Pontifications About Health Care Reform Written by Insiders Who Benefit from the Status Quo - Worse Than We Think

Perceptions that the US health care system is dysfunctional and needs major reform go way back.  A timeline from the Tampa Bay Times noted President Theodore Roosevelt's proposal for a national health service in 1912.  Nonetheless, as we have discussed endlessly, most attempts at reform failed, and health care dysfunction seems to be getting worse.

One big problem may be that we don't understand how much discussion of health care reform is driven by those who benefit from the status quo. 

A Personal Anecdote

When I began my academic career in 1983, I was often in the audience for talks about how to fix health care by people billed as experts.  Often these talks seemed oddly disconnected from the realities on the ground for a junior assistant professor with a lot of clinical and teaching responsbilities.  Worse, many of the solutions they offered seemed to entail greater burdens for health care professionals, with no obvious compensation other than the warm feeling that we would be benefiting society.  Who else these solutions might benefit was not discussed. 

One talk given a bit later stands out in my memory. On November 29, 2001, one Dr John W Rowe gave the prestigious Levinger Lecture at Brown University entitled "Good Health: Can we Afford It?" (referenced here, see items for 11/14 and 11/16)  As I recall, Dr Rowe spent considerable time scolding us hard working physicians for overuse of medical interventions leading to endless increases in health care costs, and promising more burdensome bureaucratic interventions to rein in our follies.  While promising more burdens on physicians, Dr Rowe did not dwell on how the resulting cost savings might benefit him in his role as CEO and Chairman of Aetna Inc.  Aetna had purchased the notoriously physician-unfriendly US Healthcare, and thus had become a big for-profit health care insurer already known for imposing bureaucratic burdens on physicians in hopes of decreasing their utilization, while increasing the company's revenues (look here).  Were Dr Rowe's pontifications really about improving health care for all Americans, or about justifying his previous management behavior, and perhaps supporting the price of his shares in Aetna? Why was Aetna's public relations given the patina of an academic lecture?

These days, health care professionals continue to be exhorted about health care reform.  Many such pontifications may be not so much about true health care reform as about preserving the fundamental status quo which has benefited and enriched so many insiders. The interests of the pontificators are often less obvious than those of Dr Rowe.  Maybe that is so why there has been so little real reform, and what little reform there has been seems to be under continuous attack.

Two Examples of How Hard It Is to Discover the Interests of Health Care Policy Pontificators

In the last few weeks I posted about two recent ostensibly authoritative pontifications.  One was about ways to address the worsening problem of physician burn-out (see this post). It was written by the CEOs of large, non-profit hospital systems, joined by the CEO of the American Medical Association.  The other was about a health care reform proposal from the prestigious National Academy of Medicine (see this post).  A rather uncritical article in the Washington Post hailed it as a "radical idea" because it was written by "doctors." In both cases, I was skeptical, mainly because many of the proponents had conflicts of interest, mostly undisclosed, that suggested they were already benefiting mightily from the current system.

However, it gets worse.  While I thought my posts were based on reasonable efforts to find undisclosed conflicts of interest affecting the authors of these exhortations, within a few weeks I realized I had missed one important item affecting each.  The lesson is that the web of conflicts of interest that ensnares the insiders who run most of US health care is even more complex and adherent than any of us realizes.

Dr John Noseworthy, Author of the Health Affairs Post on Reducing Physician Burnout: CEO of the Mayo Clinic, But Also Now Nominated to be a Director of Merck

Dr Noseworthy, CEO of the Mayo Clinic, was the lead author of a post in HealthAffairs about reducing physician burnout.  (Oddly enough, none of the proposed action items seemed to involve increasing physician autonomy by reducing the power of managers over health care professionals.)

Two weeks after Noseworthy and colleagues' post appeared, an article on the Minnesota Public Radio website reported that Dr Noseworthy has just been nominated to a seat on the Merck board of directors.  Presumably the possibility of this nomination had been known at the time the post was published.

I had previously written that two of the authors of the Health Affairs post were on corporate boards.  One, Dr Paul Rothman, was already on the board of Merck.  As corporate directors, they have fiduciary responsibilties to promote the revenues of their corporations.  Now it turns out there were at least three such board members among the health system CEOs who had pontificated to physicians about how to reduce their burn-out.

Yet the power of such health care systems, whose management is often mission-hostile, and who often put revenue ahead of physicians' professional values (per the shareholder value theory), is arguably a major cause of physician burnout.  Furthermore, Merck, in particular, has had its share of management misbehavior as demonstrated by a recent $830 million settlement for deceiving shareholders, a mere $5.9 million 2015 settlement for deceptive marketing, and multiple setttlements, cumulatively totaling more than $1 billion, plus one guilty plea for the historic deceptive marketing of Vioxx (see this post).

So to what extent are the authors of this pontification about reducing physician burnout (without really giving physicians much new autonomy) insiders benefiting from the status quo in health care?  It may be more than what we think, even now.

