Health IT: Garbage In, Garbage Out
By George Lundberg, MD, Editor-at-Large, MedPage Today
November 15, 2011
http://www.medpagetoday.com/Columns/29688 (video and transcript)
Click on picture to link to article/video
Transcript:
Hello and Welcome. I'm Dr. George Lundberg and this is At Large at MedPage Today.
I started working with computers in medicine in 1963. I was a Captain in the United States Army Medical Corps in San Francisco when a Lieutenant Colonel told me to "automate the California Tumor Tissue Registry."
I said, "Yes, Sir. How would I do that?" He told me to walk across the Presidio parking lot and go into a building that had a big machine in it that is called a computer.
I did that, and for the next three months, I took the information that was on a bunch of 3 by 5 cards and converted that data into punch cards, which were then fed into the computer and out came an automated California Tumor Tissue Registry.
I was hooked and, although never a "techie," I never stopped finding ways to use computers in medicine. The goal was always better, faster, cheaper.
I remain a strong advocate, and have worked in a string of jobs that strived for that goal. One of the truths I learned early on was "G I G O" -- Garbage In; Garbage Out. That has not changed.
There are indeed a huge number of medical tasks that computers can do very well if properly programmed, managed, and utilized. The eminent UCSF academic clinician Dr. Bob Wachter was early in recognizing that there were also significant downsides in applying computers in practice.
Physicians are very smart. They will quickly adopt new technology that helps them get their job done if it does not waste their time.
Most American physicians have dragged their feet on implementing computers into their practices, and with good reasons. But now they should get on with it.
I write this column as it has been announced that 100,000 U.S. physicians and hospitals have signed up for the "meaningful use" incentive program and thus been able to take the government's money to help automate their organizations.
I think this is good and I praise Dr. David Blumenthal for his major efforts to make this happen.
However, there is another harsh critic worth listening to.
His name is Dr. Scot Silverstein, and he seems to have made it his life's work to call attention to really bad problems that he discovers in this mass move to automation.
Heed his cautions. They are real.
But also recognize that where there is progress, there is trouble; but it can be worth the price.
That's my opinion. I'm Dr. George Lundberg, At Large for MedPage Today.
I thank Dr. Lundberg for his caveat, citing me, and agree with his position.
My father died in 2000 due to complications of failure to diagnose bilateral renal adenocarcinomas (malignant tumors of both kidneys) for about two years despite numerous warning signs. This occurred in a hospital without electronic medical records and was in part due to impaired clinician communications. His life could have been longer, and with far less suffering, had there been a safe and effective EHR.
Once discovered -- only due to my insistence on a renal arteriogram -- the doctors told my father he could not be treated and to "get his affairs in order." (They lost the later malpractice case that ensued.)
I was able to prolong my father's life for a few years by removing him from that hospital, "hospital A" and taking him to another hospital where he underwent bilateral heminephrectomies and other treatment. Let's call the other hospital "hospital B."
On the other hand...a caveat of my own:
Ironically and tragically, my mother died in June 2011 from complications of a medical error at "hospital B" that was due to impaired clinician communications -- caused by an EHR that to my observation was itself unsafe and ineffective.
Therefore, my caveat is that we must be very mindful of the adage "where there is progress, there is trouble; but it can be worth the price."
The price must respect medical ethics. It must not involve using patients, especially patients who have not been given informed consent and opt-out choices, as test subjects for software debugging.
As I wrote back to Dr. Lundberg:
Many thanks George. I agree with your assessments [on EHRs].
Now we have to work to ensure the pitfalls are habitually avoided.
Regards,
Scot Silverstein
Here is a memorial bench I had erected to my parents at their grave last month, near where they ran a small community pharmacy for almost four decades. My father, a pharmacist, was a go-to source for health information in the once-bucolic community of Somerton, in far Northeast Philadelphia, long before chain drugstores appeared in the region.
The inscription atop the bench reads "Owners of Lumar Pharmacy. Served This Community 1954 -1991."
