On EHR Warnings: Sure, The Experts Think You Shouldn't Ride A Bicycle Into The Eye Of A Hurricane, But We Have Our Own Theory

I frequently mention what I call an "irrational exuberance" about health IT affecting the judgment of otherwise intelligent people.

Here's an example where an expert's prescient warning about HIT problems was ignored.

This letter had been FAXed to the CEO and CC'd to the CMO of the hospital on April 21, 2010, where my mother was injured (almost exactly one month later) due to a May 19, 2010 EHR-related error.

Incidentally, they have, to my knowledge, no postdoctorally-trained Medical Informatics specialists on staff, and possibly nobody with substantive formal training in the domain.

Names of people and places have been redacted. To the best of my knowledge, the letter's concerns were ignored:

April 21, 2010

CONFIDENTIAL

[name redacted]
President and CEO
[name redacted] Hospital
[address redacted]

Re: Electronic medical records observations

Dear [CEO name redacted],

I am a Medical Informatics/Electronic Medical Records expert, architect of the Graduate Certificate Program in Healthcare Informatics at Drexel University, and [graduate of a local internal medicine residency]. My postdoctoral fellowship in Medical Informatics was at Yale School of Medicine, where I was also faculty in that field.

I am well known to [many local doctors], if just for having repaired a broken CT scanner’s computer in the middle of the night [years ago at a local hospital], when service was unavailable, to obtain an urgently needed brain CT on a critically ill ED patient.

My mother Betty Silverstein, 84 years of age, receives medical care at [your hospital]. I want to call to your attention a critical issue I’ve noted in regard to my mother’s care, related to your electronic medical records systems.

My mother was in the ED twice last week for complications of a gastrointestinal stricture noted a few months ago by a gastroenterologist.

An attempt was being made to treat the stricture medically, as she is frail, but she failed medical treatment. She required admission for observation, and then a revisit to the ED a few days later before she was stabilized. The ED physician also noted her GI problem in his conversation with me.

The problem was that, on ED-arranged referral back to GI Monday April 19, where a covering physician saw her, and then a referral from GI to colorectal surgery who saw her yesterday, the physicians she saw in follow up could not ascertain the fact of her stricture from your electronic medical records systems or printouts.

I reviewed a printout from the ED system myself, and found a collection of what I call “legible gibberish” (a mass of information as if the EMR system is just a warehouse for clinical data) but no diagnosis of her problem. A nonspecific and non-useful diagnoses of “abdominal pain” was all I could find – and that was on page 8 of an 12 page printout.

If not for my presence with my mother, the physicians would not have known of her problem. I received the impression that the follow up physicians doubted me until in the case of the GI medical physician, she was able to locate with some difficulty the diagnosis on the narrative of a colonoscopy report (not in its conclusion), and the surgeon after performing his own exam.

Clearly my mother cannot be the only patient where this problem occurred. Also, other elderly patients may not have the luxury of being accompanied by a physician-son familiar with the history.

I am concerned that EMR problems may also have contributed to a much delayed diagnosis and treatment of bronchiectasis of the lungs in my mother last year – a diagnosis made only after she called [name redacted; a pulmonary specialist who knows me well] on the phone from her hospital bed [boldface in the original - ed.] after repeated admissions for alleged simple bronchitis.

I’ve also had to stop administration of an antibiotic (Levaquin) in the recent past in the ED that she has had an adverse reaction to (torn rotator cuff), despite my having told ED intake she was allergic to it. She relates that administration of Levaquin was then almost repeated on the floor until she herself refused it during that past admission.

These observations and events cause me to believe your electronic medical records systems are not serving the patients and the physicians properly and could result in patient harm. I would like to meet with you to discuss this further.

I may be reached at [personal phone number redacted].

Sincerely,

Scot M. Silverstein, MD
Adjunct Professor of Healthcare Informatics and IT (Sept. 2007-present)
Assistant Professor of Healthcare Informatics and IT, and Director, Institute for Healthcare Informatics (2005-7)

Drexel University
College of Information Science and Technology
3141 Chestnut St., Philadelphia, PA 19104-2875
(215)661-0491

Email: sms88 AT drexel DOT edu
Bio: http://www.ischool.drexel.edu/faculty/ssilverstein/biography.htm

This letter was unfortunately far too prescient.

One month almost exactly to the day after this letter was sent, on May 19, 2010, my mother turned out to be (at least one of) the patients I predicted could be harmed. An iatrogenic cerebral hemorrhage resulted from a spectacular medication reconciliation failure.

She died a miserable death due to her injuries on June 6, 2011 after almost a year of incapacitation and repeated hospitalizations for complications including agitated delirium.

Irrational exuberance on health IT, I fear, is itself advancing towards outright delirium.

(Also see my Jan. 2011 post "Healthcare IT Delirium.")

-- SS

Health IT Ddulites and Disregard for the Rights of Others

At my Feb. 8, 2012 post "Health IT: Ddulites and Irrational Exuberance " I defined a "Ddulite" (Luddite with the first four characters reversed) as the opposite of a Luddite, specifically:

Hyper-enthusiastic technophiles who either deliberately ignore or are blinded to technology's downsides, ethical issues, and repeated local and mass failures.

An astute reader points out that "opposite" may be an incomplete description, as the Luddites:

"were a social movement of 19th-century English textile artisans who protested – often by destroying mechanized looms – against the changes produced by the Industrial Revolution, which they felt were leaving them without work and changing their way of life. The movement was named after General Ned Ludd or King Ludd, a mythical figure who, like Robin Hood, was reputed to live in Sherwood Forest."

In other words, they were merely trying to save their jobs, and their actions did not cause life-threatening adverse events, such as death by freezing due to lack of warm garments.

Ddulites, on the other hand, ignore the downsides (patient harms) of health IT.

This is despite being already aware of, or informed of patient harms, even by reputable sources such as FDA (Internal FDA memo on H-IT risks), The Joint Commission (Sentinel Events Alert on health IT), the NHS (Examples of potential harm presented by health software - Annex A starting at p. 38), and the ECRI Institute (Top ten healthcare technology risks), to name just a few.

In fact, the hyper-enthusiastic health IT technophiles will go out of their way to incorrectly dismiss risk management-valuable case reports as "anecdotes" not worthy of consideration (see "Anecdotes and medicine" essay at this link).

They will also make unsubstantiated, often hysterical-sounding claims that health IT systems are necessary to, or simply will "transform" (into what, exactly, is usually left a mystery) or even "revolutionize" medicine (whatever that means).

This is despite the fact that many of this mindset are medical and/or Medical Informatics professionals who know better. They also ignore the draining waste of resources of failed or ineffectual IT ("bad health IT"), potentially depriving patients of the best healthcare possible.

Thus, as the reader pointed out, there could be an element of psychopathy or, at best, reckless disregard for rights of others in their thinking.