Mr Leonard Schaeffer, Author of National Academy of Medicine Article on Health Care Reform: Member of the Boards of Wahlgreen Boots, Quintiles, scPharmaceuticals, but Also Long-Term Director of Amgen

Mr Schaeffer was an author of the National Academy of Medicine article, now published online in JAMA, about health care reform.  (Oddly enough, none of the "vital directions issue areas" mentioned in the article involved real challenges to the power of large health care organizations, particularly for-profit corporations, or increased autonomy for health care professionals.)

The version of the article published online by the NAM did not include any explicit disclosures of conflicts of interest.  It did note that two authors were full-time employees of health care corporations, one was a consultant to health care corporations, one was a lobbyist for health care corporations, and one was on the boards of health care corporations.  The online JAMA version added more disclosures, but these were incomplete.  In my post, I noted that fully 13 of the 19 authors had major ties to large health care corporations, as employees, lobbyists, consultants or  board members.

In particular, Mr Leonard D Schaeffer was listed in the NAM version as simply affiliated with the University of Southern California, but I found was actually on the boards of Wahlgreens Boots Alliance, Quintiles Transnational, and scPharmaceuticals Inc.  That was still an incomplete picture of his conflicts of interest.

A ProPublica article from February, 2017 recounted how big pharmaceutical companies engaged Precision Health Economics to wage public relations campaigns to try to justify high pharmaceutical prices.  The article noted the following about Mr Schaeffer.  

Amgen has ties to all three founders of Precision Health Economics. Working for other firms, Philipson has twice testified as an expert witness for Amgen, defending the company’s rights to drug patents, according to his curriculum vitae. The other two founders, Goldman and Lakdawalla, are principals at the Leonard D. Schaeffer Center for Health Policy and Economics at USC, which received $500,000 in late 2016 from Amgen for an 'innovation initiative,' according to public disclosures. Goldman said the funds were unrestricted and could be used at the center’s discretion. Robert Bradway, the CEO and chair of Amgen, is on the advisory board of the university center, and Leonard Schaeffer, a professor at USC and the namesake of the center, sat on Amgen’s board of directors for nearly a decade.

With funding from Amgen, the Schaeffer Center hosted a forum in Washington, D.C., in October 2015 on the affordability of specialty drugs. Before a panel focused on the new cholesterol treatment, Goldman cautioned against lowering drug prices.

So Mr Schaeffer, in addition to his current board positions, turns out to have had a long relationship with Amgen.  Given that according to the 2013 Amgen proxy statement, Mr Schaeffer retired from the board with at least 28,277 shares of Amgen stock and options for 15,000 more, he may have current financial ties to the company. 

So once again, to what extent were the authors of the 2017 NAM report on health care reform (which did not challenge the influence of large health care corporations over the health of US citizens) insiders benefiting from the status quo in health care?  It may be more than what we think, even now.

Summary

Health care professionals, policy makers, and the public are constantly harangued by apparently unbaised experts about health care reform.  Yet many of these authorities are insiders who benefit from the status quo.  Many of their financial connections to the corporations that make the most money from the US commercialized health care system are not disclosed.  It may take considerable investigation to determine their involvement in a web of conflicts of interest that drapes over the US health care system.

Meanwhile, audiences should demand that those who lecture us about health care reform disclose all their financial conflicts of interest.  Any whiff of deception about their personal interests should suggest intense skepticism. 

True health care reform requires honest discussion of the issues.  Honesty in this case entails complete and detailed disclosure of the discussants' conflicts of interest. Until such honesty is the rule, be very, very careful about taking sanctimonious spiels at face value. 

Institute of Medicine Committee on Patient Safety and Health Information Technology, and Thoughts on Social Aspects of Health IT Evaluation

March 2011 addendum: also see my thoughts on Meeting two of the Committee on Patient Safety and Health Information Technology at this link.

The U.S. National Research Council of the National Academy of Sciences issued a report in early 2009 on the state of health IT.

That study's report, led in part by pioneers in Medical Informatics G. Octo Barnett and William Stead, was entitled "Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions" (pre-publication PDF available free at this link). The report was announced under the following header:

CURRENT APPROACHES TO U.S. HEALTH CARE INFORMATION TECHNOLOGY ARE INSUFFICIENT

The insufficiencies were largely in the areas of difficulties with data sharing and integration, deployment of new IT capabilities, large-scale data management, and lack of cognitive support by health IT for busy clinicians.

One might reasonably conclude such deficits could affect patient safety.

Recently the Institute of Medicine (the health arm of the National Academy of Sciences) formed a Committee to study health IT safety. It held its first meeting on Dec. 14, 2010 (quite a few years late in my opinion, and only after tens of billions of dollars have been earmarked for health IT, but better late than never):

The Institute of Medicine Committee on Patient Safety and Health Information Technology is holding its first meeting on December 14-15, 2010. The first day, December 14, 2010 beginning at 10:30 am, is open to the public to observe the committee proceedings. The committee will hear presentations by the Office of the National Coordinator and other invited guests. There will also be an opportunity for members of the public and representatives of interested organizations to make a brief statement before the committee. Prior registration is requested for attendees and required for those wishing to make a statement.

