Canada: Province-wide electronic medical record computer system 'glitch' causing patients to be turned away from care

This story describes a very bad scenario for sick Canadians.  I offer just a few pithy comments, as not much more than that is needed:

http://medicinehatnews.com/news/local-news/2014/06/10/system-failure-has-docs-patients-upset/

System failure has docs, patients upset

By Gillian Slade on June 10, 2014

Many patients were turned away from their doctor’s office Monday because a province-wide electronic medical record computer system had collapsed.

Province-wide.  Stunning.  A very big argument against centralization of EHR resources.

“This is the third straight week of issues with the TELUS Wolf system,” said Dr. Donovan Nunweiler at Southlands Medical Clinic. “We feel we were encouraged by government to switch to Wolf and now it’s not working.”

I wonder when someone in the Canadian government is  going to issue that now-famous slogan "but patient safety has not been compromised"...

A year ago 202 physician clinics across Alberta using TELUS Wolf were unable to access patient records for most of the day.

More than 200 physician clinics are blind, deaf and dumb?  Wonder what happens to acute patients on days like that.

On Monday patients arrived only to be told the electronic patient files were not accessible making it impossible to see test results, past medical history and medications.

Paper never goes on strike.  Perhaps elimination of paper completely is not such a good idea?

“This is affecting me big time and affecting my income,” said Ken Hoeppner, a patient at HealthWORX Medical clinic, who had waited 15 days for his appointment. “Every time government touches something they wreck it. Our health care used to be good here before Alberta Health Services took over.”

No comment.

At HealthWORX, office manager Carel Liebenberg said the office was doing what it could to reschedule people. One patient had driven three hours to be there for his appointment early Monday.

It's just a "glitch", sir or madam.  Stop complaining. (http://hcrenewal.blogspot.com/search/label/glitch)

At Health Matters Medical Clinic, staff confirmed they too were dealing with no access to patients’ records on TELUS’s Wolf system.

Originally to encourage physicians to move to electronic medical records, the government gave a monetary incentive. Alberta Health selected TELUS Health Solutions Wolf EMR after a request for proposals in 2008.

There was a requirement for the service to be available 99.9 per cent of the time between 6 a.m. and midnight with financial penalties for failure to do so.

“There is no longer any government support,” said Nunweiler. “We (Southlands Medical Clinic) pay $2,000 a month for this. Who is going to hold TELUS accountable now? The government has abandoned us. Cost and issues switching patient data, when systems are not compatible, prevents us from going somewhere else.”

Seems to be this TELUS:  https://www.telushealth.com/health-solutions/electronic-health-records-%28ehr%29.  Sounds like a monopoly to me.

On that page:

TELUS Electronic Health Records (EHR) provides a better way to share, access and consolidate information.

Without quick, secure access to complete and reliable information, healthcare provision can be inefficient, preventing patients from receiving the best care possible.

How ironic.

Liebenberg reached TELUS at 9 a.m. Monday.

“They said they had just become aware of the issue and that their data technicians were in a meeting discussing the problem,” said Liebenberg. “Last week the system was extremely slow, taking 15 minutes for a physician to simply renew a prescription.”

Data technicians were in a meeting?  Sounds like a fantastic way to respond to a Province-wide medical emergency.

Nunweiler said he’d made notes on paper as he struggled to manage the snail’s pace of the system last week. Monday he would be adding to those notes and envisaged several hours at night entering the data to make it current.

Paper never goes on strike.

Liebenberg said the need to re-schedule appointments reflects badly on the clinic and some patients don’t understand it’s a system failure beyond the clinic’s.

That's just great for patient-physician relations.

Dr. Franz Yonker said HealthWORX had been using JonokeMed but the government endorsed TELUS Wolf and physicians were encouraged to switch.

“I think this is really bad for a government-backed system,” said Yonker.

"Wolf" is a somewhat humorous name considering these problems.  As in, a predatory EHR ... one wonders just how much better the others are.

Becky Nelson arrived for her appointment to refill prescriptions and was concerned about how long it would take to get another appointment.

“The government needs to get this on track. We are suffering the consequences,” said Nelson.