Reckless disregard: An act of proceeding to do something with a conscious awareness of danger, while ignoring any potential consequences of so doing. Reckless disregard, while not necessarily suggesting an intent to cause harm, is a harsher condition than ordinary negligence.

In my opinion, at a time of mass funding and pressure for rapid rollout of health IT in its present state of experimental development, this is not an observation that should be casually dismissed.

-- SS

Health IT: Ddulites and Irrational Exuberance

The title is not a typo.

I've often tried to explain the phenomenon of irrational exuberance where computers are concerned, especially in the domain of health IT.

In face of the literature references provided throughout this blog, including at posts such as this reading list and at sites such as here, one would think rational people would temper their exuberance somewhat, at the very least towards rapid national rollouts - as opposed to constrained, controlled experiments until the industry learns how to get the technology "right."

However, more than a decade of writing has had little effect.

I've also attempted to explain the phenomenon of irrational exuberance on a belief in technological determinism, on industry propaganda, on unquestioning IT faith being a quasi-"religion", and on profiteering or other quid pro quo. (The latter, I'm certain, is operative to an extent.)

I have now come across a term, though, that I believe accurately encapsulates the phenomenon of unquestioning beliefs that health IT + clinician automagically --> a "revolution" in medicine.

It may be a character trait. The trait has been described by the term "Ddulite." (Pronounced, I would say, 'da-dew-light'.) It is obviously a play on "Luddite" with the fist four characters backwards.

Apart from its historical meaning, a Luddite is "one who is opposed to change, especially technological change" (Merriam-Webster).

A Ddulite, on the other hand, is the opposite of a Luddite. A Ddulite is:

A person who prefers new tech to old tech even when the old tech is better--more functional

or alternately:

A person with a preference for higher tech solutions even in cases where lower tech alternatives have greater and more appropriate functionality.

My own definition, especially in healthcare:

Hyper-enthusiastic technophiles who either deliberately ignore or are blinded to technology's downsides, ethical issues, and repeated local and mass failures. [1]

Such people ignore the downsides, even if the downsides are deadly - in which case I believe it justified to describe Ddulites as "radical technophiles."

The Ddulite simply assumes if it's new technology, it has to be better, no matter the evidence because, well, it's new technology.

In other words, irrational exuberance in IT in general, and HIT specifically, is not merely a belief, it's a character trait, perhaps an ideology.

That could help explain why some otherwise very bright people, even people who promote evidence-based medical practice, seem to become blind and deaf in regard to HIT, as in the recent comment thread on my post "KevinMD: How algorithm driven medicine can affect (make more dangerous, actually) patient care."

When it comes to evidence-based IT practice, a Ddulite is eager to provide extraordinary special accommodation towards IT flaws, ethics, known dangers, etc. Someone of this ideology finds it exceptionally easy to dismiss or ignore any and all evidence that could contradict the technology's powers to "transform" medicine, and perhaps even worse (for patients), that could contradict its infallible beneficence.

Unfortunately, IT is not a magic bullet ... it can be just a bullet, period, unless "done well", an undertaking of almost wicked complexity.

Being a Ddulite can, in fact, lead to recklessness and negligence. A transition to IT must always respect the findings of Social Informatics (PDF): see especially Sec. 3.1 'Key Social Informatics Ideas' starting on pg. 117. The transition must be done - especially in a scientific domain - in a scientific manner.

In medicine, that means applying the rigors of medical research, medical science and medical ethics to the conception, design, implementation and lifecycle of health IT, with all that implies. This is certainly not the state of the HIT enterprise in 2012, which is largely based on a management information systems, i.e. merchant-computing, paradigm.

People who offer unquestioning loyalty to cybernetics, and who reflexively accuse those who are circumspect about commercial health IT of being "Luddites" who proffer "anecdotes", perhaps need to look in the mirror. They then need to think critically as to whether their reflection demonstrates Ddulite characteristics.

Unquestioning loyalty to the Empire: In A Mirror, Darkly

-- SS

Feb. 19, 2012 addendum:

Also see my post "Health IT Ddulites and Disregard for the Rights of Others" that adds another observation about the Ddulite mindset.

Notes:

[1] On mass IT failures repeatedly ignored, see "Pessimism, Computer Failure, and Information Systems Development in the Public Sector", Shaun Goldfinch, University of Otago, New Zealand, Public Administration Review 67;5:917-929, Sept/Oct. 2007.

Health Care Policy of the Insiders, by the Insiders, for the Insiders - the Newt Gingrich Case Files

Newt Gingrich's rise to the top of the pack of Republican contenders for the US presidency has earned him increased scrutiny.  The resulting investigative reporting has provided a revealing set of case studies showing how insiders have come to dominate US health care policy.

Below I have reorganized the information presented in a series of news articles from mid-November to mid-December, 2011.

Mr Gingrich's Consulting Empire

A general description of Mr Gingrich's health care "think tank" appeared in the Washington Post.(1)

A think tank founded by GOP presidential candidate Newt Gingrich collected at least $37 million over the past eight years from major health-care companies and industry groups, offering special access to the former House speaker and other perks, according to records and interviews.

The Center for Health Transformation, which opened in 2003, brought in dues of as much as $200,000 per year from insurers and other health-care firms, offering some of them 'access to Newt Gingrich' and 'direct Newt interaction,' according to promotional materials.

Despite its name, the CHT was for-profit. Much of its actual workings are confidential, per the Post,(1)

Susan Meyers, a center spokeswoman, declined to comment on the think tank’s income or staffing levels because it is a private-sector organization.

Despite its pretentious name, the CHT was apparently a vehicle for its wealthy corporate clients to influence health policy to favor their business interests.  A NY Times article(2) reported that:

His consultancy practice was centered around his ability to help big corporate interests speak the language of Republicans and navigate the corridors of Capitol Hill on issues vital to their businesses.

According to a Bloomberg article(3), the work was quite lucrative:

Two companies founded by Newt Gingrich announced yesterday that they had grossed $55 million between 2001 and 2010, part of an effort to quiet questions about how the former U.S. House speaker earned millions since he resigned from Congress in 1999.

That revenue supports the Center for Health Transformation and The Gingrich Group LLC, which have a staff of as many as 30 people, stage health-care policy events, and provide advice to clients, Nancy Desmond, the chairman and chief executive officer of the firms, said in a written statement.

The CHT was linked to a small corporate empire, as described by the Washington Post,(4)

Former House speaker Newt Gingrich transfigured himself from a political flameout into a thriving business conglomerate. The power of the Gingrich brand fueled a for-profit collection of enterprises that generated close to $100 million in revenue over the past decade, said his longtime attorney Randy Evans.