Participant lists and materials from that first meeting are available at this link.

This brings to mind some thoughts on the social aspects of health IT evaluation.

At a website by Dr. David Healy (link) on mass over-promotion and clinical trial data irregularities regarding SSRI's, academic abuses towards critical thinkers, and related affairs, I note an interesting observation in the preface. The author states:

"On the face of it, the investigation of possible hazards posed by SSRIs does not seem to have followed the conventional dynamics of science, where anomalies in the data are supposed to spur further investigation. In this case, debate has been closed down rather than opened up. Journals that might have been thought to be independent of pharmaceutical company influence have “managed” not to publish articles and the appropriate scientific forums have “managed” not to debate the issues."

This sounds eerily familiar with regard to another domain in biomedicine - health IT.

Allow me to substitute a few words:

"On the face of it, the investigation of possible hazards posed by clinical information technology does not seem to have followed the conventional dynamics of science, where anomalies in the data are supposed to spur further investigation. In this case, debate has been closed down rather than opened up. Journals that might have been thought to be independent of information technology company influence have “managed” not to publish articles and the appropriate scientific forums have “managed” not to debate the issues."

Only recently do I note this phenomenon starting to lift. I've aggregated a number of reports and articles of recent years that take a critical-thinking attitude about health IT safety, efficacy, and sociopolitical matters such as here and here. I intend to broaden and deepen this aggregation to make it more comprehensive in the coming months.

This is a somewhat personal exercise as my relative was severely injured in 2010 by health IT interference with clinician communications.

However, it's also a professional endeavor. I will be presenting at a regional health care attorney's meeting in a few months on health IT risks. In my talk I will undoubtedly recommend aggressive litigation when HIT is implicated in patient injury, and investigations of potential contributions of health IT to medical malpractice when not readily apparent. I am not alone in this stance.

Several weeks ago I also asked the IOM Committee on Patient Safety and Health Information Technology to be allowed to present my mother's case at some point, a tragic and ironic example of a family member of a physician and Medical Informatics specialist (not just a layperson) injured as a result of health IT. I have not yet received a reply.

Evaluation of health IT will likely become more than an academic endeavor in the next few years. Those engaged in it might find themselves called as expert witnesses - or as defendants.

I see a legal storm approaching in health IT. This is a domain I am somewhat familiar with, as pre-informatics I was a medical officer in public transit making safety-related medical decisions on transit authority/DOT-related matters, at a time when nationally-mandated random drug testing in the industry had recently begun. The legal implications of such work can be quite unexpected - and profound, especially when interfered with by outside sources with conflict of interest (e.g., labor unions). Train wrecks - literally, accompanied by litigation through the roof.

To those involved in health IT, this is not a scientific opinion, and thus feel free to ignore it.

At your own peril IMO.

-- SS

Throwing The National Research Council Report On Health IT Under The Bus, Part 1: MedStar Health

I wrote about the just-released National Research Council report on HIT at the post "Current Approaches to Health IT Insufficient ... and Other Master of the Obvious News."

Critiques on the National Research Council report are to be expected. It will likely have a major impact on the HIT industry and those with special interests in that industry. There will be critique, I expect, to a significant degree, unfortunately up to and including in today's political climate ad hominem attacks on its authors, I'm afraid. (I am definitely not implying the latter is the case below, however.)

The following critique, seen at the HISTalk industry-sponsored gossip site here, has me scratching my head a bit.

I'm scratching my head at the following commentary on HIT and the NRC report by an official at MedStar Health, Peter Basch, MD, Medical Director of Ambulatory Clinical Systems.

Points that leave me wanting are as follows:

... in spite of this clear support for funding and continued development of HIT, some media headlines have painted this report as harshly critical of the potential of HIT in general and EHRs in particular. This media misinterpretation resulted primarily from two faults inherent to the report:

(1) the NRC’s mislabeling of their recommendations as a change from what health IT leaders are advocating for; and

(2) the NRC’s inappropriate assignment of blame to EHRs as being the cause of dysfunction rather than their understanding that EHR functionality and implementation deficits are a result of a dysfunctional reimbursement system, which is based on volume of episodic care and verbosity of documentation.

My comments:

Did the NRC mislabel their recommendations for improving HIT as a "change" from what health IT leaders advocate? For example, I haven't heard many industry based health IT leaders advocating for -- or generally supporting with money - studies of interdisciplinary research in biomedical informatics, social science, or healthcare engineering, for example.

In fact, at the Government Health IT Conference & Exhibition 2008 in Washington, the plenary session leaders and many attendees, including the "experts" from large HIT management consulting organizations, seemed to have little idea what I was talking about when I mentioned the study of social factors. They largely blamed doctors for HIT's ills, until I gave some examples where that was decidedly not the case, and the plenary members then agreed there might be other "unknown" issues at play. Interestingly, the attendees from the VHA knew precisely what I was talking about.

