, Avatar, that was designed to streamline billing and improve care for tens of thousands of clients. Thus far, however, it has brought administrative chaos to the mental health and substance abuse services in the city.

Documents obtained by The Bay Citizen under a California Public Records Act request show that shortly after installing Avatar, providers struggled to use the new software, causing health officials to lose track of millions of dollars of services.

Officials are scrambling to fill in the missing data to meet deadlines to qualify for reimbursement from the state.

In addition to mere financial chaos:

... Problems related to the conversion to Avatar delayed for months the payment of about $450,000 to individual therapists, Anne Okubo, the health department’s deputy financial officer, told the San Francisco Health Commission on Tuesday night. The department was forced to use a third party to make the payments, which are still incomplete.

In addition, some therapists and social workers report that the demands of the new software have cut into the time they spend with patients, eroding the quality of care.

In an Aug. 19 e-mail headed “problems with Avatar,” Steven Schreibman, a social worker at Sunset Mental Health, a city-run clinic, wrote that the software required “excessive time charting and performing data entry” and had led to “shorter sessions with clients” and “delays in our capacity to accept new clients.” [This is not news to anyone familiar with poorly designed, mission hostile healthcare IT - ed.]

The customary excuses were presented. Growing pains, ignorant users:

Senior health department officials and Netsmart Technologies, Avatar’s developer, said the problems were glitches that were to be expected as the city made the transition to a more efficient record-keeping system.

“We knew it was going to be rough initially, because there is a learning curve,” said Jo Robinson, who heads the Community Health Behavioral Services division, where Avatar was introduced.

Kevin Scalia, a Netsmart Technologies executive vice president, said that he does not see this as a big problem. “From our point of view,” he said, “everything is going swimmingly.” [Translation - they're making good money - ed.]

Here's the key passage:

Department managers told the Health Commission that Avatar would lead to “improved client care” and had “positive fiscal impacts,” but they acknowledged there had been problems.

In September, the department compared the cost of mental health and substance services reported by the hospital, clinics and organizations in March, before the software was put into use, to those reported in July using the new system.

The data showed that the mental health services reported had plunged 55 percent. Substance abuse services reported fell 32 percent. The large discrepancies caused alarm because they indicated that providers were having problems using the software, according to documents and interviews. [I can also predict they've had problems _providing_ those services under the time duress added by the software - ed.]

As someone who was once a Medical Review Officer for drug testing in the public transit industry, and a colleague of the company's Employee Assistance Program liaison, I can assure readers that implementation of health IT will not effect a one-third reduction in drug abuse problems and recidivism.

After a month of use:

A month later, as more providers gained access and proficiency with the software, the picture improved, but significant discrepancies remained.

Some data modeling issues are apparent:

But some organizations worry that the services they are providing will not be fully reflected in the new system.

Here's a reverse twist on HIT vendor "Hold Harmless" clauses:

At the Health Commission meeting, Estela Garcia, executive director of the Instituto Familiar de la Raza, a community organization that provides mental health services, asked the commission to protect organizations like hers from any financial liability related to Avatar.

I want a hold-harmless policy until the system is fully up and running,” Ms. Garcia said.

How long that will take is unclear. One mental health program director, who would not allow his name to be used because it could jeopardize his relationship with the department, said his staff had gone to repeated training sessions to try to get up to speed.

“Avatar turns out to be a total disaster,” the program director said. “What is going to happen to contracted agencies if their billing is short at the end of the fiscal year as compared to the terms of their contract, because they can’t master Avatar?”

As in typical in health IT, system users are afraid to speak candidly:

A psychologist who works with a community organization under contract to the city, who spoke on the condition of anonymity because he was afraid of losing his job, said he used to do all his charting and billing on paper and was told that the new system would be more efficient. So far, that has not proved to be the case, he said.

“We are seeing the same number of patients,” he said, “but we are providing substantially less service to them, because the time we are now spending just to do the billing alone, not to mention the record keeping, it’s become the majority of our time.”

Labor unions are taking a look:

Greg Cross, a field representative for Service Employees International Union Local 1021, which represents hundreds of social workers, psychologists and counselors who work for the city, said he had met with officials to discuss Avatar’s impact on workload as well as performance expectations.

I invite SEIU Local 1021 and national SEIU leaders to read this blog, and review my academic site on HIT failure here, to better understand why these debacles repeatedly occur.