Among Gingrich’s moneymaking ventures: a health-care think tank financed by six-figure dues from corporations; a consulting business; a communications firm that handled his speeches of up to $60,000 a pop, media appearances and books; a historical documentary production company; a separate operation to administer the royalties for the historical fiction that Gingrich writes with two co-authors; even an in-house literary agency that has counted among its clients a presidential campaign rival, former senator Rick Santorum (R-Pa.).

Separate from all of that was his nonprofit political operation, American Solutions for Winning the Future.

Relationships with Big Health Care Corporations

The Center for Health Transformation was largely funded by big health care corporations. The Post first noted,(1)

The biggest funders, ... [included] firms such as AstraZeneca, Blue Cross Blue Shield and Novo Nordisk,...

Also,(1)

The center has listed scores of firms and industry groups as members over the years, amounting to a Who’s Who of the medical field, from GE Healthcare to the American Hospital Association to Wellpoint, the nation’s largest health insurer.

Other clients were listed in a Bloomberg article,(5)

Among the member companies were drugmaker Johnson & Johnson (JNJ) and health insurer Blue Cross and Blue Shield Association....

Also,(5)

Pfizer Inc. (PFE), the world’s largest drugmaker, had consulting contracts with Gingrich, according to two people familiar with the arrangements. Pfizer spokesman Ray Kerins didn’t respond to requests for comment.

The Pharmaceutical Research and Manufacturers of America, the industry’s trade group, was also a client. His firm 'was retained by the PhRMA general counsel’s office at one time to provide advice on a positioning project,' the group said.

In addition, as noted below, clients included important firms in the health care information technology (IT) sector, including GE, IBM, Microsoft, Allscripts, and Siemens.

Below, we present several cases in which Mr Gingrich apparently intervened on behalf of his clients to promote their business interests in the guise of promoting his views on health policy solutions.  In some cases, the views he promoted did not fit with what is generally regarded as his political philosophy, suggesting that the interests of his paying clients overrode his political views.

Case: End of Life Care

The New York Times reported,(2)

Writing on the Web site of the Washington Post, Mr Gingrich praised Gundersen Lutheran Health System of LaCrosse, Wis., for its successful efforts to persuade most patients to have 'advance directives,' saying if Medicare had followed Gundersen's lead on end-of-life care and other practices, it would 'save more than $33 billion a year.'

Note that

Gundersen was one of the paying clients of Mr. Gingrich's Center for Health Transformation....

However,

within weeks, Mr. Gingrich would find himself on the wrong end of what some Republicans labeled the 'death panel' issue.

At that point, Mr Gingrich abruptly changed his tune,

As it happens, shortly after Mr. Gingrich wrote his article praising Gundersen, he joined the conservative critics of the provision. 'You are asking us to trust turning power over to the government,' Mr Gingrich told George Stephanopoulos of ABC News that August 'when there are clearly people in America who believe in establishing euthanasia, including selective standards.'

This suggested that Mr Gingrich took up the cause of end-of-life decision making not be cause he deeply believed in it, but because it was expeditious given the wishes of his clients, despite the assertion made by his spokesperson,(2)

Mr. Hammond said that Mr. Gingrich did not take policy positions for pay; rather, he said, clients sought him out because of the views he already held and his expertise in communicating ideas.

Case: Medicare Prescription Coverage Sans Negotiations about Drug Prices

As reported by Bloomberg,(5)

When U.S. House Republican leaders in 2003 were short of votes to pass a $395 billion Medicare prescription drug benefit, they recruited former House Speaker Newt Gingrich for help.

In a hushed room on Capitol Hill, Gingrich told his former Republican colleagues that if he could endorse the measure, they should be comfortable with it, too, said two former senior House aides who attended the closed-door session.

Two days later, after a vote was held open for three hours as leaders corralled the final ayes, the measure passed and was eventually signed into law by President George W. Bush.

What Gingrich didn’t mention during the Republican caucus meeting was that he was also building a for-profit, health-care research company and seeking financing from drugmakers, which were investing $128.6 million in lobbying for passage of the new benefit for seniors.

Note that the legislation that provided Medicare drug coverage forbade the government from negotiating prices with drugmakers.  This was unprecedented, because drug coverage from the US Veterans Administration and Medicaid did not come with the obligation to pay whatever the drug-makers charged.  The inability of Medicare to negotiate the prices it paid for drugs certainly helped the companies' revenues while driving up the costs of Medicare, the federal deficit and the costs of health care in general.

Case: Promoting Expensive Diabetes Care

The Washington Post reported,(4)

Novo Nordisk, a Denmark-based drug firm that specializes in diabetes treatments.... paid a total of $1.2 million to Gingrich’s foundation over six years as a 'founding charter member.'

'It was strictly a business, nonpolitical relationship,' Novo Nordisk spokesman Ken Inchausti said. 'We admired his leadership on issues related to health-care delivery systems. We thought the CHT brought something to the table to us in terms of finding ways to help people prevent diabetes.'

Gingrich loaned his celebrity to causes that, whatever their other merits, could also be good for Novo Nordisk’s bottom line. For instance, he was the keynote speaker at Novo Nordisk’s 'diabetes summit' in 2005 and joined the company in issuing a 'call to action' to fight diabetes in Texas and Georgia.

One wonders how many of the widely promoted "summits" and other star-studded conferences on health care featuring corporate  and political leaders as speakers are just stealth health policy advocacy or stealth marketing.

Case: Irrational Exuberance for Electronic Health Records

My fellow Health Care Renewal blogger has often discussed the "irrational exuberance" for electronic health records (EHRs) despite scant information about their benefits, and increasing data suggesting their harms.  It now appears that Mr Gingrich, sponsored by copious funds from the health care IT sector, has been a major source of such exuberance. 

Mr Gingrich had a complex relationship with the health care information technology (IT) industry. It began to come out first in a NY Times story,(6)

When the center [for Health Transformation] sponsored a 'health transformation summit' at the Florida State Capitol in March 2006, lawmakers who attended Mr. Gingrich's keynote speech inside the House chamber received a booklet promoting not just ideas but also the specific services of two dozen of his clients. Executives from some of those companies sat on panels for discussions that lawmakers were encouraged to attend after Mr. Gingrich's address.

Gerard White, president of Clearwave, which paid about $50,000 to become a center member, used the occasion to pitch his company's system for managing patient data.

This had all began earlier,

Two years before the Florida 'summit,' Mr. Gingrich made a presentation to Republican lawmakers in Georgia, promoting the work of his member companies by citing specific benefits if they were hired. For example, 'VitalSpring could save the State Employee Program over $20 million a year.'

Minutes of the members-only conference call from March 2004 said the center had 'arranged joint meetings' for members to present their work on electronic health records to top federal officials, noting that Mr. Gingrich 'reported very positive feedback overall from these meetings.'