I believe the NRC recommendations are indeed "change we can believe in" compared to the usual and customary HIT industry chatter. I also believe the media reported accurately on the current state and potential of HIT under its current design and management paradigms (note the latter point; I am an HIT advocate, but only if done right.)

Did the NRC "blame" EHR's as the cause of dysfunction, or as a symptom of some deeper issues? The latter seems the case.

Are implementation and functionality deficits a sole result of the reimbursement system? Doubtful, see below regarding HIT in the UK and Australia. While I agree we have a dysfunctional reimbursement system here in the U.S. that makes quality HIT harder to achieve (my own organization had to sue AllScripts over a malfunctioning E&M module, for example, see civil complaint PDF here), I believe there are far more fundamental issues at play in HIT failure.

Another point made in the HISTalk posting:

... While it is true many early adopter systems believed (at the time) that merely switching off paper medical records to EHRs would lead to improved and safer care , nobody has believed that, or has advocated that position in years

My comments:

"Nobody has advocated EHRs would lead to improved and safer care in years?" ... What about the statement "To improve the quality of our health care while lowering its costs, we will make the immediate investments necessary to ensure that within five years, all of America's medical records are computerized" by the President-elect on Jan. 8, 2009 as just one example?

That's an ambitious timeline indeed for a technology our National Research Council tells us is not yet ready to provide such benefits without significant rethinking and rework. It certainly send a clear message to the public that HIT in 2009 is a magic bullet, a panacea towards better healthcare quality. It suggests the new administration has absorbed that view through ill informed HIT industry and pundit wishful thinking, and perhaps purposeful disinformation.

I can easily find myriad quotes expressing the same point of view, that EMR ipso facto equals better healthcare quality, on a google search "EMR improves care" or similar search engine query. I think those in informatics should be educating on the dangers in that view, not denying it exists.

A third point in the HISTalk posting:

... The NRC faults current EHR build as not supporting the cognitive support necessary to optimize care. This deficiency is obvious and abundantly clear to veteran EHR and HIT users – many of whom work on their own or with vendors on new and better functioning clinical decision support. However, let’s be fair as to the root cause of this deficiency. It is neither lack of vendor vision nor limitation of IT technology; it is lack of a market.

My comments:

"The root cause" of misdesign of HIT, its glaring deficiencies towards its users' needs after 40+ years of trying, is simply - market forces?

Are any of the sociotechnical ("people and their interactions with technology") issues at my website here or at other sites by those studying social-IT issues and misalignment of the business IT paradigm towards clinical computing relevant? Or, should such issues simply be thrown under the bus since under government stimulus a better market will magically appear?

Is the entire discipline of social informatics (the study of information and communication technologies in social, cultural and institutional contexts) irrelevant?

What about the problems with the UK's massively government funded national HIT program (see here), and the problems in Australia (see here)? Were the reimbursement system and the market a cause of the problems there? Doubtful. Here's what the UK national program's former leader Richard Granger had to say:

"Sometimes we put in stuff that I'm just ashamed of ... Some of the stuff that Cerner has put in recently is appalling ... Cerner and prime contractor Fujitsu had not listened to end users ... Failed marriages and co-dependency with subcontractors ... A string of problems ranging from missing appointment records, to inability to report on wait times ... Almost a dozen cancelled go-live dates ... Stupid or evil people ... Stockholm syndrome - identifying with suppliers' interests rather than your own ... A little coterie of people out there who are "alleged experts" who were dismissed for reasons of non-performance."

How familiar to Medical Informatics experts that all is.

In summary, are the market and the reimbursement system the major causes of HIT's disappointing track record as claimed in the critique? Hardly.

Perhaps there are other far more fundamental "root causes" for HIT dysfunction that this critique of the NRC report is leaving out, including the issues above as well as additional factors mentioned in my posting here.

We as clinicians, especially those who are biomedical informatics professionals, cannot improve the situation by making ill informed, wishy-washy excuses for the HIT vendors. While the latter, as in pharma, might treat us, as well as CIO's and IT hospital personnel to nice perks, promote us in speaking engagements as key opinion leaders (KOL's), give grants, etc., they have produced mediocre to very poor products for the most part for decades. This wastes resources that healthcare can ill afford, ultimately harms or at best does not help patients, and needless to say makes reports such as the NRC report and Joint Commission Sentinel Event Alert necessary.

I am aghast at the stories I hear even today of HIT products such as EHR's and CPOE's with cryptic user interaction design that inundate, confound and insult clinicians, force clinicians to "drink information from a firehose", or have other issues that waste time and create new opportunities for error.

To be quite frank, the IT industry spends exponentially more time and expense on design and debate over trivial and arcane features in computer operating systems (to ensure a "better user experience", the fluffy marketing-ish industry buzzword du jour for what used to be called "efficient interaction") than on HIT.

