Showing posts sorted by relevance for query oppression. Sort by date Show all posts
Showing posts sorted by relevance for query oppression. Sort by date Show all posts

Tuesday, January 30, 2018

Physicians Harassed by Overwhelming Levels of Messaging From Electronic Medical Records

In yet another example of the clerical overload caused by bad health IT, physicians find themselves drinking from a fire hose through cybernetics.  This, in the field of dermatology, let alone critical care specialties:

Physicians Overwhelmed by Messaging From Electronic Medical Records
MedicalResearch.com Interview with: Matilda W. Nicholas, MD, PhD
Duke Dermatology
January 29, 2018

MedicalResearch.com: What is the background for this study?
Response: I have found many physicians overwhelmed by the electronic messaging feature in Electronic Health Record systems (EHRs). I found there was very little published about this phenomenon, particularly for specialists. So, we set out to take a look at the volume and effect these systems have. 

MedicalResearch.com: What are the main findings?
 Response: We found that, on average, clinicians receive 3.24 messages per patient visit, for an average of about 50 messages per full day of clinic. The number of messages also correlated with poor reported work life balance for dermatologists.



MedicalResearch.com: What should readers take away from your report?
 Response: As previous studies have shown, physicians are spending much more time in non-direct patient care and less time with patients. This is bad for everyone involved. Targeting methods to decrease this burden would be important in improving patient care and physician wellbeing ... We are planning on examining the messages sent directly from patients more closely, hoping to target higher risk patients to decrease post and inter-visit messaging.

As at my Jan. 28, 2018 post "Medical Economics: Highly experienced physicians lost to medicine over bad health IT" at http://hcrenewal.blogspot.com/2018/01/medical-economics-highly-experienced.html and many, many others, cybernetics are proving a distraction from - and actually a deterrent to - the practice of good medicine.

With the increasing outcry of physicians and nurses against EHRs and the oppressive demands the systems place on them, and the burnout these systems cause (see the numerous posts on burnout at query link http://hcrenewal.blogspot.com/search/label/burnout), I'm increasingly of the opinion these systems are not fixable.

There is only so much that can be accomplished with surface changes to user interfaces, without substantive changes to physicians' work expectations. 

The true problem that nobody seems to want to deal with - the proverbial elephant in the living room -  is expectations of clinicians doing oppressive amounts of clerical work, in addition to their patient care responsibilities.

(Note that in this essay I am not addressing other critical drawbacks to this technology such as crashes, lack of security including growing record theft, ransomware attacks on EHR's, and so forth.)

In my view, the only solution to these problems are separation of clinicians from clerical duties (see my August 9, 2016 essay "More on uncoupling clinicians from EHR clerical oppression" at http://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html), and the use of data-entry personnel, as I set up in the Invasive Cardiology Clinical Database at Christiana Care Health System in Delaware (http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story) so many years ago. 

Of course this will likely never happen, because it's an expensive labor proposition.

Based upon my EHR forensics/expert witness work since 2010, I also believe physicians can expect no help from the public or the government on this.  The issues seem above the public's heads (with the exception of those injured or killed by bad health IT, who - or whose heirs - seem to learn very fast about the drawbacks), and conflict with the bureaucratic goals for control of medical finance.

Physicians need to take control of their occupations, for there is no help coming from government or the public regarding cybernetic oppression. The only way repair of the profession can happen is through unionization, such as I saw in my work in the public transit industry.

If physicians are unwilling to take that step, then they will have to accept being servants to the bureaucracy, and being endlessly stressed, distracted and harassed by their cybernetic overlords.

-- SS

Wednesday, January 23, 2019

Experts declare physician burnout ‘a public health crisis’ - and health IT a significant pathogen

I'm certain when the information technology hyperenthusiasts and non-clinical management information systems "experts" and pundits get the technology all figured out, this burnout crisis will end.


It will be about the same time as Zefram Cochrane invents the warp drive in Bozeman, Montana just prior to first contact by the Vulcans. That is in 2063 or so.


Experts declare physician burnout ‘a public health crisis’
January 22, 2019
https://www.healio.com/psychiatry/practice-management/news/online/%7B7f2124e2-d72e-4e3e-be53-6fbe41986186%7D/experts-declare-physician-burnout-a-public-health-crisis

Experts from leading U.S. health organizations deemed physician burnout “a public health crisis” in a recent report.

Physician burnout has received some attention in recent years, but not enough. As a result, it is both poorly understood and getting worse,” Andrew R. Iliff, MA, JD, lead writer and program manager at Harvard Global Health Institute, told Healio Psychiatry.

“Like the blind man describing an elephant, people have described the challenges in front of them, including unhelpful electronic health records and a looming physician shortage,” he continued. “We believe it is important to frame this as a systems problem, requiring systemic solutions in order to avoid further adding to ballooning health care costs and undermining the provision of care.”

In their paper, experts from Harvard T.H. Chan School of Public Health, the Harvard Global Health Institute, the Massachusetts Medical Society and the Massachusetts Health and Hospital Association recommended ways to address the prevalence of burnout among physicians and other health care providers. Recommendations included:
  • appointing an executive-level chief wellness officer (CWO) at every major health care organization;
  • providing support for those experiencing burnout; and
  • improving the efficiency of EHRs.

More on that third Pavlovian, formulaic, hackneyed, health IT amateur-proffered bullet point in a moment.

... The usability of EHRs must be addressed through reform of certification standards by the federal government; improved interoperability; use of application programming interfaces by vendors; and increased physician engagement in the records’ design, implementation and customization, according to the report.

"Certification" standards are useless towards the stated ends.  Interoperability via API's is not the major issue, either; fundamental operability and, ultimately, clinician burden is.

It is also far too late in the game for "physician engagement" to make any difference.   People in my specialty, myself included dating back to the 1990's - and me on this blog starting ca. 2004 - had been calling for clinician (and especially Medical Informatics) leadership (not merely "engagement") of health IT. 

I note that the original title for my health IT academic site, still residing here, was "Preventing Medical Errors: Medical Informatics and Leadership of Clinical Computing."  The original ca. 1999 site is partially archived at http://www.ischool.drexel.edu/faculty/ssilverstein/informaticsmd/index_org.htm.

Little has changed, and the worst predictions I'd been making about the healthcare IT bubble/experiment (see query search https://hcrenewal.blogspot.com/search/label/Healthcare%20IT%20experiment) seem to be reaching unfortunate fruition.

Regarding the "efficiency" bullet point above:  quite seriously, from the perspective of this trained-by-the-pioneers Medical Informatics specialist, the "efficiency of EHRs" can only marginally be "improved."  This is due to both technical and political reasons.  The systems are far too complex, with far too many templates, widgets, options, "tricks", "gotchas" etc.  (with user manuals hundreds of pages long for each, that cause even my eyes to glaze over), too embedded, too protected by the industry, especially those involving legacy code, and too entrenched by politics - to name just some of the issues making major reform of the systems themselves impractical.

The situation should never have gotten this far, predicted as far back as 1969 by EHR pioneer Dr. Donald A.B. Lindberg (http://www.nlm.nih.gov/od/roster/lindberg.html), who wrote that an effect of the "over sell" even occurring then has been "the feeling that logic compels us to build total hospital information systems like military command-and-control systems ... and other grotesque concepts too numerous to mention."
  

Lindberg in 1969.  From Collen, "A History of Medical Informatics in the United States: 1950 to 1990"

What is needed is a significant downgrading of required clinician (physician/nurse) interaction with these "command-and-control systems", including data entry, and the use of clericals to perform those functions.  See my August 2016 essay "More on uncoupling clinicians from EHR clerical oppression" at https://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html

More generally, see my numerous posts on this issue at https://hcrenewal.blogspot.com/search?q=oppression

One last quote from the Healio article:
... Burnout not only causes physicians suffering, it also can adversely impact patients. Prior research has shown that burnout may does increase the risk for medical errors.  [Fixed the academic equivocation - ed.]

Put more simply, physician and nurse burnout can kill you.

If a healthcare organization cannot afford the appropriate clerical help to avoid clinician burnout, then they cannot afford an EHR.