He also pressed for passage of a federal bill to increase the use of electronic health records, collaborating with one of its co-sponsors, Representative Patrick J. Kennedy of Rhode Island, and Senator Hillary Rodham Clinton of New York, both Democrats.

Furthermore,

Many of the ideas he has pushed involve the increased use of information technology, and companies specializing in that are well represented in the center's roster. They also figured prominently in an early center initiative, teaming up in 2003 with the conservative Georgia Public Policy Foundation to promote changes in health care in Mr. Gingrich's home state.

At his discussion with Georgia House Republicans in 2004, Mr. Gingrich gave examples of companies whose services could 'both improve health and start saving money,' according to the center's summary of his presentation.

And there is more,

In Washington, Mr. Gingrich's push for electronic health records illustrated how his own policy advocacy and ties to former Congressional colleagues made him a sought-out consultant for companies like Astra Zeneca and Siemens. Mr. Gingrich hailed HealthTrio, one of the center's 'founding charter members,' during a hearing held in 2003 by Senator Larry Craig, Republican of Ohio. Telling the senator that HealthTrio's chief executive had helped design the electronic records program in the United Kingdon, Mr. Gingrich said the company 'estimates we could have an electronic health record for American for about 10 cents per month, per person.'

The center later arranged for HealthTrio and I.B.M to meet with senior federal health officials and congressional leaders 'to review the U.K. approach and how it might be applied in the U.S.,' according to center records.

Some of the ideas promoted by the center found their way into the electronic health records legislation proposed by Mr. Kennedy, which was prepared with input from Mr. Gingrich.

This is especially ironic, given that the UK NHS electronic health record initiative has become a crashing failure (for example, see this post).

Even more involvement with the push for electronic health records (EHRs) appeared in a Boston Globe article,(7)

Newt Gingrich seized the TV airwaves in 2009 to bash President Obama’s stimulus package, calling it 'entirely a pork-barrel bill' that would do little to solve the recession.

Later, in a separate web video, the former House speaker stepped back from his blanket criticism. He explained that he strongly supported spending $27 billion of stimulus funds to encourage doctors and hospitals to create electronic medical records for their patients. Left unsaid was that the Gingrich Group, his consulting business in Washington, received large payments from medical technology companies that stand to profit from the federal money.

In particular,

The stimulus infusion Gingrich supported is expected to benefit health care technology companies, including those who have been clients such as GE Healthcare and Allscripts.

GE Healthcare said it pays Gingrich’s center to act as a 'collaborator and facilitator' among a diverse group of health care interests.

'We work with the Center for Health Transformation in an effort to improve the effectiveness of the health system through the use of information technology,' said GE Healthcare spokesman Corey Miller.

Allscripts spokeswoman Ariana Nikitas said the company ended its relationship with Gingrich’s center two years ago but considered the venture 'a think-tank to advance health care efforts.'

It does not stop there. Per the NY Times,(8)

Mr. Gingrich was cheering a $19 billion part of the [Obama stimulus] package that promoted the use of electronic health records, something that benefited clients of his consulting business. 'I am delighted that President Obama has picked this as a key part of the stimulus package,' he told health care executives in a January 2009 conference call.

After the bill was passed a month later, Mr. Gingrich's consultancy, the Center for Health Transformation, joined two of his clients, Allscripts and Microsoft, in an 'Electronic Health Records Stimulus Tour' that traveled the country, encouraging doctors and hospitals to buy their products with billions in federal subsidies.

We, particularly InformaticsMD, have frequently commented on how health care information technology has been promoted not just by enthusiasts in the field, and by companies that manufacture such devices, but by the government.  The bandwagon has gone down the road despite little clinical evidence that such technology is beneficial, and increasing evidence of its harms.  Now it appears that an important reason for this ruch to promote expensive, but unproven devices comes from the sort of stealth health care policy advocacy on behalf of corporate vested interests described above.
Summary

So Newt Gingrich parlayed his political track record into a lucrative "consultancy" which enthusiastically promoted the health policy objectives of its clients, who included some of the biggest US health care corporations.  Some of the policy positions the consultancy promoted seemed to run counter to Mr Gingrich's political record.  Worse, some of the initiative he successfully promoted seem to have contributed to US health care dysfunction.

These stories, some of which are many years old, only came out after Mr Gingrich became the front runner for the Republican nomination for US President.  Had he not chosen to re-enter politics, it is not clear when reporters would have had time to due the required investigations.  One wonders how many similar stories have not been made public because they do not involve prominent presidential candidates.

The bottom line seems to be that there are myriad ways corporate and political insiders push health policy agendas because of self-interest, regardless of their effects on patients' and the public's health.  Health policy in the US has become an insiders' game.  Unless it is redirected to reflect patients' and the public's health, facilitated by the knowledge of unbiased clinical and policy experts rather than corporate public relations, expect our efforts at health care reform to just increase health care dysfunction. 

Physicians, public health advocates, whatever unbiased health policy experts remain must educate the public about how health policy has been turned into a corporate sandbox.  We must try to somehow activate the public to call for health care policy of the people, by the people, and for the people.

References


1.  Eggen D. Gingrich think tank collected millions from health-care industry.  Washington Post.  November 17, 2011.  Link here.
2. Rutenberg J. Gingrich faces more scrutiny over corporate clients. NY Times, November, 17, 2011. Link here.
3. Benson C, Lerer L. Gingrich health center and group paid $55M. Bloomberg, November 22, 2011. Link here.
4. Tumulty K, Eggen D. Newt Gingrich Inc.: how the GOP hopeful went from political flameout to fortune. Washington Post, November 26, 2011. Link here.
5. Davis JH, Jensen K. Gingrich campaigning as change agent profited as an insider. Bloomberg, November 18, 2011. Link here.
6. McIntire M, Rutenberg J. Gingrich gave push to clients, not just ideas. NY Times, November 29, 2011. Link here.
7. Rowland C. Newt Gingrich supported $27 billion of President Obama's stimulus for electronic medical records, helping his consulting clients. Boston Globe, December 16, 2011. Link here.
8. Rutenberg J, McIntire M. Gingrich push on health care appears at odds with G.O.P. NY Times, December 16, 2011. Link here.

Why 99 Percent of the Irrationally Exuberant About Health IT Need To Be Removed From Healthcare

At Roy Poses' cross post "Why 99 percent of health care should be angry" over at the KevinMD blog, I introduced a comment into the "eruption of controversy" (his term here) caused by his post.

My comment was on the topic of government and health IT:

scotsilv 3 days ago

As one of Roy Poses' co-bloggers and a Medical Informaticist, I can say with certainty that government involvement in healthcare has been disastrous. Specifically, via ONC, ARRA and the HITECH Act, prematurely pushing still-experimental healthcare information technology on an unsuspecting medical profession (for the most part) and public. See "An updated reading list on health IT" at http://tinyurl.com/emrreadingl..., .

