Sunday, December 18, 2011

EHR: "The Dangerous Decade"

A new perspective piece has appeared in the Journal of the American Medical Informatics Association. Although it is not freely available, I thought posting the abstract and the opening would be of interest:

The dangerous decade
Published Online First 24 November 2011
Enrico Coiera, Jos Aarts, Casimir Kulikowski


Over the next 10 years, more information and communication technology (ICT) will be deployed in the health system than in its entire previous history. Systems will be larger in scope, more complex, and move from regional to national and supranational scale. Yet we are at roughly the same place the aviation industry was in the 1950s with respect to system safety. Even if ICT harm rates do not increase, increased ICT use will increase the absolute number of ICT related harms. Factors that could diminish ICT harm include adoption of common standards, technology maturity, better system development, testing, implementation and end user training. Factors that will increase harm rates include complexity and heterogeneity of systems and their interfaces, rapid implementation and poor training of users. Mitigating these harms will not be easy, as organizational inertia is likely to generate a hysteresis-like lag, where the paths to increase and decrease harm are not identical.

The perspective piece then opens with this:

There is a paradox in the relationship between information and communication technology (ICT) and patient safety. ICT can improve the quality, safety and effectiveness of clinical services and patient outcomes,1 although the evidence base for this is sometimes weak.2 As a consequence, the rapid deployment of ICT on a national scale is a priority for many nations faced with a diminishing clinical workforce, increasing workloads, and resource constraints. 3 4
However, ICT use can also lead to patient harm.5 Many commentators have raised concerns that ICT has yet to deliver on its promises,6 or that the rapid adoption of ICT is a risk.7 7a Errors persist in clinical practice even after ICT is introduced,8 because manual processes co-exist with the automated, and the interfaces between the two are seldom perfect. Others counter that such overemphasis on ICT-related harm only delays the implementation of a crucial technology that will save lives.9
It appears that we are caught in a bind. The demands for health system reform are now so compelling that there appears no choice but to implement complex ICT on a large, often national, scale. Yet these ICT systems appear less mature than we would like and our understanding about how to implement and use them safely remains in its infancy. As such, we are faced with a pressing policy challenge on both the national and international stages.10

They raise these rhetorical questions:

... Where is the ‘kill switch’ in our health ICT systems when large-scale privacy breaches are occurring, or large volumes of critical patient data are being corrupted? Who is authorized to activate such a switch?

The answers to these questions are, quite frankly: nowhere, and nobody. What we have instead is an environment of 'irrational exuberance' -- as well as 'rational exuberance', i.e., opportunism, often of a pecuniary nature.

To the authors' other observations I would add that:

1) "Organizational inertia" is probably too narrow a concern. I would broaden it to "cultural inertia", especially since the health IT "ecosystem" is grossly lacking of a culture of safety and accountability;

2) The authors note that "Predicting the actual harm rate and total patient harms that we will see through the use of ICT in healthcare over the next decade is currently not possible."

While I agree, and agree this inability needs to be remediated, extrapolations can be performed to achieve estimates. Regarding increased ICT use increasing the absolute number of related harms, that number could already be quite substantial as I wrote in an April 16, 2010 thought experiment at "If The Benefits Of Healthcare IT Can Be Guesstimated, So Can And Should The Dangers."

Ironically and tragically, that post was written just five days before I wrote a confidential warning letter to a hospital about EHR deficiencies I'd noted in my mother's care there, and just one month before she was severely injured at that hospital by an EHR-related error of a nature as identified in the letter. Thus, the numbers in the thought experiment should be incremented accordingly;

3) I would say regarding safety that the health IT sector is roughly in the same place as aviation was in the 1920's (e.g., unregulated, experimental technology abounding), not the 1950's, and as the maritime passenger service was in ca. 1912 (April to be precise); and

4) The authors observe that "There is however caution in the [2011 IOM] report [on health IT safety here, PDF] that safety regulations would impede industry innovation, an argument which would literally not fly in the aviation industry ... the caution toward recommending regulation may however be misplaced. Simply put, if healthcare wants the benefits of ICT then it must actively manage its risks."

I strongly agree that the IOM's cautions on regulation are misplaced, as I wrote here. Robust regulation could diminish ICT harm as in pharmaceuticals and medical devices (and aviation).

Innovation will not be harmed, and the IT industry needs to -- and can afford to -- accept the responsibilities and obligations of being involved in healthcare. See for example "No More Soft Landings For Software: Liability for Defects in an Industry That Has Come of Age" (PDF), Zollers, McMullin et al., Santa Clara Computer & High Technology Law Journal, Vol. 21 No. 4, 2005.

-- SS


Anonymous said...

