On Generic Management in Health Care: Hospital Chief Information Officers (CIOs) Say Patient Engagement is All About ... Themselves?

To laugh or to cry? - now it seems that hospital CIOs think they "own" patient engagement. 

An article in Medscape summarized a presentation at the Healthcare Information and Management Systems Society (HIMSS) Annual meeting that provided a surprising insight into how some hospital managers think.  The survey focused on the concept of patient engagement:

In separate surveys, researchers polled a national sample of 125 chief information officers, 359 primary care physicians, and 2567 patients who visited their doctor in the previous 90 days. Questions centered on beliefs about engagement, the perceived roles of the stakeholders, and barriers.

The patients seemed to have a sensible idea about their own engagement,

From the patient perspective, getting help from a provider they trust is most important, said Mazi Rasulnia, PhD, from M Consulting LLC, who is cofounder of Pack Health, a patient-activation company in Birmingham, Alabama.

What they expect most, according to the survey, is a provider who listens to them and helps them understand treatment options before they make a decision.

'Patients want questions answered around the specificity of their own health, not just what generally happens with 'patients like you' or from a population standpoint,' Dr Rasulnia said.

'What they don't really care for or expect is for providers to 'give me a website so I can access my medical information'.' That, and asking patients about their personal life, ranked lowest on patients' lists of expectations.

They want providers to help them navigate not only their disease, but also the health system. Providing access is important, but that alone won't help patients engage, he explained.

The article did not provide much information about the physicians' responses, but did suggest

When physicians talk about patient engagement, they tend to think in terms of the doctor–patient relationship,...

So in general, the doctors and patients were on the same page, but

doctors believe patients need to take more responsibility for their outcomes, and patients say they can't because their doctors, who are responsible for engaging them, don't spend enough time with them.

Setting aside the causes and approaches to the problem of insufficient time during patient encounters, the chief information officers (CIOs), had a radically different idea,

when healthcare executives talk about the patient engagement envisioned under the Affordable Care Act, they think in terms of transactions,...

Furthermore,

 Chief information officers believe they are responsible because patient engagement involves technology,...

Also,

The chief information officers surveyed 'clearly saw themselves as the owners of patient engagement,' said Lorren Pettit, MBA, vice president of market research for HIMSS Analytics, who reported on the systems perspective.

When chief information officers were asked who is most accountable for patient engagement in their organizations, 46.4% said they were, but 14.4% thought nurses were accountable for patient engagement, not physicians or patients.

Comment - on the Hubris of Generic Managers

I have to assume that the article, presentation, or the survey were hopelessly garbled. If not, what on earth were the chief information officers thinking?

Chief information officers think they are the "owners of patient engagement?"  While "patient engagement" does not seem to be a well-defined term (look here), and seems like an example of bureaucrat speak or politically correctness, it surely seems to be related to communication between patients and health care professionals.  It surely does not seem to be directly about information technology. At best, the health care information technology CIOs manage could support patient engagement.    Furthermore, the explanation apparently offered by the CIOs, that patient engagement involves technology, is not helpful because at this time, all of medicine and health care to some extent "involves technology."

So why would CIOs claim to "own" patient engagement?  Maybe they are simply clueless about what patient engagement really involves.  CIOs rarely interact with patients.  Most CIOs have no direct health care experience, and are not trained as doctors or nurses.  For example, a recent list of "100 Hospital and Health System CIOs to Know" included only 10 with health professional degrees (seven MDs, three RNs).

Why then, not simply admit that the issue is out of their area of expertise, rather than claiming "ownership."  My best guess is this is the bravado, or arrogance of generic managers.

In 1988, Alain Enthoven advocated in Theory and Practice of Managed Competition in Health Care Finance, a book published in the Netherlands, that to decrease health care costs it would be necessary to break up the "physicians' guild" and replace leadership by clinicians with leadership by managers (see 2006 post here). Thus from 1983 to 2000, the number of managers working in the US health care system grew 726%, while the number of physicians grew 39%, so the manager/physician ratio went from roughly one to six to one to one (see 2005 post here). As we noted here, the growth continued, so there are now 10 managers for every US physician.

The managers who first took over health care may have had some health care background.  Now it seems that health care managers are decreasingly likely to have any health care background, and increasingly likely to be from the world of finance.  Meanwhile, for a long time, business schools and the like seem to have teaching managers that they have a God given right to manage every organization and every aspect of society, regardless how little they know about what the particular context, business, calling, etc involves.  Presumably this is based on a faith or ideology that modern management tools are universally applicable and nigh onto supernatural in their powers.  Of course, there is not much evidence to support this, especially in health care.

We have discussed other examples of bizarre proclamations by generic managers and their supporters that seem to corroborate their belief in such divine powers.  Most recently, there was the multimillionaire hospital system CEO who proclaimed new artificial intelligence technology could replace doctors in short order (look here).   Top hospital managers are regularly lauded as "brilliant," or "extraordinary," often in terms of their managerial skills (look here), but at times because of their supposed ownership of all aspects of patient care, e.g., (look here)

They literally are on call 24/7, 365 days a year and they are running an institution where lives are at stake....

If hospital CEOs, who spend lots of time in offices, at meetings, and raising money, really see themselves as perpetually on call, and directly responsible for patients' lives, then maybe it's not surprising that their CIOs think they own patient engagment.

So in summary this latest survey shows the continued hubris of the generic manager, and hence their continued unsuitability to run health care organizations.  It is time for health care professionals to take back health care from generic managers.  True health care reform would restore leadership by people who understand the health care context, uphold health professionals' values, are willing to be held accountable, and put patients' and the public's health ahead of self-interest. 

ADDENDUM (20 April, 2015) - This post was republished on Naked Capitalism. 

An ironically titled session by ECRI Institute: "Would You Bet Your Mother's Life on the Safety of Your EHR?"

An ironically titled session by ECRI Institute "Would You Bet Your Mother's Life on the Safety of Your EHR?" is being held at the annual Health Information Management Systems Society (HIMSS) meeting by Ronni Solomon, JD and William Marella, MBA of the ECRI Institute on April 13, 2015 (http://www.himssconference.org/event.aspx?ItemNumber=36765).

It is announced in the HIMSS press release below in Healthcare IT News.