As in medicine itself, we cannot cure this situation by failing to recognize or by ignoring the symptoms, signs and features which are right before our eyes.

Ironic note - While I do not know the author of the critique, a few of the case studies of HIT dysfunction and difficulty at the above referenced sociotechnical issues website here involved a high level person now at MedStar. I can assure readers that the issues then had nothing to do with "reimbursement" and "lack of a market" and very much to do with "lack of vendor vision" as well as "lack of hospital management and IS department vision" in the prior organization.

-- SS

I Ask Again: Should The U.S. Call A Moratorium On Ambitious National Electronic Health Records Plans?

In Nov. 2008 I wrote a post "Should The U.S. Call A Moratorium On Ambitious National Electronic Health Records Plans?"

The question was raised based on reports of serious difficulty experienced by the UK in their national program for electronic health records, Connecting for Health.

I commented on how the world financial crisis of 2008-09, combined with chronic project difficulties and mismanagement and profound clinician resistance was creating such high levels of doubt about the UK's Connecting for Health (CfH) national program for electronic health records (EHR's), that the program was under consideration for actual cancellation.

From the British press:

Bank bailout puts £12.7bn NHS computer project in jeopardy

Christine Connelly, the Department of Health's recently appointed head of informatics, is understood to be reviewing whether the programme is a cost-effective way of improving the quality and safety of patient care.

She will have to find compelling arguments to stop the Treasury earmarking health service IT as a candidate for cuts to compensate for the billions spent on the bailout of the banks. However, the high cost of cancelling contracts with IT suppliers may be a factor saving the programme from cancellation.

It is simply stunning that the UK might be "locked in" to a potential disaster by IT vendors. (How is this allowed to happen?)

I'd also commented on how the lack of true Medical Informatics education and expertise in the new UK CfH "head of informatics" (and predecessors, for that matter) was a symptom of a much larger disease in healthcare IT.

The disease is a paradoxical (especially for medicine) and turned-on-its-head leadership structure where "amateurs" reign. Amateurs, in the sense that my significant telecommunications experience and even licensure as a radio amateur (ham) extra class, a hobby, would not qualify me to, say, lead a national telecommunications projects for the British Armed Forces due to lack of professional telecommunications training and credentials.

Read my Nov. 2008 "Moratorium" post for details on the UK problems.

Since that time, there have been two remarkable events in the United States (when I wrote the above posting, I had no idea whatsoever that the following would occur):

In Dec. 2008, the Joint Commission (the organization that accredits healthcare organizations here) issued a Sentinel Event Alert on HIT recommending that significantly more caution be taken in its design and implementation due to risks posed by the technology. In "Joint Commission Sentinel Event Alert On Healthcare IT" I commended the JC for taking such a step, likely to be viewed with disdain by the business sector and those infatuated with HIT as a "magic bullet" panacea for healthcare.

Then, in Jan. 2009, the highest scientific authority in the U.S., the National Research Council (NRC) of the National Academies issued their report after a several-year study of HIT entitled "Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions," a rather innocuous sounding title for a potentially explosive report.

The National Academies perform an unparalleled public service by bringing together committees of experts in all areas of scientific and technological endeavor. These experts serve pro bono to address critical national issues and give advice to the federal government and the public.

Four organizations comprise the Academies: the National Academy of Sciences, the National Academy of Engineering, the Institute of Medicine and the National Research Council.

I believe the title of the Press Release about the NRC report summarizes the report more accurately than its native title. The Press Release title is: "National Research Council: Current Approaches to Health IT Insufficient."

I presented the release at the post "Current Approaches to Health IT Insufficient ... and Other Master of the Obvious News."

While I do not know if my work had any influence on this report, its conclusions parallel those of myself and a relatively small number of colleagues who've stuck to unpopular (with the industry, that is) contrarian views on the unquestioned goodness of HIT. It is likely a number of the authors of this report were aware of my work over the years, as a frequent poster in the American Medical Informatics Association listservs and frequent writer and speaker on these issues, including some outspoken comments made at AMIA when some of the authors were in attendance. I believe the report can be better summarized by the following quote:

"Healthcare IT, dominated by non-medical IT personnel who views these tools as IT systems that happen to involve clinicians, rather than clinical tools that happen to involve computers, have mismanaged HIT through their false assumptions, lack of knowledge and lack of insight for at least several decades." - Silverstein

The NRC report found that current efforts aimed at the nationwide deployment of health care IT are not sufficient to achieve medical leaders' vision of health care in the 21st century and may even set back the cause. This conclusion was reached based partially upon site visits to eight U.S. medical centers considered leaders in the field of health care IT.