The widespread deployment of HIT devices has resulted in many deaths and injuries. The collusion and cover up between hospital and vendor and the threats of and active sham peer review of professionals who report has and will keep the horrific effects of HIT devices six feet under cover.

It was bad one decade ago. The dangers and adverse events are more prevalent now. There has not been much, if any, innovation in these devices despite zero oversight by any organization.

Shame on the HIT industry, shame on HIM$$, shame on the conflicted hospitals, and shame on the United States Government and the POTUS, and shame on AMIA.

Steve Lucas said...

As a private pilot and aircraft owner I found the aviation reference in the post of interest. Safety is paramount in aviation. No system is introduced without first testing and field experience.

The most recent news in aviation has been the glass panel. Here computer screens and computer generated information has taken the place of the old steam gauge instruments. There have also been the problems of information overload and learning new systems that may require sifting through several pages to retrieve critically needed information.

Interestingly there has been no increase in safety with the introduction of this new technology.

We are also watching competiting technologies vie for valuable resources as a plan for a national wifi system has been found to produce GPS interference in a large part of the country. Questions are now being raised about the FCC’s auction of valuable air spectrum, political connections, and a Well’s notice has been sent to the corporate investors regarding their role in promoting this endeavor.

All of this would sound very familiar to those following EMR’s and the financial interest of the players. We see at play a drive in certain parts of the government to drive a technology, wifi, that they feel is the future, while at the same time creating a more hostile environment for something, general aviation, they feel is of little or no use.

There is a mania in this country regarding technology. One aircraft manufacturer’s solution to removing all mechanical gauges from an aircraft was to add a second battery. This was, in theory, suppose to provide the backup for the pilot incase of any number of failures. Somehow training and knowledge is lost in this whole equation. Much like it is lost in the race for EMR’s.

Steve Lucas

Anonymous said...

Whatever gave anyone the idea that there are dangers from clinical IT? Hearing this makes me shake like a leaf, I am trembling.

IT for medical care has always been the panacea to solve the ills of the US healthcare system. There were not any dangers described to Congress prior to passing HITECH.

GinGrinch does not know of any dangers. Leapfrog did not know of any dangers until recently, at least, they said nothing.

This reminds me of the three monkeys sitting with hands over face and in other poses.

It is downright scary to be a patient after reading this blog. It looks bad. Is it possible to demand that the hospital use pen and paper for my care?

Geraldine P.

Anonymous said...

They are dangerous, indeed. It is only getting worse. They sap creative thought, blunting cognitive processes. Dumb things occur from this. Patients die from this.

InformaticsMD said...

Geraldine P. writes:

Is it possible to demand that the hospital use pen and paper for my care?

It is possible to demand it, but I do not know how a computerized hospital will respond.

I one day may find out (although hope not to), because if I need hospitalization you can be sure I will make that type of demand.

-- SS

InformaticsMD said...

Steve Lucas wrote:

We are also watching competiting technologies vie for valuable resources as a plan for a national wifi system has been found to produce GPS interference in a large part of the country. Questions are now being raised about the FCC’s auction of valuable air spectrum, political connections, and a Well’s notice has been sent to the corporate investors regarding their role in promoting this endeavor

Incredible. I was unaware of the GPS problem.

The amateur radio bands have long been under threat of sale to commercial interests, even though amateur radio operators represent a trained (and free) national resource in times of emergency. We have a track record of assisting in emergencies/natural disasters to prove it.

Then, there was/is plans for using commercial power lines to carry computer signals (broadband over power line or BPL). This can and does cause interference from the shortwaves on up to at least VHF, over a very wide area.

Only because the national ham radio association, ARRL, has decades of experience with such matters has this issue been kept at bay (see

On the apparent mania of replacing aircraft mechanical instruments with virtual electronic ones (even with a "battery backup"), all I can say is "idiots."

If it's salable, there are those who would sell it, even if doing so would be, in effect, to their own detriment. The people who soft-pedal EHR's to other physicians, to politicians, etc. for their own financial and professional aggrandizement are "selling the rope that may one day hang them" or a family member or friend.

-- SS

Steve Lucas said...


LighSquared was sent the Well’s notice. AOPA and other pilot organizations are raising the flag concerning GPS interference. This has not stopped LighSquared from taking out print ads in national newspapers claiming all of the problems with their technology is due to current users demanding continued access to the GPS signals paid for with our tax dollars.

Pilots share with many other hobbyist the constant challenge of defending our ability to engage in an activity without undue interference from the outside. Often those involved only see a short term financial gain and not the whole picture where radio operations are vital for safety or general aviation is vital for transportation in remote areas.

Steve Lucas