I should probably be the keynote speaker to that session, as I am suitably qualified to speak of that exact issue.  My mother and I lost such a "bet" (http://hcrenewal.blogspot.com/2013/09/on-ehr-warnings-sure-experts-think-you.html).

It's about time these topics were surfaced, but I still feel there is far too little public awareness of the risks of bad health IT.

http://www.healthcareitnews.com/news/ridding-ehrs-dangerous-often-undetectable-bad-data 
Ridding EHRs of dangerous, often undetectable, bad data

March 13, 2015

As the healthcare industry continues toward its goal of making all patient health records electronically accessible, a health system’s safety increasingly is determined by the quality of its EHR implementation.


Last November ECRI Institute, a non-profit organization that uses scientific methods to test medical products, rated “incorrect or missing data in electronic health records and other health IT systems” as the No. 2 hazard that will put patients at risk in 2015.

“Once inaccurate data gets into the electronic health record, it’s hard to get it out,” said Ronni Solomon, executive vice president and general counsel for ECRI Institute. “That’s a challenge, and the less detectable it is, the higher the risk. You don’t know it’s in there.”

Such incorrect information probably has far more impact than it did on paper, I believe; computer output is often uncritically taken as gospel, and is often cut-and-pasted to newer records without patient interaction, thus propagating an error of omission, commission or data loss or corruption (due to malfunction).

The negative impact of bad data in electronic health records is both immediate and long-lasting. “In the short-run, bad data in the system limits the effectiveness of clinical communications and the effectiveness of decision support,” added William Marella, ECRI’s executive director, PSO operations and analytics. “And basically it undermines people’s confidence in the system.”

Especially the clinicians' confidence, which is already low (e.g., see my Jan. 28, 2015 post "Multiple medical specialty societies now go on record about hazards of EHR misdirection, mismanagement and sloppy hospital computing" at http://hcrenewal.blogspot.com/2015/01/meaningful-use-not-so-meaningul.html).

Solomon and Marella will conduct an educational session at HIMSS15 in April on how healthcare organizations can apply safety science to IT and informatics to improve patient safety.

The first step they can take is to strip control of critical health IT decisions from the business-IT personnel and put heath IT under the aegis of medical leadership, especially medical leadership that contains formally-educated Medical Informatics and related professionals.  (This admittedly and unfortunately has a very low chance of happening due to hospital politics and power structures.)

“Would You Bet Your Mother's Life on the Safety of Your EHR?” is designed to help attendees create a framework for planning and implementing IT strategies, processes and tools to increase the safety of healthcare patients.

Both Ms. Solomon and Mr. Marella are aware of what happened to my mother.  I wonder out loud if the title is based on, at least in part, that incident.

... “The promise of these systems is that they’re going to make the health care system more efficient and ultimately more safe,” Marella said. “Now the administrators in hospitals and health systems that have financed these systems want a return on their investment.”

Perhaps the administrators should have done due diligence on the realities of this technology before investing the money.

The session will cover how organizations can: establish an infrastructure for identifying and responding to patient safety problems; assess safety challenges facing health IT users and implementers; identify partnerships that can accelerate safety improvements; and analyze opportunities to use informatics to prevent adverse events.


“What we’re trying to do in this talk is get in front of the IT leaders of these institutions and help them understand where patient safety people are coming from and how we can bridge these two silos within the health system, because they will both be more effective working together,” Marella said.

I add that all of these goals should have been met prior to a national rollout and, at each organization, prior to subjecting patients to these technologies, but I speak common sense, which in medicine is no longer common.  Thus, sessions like this one in 2015.

Perhaps this could be the theme poster for the session.

-- SS

"EHRs: The Real Story" - Sobering assessment from Medical Economics

From Medical Economics -

"EHRs: The Real Story",  pg. 18-27, Feb. 10, 2014, available here (PDF).

Full issue at http://medicaleconomics.modernmedicine.com/sites/default/files/images/MedicalEconomics/DigitalEdition/Medical-Economics-February-10-2014.pdf - it is large, 12 MB:

... "Despite the government’s bribe of nearly $27 billion to digitize patient records, nearly 70% of physicians say electronic health record (EHR) systems have not been worth it. It’s a sobering statistic backed by newly released data from marketing and research f rm MPI Group and Medical Economics that suggest nearly two-thirds of doctors would not purchase their current EHR system again because of poor functionality and high costs."

Here are other key findings from this national survey:

• 73% of the largest practices would not purchase their current EHR system. The data show that 66% of internal medicine specialists would not purchase their current system. About 60% of respondents in family medicine would also make another EHR choice.

• 67% of physicians dislike the functionality of their EHR systems.

• Nearly half of physicians believe the cost of these systems is too high.

• 45% of respondents say patient care is worse since implementing an EHR. Nearly 23% of internists say patient care is significantly worse.

• 65% of respondents say their EHR systems result in financial losses for the practice. About 43% of internists and other specialists/subspecialists outside of primary care characterized the losses as signifcant.

• About 69% of respondents said that coordination of care with hospitals has not improved.

• Nearly 38% of respondents doubt their system will be viable in five years.

• 74% of respondents believe their vendors will be in business over the next 5 years.

My own views are:

While some might dismiss such surveys as well as reports of harms as "anecdotes" (those same persons conflating scientific discovery with risk management, see http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html), I observe that such articles/surveys are increasing in frequency the past few years and are coming from reasonably capable observers - clinicians - .unlike, say, a Fox News survey of pedestrians on complex political matters.

Another physician survey is here:  http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html.

Here's an interesting ad hoc survey of nurses:  http://hcrenewal.blogspot.com/2013/07/candid-nurse-opinions-on-ehrs-at.html.
.
This is not what the Medical Informatics pioneers intended, and is not due to physicians being Luddites (a topic I addressed at http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html).

In my opinion, organizations that have the expertise to change the current trajectory of this technology such as the American Medical Informatics Association (AMIA) needs to leave its tweed-jacket academic comfort zone and become more proactive - or perhaps I should say aggressive - in combating the industry status quo.  

The health IT industry trade associations such as HIMSS have no such qualms about aggressively and shamelessly pushing their version of EHR utopia, an agenda that has led to massive profits for the industry... but to clinician survey results such as above.  And to injured and dead patients.