It concluded that greater emphasis should be placed on information technology that provides health care workers and patients with cognitive support, such as assistance in decision-making and problem-solving , as opposed to its current "medicine as a business" paradigm providing clinicians with, essentially, an inventory system based on 19th century accounting theorem (the major critique of IT, in fact, by Peter Drucker in his latter years). As I observed in 1999:

Management expert Peter F. Drucker, one of the most respected names in modern management thinking, offers some highly relevant insights about information issues in his book "Management Challenges for the 21st Century" (HarperBusiness, 1999). These insights amplify the importance of medical information specialists (medical informaticists) taking leadership roles in healthcare organizations, and the problems with allowing MIS to predominate on medical information issues and clinical information tool development and evaluation.

Drucker writes that "the information revolution...is not happening in IT or MIS, and is not led by CIO's...what has triggered the [real] information revolutions and is driving them is the failure of the 'information industry' - the IT people, the MIS people, the CIO's - to provide information. For 50 years, information technology has centered on data...and technology [not useful information]."

He continues, "The data available in business enterprises are still largely based on early 19th century accounting theorem. MIS has taken the data based on this theorem and computerized it. They are the data of the traditional accounting system. IT...collected the [accounting system's] data, manipulated them, analyzed them and presented them. On this rested, in large measure, the tremendous impact the new technology had on what cost accounting data were designed for: operations. But it also explains IT's near-zero impact on the management of business itself."

I'd also observed at that time that Medical Informatics and its teachings can thus be seen as a means to an end: the creation and dissemination of useful information that advances the practice, science and management of healthcare, not just facets of its operations.

In 2008 I wrote that:

... I believe the unimaginative, process over results, tightfisted control, bureacratic "data-processing" culture of the business IT (management information systems) world to be the lineal descendant of IBM's patchcord plug-panel programmed, card tabulating machines from which IBM made a large portion of their profit in the days before the electronic computer. You perhaps required such a culture when you were running huge businesses from stacks of tens of thousands of punched cards. However, such a model does not work well in meeting the information needs of clinical medicine.

... Medical informatics, a pioneering field, in many ways saw the electronic computer not as a card-based data processing machine but as a canvas for development of creative works to serve the needs of clinical medicine and its practitioners.

The National Research Council report in fact incarnates my contention that HIT is not a subspecies of MIS or management information system (i.e., business IT). I maintain that only the assumption that it is, combined with leadership by non clinicians, could result in outcomes such as this:

The report describes difficulties with data sharing and integration, deployment of new IT capabilities, and large-scale data management. 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.

Provision of cognitive support for clinicians is perhaps an alien concept to those mired in data processing paradigms.

It seems critical that the National Research Council's recommendations for

"interdisciplinary research in biomedical informatics, computer science, social science, and health care engineering"

occur, in order to change current thinking and practices in HIT design, implementation and lifecycle. Further, this research must occur, and in a manner unbiased by industry interests, before more tens or hundreds of billions of dollars are sunk into yet more HIT systems that miss the mark.

Even the vaunted VistA system of the Veterans Administration has some problems:

Software hiccups cause drug, treatment errors at VA
Associated Press
Posted: January 14, 2009 - 5:59 am EDT

Patients at Veterans Affairs health centers around the country were given incorrect doses of drugs, had needed treatments delayed and may have been exposed to other medical errors because of software glitches that showed faulty displays of their electronic health records.

The glitches, which began in August 2008 and lingered until last month, were not disclosed by the Veterans Affairs Department to patients even though they sometimes involved prolonged infusions of drugs such as heparin, which in excessive doses can be life-threatening, according to internal documents obtained by the Associated Press under the Freedom of Information Act.

There is no evidence that any patients were harmed, even as the VA says it continues to review the situation. But the issue is more pressing as the federal government begins promoting universal use of EHRs. President-elect Barack Obama has made it a part of an additional $50 billion a year in spending for health IT programs that he has proposed.

The VA's recent glitches involved medical data—vital signs, laboratory results and active medications—that sometimes popped up under another patient's name on the computer screen. Records also failed to clearly display a doctor's stop order for a treatment, leading to reported cases of unnecessary doses of intravenous drugs such as blood-thinning heparin.

In a statement, the VA said there were nine reported cases where patients at the VA medical centers in Milwaukee, Durham, N.C., and Marion, Ind., were given incorrect doses—six of them involving heparin drips that were given for up to 11 hours longer than necessary. The other cases involved infusions of either sodium chloride or dextrose mixtures that were prolonged for up to 15 hours past the doctor's prescribed deadline.

This is a rather major "glitch", even more unnerving in that it was sporadic and geographically dispersed.

With these issues in mind, I again ask the question, backed up not just by my own relatively unknown and trivial work but by the national accrediting agency for healthcare in the U.S., and the highest scientific body here as well:

Should The U.S. Call A Moratorium On Ambitious National Electronic Health Records Plans?

$50 billion a year is big money that might be better spent elsewhere - such as providing care for the poor and for disadvantaged children - until we know how to get HIT right.