Finally:

Can I now say "I told you so?" without the health IT industry sockpuppets coming out of the woodwork? (http://hcrenewal.blogspot.com/2010/01/more-on-perversity-in-hit-world.html)

-- SS

Tuesday, August 09, 2016

More on uncoupling clinicians from EHR clerical oppression

At my August 6, 2016 post (link) I wrote of my belief that "best practices" for EHR evolution call for:

... a return to paper (specialized forms depending on the setting) for clinical data capture by busy doctors and nurses, and data entry into a computer via clerical personnel.

I presented a late 1990's real-world experiment in creating such a system for invasive cardiology in the Delaware hospital system, Christiana Care Health System, where I was CMIO at that time.

As at the links http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story and http://webcache.googleusercontent.com/search?q=cache:7XKNh-fTOZ8J:ift.tt/2bd3pLl+&cd=1&hl=en&ct=clnk&gl=us (the latter a May 2002 article in the journal "Advance for Health Information Executives" written by myself and the project executive sponsor at the time), the "experiment" was a deliberate move away from the "doctors as clerical employees" article-of-faith of the health IT enthusiasts.

Enthusiasts seem to ignore the downsides and emphasize a (seemingly) sensible strong belief about efficiency, one of whose principles is that paper must be abolished in medicine.  Is work towards that end beneficial, or deleterious, to the clinical mission?

In fact, an attempt to implement such a paperless system, "Apollo" as the commercial system was known, in a cath lab performing 6,000 procedures/year proved impossible.  The busy clinicians, doctors, nurses and technicians simply did not have enough time to enter data directly into a computer.  Maneuvering around a computer application, dealing with its designber-centric menus, drop-downs, icons, widgets, annoying messages, input limitations, outright crashes with data loss, etc. was both inappropriate, and in fact impossible, in such a setting.

In 2016, one of the largest complaints of hundreds of thousands of U.S. physicians and nurses is that they spend more time interacting with the computer than with patients.  Patients complain they cannot get eye contact from clinicians - who are tethered to a computer screen entering data - during "live" encounters.

It is my belief there is no solution to this problem other than, where appropriate and advantageous, decoupling clinicians from data input and returning to paper for data entry, that is, specialized forms as in the aforementioned post.  Data input needs to be returned to clerical personnel as in the aforementioned invasive cardiology system.

The output side (with, of course, significant user-centered redesign) can remain computerized; as long as the paper forms are also made available via document imaging.

The forms for invasive cardiology looked like this, and were subject to revisions as needed.

Physician's data collection form, side 1.  Click to enlarge.
Physician's data collection form, side 2
Cath technician/nurse's data collection form, side 1
Cath technician/nurse's data collection form, side 2

The EHR itself was freed from "legacy" limitations regarding rapid customization, essential in medicine.  It was designed with the ability to rapidly incorporate changes and modifications to the dataset as needed, matching the changes to the forms.

Below I am showing some of the reports that this system produced regularly, as designed by the team of programmers, executives and cardiologists, under my medical informatics leadership. I used to do "real" informatics, e.g., leading the data modeling of entire clinical subspecialty domains and developing advanced IT based on those models, until seeing that the commercial sector was damaging the field of HIT, and medicine itself, with horribly bad health IT leading to letters such as the January 21, 2015 letter to HHS at http://mb.cision.com/Public/373/9710840/9053557230dbb768.pdf.  It was then, in the early 2000s, that I turned my attention to writing about the industry's deficits.

The major advantage of the cardiology reports shown below concerned accuracy, including the case report itself whose language and organization was also developed for optimal clinical organization and  readability -- unlike the reams of "legible gibberish" that emanates from commercial EHRs then and today.  See my post "Two weeks, two reams" at lhttp://hcrenewal.blogspot.com/2011/02/electronic-medical-records-two-weeks.html for more on that issue.

Quality data input into the system, being freed from the accuracy-impairing aspects of busy clinicians as clerical employees, and the resultant reports saved the organization close to $1 million in the first year and led to a better understanding of what worked and what didn't in treating blocked coronary arteries.

Click to enlarge:

Some statistical reports, and sample computer-generated case report front page






An evaluation of the project by the national organization, the Society for Cardiac Angiography and Interventions, was that the accomplishments were "exceptional."





All this was achieved without direct clinician data entry - and deliberately so due to the distractions of that process having failed in the same setting in prior organizational attempts, without medical informatics expertise.  Perhaps, more accurately, I should say "medical informatics expertise in someone who also thinks critically about all issues involved, including adverse effects, of IT."  Clinicians could supplement each section of the forms data if needed via dictation, which was directly transcribed by humans into the cardiology server.

"Clerical work for clerical employees, clinical work for clinicians" was the theme of the project.

Breaking from the belief that paper is to be abolished at all costs was the key to creating really useful and well-accepted health IT, even in this exceptionally busy critical care setting.  It was still being used over a decade later, ca. 2008 and may still be now.  I have not been back for a visit since then.

One argument might be made that hospitals cannot afford enough clerical employees to do all the data input.  I maintain that, with hospitals spending upwards of $100 million for EHRs, and with the data being used and sold profitably by a wide variety of stakeholders who contribute nothing for the medical data they obtain (EHR makers, insurers, regulators to name just a few), transcriptionists could be afforded.

Of course:

Physicians with simply too much free time on their hands - the majority, it might seem, based on the behavior of some of the EHR enthusiasts and government pundits - and who enjoy giving away the fruits of their labor for others' profits could still enter data directly into the computer.  If they want to.

I note that if physicians really were empowered, the current status quo of clinicians as (unpaid) data-input personnel for those who profit from the data likely would never have come to pass.

Entering orders would still be done by clinicians, although that process and the process of alerts and reminders also needs a major reworking, such as use of advanced NLP to allow a more natural input of orders.

In summary, in the late 1990s the mantras of eliminating paper from medicine, and of clinicians needing to perform clerical work, were challenged and shown to be injurious to health IT progress in a critical care setting, invasive cardiology.

The lessons learned are more valuable today as they were then, considering that the health IT "experiment" is facing significant opposition today, with significant clinician rancor.  The CEO of the American Medical Association perhaps summed it up best when he referred to HIT as "the digital snake oil of the early 21st century" as at http://www.ama-assn.org/ama/pub/news/news/2016/2016-06-11-a16-madara-address.page.

These are unfortunate and undesired positions for the AMA CEO, and for the aforementioned medical society leaders as expressed in the letter to HHS to express, but this development has its real-world reasons.

Correction calls for modifying/softening cybernetic-enthusiast ideas like "paperless" and a more appropriate allocation of computer-related tasks.  Refocusing on "Clerical work for clerical employees; clinical work for clinicians" would be a good start.

-- SS

Thursday, May 18, 2017

Death By A Thousand Clicks: Leading Boston Doctors Decry Electronic Medical Records

Channeling Lyndon Johnson on Walter Cronkite, in clinical medicine, when you've lost Boston (including MGH), you've probably lost the health IT war.

Death By A Thousand Clicks: Leading Boston Doctors Decry Electronic Medical Records
May 12, 2017
By Drs. John Levinson, Bruce H. Price and Vikas Saini
http://www.wbur.org/commonhealth/2017/05/12/boston-electronic-medical-record

It happens every day, in exam rooms across the country, something that would have been unthinkable 20 years ago: Doctors and nurses turn away from their patients and focus their attention elsewhere — on their computer screens.

By the time the doctor can finally turn back to her patient, she will have spent close to half of the appointment serving not the needs of her patient, but of the electronic medical record.

I have observed this myself in my own personal experiences in recent years observing clinicians in situ.  I (unfortunately) have also been on the receiving end of the resultant distractions, via a dead parent, at the very hospital where I did my residency training in pre-HIT days.

Electronic medical records, or EMRs, were supposed to improve the quality, safety and efficiency of health care, and provide instant access to vital patient information.

Instead, EMRs have become the bane of doctors and nurses everywhere. They are the medical equivalent of texting while driving, sucking the soul out of the practice of medicine while failing to improve care.

"Texting while driving" is, in fact, an excellent metaphor.  The practice of medicine is often a highly-demanding activity, cognitively speaking, just as driving is.  Slip up even for a moment, and accidents and catastrophe can occur.
To fix them, hospital administrators and clinicians need to work together to demand better products from EMR manufacturers and to urge government to relax several provisions of the HITECH Act, the 2009 law that spawned many of the problems with EMRs.

I do not think this is feasible, nor do I think it would solve the problems.  More on that below.