I wonder if any patients will suffer the ultimate consequence.  (Hint to Canadians:  never become too dependent on the Government.  Stuff like this happens.)

Donna Schneider brought her mother Vernie Ferguson in for results of some tests. Ferguson said she was not at all well.

“There is nowhere else to go and get my test results,” said Ferguson.

Held medical hostage to bad health IT.  How horrible.

The News requested an interview with TELUS but there was no response on Monday afternoon.

The News requested information from Alberta Health but that was not available on Monday.

Perhaps they're busy, in meetings discussing how to fix the problem.

-- SS

Another Sign The EHR Experiment is Producing Undesired (But Predictable) Results: ED EHRs Produce No Efficiency Gains

Adverse results that run counter to the industry meme of healthcare IT exceptionalism are coming fast and furious.  It's hard for me to keep up with it all.

In addition to my post today "EHR Exceptionalism Debunked: Care Quality Variances Among VA Hospitals Suggest the True Value of Health IT Has Been Grossly Exaggerated" (http://hcrenewal.blogspot.com/2014/06/ehr-exceptionalism-debunked-care.html), here's another.

I won't comment on this very much:

http://www.jwatch.org/na34646/2014/05/30/electronic-charting-less-efficient-paper-charting

May 30, 2014 

Is Electronic Charting Less Efficient Than Paper Charting?
Daniel J. Pallin, MD, MPH reviewing Ward MJ et al. Ann Emerg Med 2014 Jun.

Operational performance was similar before and after computerization at 23 community emergency departments.

The federal government has provided $17 billion in incentives to computerize healthcare. The potential benefits include improved error checking, decision support, better billing, and more data for research. However, some research has suggested that going paperless adversely affects productivity.

To further examine this issue, investigators measured operational efficiency 6 months before and 6 months after implementation of an electronic health record system at 23 community emergency departments. No significant differences between the two time points were found in all efficiency factors that were measured, including time to provider, lengths of stay, walkouts, patient satisfaction, patients seen per provider per hour, and significant return visits.

Citation(s):

Ward MJ et al. The effect of electronic health record implementation on community emergency department operational measures of performance. Ann Emerg Med 2014 Jun; 63:723. (http://dx.doi.org/10.1016/j.annemergmed.2013.12.019)

One might seek to get better results for their $17 billion than, at best, parity to paper.

Finally, the reader comments at that post suggest ED physicians are the ones helping foot the bill.  As one commenter put it:

"Most quality EM docs won't let a record slow their care up front--especially when quaility metrics are staring us down on time until seen or discharge. So we just chart later and go home later."

We as patients certainly should not find a development like that desirable.

Note that in my work as a hospital Chief Medical Informatics Officer (CMIO) I recommended simple document imaging solutions for risk-laden ED's (where charts are usually short) to capture and make the paper chart content available anywhere/anytime ... not full-blown digital electronic medical records systems.

-- SS

Most quality EM docs won't let a record slow their care up front--especially when quaility metrics are staring us down on time until seen or dischage. So we just chart later and go home later. - See more at: http://www.jwatch.org/na34646/2014/05/30/electronic-charting-less-efficient-paper-charting#sthash.WCiV8FQg.dpuf

Most quality EM docs won't let a record slow their care up front--especially when quaility metrics are staring us down on time until seen or dischage. So we just chart later and go home later. - See more at: http://www.jwatch.org/na34646/2014/05/30/electronic-charting-less-efficient-paper-charting#sthash.WCiV8FQg.dpuf

Most quality EM docs won't let a record slow their care up front--especially when quaility metrics are staring us down on time until seen or dischage. So we just chart later and go home later. - See more at: http://www.jwatch.org/na34646/2014/05/30/electronic-charting-less-efficient-paper-charting#sthash.WCiV8FQg.dpuf

Most quality EM docs won't let a record slow their care up front--especially when quaility metrics are staring us down on time until seen or dischage. So we just chart later and go home later. - See more at: http://www.jwatch.org/na34646/2014/05/30/electronic-charting-less-efficient-paper-charting#sthash.WCiV8FQg.dpuf"

From a physician and former USAF air traffic controller/pilot on the state of healthcare IT

From a colleague, a physician and blogger and fellow AMIA member with an eclectic background, on the state of healthcare information technology.  Reposted with his permission.