-- SS

Texas Medical Association slams ONC Healthcare IT safety plan

The Texas Medical Association offers views similar to the views I have been writing about for a decade and a half on healthcare IT quality and patient care risks:

FierceHealth IT today

Texas Medical Association slams ONC safety plan

By Dan Bowman

The health IT safety action plan proposed by the Office of the National Coordinator for Health IT in December is not specific enough to succeed, according to recent comments made by the Texas Medical Association. In its letter to National Coordinator for Health IT Farzad Mostashari, TMA said that responsibility for the plan "lacks focus," and should be overseen by a "highly visible HIT Safety Czar. TMA also called setting mandatory deadlines and developing a "robust" reporting and learning system imperative to the success of the plan, saying that the plan's current reliance on voluntary reporting and funding represents a "fundamental weakness." "TMA believes that significant patient safety risks exist now, and new ones will emerge in the next one to two years as many [electronic health record] and other HIT vendors merge or go out of business," the letter said. Additionally, the group expressed doubts about a code of conduct proposed to keep vendors in line as far as ensuring cooperation with safety organizations for adverse event reporting. "TMA is concerned that this will not materially affect industry accountability and generate the changes that are needed," the letter said. "For example, what if a developer does not comply with said code of conduct? There is no penalty or impetus for change." The American Medical Association was a bit less harsh in its assessment of ONC's plan. It supports most of the ideas outlined in the plan, although it called for more research to be done on the impact of electronic health record use regarding patient safety in the ambulatory setting. "Physicians are concerned about potential liabilities from EHR system design and software flaws, as well as lack of interoperability among EHR systems that could result in incomplete or missing information, which may lead to errors in patient diagnosis and treatment," the AMA letter said. "In addition, the impact that EHRs have on physician practice workflows can lead to unintended consequences. Those impacts are the result of how the software is developed." HIMSS said in its letter to Mostashari that it wants to see more provider-vendor cooperation when it comes to investigation of patient safety events, as well as usability, while the AHA said in its letter that its stakeholders would like to see more of a focus on a single, national approach to matching patients with their records with a goal of patient safety. The College of Healthcare Information Management Executives, meanwhile, said that the plan needs to be facilitated by stakeholders not directly under government control. To learn more: - here's the TMA letter (.pdf) - read the AMA letter (.pdf) Related Articles:HIMSS, AHA support ONC's patient safety plan CHIME: ONC's role in health IT safety plan 'overstated' HHS issues health IT safety action plan

The TMA and AMA letters linked above are worth reading in their entirety.

I note, with little surprise, the "softer" stances (e.g., self-policing vs. government oversight) taken by industry-dominated bodies such as HIMSS and CHIME.

On the other hand, I find the AMA's "less harsh" views somewhat disappointing.  Their letter is welcome, and more research needs to be done as to risks in ambulatory settings (and inpatient settings as well).  However, the delays in action during the research are of concern.

Where patient safety is concerned, fast action is a top priority.  Patients, needless to say, have more rights than computers and their sellers.

-- SS

The HIT Scam

Worth a read -

The HIT Scam By Greg Scandlen

Notable in the piece are these observations:

 ... even the editors of the Washington Post have come to agree the whole [national health IT] project was a fiasco — but only after we wasted $27 billion of taxpayer money.

Yet, those who are enriching themselves on the $27 billion are just happy as clams over the program. John Hoyt, the Executive Vice President of the Healthcare Information and Management Systems Society (HIMSS) was quoted in a recent Health Change Bulletin as saying −

This data suggests that the HITECH portion of the 2009 stimulus law is achieving its intended result of encouraging increased implementation and meaningful use of electronic health records among hospitals. Facilities…are laying the groundwork for interoperability to occur. Stage 6 and Stage 7 hospitals are fully prepared for provider-to-provider or facility-to-facility interoperability, as well as increasing the provider or facility’s ability to provide electronic health data reporting to public health and immunization registries to support population health review and syndromic surveillance.

There, aren’t you greatly reassured? By the way, the New York Times piece cited above reported that –

RAND’s 2005 report was paid for by a group of companies, including General Electric and Cerner Corporation, that have profited by developing and selling electronic records systems to hospitals and physician practices. Cerner’s revenue has nearly tripled since the report was released, to a projected $3 billion in 2013, from $1 billion in 2005.

No doubt the companies that paid for the RAND study are also members of HIMSS. And General Electric certainly has what might be called a “special” relationship with President Obama.

I've been writing on similar issues for more than a decade.

It's well past the time when the same rigor that applies to pharma and medical devices be applied to the health IT sector.  And the marketing hype, along with bad health IT, abolished.

-- SS 

Good HIT, Bad HIT, HIMSS And Reckless Technology Advocacy: Will This Hurt President Obama?

HIMSS, the Health Information Systems Management Society, is the large vendor trade group representing healthcare IT sellers.

At the HIMSS blog entitled "Health IT is an essential element to transform the Nation’s healthcare system" (link), Carla M Smith, MA, CNM, FHIMSS writes this with regard to the House  letter to HHS Secretary Sebelius asking her to suspend payments for the EHR Incentive Payments authorized in the American Recovery & Reinvestment Act of 2009:

HIMSS opposes halting the Meaningful Use EHR Incentive Program. Health IT is an essential, foundational element of any meaningful transformation of the Nation’s healthcare delivery system. 

(Of course, not mentioned is "transformed" into what, exactly; this utopian ideation is a topic for another time.)

A chart is then presented as to "how US civilian hospitals have, since the first incentive payments were made in second quarter, 2011, matured in their use of health IT."  Then this statement is made:

Healthcare providers are adopting certified EHRs and using them for meaningful purposes; thus, achieving Congressional intent to improve the quality, safety, and cost-effectiveness of care in U.S.

Really?  (See my Feb. 2012 post "Hospitals and Doctors Use Health IT at Their Own Risk - Even if Certified.")

This non-evidence based, amoral advocacy by HIMSS for health IT may cost the President the November election.  HIMSS has beguiled the president into similar unquestioning advocacy for the technology in its present form, which his opponents are now (rightfully) seizing upon as in the House letter.

The reckless mistakes made by HIMSS and their advocates include these two:

1.   The unquestioned belief that this expensive technology would save billions of dollars in healthcare costs, instead of depleting precious healthcare resources better spent on, say, improvement of healthcare services for the poor.