How did technology that has increased efficiency in every other industry become such a drag on health care? For starters, people who take care of patients did not design or choose these systems. They were foisted upon us.

Doctors and nurses know that good diagnosis and treatment requires listening attentively to their patients. They spend years learning to parse the clues that patients offer, both the physiological and personal, in order to provide the right care.

The sound of medicine is not the click of a mouse. It is the human voice. Let’s bring it back.

To do this well takes time and undivided attention.

"Undivided attention to the patient" and "use of health IT" under the current paradigms are incompatible.  The terms do not belong in the same sentence.  Again, more on that below.

... Instead of making this easier, most EMRs create extra work. A lot of extra work, thanks to endless prompts with multiple choice answers that hardly ever fit the facts and that demand click after click to get anything done.

Want to order a simple test? That requires getting through multiple prompts. Need to write a prescription -- an exercise that used to take less than 15 seconds? Another set of clicks.

Template madness is the coin of the realm.


Four screens of hundreds, from just one EHR, of many EHRs that a clinician might need to use in practice of medicine.

Typing, filing, mailing results and placing referrals all used to be done by assistants. Now, EMRs put that burden on clinicians, and we must do it during office visits, or “encounters,” as EMRs call them. And when the wrong button is clicked, the wrong test or drug is ordered, or it does not go through at all, delaying medical care.

It’s death by a thousand clicks, and it happens every day.

Another excellent metaphor, a derivation of "death by a thousand cuts."  However, in this case, it is not just referring to death of the ability to maintain medical practice and retain sanity (and health of the practitioner), but also injury and death of patients.

We are frustrated by EMRs because they pull us away from our patients. We are driven mad by the fact that EMRs in different locations do not talk to each other. And we think it’s just wrong that much of the EMR’s busywork is about optimizing billing for the hospital.

The lack of interoperability is likely protective against, in effect, mass copy-and-paste on a grand scale through importation of a chart from one EHR to another, resulting in propagation of errors.  In any case, interoperability needs to take a back seat to operability (usability).

Who is to blame? Start with EMR manufacturers, who lobbied Congress to require every hospital and doctor’s office to install an EMR system; hospital administrators who bought technology that conveniently pushed billing duties onto doctors and nurses; and federal regulators, who imposed on EMRs numerous quality metric requirements that do nothing to improve care.

Everyone in healthcare is to blame, including clinicians who DID NOT SPEAK OUT until obvious issues crated the terrible state clinicians find themselves in now.

We do not want to go backward. We believe that computing is essential to the future of medicine. We simply want all EMRs to live up to their promise of improving care and making patient information readily available.

I've been calling the problems out for close to two decades now.

The issue becomes:  what to do about it?

My area of Medical Informatics research in the early 1990s was to move away from the traditional GUI paradigm of menus, widgets, control buttons, etc to explore novel (and menu-free) paradigms of EHR-based data content visualization, navigation and querying.  The commercial companies, when shown this, had no interest in even considering such ideas.

Other avenues to enhance the traditional GUI interface - e.g., AI-based "wizards" of one sort or another that anticipated likely down-the-line choices from currently entered data and presented the choices to the user, better-designed EHR roadmaps and/or AI based on data entry to-the-moment to  allow simpler and less time-consuming navigation, etc. - all proved not very helpful due to the complexity of the domain, not to mention its specialties and subspecialties.  This experience informed my decision down the line to move to specialized and malleable paper forms for the clinicians, and data entry clerical teams, for high risk and/or high volume procedural or critical care areas such as invasive cardiology, cardiac surgery and the ED.

See my Aug. 2016 post "More on uncoupling clinicians from EHR clerical oppression" at http://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html for a specific, highly successful example.

It is my belief that the "traditional" model - GUI-based EHRs with the typical paradigms, and clinicians doing the bulk of the data entry that itself is bloated relative to the actual clinical need, and tying all human-computer interaction to a computer screen roughly at the resolution of one or two legal-sized pieces of paper, can never be improved to the point of not impairing the clinical workday.

The entire health IT enterprise needs to be rebooted (rethought), especially regarding roles, workflow, and most especially the "data capture load per clinician".

When I was writing about EHR issues in the late 1990s and into the 2000s, I was called a Luddite and alarmist (or worse, e.g., see my 2010 posts "The Dangers of Critical Thinking in A Politicized, Irrational Culture" at http://hcrenewal.blogspot.com/2010/09/dangers-of-critical-thinking-in.html and "More on Perversity in the Healthcare IT World: Is Meditech Employing Sockpuppets?" at http://hcrenewal.blogspot.com/2010/01/more-on-perversity-in-hit-world.html).

It appears I was correct.

My issuing the prediction that the current model of health IT is irreparably broken (or, said differently, that the health IT experiment - and it has been an experiment - under its current paradigms has failed), and needs a top-to-bottom rethinking, will probably be taken the same way.

Until it isn't.

-- SS

Monday, August 15, 2016

Stanford authors: Evolutionary Pressures on the Electronic Health Record - "Deimplementing the EHR could actively enhance care in many clinical scenarios"

A brief post.  In this new JAMA article by Stanford authors:

Evolutionary Pressures on the Electronic Health Record
http://jama.jamanetwork.com/article.aspx?articleid=2545405 
Donna M. Zulman, MD, MS1,2; Nigam H. Shah, MBBS, PhD3; Abraham Verghese, MD4

I note the passage:

... Deimplementing the EHR could actively enhance care in many clinical scenarios. Simply listening to the history and carefully examining the patient who presents with a focused concern is an important means of avoiding diagnostic error.7 Many phenotypic observations (the outline of a cigarette packet in a shirt pocket, or spotting neurofibroma, fasciculation, or rash) change the diagnostic algorithm and are easy to miss when work revolves around the computer and not the patient.

I predict pushback against such a bold and contrarian "de-implementation" assertion (contrarian to the hyper-enthusiast and industry narratives, that is).

The authors continue:

There is building resentment against the shackles of the present EHR; every additional click inflicts a nick on physicians’ morale. Current records miss opportunities to harness available data and predictive analytics to individualize treatment. Meanwhile, sophisticated advances in technology are going untapped. Better medical record systems are needed that are dissociated from billing, intuitive and helpful, and allow physicians to be fully present with their patients.
 
I also wrote the primary author with a link to an alternate solution to de-implementation that can "allow physicians to be fully present with their patients", namely, my Aug. 9, 2016 post "More on uncoupling clinicians from EHR clerical oppression" at http://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html
 
-- SS

Sunday, January 28, 2018

Medical Economics: Highly experienced physicians lost to medicine over bad health IT

The title of the article is actually "Physicians leaving profession over EHRs", but that title omits the real impact of the phenomenon: seasoned physicians, along with their medical expertise, judgment and experience, are lost to the pool of people entrusted to provide care thanks to poorly designed and badly implemented IT:


http://cci.drexel.edu/faculty/ssilverstein/cases/
Bad Health IT is IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, lacking in evidentiary soundness, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.

This is yet another article observing that the trajectory of health IT is not what the pioneers who taught me Medical Informatics intended:

Physicians leaving profession over EHRs
Medical Economics

January 24, 2018
http://medicaleconomics.modernmedicine.com/medical-economics/news/physicians-leaving-profession-over-ehrs

Until recently, most doctors created their own workflows and utilized only the technology they were comfortable using. But with the implementation of the Health Information Technology for Economic and Clinical Health Act (HITECH Act) in 2009 to stimulate the adoption of electronic health records (EHR), many physicians are finding things a bit too stressful.

In fact, a new study in Mayo Clinic Proceedings showed that physicians who are uncomfortable using EHRs are more likely to reduce hours or leave the profession.


I think it very fair to say that a majority of physicians are "uncomfortable" or at least "highly displeased" using today's EHRs.  Evidence for this assertion includes, among others, the Jan. 2015 letter from approximately 40 medical societies including AMA, American College of Physicians, American College of Surgeons, and many sub-specialty societies expressing their displeasure directly to HHS. 

See my January 28, 2015 essay "Meaningful Use not so meaningful: Multiple medical specialty societies now go on record about hazards of EHR misdirection, mismanagement and sloppy hospital computing" at http://hcrenewal.blogspot.com/2015/01/meaningful-use-not-so-meaningul.html, and the Medical Societies letter itself at http://mb.cision.com/Public/373/9710840/9053557230dbb768.pdf.