Emphases in bold are mine:

To restate the old joke, the nice things about medical informatics standards, are their are so many of them too chose from… don’t think we necessarily need to invest even more time and energy on ever more sophisticated data models or ever more exhaustive standards (which are then largely ignored). 

The fact of the matter is that the EMR remains in the United States a tool for maximization of reimbursement and as such is not a  technological destination but rather a technological dead end. The driver for proliferation of this ‘dead end’ is the government being willing to fund its expansion with their fervent hope that it will be their magic bullet for finding the cheats and cheaters of Medicare. 

When I was in the USAF, I was trained to be a software and systems engineer at their great expense and at my great pleasure. Additionally, I was for several years prior to my medical school career a USAF Air Traffic Controller and so I was intimately familiar with perhaps the most perfect of all known systems engineering efforts the Worldwide Air Traffic Control System, and most remarkably (from the wellsprings of my fading memories) I have 50 hours of stick time in the F-16. 

The flying environment of the F-16 which is ‘eyes outside the cockpit’ was made possible by advanced human engineering efforts that resulted in Heads Up Displays of both intense rational and aesthetic beauty that made the machine a joy to fly. 

Fast forward 20 years and what am I given as a clinician to work with…. to keep my head out of the cockpit…… spreadsheets…… designed by engineers who like spreadsheets and think in spread sheets…..  and who don’t even take the 30 minutes it takes to articulate the logic of presentation of clinical data, i.e., present the serum salts together with the BUN/Creatinine, present the RDW with the RBC indices and the hematocrit and hemoglobin … present the last 3 d’s worth of data together aggregated by type rather than alphabetized and homogenized and distributed in clinically illogical boxes. 

The F-16 was designed by engineers, but pilots oversaw its development and the display of its information systems were always the results of intense end user interaction with the design teams. This type of intense physician interaction and veto power of poor information design efforts does not exist in [the health IT] industry. Their goal is feature proliferation and uniqueness (not commonality) of function as a market differentiation tool and to avoid suits for ‘look and feel’ viz a viz the Apple vs Microsoft suits of the 80’s. 

The reality is the train has left, those of us addicted to patient care watch in dismayed horror as our productivity plunges and we struggle to restructure not our workflows but our clinical thought processes to badly designed, logically flawed, and obscenely overpriced documentation tools that distract the expert clinician from a high quality clinical encounter. 

Quite honestly gentleman and gentlewomen of the jury, I don’t give a ‘rats a**’ about superior documentation, I am obsessed with superior outcomes, and as somebody who actually has to work with this junk, it all sucks………. and will continue to suck until such time as real world clinicians have veto power over the efforts of systems design teams with respect to their information design efforts…. What information design efforts?  My point precisely……. 

As always Acerbically Yours, 

frnk m (Frank Meissner)

“I am not a pessimist, I am an optimist who has not arrived’ 

                                                                      Mark Twain

My reply back was:

Frank, on a related note, I was at a fleamarket yesterday looking for radio & electronics stuff (my hobby) and came across a man selling copies of "Aviation Week" from 1960.  He had the entire year's set.

I looked through them and was STUNNED.

The engineering prowess described in not just the articles but in the advertisements as well - bearings, servos, instrumentation, etc. for aircraft and spacecraft was stunning.  There was even an ad for a desktop computer, a Packard Bell PB-250 with "microsecond add time, 350 transistors and 46 (or so) instructions" for a mere $30,000.

What you are describing - and what I have been trying to describe for over a decade and a half - is an intellectually impoverished industry that ignores our specialty [Medical Informatics] and good engineering practices in general.

That AMIA has made itself appear comfortable with that status quo has been a disappointment to say the least.  What you just wrote should have come from the leadership, and years ago, not from the grass roots.

If physicians could refuse use of clinical IT without sanction, I believe in 2014 that most would walk away.

The fact that this technology is now forced on clinicians is not what the pioneers in informatics intended, I am confident; our medical leadership, furthermore, should be ashamed of this set of affairs. As a former medical manager for the Southeastern PA Transportation Authority, even bus drivers and porters in public transit had more rights to determine what equipment they would or would not use in their work, and its configuration, than physicians have in theirs.