They, like I, also toiled to safeguard and improve the health of the public.
May they rest in peace:
Click to enlarge.-- SS
"Most American physicians have dragged their feet on implementing computers into their practices, and with good reasons. But now they should get on with it."
ReplyDeleteWhy should we get on with it now, Dr. Lundberg? Those good reasons have not gone away; they've only become more evident.
Meaningful use has only made GI,GO the law of the land.
I respect Dr. Lundberg, but he speaks with forked tongue.
ReplyDeleteHe also forgot to mention QIGO, a common phenomena associated with ill designed and defective EMR and CPOE devices.
I do not understand how can he suck up to Blumenthal and compliment Dr. Silverstein in adjoining paragraphs?
Anonymous November 16, 2011 9:30:00 PM EST writes:
ReplyDeleteI do not understand how can he suck up to Blumenthal and compliment Dr. Silverstein in adjoining paragraphs?
I believe he is saying what I say:
Health IT is capable of many benefits, but only if done well.
I put much more emphasis on the "done well" part than our government and health IT industry do. Physicians and other clinicians themselves (other then me) need to do this also. Forcefully so. Crap software belongs in the the Trashcan, not on computer screens in hospitals.
Another informatics specialist recently informed me that:
I was recently on a flight where I sat next to the Dean of a large business school. He said that, from what he’s ascertained, the whole HIT debacle reflects incredible incompetence and disregard for best practices, etc.
Clinicians are being way too passive.
-- SS
My family and I have had first-hand experience with the dynamics of EHRs in the clinical setting when my father (this past spring) was in a critical care unit during the week that electronic health records were "going live" in that hospital. He passed away that week. And, judging by the increase in overhead Code Blues and Rapid Responses, my father's death was not the only one. We found out later that, during the following week, the computer company involved with the EHRs had to call in extra personnel, as patient care was being compromised. They finally realized that lives were at stake.
ReplyDeleteNeedless to say, I wholeheartedly share Dr. Silverstein’s views on the unbridled caution that must be used in assessing, implementing, and using electronic health records. In addition to compromising patient care, I like that he points out (in other writings) the highly manipulatable electronic environment. HIPAA even seems to be taking a back seat to this "greater good". And where, indeed, are all the clinical trials that should have been done to show proof of worth before this experimental "drug" hit the clinics?
This is just one more step that medicine is taking in becoming yet more impersonal. Patient-centeredness is becoming further and further out of reach with each new health care "incentive". I recognize entirely the worth of EHRs but, as a patient, I have experienced a very dangerous side. For one, its implementation should not be in the form of "on the job training". Deaths and injury to patients, it seems, is just the "cost of doing business" for some hospitals; the “collateral damage” of EHR implementation.
My family and I fear for the future of health care, but we have hope in knowing that there are doctors like Dr. Silverstein that are trying to stem the tide of unnecessary injury and death of patients at the cost of fulfillng an incentive.
On “impaired physician communication”…my father’s hospital stay was affected by this beast also. Due to his primary care physician being on vacation, he unwittingly found himself in the Hospitalist system. In my personal opinion, the very nature of the Hospitalist system lends itself to miscommunication. In my view, this system is a very bad game of "telephone". It’s deadly, and it must be stopped. Again, only my personal opinion, created by personal experiences.
ReplyDeleteAnonymous November 17, 2011 12:18:00 PM EST said:
ReplyDeleteDue to his primary care physician being on vacation, he unwittingly found himself in the Hospitalist system. In my personal opinion, the very nature of the Hospitalist system lends itself to miscommunication. In my view, this system is a very bad game of "telephone". It’s deadly, and it must be stopped.
I agree. It violates everything I learned in medical school, namely, that intimate familiarity with a patient's history is crucial to their care. That's what we spend 4 years in medical school, and more in residency, learning how to obtain.
Hospitalists are the "fast food" section of the medical profession.
I believe in some hospitals, the patient's outside attending is not even permitted to see the patient in the hospital, or at least not paid to do so.
-- SS