I suggest it may be best not to go all-out for HIT under the current paradigm. It is my belief, in fact, based on the above issues plus a chronic influx of HIT difficulty and mismanagement stories I hear from colleagues, ex-colleagues, recruiters, etc., that healthcare organizations not contractually obligated should consider a postponement of plans to purchase clinical IT (i.e., systems for direct use by clinicians such as EHR's).

This postponement should last at least until the issues that lead to ineffective and counterproductive HIT can be better understood and corrections initiated in the industry.

-- SS

National Research Council: Current Approaches to Health IT Insufficient ... and Other "Master of the Obvious" News

The National Research Council has issued a remarkable press release about a new report on HIT. The press release is at this link:

Current Approaches to U.S. Health Care Information Technology are Insufficient

(Jan 12 addendum: a prepublication pdf of the report itself is here.)

I reproduce the press release below, but please do read my polemic before reviewing it.

My early mentor, cardiothoracic surgery pioneer Victor P. Satinsky, M.D., used to become irritated when people or organizations presented views that qualified them as "Masters of the Obvious." I believe the following release by the highest scientific authorities in the land qualifies for such a categorization.

Sadly, the release by the National Research Council outlines the "what" (what is wrong), but not the "why." Perhaps that will be found in the full report, although many of the "whys" (that is, why these health IT problems exist at all, and why the Joint Commission and NRC reports are even necessary, after 40+ years of Biomedical Informatics, IT-sociology and other research) can be found right here on Healthcare Renewal.

On the positive side for clinicians, life as a typical hospital CIO or other non-medical executive may have just become substantially more aligned towards serving the needs of clinicians, via being compelled by this report and its aftermath to make major changes in the way HIT is pursued. These changes would replace the familiar pursuit of building self-serving IT empires.

In fact, if you're a CIO who is accustomed to doing typical deals with HIT vendors, hires typical business IT staff unknowledgeable and untried in anything medical to work in clinical IT, along with lots of ham-fisted but hats-in-hand consultants who then try to clean up the mess the IT staff make, and who bullies and brands with a scarlet letter anyone who challenges the status quo (such as Medical Informaticists and other cross-disciplinary specialists who actually know what they're doing in HIT) while the latter actually try to protect the "customers" also known as "patients", your life has just become a bit more challenging.

I'd thought the December 2008 Joint Commission Sentinel Event Alert on Health IT, on the risks posed by improperly designed and implemented Health IT had been a one-up. I thought it might have been a fluke, written and released by some young disgruntled employee like Justen Deal who would be fired. I thought the Joint Commission Alert would be ignored by the players in the highly lucrative and often exploitative (of clinician ignorance and learned helplessness, that is) HIT ecosystem.

I may have been mistaken. The NRC report may change that.

Significantly, the NRC report was about a number of the best medical organizations in this country, not about the smaller less experienced hospitals where things are far worse.

Finally, the report is not news to me, others who objectively observe HIT (especially those without financial or other conflicts of interest), or to readers of this blog. In the words of abducted-by-aliens, ignored-by-the-experts pilot Russell Casse after several cities are destroyed by the aliens:

"I've been sayin' it, I've been sayin' it, ain't I been sayin' it?"

Read the whole Press Release below.

Perhaps we as a profession should feel for patients who were denied care due to lack of funds while the IT industry diverted capital out of healthcare for "insufficient" HIT, or were denied good care through malfunctioning HIT or non-functioning HIT, or who suffered outcomes that good HIT could have prevented (i.e., the cost of lost opportunity - my own father died from malpractice as a result of informational confusion a good EHR might have prevented). All while the society's gatekeepers ignored the Distant Early Warning Line of the HIT pioneers that all was not well. (Anyone know of other sectors that crashed this past year where such warnings were ignored?)

The Press Release should be read in its entirety. I will not comment on it here further, other than to say that HC Renewal can be searched on the term "Medical Informatics", "EMR" or similar for much more material on these issues.

Emphases in boldface are mine.

The National Academies

Date: Jan. 9, 2009

FOR IMMEDIATE RELEASE

CURRENT APPROACHES TO U.S. HEALTH CARE INFORMATION TECHNOLOGY ARE INSUFFICIENT

WASHINGTON -- Current efforts aimed at the nationwide deployment of health care information technology (IT) will not be sufficient to achieve medical leaders' vision of health care in the 21st century and may even set back the cause, says a new report from the National Research Council. The report, based partially on site visits to eight U.S. medical centers considered leaders in the field of health care IT, concludes that greater emphasis should be placed on information technology that provides health care workers and patients with cognitive support, such as assistance in decision-making and problem-solving.