The research showed that while EHRs hold great promise for enhancing coordination of care and improving quality of care, in its current form and implementation, it has created a number of unintended negative consequences including reducing efficiency, increasing clerical burden and increasing the risk of burnout for physicians.

Typical of the anodyne stories in the media on bad health IT, the issue of causing increased risk and actual patient harm is omitted.

Tom Davis, MD, FAAFP, who practiced family medicine for almost 25 years in the greater St. Louis area, says the primary reason he walked away from a successful practice was the EHR, citing its use, the ethics and the burden.

“I had 3,000 patients, many I’ve known for a quarter century, a few hundred of which I delivered, all immensely valuable relationships—and all burned to the ground mostly because of the burdens of the HITECH Act,” he says. “The demands of data entry, the use of that data to direct care and my overall uncertainty about how medical data was used in aggregate all helped poison the well from which my passion for serving my patients was drawn.

In other words, his expertise, knowledge and experience, and valuable personal relationships (enhancing trust and the obtaining of the best medical histories) with his patients was sacrificed to, in essence, utopians' notions of cybernetic medicine and the wants of the financialization-of-medicine sector.

He believes that the information collected through the EHR is being used (at least in aggregate) for purposes other than the direct benefit of the individual patient so it would be unethical for him to represent otherwise to the patient. 

I had previously written on this site about the EHR companies trafficking in medical data, as in my October 7, 2009 essay "Health IT Vendors Trafficking in Patient Data?" at http://hcrenewal.blogspot.com/2009/10/health-it-vendors-trafficking-in.html.

In the research realm, formerly working with one of the key figures in the now-defunct Human Genome Diversity Project at Yale, I myself am personally aware of indigenous peoples refusing to take part in data collection by western scientists because they feared misuse of the data. 

I was right; the researcher proposed, and may have experimented with, using the genetic data to perfect a "forensic" identification capability essentially based on ethnic ("population") origins. 

I wrote on these issues at my September 8, 2005 essay "Academic abuses in biomedicine vs. Indigenous Peoples: The Genographic Project" at http://hcrenewal.blogspot.com/2005/09/academic-abuses-in-biomedicine-vs.html and my July 26, 2007 essay "Informed consent, exploitation and 'Developing a SNP panel for forensic identification of individuals'" at http://hcrenewal.blogspot.com/2007/07/informed-consent-and-developing-snp.html.

I thus opine Dr. Davis' concerns are quite legitimate.

As far as the burden, he notes he spent about four minutes of keyboard time for every minute of face-to-face time with a patient.

That is a huge waste of clinician time, with few proven benefits (at least outside the financial world) and known risk, e.g., ECRI Institute's yearly "Top ten technology risks in healthcare" where health IT is usually highly ranking on that list, such as at my April 2014 essay at http://hcrenewal.blogspot.com/2014/04/in-ecri-institutes-new-2014-top-10.html.

Ramin Javahery, MD, chief of adult and pediatric neurosurgery at Long Beach Memorial, Long Beach, California, says there are obvious financial pressures that drive people out of private practice into a larger corporate structure, but the changes in the workplace brought about by EHRs are also driving older doctors to retire rather than deal with the costs or increased work required.

“Younger physicians who are comfortable with typing, computers and the truncated patient interactions generated by EHRs do not resist its presence,” he says. “Older physicians, however, are more likely to lack those comforts. When faced with a less comfortable work environment, they choose to retire, especially since many have saved enough to be comfortable financially.”


Where do I even start?  Older doctors have a wealth of experience and hard-earned wisdom that is being sacrificed to the whims of those who think the medical robots of "Silent Running" are just on the horizon, it seems...


These robots could perform surgery.

Regarding younger (i.e., less experienced) physicians and the "truncated patient interactions generated by EHRs", those are two deleterious results of the technology.  Less experience combined with less patient interaction, plus the distractions imposed by EHR-related clerical work, create increased risk of error and patient adverse consequences.   There is little to debate on that point.

Kevin Gebke, MD, a family and sports medicine practitioner at Indiana University Health in Indianapolis, says the issue is not fear, rather it’s a matter of dramatic workflow change.

“EHRs were not designed by practicing clinicians and are not intuitive regarding the different processes that take place during a patient encounter,” he says. “Physicians must often choose between communicating with the patient and navigating within the records to enter or view relevant data. That can fragment care during a patient visit.”

His experience with EHRs is it has slowed down his workflow, causing a significant decrease in productivity.

The issue is certainly not "fear" or physicians being "Luddites", as I've pointed out in my March 11, 2012 essay "Doctors and EHRs: Reframing the 'Modernists v. Luddites' Canard to The Accurate 'Ardent Technophiles vs. Pragmatists' Reality" at http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html

The tension is not between doctors who "fear" technology or are Luddites, vs. the modernists.  Rather, the true tension is between clinician pragmatists and technology hyper-enthusiasts ("Ddulites") who ignore technology's clinical downsides.

“Spread this decreased capacity to see patients across the country and we then have a magnified shortage of primary care providers,” Gebke says.

That shortage is, in fact, at odds with national policy on re-populating the pool of generalists to reduce costs.

Because of this, he believes a way to keep physicians from leaving the profession over EHR issues is to get them involved in design and improvement processes.

EHR redesign can only accomplish so much.  I have reached the point where I believe the only solution to this seeming conundrum is to stop focusing on computers, and decouple physicians and nurses from cybernetic oppressionSee my August 9, 2016 essay "More on uncoupling clinicians from EHR clerical oppression" at http://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html

I observed:

... In 2016, one of the largest complaints of hundreds of thousands of U.S. physicians and nurses is that they spend more time interacting with the computer than with patients.  Patients complain they cannot get eye contact from clinicians - who are tethered to a computer screen entering data - during "live" encounters.

It is my belief there is no solution to this problem other than, where appropriate and advantageous, decoupling clinicians from data input and returning to paper for data entry, that is, specialized forms as in the aforementioned post.  Data input needs to be returned to clerical personnel as in the aforementioned invasive cardiology system.

Finally, the predictable "things are getting better and utopia is just around the corner" ending to articles on the impact of bad health IT ends this Medical Economics article:
  
Things are improving

Munzoor Shaikh, director of West Monroe’s healthcare and life sciences practice in Chicago, says that while some doctors are leaving medicine due to technology learning curves, the industry is past the EHR implementation phase and has entered an EHR optimization phase where the user experience on the physician side should be improving.

“Those who have more patience than others have stuck around; hopefully this optimization phase will save some more doctors from leaving,” he says. “That said, there are some physicians who are fundamentally not built for this tech-driven world.”

The final line is nothing short of outrageous.

The truth is, there are all to many clinical information systems that are fundamentally not built for the good-practice-of-medicine-driven world.

-- SS

Saturday, May 06, 2017

New HHS Secretary, rather than singing unabashed praise for EMRs like his predecessors, states the obvious. However, the "solutions" are the usual boilerplate.

In the past, politicians on both sides of the aisle have generally sung unfettered and uncritical praise for electronic medical records and other health IT systems.

Perhaps letters like this one from Jan. 2015, from near 40 major US medical societies bemoaning the injurious effects of health IT on medical practice, have finally had an effect:  http://mb.cision.com/Public/373/9710840/9053557230dbb768.pdf



First page preview of Jan. 2015 medical societies complaint letter to HHS about health IT.  Full letter at http://mb.cision.com/Public/373/9710840/9053557230dbb768.pdf


In any case, this recent article caught me by surprise:


HHS Secretary Price promises reduced health IT burden for physicians
April 27, 2017
Gregory Twachtman
Frontline Medical News
http://www.mdedge.com/acssurgerynews/article/136747/business-medicine/hhs-secretary-price-promises-reduced-health-it

– Reducing IT burden for doctors and fostering interoperability are two top tech priorities for Health and Human Services Secretary Tom Price, MD.

"We simply have to do a better job of reducing the burden of health IT on physicians and all health care providers,” Dr. Price said April 27 at Health Datapalooza, an annual conference on health data transparency. “The promise of big data and health information technology is so great and absolutely remarkable but we must not, we cannot continue to get this wrong.”