-- SS

James Fallows - The Atlantic - "The Use and Misuse of Information Technology in Health Care"

James Fallows, a national correspondent for The Atlantic, wrote "The Use and Misuse of Information Technology in Health Care: Several Doctors Reply" at http://www.theatlantic.com/health/archive/2014/03/the-use-and-misuse-of-information-technology-in-health-care-several-doctors-reply/284601/

It includes several physician responses to an interview with health IT hyper-enthusiast David Blumenthal, former ONC director, at http://www.theatlantic.com/magazine/archive/2014/04/the-paper-cure/358639/.

It would be a poor use of your time for me to add commentary.  Simply read the pieces at the links above.

The doctors' responses piece speaks for itself.

(Actually. I will add commentary:  the sum total of all my posts on health IT here at HC Renewal blog dating to 2004, and all my writing at my site at http://cci.drexel.edu/faculty/ssilverstein/cases/ dating to 1998.)

-- SS

WaPo: "When treating a patient with dementia, electronic health records fall short"

Which raises the question:  for what patient types do EHRs in 2014 not "fall short" in many of the ways cited by this author?

When treating a patient with dementia, electronic health records fall short
By Regina Harrell and Pulse
December 23, 2013
http://www.washingtonpost.com/national/health-science/when-treating-a-patient-with-dementia-electronic-health-records-fall-short/2013/12/20/7bb51b34-416d-11e3-a751-f032898f2dbc_story.html

I am a primary-care doctor who makes house calls in and around Tuscaloosa, Ala. Today my rounds start at a house located down a dirt road a few miles outside town.

... We chat about the spring garden and the rain, then we move on to Mr. Edgars’s arthritis. Earlier on in his dementia, he wandered the woods, and his wife was afraid he would get lost and die, although the entire family agreed that this was how he would want it.

... We talk about how anxious he grows whenever she’s out of his sight and how one of his children comes to sit with him so that she can run errands.

The omitted lines of this physician's encounter are poignant.  Read them at the Wash. Post link above.

... When I get back to the office, I turn on the computer to write a progress note in Mr. Edgars’s electronic health record, or EHR. In addition to recording the details of our visit, I must try to meet the new federal criteria for “meaningful use,” criteria that have been adopted by my office with threats that I won’t get paid for my work if I don’t.

The "meaningful use" criteria, I point out, are an unproven experiment, decided upon by committee.   They are not evidence-based.  Physicians are, in effect, being threatened with nonpayment as part of the experiment.  They have become experimental subjects themselves, for free, and without true informed consent.

Under “History of Present Illness” (HPI), I enter “knee pain.” Up pops a check-box menu: injury-related (surely the chronic wear on Mr. Edgars’s knees from his work as a farmer is some sort of injury, but I don’t think that’s what the computer programmer had in mind), worsening factors (I know of none that apply, since he couldn’t give his own history), relieving factors (there’s no check box for a tired, sleep-deprived wife who’s purposely keeping the dose of acetaminophen low) and so on. Nothing fits, so I exit the HPI and type in “follow-up” (f/u), for which my EHR doesn’t have a pop-up menu. It yields only a blank screen.

As a medical student, I was forbidden to use paper templates to "remind me" of what I needed to record in an H&P or progress note.  The "table of contents" had to be learned and applied from memory.  The continued patronization of physicians, nurses and other clinicians via templates like this, and the resultant de-skilling, time-wasting and other deleterious effects, is harmful to quality care.  This physician comments later that without EHRs and "meaningful use," she could see twice as many patients.

I type the Edgars’s story in my own words, so different from the computer-speak generated by the check boxes. I move on to the Review of Systems — another pop-up menu.

Translation:  handwritten or typed narrative is meaningful; computer-generated prose is largely "legible gibberish", i.e., garbage.  I note that the EHR output in a recent ED visit of my own would have received a failing grade for documentation quality when I was in medical school - and I would have had serious words with a trainee who'd written such sloppy prose when I was a senior resident and attending.