2.  More importantly, the appallingly naïve belief that any health IT is good health IT, and that any health IT is only capable of good, not bad.

HIMSS has thus failed to recognize - or perhaps worse, recognized but recklessly ignored - the profound difference between good health IT (GHIT) and bad health IT (BHIT).

As I defined at my teaching site on Medical Informatics:

Good Health IT ("GHIT") is defined as IT that provides a good user experience, enhances cognitive function, puts essential information as effortlessly as possible into the physician’s hands, keeps eHealth information secure, protects patient privacy and facilitates better practice of medicine and better outcomes.

Bad Health IT ("BHIT") is defined as IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.  

I am an advocate of the former, and an opponent of the latter.

Bad health IT is prevalent in 2012 due to lack of meaningful quality control, software validation, usability standards and testing, and regulation of any type - a situation HIMSS long favored.   (The failed National Programme for HIT [NPfIT] in the NHS learned this the hard way, as will Australians needing emergency care, I predict.)

Put bluntly, in the end BHIT maims and kills patients, squanders precious healthcare resources, and drains the treasury into IT industry pockets (see my Oct. 3, 2012 post "Honesty and Good Sense on Electronic Medical Records From Down Under" and this query link on health IT risks). 

Further, the failure to recognize that the technology's downsides need to be understood and remediated before national deployment occurs and under controlled conditions, not after (which uses patients as non-consenting experimental subjects for software debugging), speaks to gross corporate negligence on the part of HIMSS.  It's not as if they did not have advance warning of all of healthcare IT's deficiencies. 

BHIT also permits record alterations after the fact that may be to conceal medical error.  I am aware of numerous instances of such alterations, fortunately caught by critical-thinking, detail-minded attorneys.  However, like health IT harms, the incidences of known alteration attempts likely reflect the "tip of the iceberg."

HIMSS and its fellow travelers have thus led this administration down the Garden Path of health IT perdition.

I warned of this in a Feb. 18, 2009 Wall Street Journal letter to the editor:

Dear Wall Street Journal:

You observe that the true political goal is socialized medicine facilitated by health care information technology. You note that the public is being deceived, as the rules behind this takeover were stealthily inserted in the stimulus bill.

I have a different view on who is deceiving whom. In fact, it is the government that has been deceived by the HIT industry and its pundits. Stated directly, the administration is deluded about the true difficulty of making large-scale health IT work. The beneficiaries will largely be the IT industry and IT management consultants.

For £12.7 billion the U.K., which already has socialized medicine, still does not have a working national HIT system, but instead has a major IT quagmire, some of it caused by U.S. HIT vendors. [That project, the NPfIT in the NHS, has now been abandoned - ed.]

HIT (with a few exceptions) is largely a disaster. I'm far more concerned about a mega-expensive IT misadventure than an IT-empowered takeover of medicine.

The stimulus bill, to its credit, recognizes the need for research on improving HIT. However this is a tool to facilitate clinical care, not a cybernetic miracle to revolutionize medicine. The government has bought the IT magic bullet exuberance hook, line and sinker.

I can only hope patients get something worthwhile for the $20 billion.

Scot Silverstein, MD

Mr. President, again, quite bluntly, the health IT industry took you for a ride, and the damage is done and is continuing due to lack of any meaningful health IT post market surveillance.   (As I wrote here, the untoward results have already been used against the current administration, with more perhaps to follow.)

In the U.S. we have the 1938 Federal Food, Drug, and Cosmetic Act (FD&C Act) in place:

The introduction of this act was influenced by the death of more than 100 patients due to a sulfanilamide medication where diethylene glycol was used to dissolve the drug and make a liquid form.  See Elixir Sulfanilamide disaster. It replaced the earlier Pure Food and Drug Act of 1906.

It should be honored, not ignored via special accommodation to the health IT industry and its trade group.

HITECH also needs to be put in dormancy until the problems with these unregulated medical devices get worked out in relatively small, controlled settings to minimize risk, with patient informed consent.  This is in accord with human rights documents dating at least to the Nuremberg Code, as in any new, experimental or partly-experimental medical device, pharmaceutical, or therapy.

-- SS
 

HIMSS Senior Vice President on Medical Ethics: Ignore Health IT Downsides for the Greater Good

The Health Information Management Systems Society (HIMSS) is the large health IT vendor trade group in the U.S.  At a Sept. 21, 2012 HIMSS blog post, John Casillas, Senior Vice President of HIMSS Financial-Centered Systems and HIMSS Medical Banking Project dismisses concerns about health IT with the refrain:

... To argue that the existence of something good for healthcare in many other ways, such as having the right information at the point of care when it’s needed, is actually bad because outliers use it to misrepresent claims activity is deeply flawed.

Through the best use of health IT and management systems, we have the opportunity to improve the quality of care, reduce medical errors and increase patient safety. Don’t let the arguments of some cast a cloud over the critical importance and achievement of digitizing patient health records.

Surely, no one can argue paper records are the path forward. Name one other industry where this is the case. I can’t.

Let’s not let the errors of a few become the enemy of good.

The ethics of these statements from a non-clinician are particularly perverse.

The statement "Don’t let the arguments of some cast a cloud over the critical importance and achievement of digitizing patient health records" is particularly troubling.

When those "some" include organizations such as FDA (see FDA Internal 2010 memo on HIT risks, link) and IOM's Committee on Patient Safety and Health Information Technology (see 2012 report on health IT safety, link) both stating that harms are definite but magnitude unknown due to systematic impediments to collecting the data, and the ECRI Institute having had health IT in its "top ten healthcare technology risks" for several years running, link, the dismissal of "clouds" is unethical on its face.

These reports indicate that nobody knows if today's EHRs improve or worsen outcomes over good paper record systems or not.  The evidence is certainly conflicting (see here).

It also means that the current hyper-enthusiasm to roll out this software nationwide in its present state could very likely be at the expense of the unfortunate patients who find themselves as roadkill on the way to the unregulated health IT utopia.

That's not medicine, that's perverse human subjects experimentation without safeguards or consent.

As a HC Renewal reader noted:

Astounding hubris, although it does seem to be effective.  Such is PC hubris.  Who could ever call for reducing the budget of the NIH that is intended to improve health.  Has health improved?  No.