A reply typical of the irrationally exuberant was added to the thread (emphases mine):

Brett Mello 1 day ago in reply to scotsilv

What are you basing your "certainty" on? The examples discussed in the links sound like a case of bad configuration of an EMR. It could also be a just a poor solution from a vendor. Do you know if these were even a certified applications? I would like to suggest not painting all EMR implementations and the overall value of EMR’s from a single, albeit tragic, example. [I.e., an "anecdote" - ed.] A well implemented EMR, configured in collaboration with an organization’s physicians, has been repeatedly proven to reduce medical and medication errors. Why would any educated person, including legislators and executives, support the use of a tool that would increase harm, not safety.

Education aside, we will all be patients at some point so our innate need for self preservation would seem contrarian to arbitrary investments in useless technology to manage our care. Our current health delivery method produces far more harm than the new technology being implemented to address it. We need to embrace technology and make it work for us rather than putting our heads in the sand. Take the following quote as an example:

"That it will ever come into general use, notwithstanding its value, is extremely doubtful because its beneficial application requires much time and gives a good bit of trouble, both to the patient and to the practitioner because its hue and character are foreign and opposed to all our habits and associations." - The London Times, 1834 commenting on the "stethoscope"

Note that this reply came after I presented a link to a long list of articles, more than 50, with links to each article or its abstract for ease of reference, and a personal account of healthcare IT failure.

The articles challenge the beliefs in technological determinism common about health IT, i.e., that computers + medicine 'automagically' lead to better medicine, because, well, of the addition of computers, which must improve medicine, just - because.

The reason I write that the reply was typical of the irrationally exuberant is due to the interrelationship between irrationality, logical fallacy, and absence of evidence. These characteristics are usually present in the writings proffered by those so afflicted - and, to those with vested interests in health IT, a.k.a. conflicts of interest, I should add.

I replied:

medinf 16 hours ago in reply to Brett Mello

You are lacking references supporting your arguments, which in themselves display logical fallacy.

I urge all readers to see my linked references list at the top of this thread, examine some of them (such as Jon Patrick's work on gross EHR defects, the ECRI Institute's Top Ten List of Healthcare Hazards, Romano et al.'s "Electronic Health Records and Clinical Decision Support Systems: Impact on National Ambulatory Care Quality" and others).

There are articles from reputable sources indicating today's health IT, lacking cognitive support and other necessities for clinicians (such as per the National Research Council itself in an investigation led by health IT pioneers Octo Barnett and William Stead, see http://www8.nationalacademies.... ) does not improve quality of care, and can cause harm.

These articles should raise caution in any physician, nurse or hospital contemplating use of this technology. These reports should not be cavalierly ignored, but should be a flag for great caution. The point is, with the literature conflicting, the technology should be considered experimental and caution used when deployed on human subjects. That includes both patients and clinicians, the former who can be injured or killed, the latter whose careers can be ruined through computer-caused or computer-aggravated errors. [Note: in health IT experiments, clinicians are, in fact, also experimental subjects - ed.]

Re: "The examples discussed in the links sound like a case of bad configuration of an EMR" - you omit the existence of clinical IT defects and problems such as poor software engineering causing unreliability, mission hostile human-computer interfaces (e.g., see http://www.tinyurl.com/hostile... ), incorrect or incomplete decision support algorithms, terminological problems, and other issues. You seem to indicate the findings in the reading list may be "anecdotal." A crushing reply to that line of thought, from an expert in Australia, is here: http://hcrenewal.blogspot.com/... .

As far as "certification" of HIT, this has little if anything to do with safety, reliability, usability, etc. ( e.g,, see http://hcrenewal.blogspot.com/... ). "Certification" of health IT is not validation of safety, usability, efficacy, etc., but a pre-flight checklist of features, interoperability, security and the like. The certifiers admit this explicitly. See the CCHIT web pages for example.

You use the logical fallacy of "appeal to authority" - or show severe naivete - in asking "why would any educated person, including legislators and executives, support the use of a tool that would increase harm, not safety."

"We need to embrace technology and make it work for us rather than putting our heads in the sand" - I ask - why now, if the technology is not ready? This seems like an appeal to novelty and perhaps the bandwagon fallacy (see http://www.nizkor.org/features... ).

Regarding your 1834 London Times quote, that was in a time before the human subjects experimentation guidelines such as the Belmont Report, World Medical Association Declaration of Helsinki, Guidelines for Conduct of Research Involving Human Subjects at NIH, the Nuremberg Code, and others came into being.

That said, the use of the 1834 stethoscope analogy is a type of red herring fallacy (http://www.nizkor.org/features... ). A stethoscope and enterprise clinical IT have little in common, the latter being potentially harmful to the point of causing patient death through interference in clinical care. (I note that if the 1834 story was brought up as an allusion to doctors and nurses who dislike today's IT being "Luddites" or the like, then that's an ad hominem fallacy.)

We as a society have supposedly learned something since 1834 regarding experimental medical devices. Or have we? FDA's Jeffrey Shuren MD, JD, Director of CDRH has admitted explicitly that health IT are medical devices with definite, but unknown, levels of risk - FDA stats "may represent only the tip of the iceberg in terms of the HIT-related problems that exist" were the exact words. That is prima facie evidence the devices are experimental.

However FDA refrains from regulating them under the FD&C Act, as they do pharma IT, other medical devices, drugs, etc. because they are a political "hot potato" - as at http://hcrenewal.blogspot.com/... , http://hcrenewal.blogspot.com/..., and http://hcrenewal.blogspot.com/... ).

As is customary at Healthcare Renewal, at those three posts are links to source, quoted in full context.

I've replied to so many irrationally exuberant commenters on this very blog, that I could have authored the reply above in my sleep.

Two points:

1. My reply and its links (and the source those links lead to) can and should be used as a "template" by clinicians to educate themselves, to reply to the health IT irrationally exuberant in their organizations, and to those in government prematurely pushing this technology onto clinicians;

2. The health IT irrationally exuberant, being irrational, ill-informed, and often markedly resistant to education, need to be removed from healthcare entirely. Their cavalier attitudes about cybernetic medical experiments are dangerous, and have no place in medical affairs. Such people impede, rather then help remediate the quality, safety, usability, and efficacy of health IT. In doing so, they contribute to increased risk and to actual patient harm. The irrationally exuberant are part of the problem, not part of the solution.

-- SS

Why bankers need to stick to banking, and keep their profound lack of knowledge of biomedicine and Medical Informatics to themselves

[Note: this post is very rich with hyperlinks. To fully understand the post, at least open the hyperlinks in a separate window and browse their material - ed.]