The burdens have become so onerous that the new HHS secretary made these statements:

EHR requirements are causing some physicians to retire too early, Dr. Tom Price said at Health Datapolooza.
Dr. Price said that the burden being placed on physicians is causing many to leave practice way too early. He noted that his grandfather retired from practice at age 94 and his father retired in his early 80s.

“Now we are seeing physicians leaving the practice of medicine when they are 60 or 55,” he said. “Many of my colleagues, my personal friends who have been practicing, right now they are looking for the exit doors. They are trying to figure out how to get out of practicing medicine and I think it is incredibly important for us as a society to step back and ask, why?”

A significant factor is the shift to electronic health records, which has caused doctors to spend much more time looking at screens and feeling more like data entry clerks than health care providers, he said.

“I know that we have lost more than one physician to retirement because of the kinds of burdens that have been placed on a lot of them and that simply ought to be unacceptable to us,” he said. “You think of the intellectual capital that has been lost by this nation because of the kinds of burdens that clinicians have seen.”

First, an aside on the term "Datapalooza."   Such an injudicious, "let's party" term as "datapalooza" reflects in my opinion the irrational exuberance that has characterized health IT for decades and led to the dilemma faced by physicians in 2017.  I've mentioned this before.  At my May 10, 2012 post "ONC's 'Health Data Palooza' - A Title of Exceptionally Bad Taste" at https://hcrenewal.blogspot.com/2012/05/oncs-health-data-palooza-title-of.html, I observed:

... This title for a government-sponsored meeting is bizarre and tasteless in my opinion.  What is deemed by ONC to be the major source of this data?  Health IT. 

"Palooza?" 

From Urban Dictionary: 

Palooza - http://www.urbandictionary.com/define.php?term=palooza 

An all-out crazy party; partying at one place with a ton of people like there's no tomorrow; The art of throwing a very drunken extravagant party with a plethora of friends

Also, the Secretary reiterates the other hyper-enthusiast-promoted line:

... The promise of big data and health information technology is so great and absolutely remarkable

This is the decidedly un-sober "revolutionizing medicine" claim I've been hearing about health IT for the past several decades.  As I observed at my August 2016 post at http://hcrenewal.blogspot.com/2016/08/ioannidis-what-happens-when.html, Ioannidis et al. wrote about this phenomenon more eloquently than I could regarding Big Data and biomedicine:

What Happens When Underperforming Big Ideas in Research Become Entrenched?
Michael J. Joyner, MD1; Nigel Paneth, MD, MPH2; John P. A. Ioannidis, MD, DSc3
JAMA. Published online July 28, 2016. doi:10.1001/jama.2016.11076
http://jama.jamanetwork.com/article.aspx?articleid=2541515

For several decades now the biomedical research community has pursued a narrative positing that a combination of ever-deeper knowledge of subcellular biology, especially genetics, coupled with information technology will lead to transformative improvements in health care and human health. In this Viewpoint, we provide evidence for the extraordinary dominance of this narrative in biomedical funding and journal publications; discuss several prominent themes embedded in the narrative to show that this approach has largely failed; and propose a wholesale reevaluation of the way forward in biomedical research 

and this:

... The financial and clinical benefits predicted from shifting to EHRs have also largely failed to materialize because of difficulties in interoperability, poor quality, and accuracy of the collected information; cost overruns associated with installation and operation of EHRs at many institutions; and ongoing privacy and security concerns that further increase operational costs.

Those things said:

Regarding Dr. Price's statement that "We simply have to do a better job of reducing the burden of health IT on physicians and all health care providers", I find the statement remarkable coming from the top echelon of government.

It's about time, I opine.

Still more time is needed, however, before the government and organized medicine truly understand health IT enthusiast culture.  One might wonder if Dr. Price read my Aug. 9, 2016 post "More on uncoupling clinicians from EHR clerical oppression" at http://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html - that is, until one reads his proposed solutions:

... He challenged the health IT professionals at the meeting to make their products more user friendly.

“We will work on reducing the burdens at the federal level, but we also need clinicians and IT folks on the ground to help make certain that technology implementation is done in a way that it enhances usability and increases efficiency,” Dr. Price said.

This assumes that complex major information systems such as EHR's can be made significantly more "usable", considering the constraints of time and the cognitive burdens such systems place on already-taxed clinicians

As I have pointed out, these "EHRs" are really complex command-and-control systems with dozens of component systems:


The term "EHR"/"EMR" is a misleading anachronism, no longer reflecting a medical file cabinet replacement but a far larger, complex amalgam of information systems.


I do not believe these systems really can be made less burdensome to clinicians to a major degree, no matter how clever the user interaction design.  The user manuals to the best of these systems are hundreds of pages long, and many clinicians user more than one system.  Further, paper will always be far simpler to use than computers, and no information system in a complex field like medicine will ever duplicate that ease-of-use.

The real-world solution to decrease clerical burden on busy and overtaxed clinicians is either to significantly decrease their patient load (unlikely to occur), or to decrease the amount of time they have to spend at computers and the amount of data they are called upon to enter per capita.  That solution cannot be accomplished without help from a significant number of - no surprise here - clerical personnel, for data entry, data abstraction and related mundane tasks.

... [Dr. Price] also called for true interoperability, a common goal that has persisted since electronic health records were mandated under the HITECH Act but remains an elusive target.

“This has always been the goal and it just seems so simple,” he said. “Somehow something has happened between the idea of interoperability and now that has made it so much more challenging.”

Achieving interoperability among many complex information systems that contain the massively complex datasets of biomedicine, a terminology set containing a massive number of unique concepts and terms, with millions of synonyms and subtleties (cf.:  Unified Medical Language System, https://www.nlm.nih.gov/research/umls/) is NOT so simple:

Scott Adams expressed the misconception here succinctly:

ANYTHING YOU DON’T UNDERSTAND IS EASY TO DO
ExampIe: If you have the right tools, how hard could it be to generate nuclear fission at home?

Further, and even worse:

It is my great concern that, should significant inter-EHR system interoperability be achieved, wholesale import of patient data from one system to the next could (and likely would) encourage 'laziness', e.g., uncritical acceptance of the incoming data as correct.   The propagation of inaccuracies and errors (already a significant issue with intra-system "cut and paste" as one example), would more readily propagate from one clinician and/or facility to another. 

The repeat history-taking and fresh rewriting of a new chart regarding new encounters serves a corrective function that could be bypassed through seamless health IT "interoperability."

As I've written at this blog numerous times, the issue of basic operability is more important towards practical use of EHRs in the real-world care of individual patients (which I consider the heart and soul of medicine) than interoperability.

... He placed that fault on current federal regulation around interoperability and pledged to create an environment that reduces regulatory roadblocks and allows the technology sector to innovate and foster the free flow of data.

This idea is dead in the water if history is any lesson.  The lack of any meaningful regulation of the health IT industry over the past several decades, that is, the unprecedented regulatory accommodation afforded the health IT sector, certainly did not promote meaningful innovation in the technology or in interoperability.   The primary driver and business equation is "proprietary" == locked-in customers.

“From my perspective it seems that what we ought to be doing is deciding the rules of the road,” Dr. Price said. “We are going to drive on the right side. We are going to stop at the red light. This is the language we are going to do. This is what a triangular sign looks like, as opposed to stipulating every single dot... all the way down the line.”

Dr. Price has taken the first (remarkable) step in calling out the severe impact of the burdens placed on clinicians by current health IT systems and practices.

What he and his advisors have not yet done is truly think through the solutions critically.

That needs to occur, for the proposed solutions are no "solution" at all.  They are merely more of the same muddled thinking and hyper-enthusiastic boilerplate that got clinicians into the cybernetic mess they are in to begin with.

-- SS

Monday, August 15, 2016

Ioannidis et al.: What Happens When Underperforming Big Ideas in Research [such as Healthcare IT Exceptionalism] Become Entrenched?

Some years ago, John P. A. Ioannidis, MD wrote this piece:

"Why Most Published Research Findings Are False", John P. A. Ioannidis, PLoS medicine, 2005 August; 2(8): e124

He wrote:

There is increasing concern that most current published research findings are false. The probability that a research claim is true may depend on study power and bias, the number of other studies on the same question, and, importantly, the ratio of true to no relationships among the relationships probed in each scientific field. In this framework, a research finding is less likely to be true when the studies conducted in a field are smaller; when effect sizes are smaller; when there is a greater number and lesser preselection of tested relationships; where there is greater flexibility in designs, definitions, outcomes, and analytical modes; when there is greater financial and other interest and prejudice; and when more teams are involved in a scientific field in chase of statistical significance. Simulations show that for most study designs and settings, it is more likely for a research claim to be false than true. Moreover, for many current scientific fields, claimed research findings may often be simply accurate measures of the prevailing bias.