So why does a group with spotty successes if not outright failure never get cut?  It’s not the results, it’s the mission that deserves the funding.  So it’s not the reality of HIT, it’s the promise, the mission, that gets the support.  Never mind the outcome, it’s bound to improve with the continued support of the mission.

Is this HIMSS VP aware of these reports?  Does he even care?

Does he believe patients harmed or killed as a result of bad health IT (and I know of a number of cases personally through my advocacy work, including, horribly, infants and the elderly) are gladly sacrificing themselves for the greater good of IT progress?

It's difficult to draw any other conclusion from health IT excuses such as proffered, other than he and HIMSS simply don't care about unintended consequences of health IT.

Regarding "Surely, no one can argue paper records are the path forward" - well, yes, I can.  (Not the path 'forward', but the path for now, at least, until health IT is debugged and its adoption and effects better understood).  And I did so argue, at my recent posts "Good Health IT v. Bad Health IT: Paper is Better Than The Latter" and "A Good Reason to Refuse Use of Today's EHR's in Your Health Care, and Demand Paper".  I wrote:

I opine that the elephant in the living room of health IT discussions is that bad health IT is infrequently, if ever, made a major issue in healthcare policy discussions.

I also opine that bad health IT is far worse, in terms of diluting and decreasing the quality and privacy of healthcare, than a very good or even average paper-based record-keeping and ordering system.  

This is a simple concept, but I believe it needs to be stated explicitly. 

A "path forward" that does not take into account these issues is the path forward of the hyper-enthusiastic technophile who either deliberately ignores or is blinded to technology's downsides, ethical issues, and repeated local and mass failures.

If today's health IT is not ready for national rollout, e.g., causes harms of unknown magnitude (e.g., see this query link), results in massive breaches of security as the "Good Reason" post above, and mayhem such as at this link, then:

The best - and most ethical - option is to slow down HIT implementation and allow paper-based organizations and clinicians to continue to resort to paper until these issues are resolved.  Resolution needs to occur in lab or experimental clinical settings without putting patients at risk - and with their informed consent.

Anything else is akin to the medical experimentation abuses of the past that led to current research subjects protections such as the "Ethical Guidelines & Regulations" used by NIH.

-- SS

HIMSS Annual Meeting in Las Vegas - Fitting for People Who Gamble With People's Lives to Make a Buck?

The setting for the Feb. 2012 annual meeting of HIMSS (the Health Information Management Systems Society, the gargantuan health IT trade group), ongoing as of this writing, is the Venetian Sands Expo Center in Las Vegas, NV.

Judging by the pictures posted at the HisTALK blog here of the event, now ongoing, it seems to be one big, happy party:

Rolling the dice at HIMSS 2012, Las Vegas.

This is ironically apopos for an organization whose leaders beg for special accommodation for a technology they know their industry has not learned how to "do right" after decades of profiteering (at patient's expense), thus gambling with live, unconsenting people as the poker chips:

Barry Chaiken, former HIMSS Chairman of the Board, July 2010 interview: "We’re still learning, in healthcare, about that user interface. We’re still learning about how to put the applications together in a clinical workflow that’s going to be valuable to the patients and to the people who are providing care. Let’s be patient. Let’s give them a chance to figure out the right way to do this. Let’s give the application providers an opportunity to make this better." [While the systems remain in use on live, unconsenting patients - ed.]

It is difficult to imagine such a statement coming from the aviation, nuclear energy or other lives-at-risk industries.

HIMSS 2012 really seems to be a fun party. Even Elvis was in attendance:

Elvis, a fitting icon for an industry trade show on health IT? Journalist Tony Scherman wrote that by early 1977, "Elvis Presley had become a grotesque caricature of his sleek, energetic former self. Hugely overweight, his mind dulled by the pharmacopoeia he daily ingested, he was barely able to pull himself through his abbreviated concerts."

Sounds like what the commercial health IT sector has done to the good intentions and well-thought out applications created by the health IT pioneers.

I note that prostitution is legal in Las Vegas as well. This allows making money from objectification of human beings, although at least the latter give consent to the exploitation of their bodies.

Final thought:

What was missing from HIMSS was the ED EHR Slot Machine of Risk. (From my March 2011 post "On an EMR Forensic Evaluation by Professor Jon Patrick from Down Under: More Thoughts.")

The ED EHR Slot Machine. Click to enlarge. You've hit the ED EHR mis-processing jackpot! Perhaps today is a good day to die...

-- SS

HIMSS and Healthcare IT: We Don't Need A "Usability Maturity Model." We Need - USABILITY - and Less of Cold-Blooded Calculus

Health IT industry consortium HIMSS has followed up its Master of the Obvious, 50-years-too-late paper "Defining and Testing EMR Usability: Principles and Proposed Methods of EMR Usability Evaluation and Rating" (June 2009) that I wrote about in a Dec. 2010 post "Unintended errors with EHR-based result management: a case series, and a special pleading for health IT" with a new report:

Promoting Usability in Health Organizations: Usability Maturity Model (PDF, Feb. 2011)

I knew I was in for a heaping helping of gobbledygook after reading the title itself:

“Promoting Usability in Health Organizations: Initial Steps and Progress Toward a Healthcare Usability Maturity Model”

A “Healthcare Usability Maturity Model” is a clue that what follows will take simplicity, and expend considerable ink to tangle it into a mess of process mysticism, buzzwords, paradigms, very pretty charts, and other Master-of-the-Obvious-made-to-look-sophisticated, destined-for-the-dusty-shelf consultant report.

That is largely what follows. See for yourself.

This passage in the Executive Summary is pathognomonic of the amoral, money-over-blood, patients-as-guinea-pigs mentality that inhabits the commercial health IT sector. I find it particularly revealing and revolting:

... Leaders may be reluctant to incorporate usability principles and practices [in a safety-critical technology increasingly mediating all aspects of medical care delivery - ed.] because of perceptions that these methods may slow development and product fielding. However, data exist on usability return on investment (ROI), outlining the value of adopting usability in health organizations.

Excuse me? It takes proof of "ROI" to convince these companies to produce usable (which subsumes the concept of "safe") health IT?

This is as cold-blooded a calculus as it gets. This is Ford Pinto material:

... Critics alleged that the vehicle's lack of reinforcing structure between the rear panel and the tank meant the tank would be pushed forward and punctured by the protruding bolts of the differential^[15] [by a rear end collision of only 20 mph/32 km/h, causing a fire - ed.]— making the car less safe than its contemporaries.