In April 2011 I referenced a 2007 comment about health IT ROI, by then-Congressional Budget Office (CBO) head Peter Orszag, in a post entitled "Medicare/Medicaid Cuts? Spend Money on Patients - Not Computer Experiments":

... More on purported cost savings - Peter Orszag, former head of the Congressional Budget Office, said the use of electronic health records, without a major change in health care delivery, "would not significantly reduce overall health care costs" in the agency's 2007 report on long-term health care spending. He also said that according to data from the report, the return on investment for EHR's "is not going to be as substantial as people think." The CBO concluded that predictions of cost savings from EHR's relied on "overly optimistic" assumptions and said much is unknown about the potential impact of health information technology. [That is, it is an experimental technology - ed.] Mass savings from health IT is an assertion that is both unproven and highly unlikely in my view.

Mr. Orszag is now Vice Chairman of Global Banking at Citigroup.

He seems to have changed his tune somewhat.

In an Aug. 16, 2011 piece in Bloomberg entitled "Health Care Prognosis Better With Digital Law: Peter Orszag" he opines:

Even with the all-too- depressing illustrations of political paralysis we’ve seen recently, government can still act to improve our lives. A good case in point: The U.S. health sector is rapidly digitizing, and federal legislation from early 2009 , passed well before the health-care reform act, is an important reason why.

He refers to the Health Information Technology for Economic and Clinical Health a.k.a. HITECH Act embedded in the 'economic stimulus' ARRA bill.

... Partners HealthCare has used its health IT to be more selective about which patients should have diagnostic imaging tests, such as MRIs and CT scans. The cost to Medicare for imaging tests nationwide roughly doubled from 2001 to 2009. And such tests are not only expensive but potentially dangerous. Frequently imaged patients face an increased risk of cancer because of exposure to excessive radiation. [That risk is not very large; on the other hand, insufficiently imaged patients are playing the "slot machine of life", which when they are unlucky leads to missed diagnoses, injury and death - ed.]

Doctors at Partners now order imaging scans through the computer system and are automatically queried about the patients’ characteristics. For each case, the software then provides an “appropriateness” score, reflecting evidence- based protocols [i.e., likely based on averages, not the individual patient's nuances - ed.] for the image requested. And in some cases, the program suggests an alternative to imaging.

I presume doctors' use of imaging is monitored based on the cybernetic "score." Orszag states:

Comparing doctors: the system is also used to compare doctors to one another, so they know if they use imaging tests more or less than their peers do.

I have yet to see robust (e.g., RCT-based) outcomes of this "regulator of care" function of health IT, wherein the physician is no longer the learned intermediary between patient and computer, but the computer instead is the cybernetic regulator of care between doctor and patient. I do know of a case, however, where cybernetic "regulation" of imaging seems to have helped kill an infant at another hospital (link).

From 2006 to 2009, imaging rates at Partners flattened, and in some specialties even started to decline, sometimes significantly. The number of outpatient images per patient, for example, fell 25 percent in that period, even after adjusting for patient characteristics such as age, ethnicity, gender, medical history and medications.

... The IT interventions appear to have been effective at reducing imaging rates across the board, including among the doctors who ordered the tests most. By 2009, that doctor at the 90th percentile ordered 20 images per 100 patients, a decline of almost 10. This one doctor’s net decrease in scans was larger than the total number of scans ordered by the doctor at the 10th percentile even in 2006. And the low-use doctor reduced his rate, too, by about two images per 100 patients.

I'm still not seeing comparisons of how patients fared under the cybernetic imaging-control regime.

More broadly, health IT is a necessary but not by itself sufficient step toward improving value in health care. A review of the health IT studies by the Congressional Budget Office, published in 2008, while I was the director of that agency, concluded that it “has the potential to significantly increase the efficiency of the health sector by helping providers manage information.” The CBO also found, however, that health IT couldn’t realize this potential without a supportive health-care delivery system that uses it aggressively. The most auspicious examples of IT use were in relatively integrated systems, such as Veterans Affairs, Partners HealthCare, Kaiser Permanente and Group Health Cooperative in Seattle.

Here's where Orszag goes off the irrational-exuberance rails.

He states the "potential" of HIT to "help providers manage information" is not reached because HIT is not widespread enough.

He omits the potential of the technology to cause providers to mismanage information. Such mismanagement turned a close relative of mine into roadkill, which apparently is OK on the road to HIT utopia.

He cites the VA, where highly specialized non-commercial HIT took decades to develop under relatively ideal conditions far removed from the traditional management information systems morass in the private sector (link), and Kaiser (with this history) and Group Health, who are not exactly prolific publishers about their mishaps and travails with HIT.

He omits the fact the FDA admits they know of HIT-related injury and deaths (link to FDA internal memo of Feb. 2010), do not know the true levels of it but that their data probably represents the "tip of the iceberg" (link), and that HIT is a medical device that should fall under the FD&C Act, but that is left unregulated (link) because it's a "political hot potato." (Thus, in effect, its subjects, patients, are experimental test subjects without having given informed consent.)

He omits the mission hostile nature of much commercial HIT (e.g., as demonstrated in the nine-part series here).

He omits a growing body of literature suggesting health IT's outcomes are neutral or negative, despite billions of dollars of expense (link to Reading List).

He omits acknowledged national HIT failures in the UK (link, link), and Australia and elsewhere (link), in healthcare systems far smaller, more government-controlled and less complex than ours, efforts largely led by and utilizing American companies and products.

He omits the apparently low quality and fundamental unreliability and unsuitability of today's commercial software (see examples at link, link).

He omits independent, renowned medical device testing organizations listing health IT as one of the top health risks of 2011 (link).

He omits the general futility of large-scale government IT initiatives, as in an article hidden in the Public Administration Review that contains near 150 references (link, PDF).

In effect, commercial health IT is nowhere near fit for national rollout in 2011.

I have two suggestions:

1. Bankers need to stick to banking, and keep their embarrassing lack of knowledge of biomedicine and Medical Informatics to themselves.

2. Mr. Orszag needs to spend some time reading the IT literature, without wearing blinders.

Finally, on a personal note, I will not be taking investment advice from Mr. Orszag. I would not trust it, often finding that those deficient in publicly-available knowledge in one domain are often lacking knowledge in others. That's simply my personal preference.

-- SS

AMA, Deluded on Health IT, Begs For Doctor Penalty Extension - Not Penalty Termination

The American Medical Association (AMA) has become worse than useless:

AMA urges issuance of EMR penalties be delayed

Congressional Quarterly's CQ Weekly (3/14, Zeller) reports that "Congress strongly believes that electronic medical records will bring down the cost of healthcare, so much so that it has passed two laws providing incentives for doctors who upgrade their systems and levying penalties on those who don't."

But, the American Medical Association is urging that the penalties be delayed. Notably, the association "says a Government Accountability Office study released in February bolsters its point that the two laws create competing incentives that contradict each other." [Just our sub-15% approval rating Congress at work - ed.]