In other words, in the all-too-common insufficiently powered studies, and even seemingly robust studies in domains with small effect sizes, financial interests, prejudices and other factors more often than not produce false results.

Ioannidis and co-authors recently took their sword to "underperforming Big Ideas in research" (including the "miracles" touted by hyper-enthusiasts such as in genomics and in cybernetics), via a new JAMA viewpoint piece:

What Happens When Underperforming Big Ideas in Research Become Entrenched?
Michael J. Joyner, MD1; Nigel Paneth, MD, MPH2; John P. A. Ioannidis, MD, DSc3
JAMA. Published online July 28, 2016. doi:10.1001/jama.2016.11076
http://jama.jamanetwork.com/article.aspx?articleid=2541515

For several decades now the biomedical research community has pursued a narrative positing that a combination of ever-deeper knowledge of subcellular biology, especially genetics, coupled with information technology will lead to transformative improvements in health care and human health. In this Viewpoint, we provide evidence for the extraordinary dominance of this narrative in biomedical funding and journal publications; discuss several prominent themes embedded in the narrative to show that this approach has largely failed; and propose a wholesale reevaluation of the way forward in biomedical research.

The key word is "narrative."   As per Hayek, those with little real-world operational experience, i.e., intellectuals and academics, often the uncritical cheerleaders for electronic records despite considerable downsides, have only the "narrative" upon which they base their beliefs in healthcare IT exceptionalism:

It is perhaps the most characteristic feature of the intellectual that he judges new ideas not by their specific merits but by the readiness with which they fit into his general conceptions, into the picture of the world which he regards as modern or advanced. . . . As he knows little about particular issues, his criterion must be consistency with his other views and suitability for combining into a coherent picture of the world. . . . It is the intellectuals in this sense who decide what views and opinions are to reach us, which facts are important enough to be told to us, and in what form and from what angle they are to be presented. Whether we shall ever learn of the results of the work of the expert and the original thinker depends mainly on their decision.

(I can add that blogs have to some small degree ameloriated "whether we shall ever learn of the results of the work of the expert and the original thinker", but only to a small degree.)

The "general conception" in cybernetics is that computers are a silver bullet in any domain, and can only result in massive improvements. 

My experience for the past twenty+ years in the Electronic Medical Records/clinical information technology domain, where quality, safety, usability, confidentiality, and other critical real-world issues have been ignored in favor of EHR hyper-enthusiasm, supports Hayek's observations regarding prevalent unfettered beliefs in healthcare IT exceptionalism.

Ioannidis et al. state the factual situation with EHR technology unapologetically, clearly and succinctly:

... The financial and clinical benefits predicted from shifting to EHRs have also largely failed to materialize because of difficulties in interoperability, poor quality, and accuracy of the collected information; cost overruns associated with installation and operation of EHRs at many institutions; and ongoing privacy and security concerns that further increase operational costs.

I would change "interoperability" to "operability."  Otherwise, they're quite correct.  For example, the "Big Data" hyper-enthusiasts quite irrationally believe data from these systems - as they are today -  will somehow "revolutionize" medicine, while at the very same time the IT industry itself and its pundits ignore fundamental precepts of computer science, information science, biomedical informatics, biomedicine and biomedical research itself. 

Some of the hyper-enthusiasts have made predictions that are astonishingly naive, delusionally grandiose and just plain perverse, e.g., see for instance my Jan. 2014 post "Computers + a few docs can manage 'an entire city', and other cybernetic miracles" at http://hcrenewal.blogspot.com/2014/01/computers-few-docs-can-manage-entire.html

The new JAMA paper continues:

... These features make the use of EHRs for research into the origins of disease, as proposed in the Precision Medicine Initiative, highly problematic.No clearly specified targets for either improved outcomes or reduced costs have been developed to assess the performance efficiency of EHRs.

Those targets were never specified, but The Market seems to have corrected for that, e.g., via this Jan. 2015 letter from ~40 different medical societies:

 Full letter to HHS available at http://mb.cision.com/Public/373/9710840/9053557230dbb768.pdf

The authors continue:

... Although it is difficult to argue for a return to paper records, any claim of future transformation of the medical record should include well-defined accountability and review mechanisms. Otherwise, the health care system may become hostage, wasting increasing resources to continuously upgrade electronic technology without really helping patients.

It is clear to me that the health care system and its clinicians are already hostage to the cybernetic hyper-enthusiasts, as evidenced by letters such as the above and many other sources about the mayhem being caused, e.g., a small sampling on this blog at query links http://hcrenewal.blogspot.com/search/label/glitch, http://hcrenewal.blogspot.com/search/label/healthcare%20IT%20difficulties and http://hcrenewal.blogspot.com/search/label/medical%20record%20confidentiality.

Finally, I disagree with the authors that "it is difficult to argue for a return to paper records."

Paper has its proper place, and "paperless" is a utopian dream of the hyper-enthusiasts that causes significant damage to the primary role of clinicians - to take care of patients.  I make this argument (with a real-world, highly successful example of my own creation) at my Aug. 9, 2016 post "More on uncoupling clinicians from EHR clerical oppression" at http://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html.

In summary, the authors of this JAMA piece clearly and succinctly break through the "narrative" about hyper-enthusiast dominated fields, including clinical information technology and the belief in 
healthcare IT exceptionalism.
 

Sadly, theirs is almost a single voice in a wilderness dominated by the hyper-enthusiasts - and the profiteers.

-- SS

Monday, April 10, 2017

Pittsburgh Post-Gazette: "Medication errors in hospitals don’t disappear with new technology". Government: "It's the doctors' fault." I am cited.

The Pittsburgh Post-Gazette published an article on EHR problems yesterday entitled "Medication errors in hospitals don’t disappear with new technology."  It is based on a recent study by the Pennsylvania Patient Safety Authority, retrievable here:  http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2017/Mar;14(1)/Pages/01.aspx

I am cited.  Also cited is an HHS official, Dr. Andrew Gettinger, acting deputy national coordinator for health information technology in the U.S. Dept. of Health and Human Services, who disagreed with my views.  I am familiar with Dr. Gettinger's views.  More on that later.

Medication errors in hospitals don’t disappear with new technology
Steve Twedt
Pittsburgh Post-Gazette
http://www.post-gazette.com/business/healthcare-business/2017/04/10/medication-error-electronic-health-record-hospitals-patient-safety-authority/stories/201704090072

In the first six months of 2016, Pennsylvania hospitals reported 889 medication errors or close calls that were attributed, at least in part, to electronic health records and other technology used to monitor and record patients’ treatment.

A majority of the errors pertained to dosages — either missed dosages or an administration of the wrong dose. Of the 889 errors, nearly 70 percent reached the patient. Among those, eight patients were actually harmed, including three involving critical drugs such as insulin, anticoagulants and opioids.

The extent of the injuries was not detailed, although no deaths were recorded.  Those are the stark numbers in a new analysis by the Pennsylvania Patient Safety Authority, an independent state agency that looks at ways to reduce medical errors.

But interpretations of the report’s significance — and specifically the overall benefits and risks of information technology in a hospital setting — cross a wide spectrum.

The wide spectrum is the gap between those who believe in what might be called cybernetic supremacy (that is, the hyper-enthusiasts who ignore the real-world downsides of technology such as today's EMRs) versus those who promote what I call cybernetic sobriety (a more candid, mature attitude fostered by actual knowledge of the long history of cybernetic failures and the myriad causes of such failures).

Some view reports such as that of the Pennsylvania Patient Safety Authority (PPSA) in a reasonably patient rights-oriented manner, including the PPSA itself:

“This is the classic ‘tip of the iceberg,’” said pharmacist Matthew Grissinger, manager of medication safety analysis for the Patient Safety Authority in Harrisburg and co-author of the analysis with fellow pharmacist Staley Lawes. “We know for a ton of reasons not every error is reported.”