According to a 1977 Mother Jones article, Ford allegedly was aware of the design flaw, refused to pay for a redesign, and decided it would be cheaper to pay off possible lawsuits for resulting deaths. The magazine obtained a cost-benefit analysis that it said Ford had used to compare the cost of an $11 repair against the monetary value of a human life—what became known as the Ford Pinto Memo.^[13][16][17]

An example of a Pinto rear-end accident that led to a lawsuit was the 1972 accident that killed Lilly Gray and severely burned 13-year old Richard Grimshaw. The accident resulted in the court case Grimshaw v. Ford Motor Co.,^[18] in which the California Court of Appeal for the Fourth Appellate District upheld compensatory damages of $2.5 million and punitive damages of $3.5 million against Ford, partially because Ford had been aware of the design defects before production but had decided against changing the design.

[In more recent years, others said the Ford Pinto scandal was not clear-cut, but health IT unusability increasing odds for medical errors is clear-cut - ed.]

Why are these companies and their leadership getting to play God - in a field such as Medicine?

Usability? Those Luddite doctors and crummy patients will get usability over my - er, their - dead bodies, if I don't profit handsomely from it.

Finally, I have several meta-observations about this new report:

• We don't need a "usability maturity model." We need USABILITY. We need the common and longstanding knowledge of software usability in other mission critical sectors to be applied on the development whiteboard and usability testing labs (if any!) at HIT vendors.
  

• Why is it that health IT usability has to be written about, basically as if from the grade school level, in 2011 - some sixty years into the “computer revolution?” Do we still write treatises on why it’s wise to use sterile technique and good lighting in operating rooms? What is the major malfunction in this industry?
  

• Why is this treatise not entitled “Promoting Usability in Health IT Vendor Development Shops: A Vendor Responsibility Model”?

• The frequent use of the terminology "user experience" as applied to healthcare IT in this report struck my eye. It has been adopted in this report, but was uncommon regarding health IT until recently, as in my posts about the health IT mission hostile user experience.
  

The terminology is conspicuously absent in the aforementioned earlier 2009 HIMSS report. It would not take Sherlock Holmes to theorize that I might be an unattributed contributor to the new 2011 HIMSS report. If anyone knows differently, I'd be interested to hear about it.

-- SS

HITECH and Funding Cuts: The Battle Begins

At "US House of Representatives Proposes to Defund Largest Non-Consented Medical Experiment in U.S. History: HITECH" I predicted this:

... I have no financial conflicts of interest regarding HITECH or health IT to weep about. Others do, and it's not hard to predict their financial interests will push them to oppose repeal "by any means necessary."

The next few months should be an interesting time in the politics of healthcare IT.

A replacement HITECH act that's "HI" on research and caution, but not so "HIGH" on stealth, coercion and euphoria (i.e., as on mind altering substances) would be welcomed.

The battle's already begun. At "Meaningful Use incentives jeopardized by GOP bill", Jan. 28, 2011 by at Dan Bowman at FierceHealthIT.com, views exactly as I expected have begun being proffered by the industry:

... All of that [possibility of HITECH funding termination] has HIMSS Vice President for government relations Dave Roberts just a little on edge, reports Healthcare IT News.

"We're trying to tell people that this process is going on. This is only one body [of Congress]. Don't let this be a concern," he said. But "if this is a new way of thinking, that could be concerning. So I think that while this particular bill may not pass, it's something that has to be watched closely."

Patti Dodgren, CEO of Hielix--which helps to facilitate electronic health information exchanges across the U.S., shares Roberts' view. [Any possible conflicts of interest towards full-speed-ahead-damn-the-torpedoes health IT diffusion in that role, I ask? - ed.]

"Just the suggestion of repealing HITECH stimulus funds for physicians...is short-sighted at best, and threatens the very progress that is already beginning to be realized within the industry to move our healthcare system into the 20^th [yes, 20th] Century," Dodgren told FierceHealthIT. "All this bill serves to do is strengthen the cynics of health IT.

[Translation: "short sighted" and "cynic" = those more interested in taking the time to do health IT "right" and in patient rights and patient well being, than in personal gain - ed.]

We work with thousands of physicians and state government healthcare officials who have worked tirelessly over the past months to achieve the benefits that healthcare IT promises [no, Ms. Dodgren, they haven't, actually; you and they have merely encouraged a rushed, cavalier and reckless rollout (of a technology even HIMSS' former Chairman of the Board, a physician, admitted is not ready), damaging - not helping - health IT's prospects. See below - ed.], and this bill is a disservice to them and to the healthcare industry."

It may be a "disservice" to those who stand to profit from the health IT industry, but it's a great service to the healthcare industry and to the patients it serves.

I didn't really need to look, as experience at HC Renewal has proven time and again about the healthcare pundits, but the credentials of someone making such claims about health IT are not impressive IMO.

From an online bio, Ms. Dodgren holds the illustrious "CPHIMS" certification that I wrote about at my April 2008 post "Is the HIMSS Certified Professional in Healthcare Information and Management Systems stamp substantive, or just alphabet soup?". After 8 years as Director Budgeting & Financial Systems at (now-defunct) Digital Equipment Corp. (DEC) and 4 years as Senior Business Analyst at Dun & Bradstreet, she has been a "change management professional" for twenty years who "co-founded a management consulting practice which specializes in the application of change management principles to health information technology." I note no medical (or medical informatics) training or experience.

My reply to these people is as follows, as posted in a FierceHealthIT comment:

By S Silverstein MD | Posted 7:09pm | January 30, 2011

Patti Dodgren and Dave Roberts seem to favor continuation of a risky and even harmful national medical experiment that does not even have the fundamental decency to seek patient informed consent.

See http://hcrenewal.blogspot.com/2011/01/maude-and-hit-risk-mother-mary-what-in.html for examples of some of the risks.

The former Board Chair of HIMSS, Barry Chaiken, MD, MPH, FHIMSS said it best in July 2010:

http://histalk2.com/2010/07/19/histalk-interviews-barry-chaiken/

... We’re still learning, in healthcare, about that user interface. We’re still learning about how to put the applications together in a clinical workflow that’s going to be valuable to the patients and to the people who are providing care. Let’s be patient. Let’s give them a chance to figure out the right way to do this. Let’s give the application providers an opportunity to make this better.