In 2001, the Institute of Medicine -- which with the Research Council, National Academy of Sciences, and National Academy of Engineering make up the National Academies -- laid out a vision of 21st century health care that involves care which is safe, effective, patient-centered, timely, efficient, and equitable. Many aspects of this vision involve information technology, such as having access to comprehensive data on patients, tools to integrate evidence into practice, and the ability to highlight problems as they arise. To see how leaders in U.S. health care use computing and information management in providing care, the committee that wrote the new report visited eight medical centers -- University of Pittsburgh Medical Center; Veterans Affairs Medical Center in Washington, D.C.; HCA TriStar and the Vanderbilt University Medical Center, both in Nashville, Tenn.; Partners HealthCare System in Boston; Intermountain Healthcare in Salt Lake City; University of California-San Francisco Medical Center; and Palo Alto Medical Foundation in California.

Although the institutions showed a strong commitment to delivering quality health care, the IT systems seen by the committee fall short of what will be needed to realize IOM's vision. The report describes difficulties with data sharing and integration, deployment of new IT capabilities, and large-scale data management. 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.

Ideally, IT systems would place raw data into context with current medical knowledge to provide clinicians with computer models, "virtual patients," that depict the health status of the patient, including information on how different organ systems are interacting, epidemiological insight into the local prevalence of disease, and potential patient-specific treatment regimens. Although health care workers could still have access to the raw data if they needed it, clinicians would be able to work with models without drowning in data. This cognitive support would help clinicians more efficiently and effectively determine a course of action through improved understanding of a patient's status, says the report.

The report identifies several principles for improving health care IT. In the short term, government, health care providers, and health care IT vendors should embrace measurable improvements in quality of care as the driving rationale for adopting health care IT, and should avoid programs that focus on adoption of specific clinical applications. In the long term, success will depend upon accelerating interdisciplinary research in biomedical informatics, computer science, social science, and health care engineering.

This report was sponsored by the U.S. National Library of Medicine, National Institutes of Health, U.S. National Science Foundation, Partners HealthCare System, Vanderbilt University Medical Center , the Commonwealth Fund, and the Robert Wood Johnson Foundation. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine , and National Research Council are private, nonprofit institutions that provide science, technology, and health policy advice under a congressional charter. The Research Council is the principal operating agency of the National Academy of Sciences and the National Academy of Engineering. A committee roster follows.

Copies of COMPUTATIONAL TECHNOLOGY FOR EFFECTIVE HEALTH CARE: IMMEDIATE STEPS AND STRATEGIC DIRECTIONS are available from the National Academies Press; tel. 202-334-3313 or 1-800-624-6242 or on the Internet at HTTP://WWW.NAP.EDU. Reporters may obtain a copy from the Office of News and Public Information (contacts listed above).

# # #

[ This news release and report are available at HTTP://NATIONAL-ACADEMIES.ORG ]

NATIONAL RESEARCH COUNCIL
Division on Engineering and Physical Sciences
Computer Science and Telecommunications Board

COMMITTEE ON ENGAGING THE COMPUTER SCIENCE RESEARCH COMMUNITY IN HEALTH CARE INFORMATICS

WILLIAM W. STEAD ¹ (CHAIR)
McKesson Foundation Professor of Medicine and Biomedical
Informatics, and
Associate Vice Chancellor for Strategy and Transformation
Vanderbilt University
Nashville , Tenn.

G. OCTO BARNETT ¹
Professor of Medicine
Harvard Medical School , and
Senior Scientific Director
Laboratory of Computer Science
Massachusetts General Hospital
Boston

SUSAN B. DAVIDSON
Weiss Professor and Chair
Computer and Information Science
University of Pennsylvania
Philadelphia

ERIC DISHMAN
General Manager and Global Director
Intel Corp.
Hillsboro , Ore.

DEBORAH L. ESTRIN
Professor of Computer Science, and
Director
Center for Embedded Networked Sensing
Department of Computer Science
University of California
Los Angeles

ALON HALEVY
Research Scientist
Department of Engineering
Google Inc.
Seattle

DONALD A. NORMAN
Co-Founder
Neilsen Norman Group
Northbrook , Ill.

IDA SIM
Associate Professor of Medicine
Department of Medicine
School of Medicine
University of California
San Francisco

ALFRED Z. SPECTOR ²
Vice President of Research and Special Initiatives
Google Inc.
New York City

PETER SZOLOVITS ¹
Head
Clinical Decision-Making Group
Computer Science and Artificial Intelligence Laboratory, and
Professor of Computer Science and Engineering
Massachusetts Institute of Technology
Cambridge

ANDRIES VAN DAM ²
University Professor of Technology and Education and
Professor of Computer Science
Brown University
Providence , R.I.

GIO WIEDERHOLD
Professor Emeritus
Department of Computer Science
Stanford University
Stanford , Calif.

RESEARCH COUNCIL STAFF

HERB LIN
Study Director

1 Member, Institute of Medicine
2 Member, National Academy of Engineering

Supplementary points: sometimes saying "I told you so" to those who place the scarlet letters upon those not afflicted with HIT irrational exuberance is appropriate. This is one of those times.

To patients harmed or killed by the clouded vision and/or conflicts of interest of the pundits, I hereby apologize for the learned helplessness of the healthcare community in not taking charge of this situation sooner.

-- SS