I've written extensively at HC Renewal on the "tip of the iceberg" issue, a phrase also used in the past by the FDA CDER (Center for Devices & Radiological Health) director Jeffrey Shuren MD JD and others.  See for example my February 28, 2010 post "FDA on Health IT Adverse Consequences: 44 Reported Injuries And 6 Deaths In Two Years, Probably Just 'Tip of Iceberg'" at  http://hcrenewal.blogspot.com/2010/02/fda-on-health-it-adverse-consequences.html as well as my January 8, 2016 post "Yet another observation that known health IT-caused injuries and deaths are 'the tip of the iceberg'" at http://hcrenewal.blogspot.com/2016/01/yet-another-observation-that-known.html.

Of course, a PPSA disclaimer was issued, in my view perhaps to placate the health IT industry:

...Mr. Grissinger cautioned that the findings are “absolutely not” an indicator that patients are less safe, as hospitals have moved from paper to electronic records incorporating health information technology...the authors did conclude that technology meant to improve patient safety “has led to new, often unforeseen types of errors” due to system problems or user mistakes.

A more correct statement might have been that "these most current findings are yet another red flag that patients could be less safe with bad health IT, but since there are a 'ton of reasons' not every error is reported, we just don't know - and we truly need to devote a great deal of effort towards filling the gaps in our limited knowledge."

I've written on the issue of not jumping to health IT safety conclusions, one way or another, based on current data, especially when that data is admittedly limited.  For example, see my April 9, 2014 post "FDA on health IT risk:  "We don't know the magnitude of the risk, and what we do know is the tip of the iceberg, but health IT is of 'sufficiently low risk' that we don't need to regulate it" at http://hcrenewal.blogspot.com/2014/04/fda-on-health-it-risk-reckless-or.html.

In that post I noted that a secret 2010 FDA internal report on health IT risk (marked "not for public use") unearthed by investigative reporter Fred Schulte stated that "...In summary, the results of this data review suggest significant clinical implications and public safety issues surrounding Health Information Technology...The absence of mandatory reporting enforcement of H-IT safety issues limits the number of relevant MDRs [device reports] and impedes a more comprehensive understanding of the actual problems and implications."

We don't know what we don't know, but to date the efforts to robustly learn the truth has been milquetoast to non-existent.  "Proof (of safety) by lack of evidence" - in an area where we admit the evidence is likely severely deficient - seems to be the default industry go-to position.  "Proof by lack of evidence", of course, is a logical fallacy.

Back to the Pittsburgh Post-Gazette:


... Frustration with the technology
In January 2015, 35 physician groups — including the American Medical Association, the American Academy of Family Physicians and the American Society of Anesthesiologists — sent a nine-page letter about electronic health records to the national coordinator for health information at the U.S. Department of Health and Human Services.

Their purpose was to convey their “growing frustration with the way EHRs are performing,” the letter stated.

“Many physicians find these systems cumbersome, do not meet their workflow needs, decrease efficiency, and have limited, if any, interoperability. Most importantly, certified EHR technology can present safety concerns for patients.”

That Jan. 2015 letter is at http://mb.cision.com/Public/373/9710840/9053557230dbb768.pdf and speaks for itself.  Kudos to the Post-Gazette for citing it; the public is largely unaware of its existence.

I am then cited in the Gazette article:

Physician Scot Silverstein, a Philadelphia-based consultant and independent expert in electronic health records and vocal critic of such systems, calls the software “legible gibberish” better designed for handling warehouse inventory than managing and monitoring patient care in a clinical setting.

“Electronic health records are a massively complex computer application, far too complex than is needed for a clinic taking care of patients,” he said in a phone interview. “EHRs need to be toned down, be less complex, and be used less.”

Opportunities for mistakes are numerous, he said, as a physician may have to scroll through multiple screens, while each screen with a dozen or more columns plus an array of drop down menus. Some systems, he said, allow doctors to keep screens on multiple patients open simultaneously, increasing the chances of a medication mix-up.

“The software needs to be designed better.”

I am a vocal critic of bad health IT, and actually called the output of the systems to be "legible gibberish" as at my Feb. 27, 2011 post "Two weeks, two reams" at http://hcrenewal.blogspot.com/2011/02/electronic-medical-records-two-weeks.html, but the quote is close enough.

Indeed, today's EHRs seem more designed for mercantile, manufacturing and management settings, and "calm, solitary office environments" (channeling Joan Ash) rather than the incredibly complex, poorly bounded and unpredictable environment of clinical medicine.

I am quoted accurately on the complexity and overuse issue, although the issue of preventing  physicians from having multiple patient screens open was actually a short term workaround known to me to have been put in effect some years back.  This was done when a major EHR was unpredictably transposing orders into wrong charts when multiple patient's screens were open (creating two potential patients at risk).

The software indeed needs to be designed better, to meet clinical needs.


Dr. Silverstein, who says his mother’s death was precipitated by a heart medication mix-up involving her electronic health record, cites federal initiatives giving hospitals financial incentive to implement electronic health systems as pushing the programs without sufficient vetting.

“The thinking was, ‘Computers plus doctors equals better medicine,’ period. But the technology was not and is still not ready for that kind of push.”

Indeed it was not ready, being experimental technology. Further, vetting in real-world settings via robust premarket surveillance, and postmarket surveillance of any rigor were, in fact, absent when massive incentives (and penalties) were announced as part of the so-called Economic Recovery Act and its "HITECH" component.

Instead, he recommends some combination of paper, with paper imaging capability so records are accessible, and electronic systems. “I don’t think paper should or ever will go away completely,” he said.

On this issue, and for a highly successful real-world example, see my August 6, 2016 post "More on uncoupling clinicians from EHR clerical oppression" at http://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html.

I note with some irony about the above linked post (regarding a highly successful EMR that protected clinicians from oppressive clerical burdens) that the newly-appointed Director of the Office of the National Coordinator for Health IT (ONC), Dr. Donald Rucker (http://www.healthcareitnews.com/news/donald-rucker-named-new-national-coordinator-onc), was formerly the Chief Medical Officer of Shared Medical Systems, a hospital infrastructure IT provider.  He then became CMO of the failed Siemens Healthcare EMR effort after SMS was bought out ca. 2000.  Siemens Healthcare officials told me ca. 2007 that the real-world, highly successful invasive cardiology information system I'd developed as shown in the aformentioned Aug. 2016 post was "impractical" for commercial emulation.

Back to the Post-Gazette article.  In it, a government health IT official blames the doctors, a line I've heard dating back to the early 1990s when I was a postdoctoral informatics fellow at Yale:

A need for better training

Anesthesiologist Andrew Gettinger, acting deputy national coordinator for health information technology in the U.S. Dept. of Health and Human Services, disagrees with Dr. Silverstein.

He identified three key components to a successful electronic health record system — good design and implementation and the users’ good understanding of the system.

I have no disagreement there, only on the route to achieve those goals.

“What we find is that many clinicians who complain vociferously about the software and how many clicks it takes, and how user unfriendly it is, have not actually taken the time to understand the system,” he said.

This seems the "blame the physicians, they're just complainers and Luddites" canard I've written about for almost 20 years now.

Gettinger seems to ignore the issue of bad health IT and use error:

  • Bad Health IT is health IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, lacking in evidentiary soundness, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.   (S. Silverstein and J. Patrick).
  • Use error (as opposed to user error) is defined by another U.S. government agency, the National Institute of Standards and Technology (NIST) as follows: "Use error" is a term used very specifically by NIST to refer to user interface designs that will engender users to make errors of commission or omission. It is true that users do make errors, but many errors are due not to user error per se but due to designs that are flawed, e.g., poorly written messaging, misuse of color-coding conventions, omission of information, etc. From "NISTIR 7804: Technical Evaluation, Testing and Validation of the Usability of Electronic Health Records." It is available at
http://www.nist.gov/healthcare/usability/upload/Draft_EUP_09_28_11.pdf (PDF).

No amount of "training" can compensate for those issues.  Further, physicians and nurses just don't have abundant time for such training about mega-complex systems, on which they're already spending 50% or more of their time.  They especially don't have the time to learn multiple EHR's, a situation that exists for clinicians who work on more than one hospital.  I possess the physician and nurse user guides for a number of EHRs though my forensics work.  A manual for an EHR is as complex as a manual for an office suite like MS Office, or an OS such as Windows.