Let the industry learn the responsible way, not on patients' and physicians' blood, sweat and tears through way-too-early national initiatives that will only add to the $14 trillion national debt (http://www.usdebtclock.org/), and throw some of the money into industry pockets.

Franky, as a physician with no financial conflict-of-interest axes to grind, I am increasingly disgusted with the cavalier, money-grubbing attitudes of the health IT industry and its pundits. Their attitudes and behaviors represent a poster study of healthcare industry at its worst.

This latter fact is not lost on me as I speak with government representatives seeking to improve medical drug/device watchdog legislation, and to attorneys looking to protect patients from harm or gain recompense for those already injured as a result of faulty IT.

-- SS

Barry Chaiken, MD, MPH: "Let's be patient" with experimental devices that harm patients

At an interview of Barry Chaiken, MD, MPH, FHIMSS, former Chairman of the Board of health IT trade group HIMSS and chief medical officer of Imprivata, a company specializing in healthcare IT security, Chaiken pleads for the following special accommodations for Health IT relative to other medical sectors:

... We’re still learning, in healthcare, about that user interface. We’re still learning about how to put the applications together in a clinical workflow that’s going to be valuable to the patients and to the people who are providing care. Let’s be patient. Let’s give them a chance to figure out the right way to do this. Let’s give the application providers an opportunity to make this better.

[Why are the health IT applications bad to begin with, I ask? - ed.]

I note the following.

• If 'we're' still learning (and I don't include people with genuine clinical computing expertise in that subgroup, but it does include the plethora of amateurs in the commercial health IT industry), then the technology is experimental.
• Worse, it's unregulated - a major special accommodation in and of itself.
  
• These sentiments about "being patient" would be appropriate - if the subjects of this experimental technology that vendors need to be "given a chance" to make better were experimental lab rats.

Instead, the subjects of the experimental technology are unwitting, unconsenting human beings, who are being used as experimental test subjects for software development, and being put at risk, injured and indeed killed by the disruptions these experimental technologies cause.

Under these realities, the position presented by Chaiken is, in my opinion, ethically perverse.

That such sentiments come from someone who holds the MD degree and who I assume took the Hippocratic oath in some form is stunning.

In the health IT industry, "Primum non nocere" seems to have been replaced with "Kybernetik über alle."

Further, the commercial health IT vendors have had the good part of five decades to "get it right." How long is long enough?

Their software is unavailable for detailed evaluation and open critique of the user experience by impartial experts, unlike open source EHR's like VistA CPRS, demo version available at this link where anyone can:

• Download the latest version of CPRS today and get access to new features including graphing functionality
• Use the software as if you were a provider by entering orders, entering documentation, retrieving reports (and graphs) and viewing alerts and notifications that help with decision support
• Learn first hand how VA’s electronic health record system works

Personally, I've had to use stealth simply to obtain and post graphical representations of some simply inexcusable commercial HIT interface sins (link). Why should a secretive industry be given additional special accommodation?

Dr. Chaiken goes on to state:

Let’s hold them accountable if they don’t [make the applications better]. Absolutely, hold them accountable if they don’t; and the marketplace, I hope, will be able to make those choices and hold them accountable when they don’t. But, we’re still learning.

Again, I'm not sure who the "we're" refers to, but "holding companies accountable" will not really help victims of the experiments who are seriously injured or killed.

A better solution, as I have written on this blog (such as at my Nov. 2008 post "Should The U.S. Call A Moratorium On Ambitious National Electronic Health Records Plans?" and at other sites as well:

Protect patients. Constrain the health IT experiment temporally and geographically, and apply the laws, customs and regulations of medical experimentation until this industry "has learned" whatever lessons Chaiken thinks they need to learn, e.g., from decades of Medical Informatics, Social Informatics, Computer Science, HCI and other research. None of these fields - last time I looked - are classified or protected intellectual property. Share information on patient adverse outcomes and near misses, instead of concealing them and contractually gagging users from openly speaking about problems.

That would be the ethical approach.

Further, how many more decades should we wait for the health IT industry to figure out how to look for better leaders beyond the "school of hard knocks" bias that's existed for at least the past decade? How many substandard health IT leaders were placed in hospitals the past few decades as a result of outrageous attitudes like these below from the major recrutiers, centered on spreading the wealth?

I don't think a degree gets you anything," says healthcare recruiter Lion Goodman, president of the Goodman Group in San Rafael, California about CIO's and other healthcare MIS staffers. Healthcare MIS recruiter Betsy Hersher of Hersher Associates, Northbrook, Illinois, agreed, stating "There's nothing like the school of hard knocks." In seeking out CIO talent, recruiter Lion Goodman "doesn't think clinical experience yields [hospital] IT people who have broad enough perspective. Physicians in particular make poor choices for CIOs. They don't think of the business issues at hand because they're consumed with patient care issues," according to Goodman. Healthcare Informatics, "Who's Growing CIO's."

[No, that line about 'being consumed with patient care issues' as a strike against health IT leadership didn't come from a Scott Adams business-idiot parody cartoon - ed.]

As in clinical medicine itself, if you're going to be anywhere near patient care and making decisions affecting its delivery, a degree damn well "gets you something."

At about the same time the above appeared in Healthcare Informatics, a generalist IT recruiter wrote me this:

... What is happening to MDs trying to change careers is providing a window into broader issues about professionals in society today - narrow training, pigeonholing in the marketplace, difficulty making lateral and cross-industry transition, what a handicap it is to be creative, entrepreneurial, or cross-disciplinary in the current marketplace, and the wasted intellectual capital represented by the high caliber of individuals who can't find ways to fruitfully plug themselves into the marketplace.

I continue to be amazed at this general phenomenon...the remarkable quality of a number of candidates I've met, and the lack of recruiters' ability to get them in the door of good companies. The interesting part of the story is that when I am able to get access to high level execs in some of these companies (not just IT, but devices, pharmaceuticals, etc. also) they are dismayed at the quality of those that they hire. They know that something is wrong in how the recruitment process is working. (eg, one of the major device cos. just devoted the time of 1 FTE in Human Resources to 'finding innovative ways of identifying and recruiting good talent into the company.')