The article adds that the Department of Health and Human Services "announced that doctors will face penalties of 1 percent of their Medicare fees if they don't start issuing electronic prescriptions this year," which the AMA says would be a waste because physicians would buy e-prescribing software that they would discard when they install records systems in 2012.

[Lest they face other Medicare penalties for non-"meaningful use" of EMR's - ed.]

Aside from the Congressional mayhem created by conflicts between e-Prescribing and EMR coercion laws, if the AMA were not completely useless, and truly represented physicians (and patients), they'd be pushing not for a delay in penalties, but for their abolition.

This would help return HIT to a sensible voluntary path from the path of irrational exuberance it's now on.

-- SS

Meaningful Use Final Rule: Have the Administration and ONC Put the Cart Before the Horse on Health IT?

Meaningful use before meaningful usability?

The Dept. of HHS today has released the final version of "Meaningful Use" rules on HIT, which can be seen here: Meaningful Use – Final Version Full Text.

By what category of diligence were the rules for "meaningful use" finalized on the same date that a NIST conference is being held on health IT "usability" ("Usability in Health IT: Technical Strategy, Research, and Implementation", http://www.nist.gov/itl/usability_hit.cfm), implying there's a problem with usability of these experimental devices physicians are supposed to "meaningfully use?"

Don't take my word on the issue of usability problems...

The National Research Council of the National Academies (considered the highest scientific authority in the U.S.) issued a 2009 report on HIT. In that report, presided over by noted HIT pioneers G. Octo Barnett (Harvard/MGH) and William Stead (Vanderbilt), were findings that current HIT does not support clinicians' cognitive needs as here:

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.

How about HIT industry trade/"educational" group HIMSS itself? I think reasonable people might conclude the technology is not ready for "meaningful use" on a national scale from their mid 2009 report:

Defining and Testing EMR Usability: Principles and Proposed Methods of EMR Usability Evaluation and Rating (PDF)
HIMSS EHR Usability Task Force
June 2009

EXECUTIVE SUMMARY
Electronic medical record (EMR) adoption rates have been slower than expected in the United States, especially in comparison to other industry sectors and other developed countries. A key reason, aside from initial costs and lost productivity during EMR implementation, is lack of efficiency and usability of EMRs currently available. Achieving the healthcare reform goals of broad EMR adoption and “meaningful use” will require that efficiency and usability be effectively addressed at a fundamental level.

These "usability" problems require long term solutions. There are no quick fix, plug and play solutions. Years of research are needed, and years of system migrations as well for existing installations.

Yet we now have an HHS Final Rule on "meaningful use" regarding experimental, unregulated medical devices the industry itself admits have major usability problems, along with a growing body of literature on the risks entailed.

For crying out loud, talk about putting the cart before the horse...

Something's very wrong here...

However, this situation is anything but humorous.

How more "cart before the horse" can government get?

Poor usability promotes medical error. Medical error puts patients at risk of iatrogenic injury and death.

Are we are entering an era of cybernetic medical assault on our patients (and perhaps criminal negligence and manslaughter, a term I do not use lightly) through irrational exuberance in computing -- and through exuberance about the profits to be made by the HIT industry?

Unless we slow down in our exuberance and recklessness on HIT diffusion, my fear is that we very well might be.

-- SS

Addendum:

Also see my followup July 14, 2010 post "Science or Politics? The New England Journal and "The 'Meaningful Use' Regulation for Electronic Health Records."

-- SS

NSW Nightmare and Overuse of Computers: Do We Really Need Full EHR's in ED's?

At "From Down Under: The Story of the Deployment of an ED Clinical Information System ‐ Systemic Failure or Bad Luck" I posted excerpts from a paper of the same name by an Australian medical informatics specialist, Professor Jon Patrick from the Health Information Technologies Research Laboratory (HITRL), University of Sydney, about what appears to be an Emergency Department (ED) nightmare. The paper is here. [10/24 note: not available at present at this link or from its author in Australia; I pulled it from the Drexel U. server in the U.S. at the author's request while his right to post it on his department's server in Australia is being discussed Down Under - ed.]

[2010 update: the paper is now at the following link (PDF): A Critical Essay on the Deployment of an ED Clinical Information System - Systemic Failure or Bad Luck, version 6. Prof. Jon Patrick, Health Information Technologies Research Laboratory, University of Sydney, Australia, Dec. 2009.]

Those excerpts should be frightening to anyone who ever gets ill and might need to visit an ED (meaning, all of us).

An ED electronic health record system (EHR) is being installed in an entire Australian state, New South Wales (NSW), with 200+ hospitals that apparently presents a mission hostile user experience and is causing great opposition by critical care physicians in a setting where death can occur - suddenly and irreversibly - in the flash of an eye.

His essay about the problems with complex EHR's (of American design and manufacture, no less) being installed in Australian ED's -- without doubt a highly expensive undertaking -- raises several questions about both the EHR industry and hospitals themselves.

When I was a CMIO at a 1400+ bed hospital system a decade ago, a regional center in a state with very few hospitals at all (Medical Center of Delaware, now Christiana Care Health System), I counseled that the best solution in my opinion for the very, very busy ED was document imaging of paper, supplemented by a nurse/intake triage system to rapidly record and/or confirm basics (e.g., meds/major problems/allergies/vitals) that was interfaced to the main EHR system.

I based this on the assessment that in the ED, a localized and "closed" environment, the incidence of charts getting lost or writing being illegible resulting in adverse outcomes was minimal. ED charts also did not get lost when patients moved to the floors and the information passed along on paper was adequate for quick transfer and acceptance. Therefore we felt images of past ED charts (of paper) would be satisfactory for assisting care in the ED, where time constraints and hectic pace made the type of EHR system and primary data entry described in the Australian paper disadvantageous (and for exactly the reasons described in the above linked essay from Down Under).

Document imaging is a proven technology that works well even in high volume settings. For example I managed a pharma departmental budget of $13 million, as did an entire pharma company, using an enterprise document imaging system.

I've also been startled by the ED EHR installed at the hospital where I take my mother, who unfortunately has needed far too many admissions in recent years than I care to see. Some of the ED staff were my former medical colleagues and even high school classmates. They've told me, in no uncertain terms, that they felt the system was terrible, again for many of the reasons cited in the Australian essay. My own views of it (albeit brief) showed what appeared to be a mission hostile user environment, including multiple very tiny pulldowns, cornucopia-like picklists, and screens.

Most recently that system did not prevent busy ED docs from almost giving my mother Levaquin after her telling the triage nurse it had caused tendon rupture in the past - and the data being entered. They actually brought in a bag of it to hang, and if I'd not been there as medical advocate for my mother they might have given it. Then when she got to the floor, the next day they almost gave it to her again, except by this time mom was her own medical advocate. I trained in that hospital, and as Admitting Officer for the ED held the record for the most number of admissions, ever, in one night (New Year's Eve 1986), when it was beyond crazy, starting out with one of our own physicians being brought in, shot in the chest, and dying after open heart massage just to set the mood.