At the Health Commission meeting, Fred McGregor, the health department’s senior information technology manager for community programs, said that the department was aware that providers find the demands of Avatar “a little onerous” and that it was working on a redesign to make clinical assessment more efficient.

A "little onerous"?

"Working on a redesign to make clinical assessment more efficient"?

What about getting it right the first time, based on the significant amount of literature that exists on proper IT design?

I, for one, am tired of hearing this corporate mumbo-jumbo every time another health IT system impairs users.

What is needed here is a full scale investigation and evaluation of the competence and expertise of the project leaders, designers, and implementers to be experimenting in the complex field of healthcare information technology.

Mr. Schreibman, the social worker, made it clear in his August e-mail that change was needed quickly.

“The kind and amount of work skill involved using this software represents a change in our job description,” he wrote. “This is not the job we accepted when we chose to do clinical work for the city.”

In other words, they did not accept a job as data entry clerks and directors of workarounds to the mission hostile user experience presented by poorly designed healthcare information systems.

I note that missing in this story are the human tragedies (such as pain & suffering, injury, death) these IT "glitches" may have caused.

Until the memes of complete health IT beneficence and "anyone can do it" are soundly pounded into the ground and out of the heads of hapless politicians, healthcare leaders, and IT personnel, this type of mishap will continue.

Sadly, health IT mishaps are likely to be occurring on a national scale, soon, in a neighborhood near you, thanks to the timelines and penalties expounded in the HITECH act. HITECH was an integral part of the legislation known as the ARRA (American Recovery and Reinvestment Act of 2009).

-- SS


Anonymous said...

Just a few teething pains, right? "'From our point of view,” he said, “everything is going swimmingly.'”

The only swimming I see is the swimming in the cesspool of mission hostile HIT devices.

Are these devices meaningfully useless and meaningfully disruptive to work flow?

Tell San Francisco that these devices are illegal, never having been approved as being safe and efficacious.

Live it or live with it said...

You would think that government should learn -- look at the reports on the VA HIT debacles, and now the DoD debacles. They are getting taken by vendors who profit no matter what disaster they cause. Less expensive more compliant junior employees are easier to manage and more profitable for the HIT vendor.

"Certification" is useless too because the certifiers work for the vendors and hand out "certifications" like candy to those willing to pay -- and the only ones willing to pay are the HIT vendors making those same big profits. A systemic circle of madness.

It is a reflection of how business is done today in HIT. So similar to the vaporware era of the 1980s it is scary.

In government work misrepresentation during the contract award process is a punishable offense. I think it is time to start the investigations and prosecutions.

Anonymous said...

The Avatar vendor should be sued for providing such swimmingly defective devices. What it did is known as fraud.

Anonymous said...

Hmmm, on its website, Netsmart Technologies has a list of recent news reports. If San Francisco is going so swimmingly well, gee, you would think the NY Times report would be listed.

Jon Patrick said...

Throwing brickbats at the vendors may be good sport but it is not getting down the real task of what needs to be done about preventing this type of disaster. We need to focus on the key issues that would have prevented this occurrence. I humbly suggest this changes:
1. The software needs to testable by the client in practical operational situations, before commissioning it.
2. The software needs to be changeable in real-time and
3. The users needs to be in control of the design.
All these things are possible with modern software engineering methods.
Anyone who says they aren't is not up with the game and you shouldn't be using their services.

InformaticsMD said...

Re: Anyone who says they aren't is not up with the game and you shouldn't be using their services.

Such vendors are Luddites regarding modern software engineering methods.

-- SS

Carole Diamond said...

This system is a nightmare. Our health center started using Avatar on January 2, 2014. Decreased productivity, lost notes..this system is a dinosaur. All we hear is, 'you were trained to use it'. Two weeks later still losing notes..whole intake "bundles"lost. Additional PATIENT CARE TIME, such as phone calls, letters, prior authorizations, indigent patient medications, continuity of care with colleagues--gone to AVATAR!

Anonymous said...

The MH Facility I work at started using Avatar in August of 2013. I am on the billing side of things. We have yet to get a bill out of this system electonically and have just discovered, to the dismay of Netsmart, that we were able to get paper bills printed. Very laborous system, takes me months to complete something that used to take hours! If your company is thinking of switching, please go elsewhere!
Anonymous due to fear of losing job