Whose fault were the outrageous, deleterious hiring practices prevalent in this industry that contributed materially to its production of substandard products, hiring practices that persist to this day? (See example here.)

Why should we be "patient", and "give them [yet more chances] to figure out the right way to do this", and why should patients permit themselves to continue to be guinea pigs to such a sloppy, cavalier industry?

I note that Chaiken's credentials appear to fit the template, as colleague Roy Poses describes at various posts including here, of an "executive isolated from the real world of health care" and member of the superclass. From the interview linked above:

... According to your LinkedIn profile, you’re CMO for Imprivata, CMIO for Symphony Corporation, and CMO of DocsNetwork. You’re on a couple of advisory boards, you own a vineyard, and you just finished your term as chair of the HIMSS board.

Perhaps that helps explain the mantra of "computers [and profit] first, patients second."

Finally, in answer to my own question above "Why are the health IT applications bad to begin with", I suggest complacency, incompetence, willful ignorance, and negligence (including criminal negligence) as possible answers.

-- SS

Addendum:

The following in today's WSJ caught my eye ("What we've learned from the Gulf spill", Michio Kaku, July 20, 2010):

The nagging question is: Why did it take so long? Why couldn't they have capped the leak months ago? For three agonizing months, BP's engineers and executives were essentially making things up as they went along, conducting a billion dollar science project with the American people as guinea pigs. The basic science of stopping oil leaks at 5,000 feet below sea level should have been done years ago.

Concepts are similar. With just a few edits, we have this:

The nagging question is: Why is it taking so long? Why couldn't they have learned to create useful health IT decades ago? For at least thirty agonizing years, Health IT vendors' engineers and executives were essentially making things up as they went along, conducting a multibillion dollar science project with the American people as guinea pigs. The basic science of producing safe, effective, usable health IT should have been done years ago.

-- SS

Is H. Stephen Lieber, CEO of HIT Industry Trade Group HIMSS, Misinformed or Simply Lying?

In the Wall Street Journal article today entitled "Can Technology Cure Health Care?" by erstwhile WSJ reporter Jacob Goldstein, H. Stephen Lieber, CEO of the health IT trade group HIMSS disputes the idea that "electronic medical records systems focus on billing [and other administrative tasks] at the expense of patient care" and says:

[These systems] are "primarily designed for improving clinical outcomes, and a secondary benefit is that they improve administrative efficiencies."

Is Mr. Lieber misinformed, or worse, could he simply be lying?

In fact, these systems do neither of these things, as repeated studies are showing such as I aggregated in "2009 a Pivotal Year in Healthcare IT" at http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=2009, and as in this new 2010 study report in Health Affairs:

Electronic Health Records' Limited Successes Suggest More Targeted Uses

The team, led by Harvard Medical School professor Catherine M. DesRoches, surveyed more than 3,000 U.S. community hospitals to assess factors such as inpatient costs and mortality and readmission rates. Here are their findings:

Understanding whether electronic health records, as currently adopted, improve quality and efficiency has important implications for how best to employ the estimated $20 billion in health information technology incentives authorized by the American Recovery and Reinvestment Act of 2009. We examined electronic health record adoption in U.S. hospitals and the relationship to quality and efficiency. Across a large number of metrics examined, the relationships were modest at best and generally lacked statistical or clinical significance. However, the presence of clinical decision support was associated with small quality gains. Our findings suggest that to drive substantial gains in quality and efficiency, simply adopting electronic health records is likely to be insufficient. Instead, policies are needed that encourage the use of electronic health records in ways that will lead to improvements in care.

... the researchers determined that the technological systems, as currently implemented, do not have a significant impact on improving care and reducing costs, DesRoches said.

A key phrase is "as currently implemented." To that, I'd add "as currently designed under the leadership of the HIT industry", which is to say, poorly.

I commented on this report in my prior post "Yet Another Study Shows Health IT Does Not Bat The Ball Out of the Park; And, is HIT an Issue of States' Rights?" at this link.

These results are also in line with the 2009 National Research Council report, the highest scientific authority in the U.S. that involved Octo Barnett and other health IT pioneers. The NRC report calls current approaches to health IT "insufficient" and calls for major redesign of health IT to support clinicians' cognitive needs.

From the NRC report:

Most importantly, current health care IT systems offer little cognitive support; clinicians spend a great deal of time sifting through large amounts of raw data (such as lab and other test results) and integrating it with their medical knowledge to form a whole picture of the patient. Many care providers told the committee that data entered into their IT systems was used mainly to comply with regulations or to defend against lawsuits, rather than to improve care. As a result, valuable time and energy is spent managing data as opposed to understanding the patient.

And this was from the country's most advanced centers in terms of healthcare IT.

As to cost savings, there's the Nov. 2009 “Hospital Computing and the Costs and Quality of Care: A National Study” (Amer J Med 123:1; 40-46) by Himmelstein and Woolhandler at Harvard Medical School, that also concluded “as currently implemented, hospital computing might [very] modestly improve process measures of quality but not administrative or overall costs."

There's also the June 2009 Wharton School of Business article "Information Technology: Not a Cure for the High Cost of Health Care" that I wrote about at this HC Renewal post.

Typical of the recalcitrant, recidivist IT industry, Lieber goes on to blame doctors:

"... there is a resistance on the part of some to recognize the professional clinical advantage that these systems give them, many default to 'This is designed for billing, not clinical outcomes.'"

Never does he consider that doctors might have good reasons to avoid the technology - as in, to protect the lives of the patients in their trust. (When they see user-hostile HIT products from major vendors such as these, who can blame them?)

He then waves off "glitches" - the kind that result in untold clinician inconvenience and disruption, and have resulted in an unknown but "tip of the iceberg" rate of patient injury and death per the FDA - by stating that:

"There is a range of systems out there, just as in any kind of product line, ranging from poor to mediocre to excellent."

His merchant computing, card tabulator/data processing mindset reveals itself in this statement. Unfortunately, health IT, as in other medical devices, IS NOT JUST ANY KIND OF PRODUCT LINE. Malfunctions and poor design do not simply cause a truckload of candy bars to be delivered to the wrong merchant.

As in pharma and other medical devices, when trade group leaders of the HIT medical device companies are unaware of current research, dismiss it, and blame end users, or simply are liars, that industry deserves serious academic and governmental scrutiny.

-- SS