There's also the fact that physicians and nurses are not reimbursed for the hours they spend feeding the payers and other profit-makers the data, for free.

“Quite frankly, doctors are not always the best at signing up for training and taking the training...

Blaming the doctors again.

... , and some of the training is not always the best.”

Not that, as mentioned previously, "training" is at the root of the EHR problem.


He allowed that the usability criticism “is a very legitimate thing to look at”... 

How kind of Dr. Gettinger to acknowledge what has been known in the IT world for decades about poor usability, e.g., this mid 1980's wisdom written for the U.S. Air Force on user interfaces:



GUIDELINES FOR DESIGNING USER INTERFACE SOFTWARE
ESD-TR-86-278
August 1986
Sidney L. Smith and Jane N. Mosier
The MITRE Corporation
Bedford, Massachusetts, USA
Prepared for Deputy Commander for Development Plans and Support Systems, Electronic Systems Division, AFSC,
United States Air Force, Hanscom Air Force Base, Massachusetts.
Approved for public release; distribution unlimited.
SIGNIFICANCE OF THE USER INTERFACE

The design of user interface software is not only expensive and time-consuming, but it is also critical for effective system performance. To be sure, users can sometimes compensate for poor design with extra effort. Probably no single user interface design flaw, in itself, will cause system failure. But there is a limit to how well users can adapt to a poorly designed interface. As one deficiency is added to another, the cumulative negative effects may eventually result in system failure, poor performance, and/or user complaints.

Outright system failure can be seen in systems that are underused, where use is optional, or are abandoned entirely. There may be retention of (or reversion to) manual data handling procedures, with little use of automated capabilities. When a system fails in this way, the result is disrupted operation, wasted time, effort and money, and failure to achieve the potential benefits of automated information handling.

In a constrained environment, such as that of many military and commercial information systems, users may have little choice but to make do with whatever interface design is provided. There the symptoms of poor user interface design may appear in degraded performance. Frequent and/or serious errors in data handling may result from confusing user interface design [in medicine, this often translates to reduced safety and reduced care quality - ed.] Tedious user procedures may slow data processing, resulting in longer queues at the checkout counter, the teller's window, the visa office, the truck dock, [the hospital floor or doctor's office - ed.] or any other workplace where the potential benefits of computer support are outweighed by an unintended increase in human effort.

In situations where degradation in system performance is not so easily measured, symptoms of poor user interface design may appear as user complaints. The system may be described as hard to learn, or clumsy, tiring and slow to use [often heard in medicine, but too often blamed on "physician resistance" - ed.] The users' view of a system is conditioned chiefly by experience with its interface. If the user interface is unsatisfactory, the users' view of the system will be negative regardless of any niceties of internal computer processing.

Back to Dr. Gettinger for a somewhat non-sequitur 'BUT' disclaimer:

... BUT he defended the federal incentives, saying they defrayed the cost to hospitals while encouraging vendors to develop better systems.

I would say the incentives, just like the spectacularly failed subprime mortgage market a decade ago, just incented the health industry to waste hundreds of billions of dollars on half-baked, experimental technology, alienating physicians and nurses (cf.: the 2015 Medical Societies letter mentioned above).  The incented effort even put some organizations in financial jeopardy, e.g.,

 "MD Anderson to cut about 1,000 jobs due to 'financial downfall officials largely attributed to its EPIC EHR implementation project'
" at
http://hcrenewal.blogspot.com/2017/01/heath-it-mismanagement-md-anderson-to.html

"What is more important in healthcare, computers, or nurses and other human beings? Southcoast Health cutting dozens of jobs on heels of expensive IT upgrade" at http://hcrenewal.blogspot.com/2016/04/what-is-more-important-in-healthcare.html

"Lahey Health: hospital jobs lost, but computer vendors prosper" at http://hcrenewal.blogspot.com/2015/05/lahey-health-hospital-jobs-lost-but.html,

"Monetary losses and layoffs from EHR expenses and EHR mismanagement" (http://hcrenewal.blogspot.com/2013/06/monetary-losses-and-layoffs-from-ehr.html),

"Financial woes at Maine Medical Center: Reading this blog might have saved them millions of dollars, and prevented massive 'cost saving initiatives'" (http://hcrenewal.blogspot.com/2013/05/financial-woes-at-maine-medical-center.html),

and "In Fixing Those 9,553 EHR "Issues", Southern Arizona’s Largest Health Network is $28.5 Million In The Red" (http://hcrenewal.blogspot.com/2014/06/in-fixing-those-9553-ehr-issues.html)

I also believe the easy money disincented the vendors from improving the techology, instead selling what they had on hand and acting to discourage innovation and competition to maximize their profits, e.g., see my April 16, 2010 post "Healthcare IT Corporate Ethics 101: 'A Strategy for Cerner Corporation to Address the HIT Stimulus Plan'" at
http://hcrenewal.blogspot.com/2010/04/healthcare-it-corporate-ethics-101.html and my August 31, 2012 post "Health IT Vendor EPIC Caught Red-Handed: Ghostwriting And Using Customers as Stealth Lobbyists - Did ONC Ignore This?" at http://hcrenewal.blogspot.com/2012/08/health-it-vendor-epic-uses-clients-as.html.

Finally, I regrettably note that Gettinger seems to possess a rather hard-nosed attitude about health IT harms.  I have contributed, of course, to articles about EHR's in other publications, including, among many others, Politico.  Arthur Allen at Politico wrote me this in 2015 regarding my opposition to the toothless "Health IT safety center" concept, and my promotion of a need for true HIT regulation:


On Wed, Jun 17, 2015 at 1:13 PM, Arthur Allen <aallen@politico.com> wrote:
I’m putting together a piece on the safety center with some notes from an interview I did with Andy Gettinger a few weeks ago. I asked him whether he though the RTI panel (which RTI named, apparently) would have come to the same consensus – that the safety center should be a safe harbor, not an investigatory agency – if you [i.e., me - Scot  - ed.] had been on the panel.

He said,
“he [i.e., me - Scot - ed.] may have heard what we were intending and been able to step back from specific things relative to his mother’s care and gotten to a space to see that this initiative has the potential of making real change in the EHRs used throughout the country. I would have loved to have Scot at the table.”

Any response?


In other words, if only I was able to "step back" from my mother's severe injury, year's worth of horrible suffering as a cripple before she died as a mentally-impaired vegetable, and my lovely mother being taken away from my home in a body bag as a result of a health IT mishap, I'd be able to see just how wonderful a toothless HIT safety center would be.  (Also, I was never asked to be "at the table".)

What a kind comment that was. 

In conclusion:

While I wish the Pittsburgh Post-Gazette article was longer, in its limited space its author did touch upon the major relevant issues well regarding the PA Patient Safety Authority study and its implications towards national Health IT policy.

ONC's Dr. Andrew Gettinger's responses, however, seems to reflect an unwillingness of he and the government to acknowledge Bad Health IT.  His repsonses also appear to show a lack of appreciation of the complaints about EMRs from nearly 40 medical societies.  "It's the doctors fault" for not training enough.

He does acknowledge that better IT would be a good thing, but to date the best HHS could come up with to achieve that goal is a toothless Safety Center. Healthcare IT would be the only healthcare device sector afforded that extraordinary regulatory accommodation.

The notion that all that is needed to solve EMR problems is clerical training of (resistant) physicians seems that of a computing dilettante, and/or a health IT hyperenthusiast.  Such a view ignores decades of knowledge of bad IT, and in multiple sectors.

The blaming of physicians is also decidedly unhelpful towards the reputation of the technology and its enthusiasts in government.  Bad enough that physicians are already spending 50% or more of their time at computers, distracting from patient care.  Gettinger's "solution" also fails to acknowledge that physicians often work in multiple hospitals with different EHRs. They don't have the time to become clerical experts in multiple mega-complex systems.

Claiming the national incentives promoted the vendors to make better health it is also absurd. It actually promoted them to sell the bad health IT they had on hand, and lessened any motivation to improve the technology.

What the issues really boil down to is a conflict between those who believe in cybernetic supremacy (the hyperenthusiasts who ignore the real-world downsides) versus those who promote what I call cybernetic sobriety (a more candid, mature attitude fostered by actual knowledge of the long history of cybernetic failures and the myriad causes of such failures).

-- SS