The surgeons did the cutting. The heart massage was relegated to the physician present who didn't cut - the internal medicine representative - me.

We managed to treat hundreds and admit several dozens of sick patients using paper, and despite our gloomy emotional state not a single error occurred, to my knowledge.

With all this in mind, I raise these questions:

• Can the EHR industry actually produce a competent ED EHR that can be used by ED physicians to enter detailed data in real time?

• Do we really need full EHR's in the ED?

• A related question: is the extent of ED adverse events related to lost or illegible ED charts (that could not be remediated with non-technology-based solutions far less expensive and troublesome than EHR's) known to a significant degree of confidence?

• Is there trustworthy literature that shows that the time, expense, and resources for a full ED EHR are worth it in terms of clinical outcomes, ROI etc.? (By trustworthy, I mean scientific peer reviewed literature without author conflict of interest - common in biomedicine as readers of this and other healthcare blogs know, e.g., see this link - not glossy pseudo-P.R. health IT throwaway journals.)

• Considering that the literature on benefits of EHR's in general is equivocal, I should also ask, is there literature that refutes the value of full ED EHR's, or shows it as possibly having a negative return?
  

Or:

• Are we over-computerizing healthcare, even specialties and subspecialties where doing so might actually be deleterious due to the nature of their specific medical environments, just because "we can" (and because there is money to be made by some)?

• Are we doing so based on irrational exuberance, leap of faith, hope, and/or an uncritical belief that if health IT provides benefits to medical domain "A0", it therefore must benefit medical domains and subdomains B1 to B99 through Z1 to Z99 as well?
  

I am concerned about the probability that the latter is the case.

I think it not unreasonable to ask these questions before we in the United States spend billions of dollars on our own ED's.

-- SS

Wharton on Healthcare IT: Can I Go Home Now?

Professors at the Wharton School of the University of Pennsylvania (one of the most prestigious business colleges in the world) had some very interesting observations about healthcare IT yesterday in an article entitled:

"Information Technology: Not a Cure for the High Cost of Health Care."

I have been writing on these same themes - irrational exuberance, HIT not being a panacea or cybernetic miracle, HIT as a facilitating tool in medicine, not a revolutionary one (but only if "done right"), inadequate research to back up the often grandiose claims, and so forth for over a decade ("Contemporary Issues in Medical Informatics: Common Examples of Healthcare IT Failure", link). I penned such sacrilege, often at risk to my career due the unpopularity of these ideas, itself due to the irrational exuberance of the HIT community (these attitudes were perhaps in part manufactured by a healthcare IT lobby).

Here are excerpts of what Wharton professors observed. Do read the entire article at the link above:

President Obama made information technology a linchpin in his plan to reform health care when he included $19 billion in computerized medical record funding in the $787 billion American Recovery and Reinvestment Act of 2009. The goal: Use technology to reduce costs and improve the quality of care. The reality: Technology could increase health care costs without markedly improving quality, according to experts at Wharton [except perhaps in very highly specialized projects, not easily portable, such as here - and not without its own set of problems - ed.]

... "No one has done the careful research to indicate that if one health care system has information technology and the other doesn't, then the care is different. There are no controlled trials," says Mark Pauly, a health care management professor at Wharton. All that technology is no panacea, he warns. In fact, he believes IT could actually raise costs because of culture clashes, training, the implementation of the systems [I would say "the mayhem that often goes on during the implementation" - ed.] and the labor required to maintain the new technology.

"The best-case scenario is that information technology will improve quality but not lower costs. The worst case is that there's no difference at all." [I believe if HIT is "done well", we can achieve best case, and lower costs as well to an extent, but there is enormous complexity behind the two simple words "done well" that I'm not sure we've fully mastered as a society yet - ed.]

... That opinion is echoed by other experts at Wharton and the University of Pennsylvania. "The focus on IT in health care is a good thing, but there's way too much hype about it [an understatement - ed.] and misunderstanding about what the benefits will be and how quickly they will come," says Peter Gabriel, medical director of clinical information systems at the University of Pennsylvania Health System.

[Kevin Volpp, professor of medicine and health care management] agrees that tracking real cost savings from health care IT is a difficult task, but he expects there to be some benefits from spotting and eliminating redundant care. [Agree - ed.] But those benefits aren't likely to add up to big savings, says Lawton R. Burns, director of the Wharton Center for Health Management and Economics. "I agree that information technology is important, but it's not the slam dunk it's portrayed to be," he says. The chase to reduce costs, improve quality and expand coverage is deemed the "iron triangle of health care. A lot of us wince [at that goal]," Burns notes. "It's arguable that we can't do any of those things well."

David A. Asch, a Wharton health care management and economics professor, agrees that technology is a big part of reform. "No one is arguing against it, but that doesn't mean that it's not oversold," he says. Gabriel likens the fascination over IT in health care to a shiny new object that's easier to focus on relative to more daunting issues.

... In addition, it's unclear what cultural issues [a big theme in my writings - ed.] will emerge as information technology is adopted. These cultural issues are in the forefront of primary care physician relationships. Experts at Wharton and Penn say physicians are generally skeptical of the technology movement. How much will a technology overhaul add to operating costs? How much will it cost to retrain workers? What's the electronic record learning curve? And what happens when a doctor has a laptop between him and the patient?

"Individual physicians just don't know where the money is going to come from," says Pauly. "If IT is tied to reimbursements it could work, but [many] are skeptical." Burns adds that the physician-patient relationship can also be altered. "Technology adoption changes the way you practice. What happens when your primary care physician is looking at his screen instead of you?"

All themes obvious to me after an informatics fellowship and term as CMIO at a major hospital, and to a number of my like minded colleagues as well. However, these themes were as hard to get published and recognized (i.e., turned into "memes") as a book against Global Warming ...

The Wharton article concludes with this pithy wisdom:

Experts say these projects are worth the effort, but the industry should keep its expectations in check [i.e., ditch the irrational exuberance - ed.] and closely scrutinize investments. "To the extent [that] these technologies improve the quality of care and get the patient more involved, I'm all for them," says [Richard Neill, residency director and vice chair at the University of Pennsylvania's Department of Family Medicine and Community Health]. "But the technology is not a sea change -- just a chance to change."

Anyone in Washington listening?

Finally, after a decade of writing on these same observations to a public apparently inclined to believe the myths and promised cybernetic miracles nourished by the IT industry, and getting nowhere until some very serious organizations caught on this year and joined in (the Joint Commission, the National Research Council, UK House of Commons, JAMA, AMIA, Wharton, etc.) I ask: can I go home now?

-- SS