I used to simply write “patient is an unreliable historian” at the beginning of this section, but the computer doesn’t understand that this statement could apply to the entire review.  [Actually, the designers and programmers who believe they are "revolutionizing" the field didn't understand the real world of clinical medicine - ed.] Using a template, it generates a page of 13 sentences, one for each body system, and, under each sentence, the option “Positive: Other: unreliable historian.”  [Which much then be clicked 13 times - ed.]

Sometimes I wonder if it is disrespectful to a patient to say 13 times in one progress note how unreliable a historian he or she is, but I remember that this is great data to mine for research, so I plug on.

This is not just "disrespectful", but a waste of clinician time.

Under “Physical Exam,” there is a template for geriatric patients. I pretend that the computer-speak it generates creates logical sentences, although I know better. In the check boxes, a person can be oriented to person, place and time, or not. Mr. Edgars is oriented to person and place; he knows that he is with his wife and at home, and is happy nowhere else. He no longer cares what year it is. There isn’t a check box for that.

Obviously this "feature" was not even run by medical students, who know that orientation is not "x3" or "none" as the only pertinent options.

Technically speaking, this represents inadequate and insufficiently granular data modeling ... a task I wrote years ago that requires the highest levels of clinical and biomedical informatics expertise, not computer or programming expertise.  There are likely many other examples of poor data modeling in this EHR.

I remember that I must go back to “Social History” and document tobacco use. It occurs to me that if you have not tried tobacco products by your 80th birthday, you are unlikely to suddenly change your mind. Especially when you can’t remember where the store is to buy them. So I slog through the series of check boxes for “never smoker,” an extra six mouse clicks.

More wasted time.

After 15 minutes, the note is finished. And on goes my day of house calls, five in all.  There aren’t enough physicians to see all the homebound patients in my area, so I try to visit as many as I can safely care for.

At day’s end, I review my meaningful use.  I spent more time checking boxes than talking to patients and their families.

I could see twice as many patients if I could write their notes at the bedside while visiting with them.

In other words, in this underserved area in and around Tuscaloosa, Ala., the "meaningul use" of EHRs deprives homebound patients of care.

I would happily do this on paper or using an EHR that created a logical note within the same amount of time. But that is not an option.

Such EHRs are rare, if they exist at all.  Besides, this physician is likely contractually bound to use some larger organization's choice.

The reality is that I spend more time talking to the Information Technology people about Internet connections, firewalls and box-checking than I do answering messages from concerned family members.

In other words, computerization is in the way of the best practice of medicine.

As a teaching doctor, my feedback to the residents now consists mainly of explaining how to document their visits so that we will all get paid, instead of teaching them how to take care of frail elders in their homes.

I remember my community medicine clerkship in the early 1980s in a relatively underserved region in Maine.   Other classmates at Boston University School of Medicine did similar clerkships in Roxbury, an exceptionally poor and harsh section of Boston near Boston City Hospital.  We were taught patient care...with nothing less than the patient's best interests at heart.  Medicine today is now being financially and cybernetically deprived of its heart and soul.

 

I believe I can honestly say the EHR here contributed nothing to the care of this patient, and was deleterious to the overall clinical mission for this patient, and for others.

Harrell is a geriatrician and assistant professor of family medicine at the College of Community Health Sciences, University of Alabama. This is an edited version of a story that originally appeared in Pulse — Voices From the Heart of Medicine, an online magazine of stories and poems from patients and health-care professionals.

I hope that patients who are not suffering dementia will increasingly take notice that these systems are depriving them of their clinicians' attention and of providing good documentation for their future care.  

 

Clinicians themselves, with the exception of some unionized nurses, have grown largely complacent about bad health IT, the "meaningul use" experiment and IT's getting in the way of medical care to feed the bureaucracy.

-- SS

 

Jan. 15, 2014 Addendum: 

 

The reader comments at the original story in "Pulse" magazine are worth reading, and are at the bottom of this page:  http://pulsemagazine.org/archive/stories/310-checking-boxes

-- SS

"Doctors' Dissatisfaction With EHRs May Be Early Warning of Deeper Quality Problems" - And Some Common Sense on EHRs and Clinician Distraction and Time-Wasting

The following article was published regarding physician dissatisfaction with EHRs, referencing a RAND study on EHRs commissioned by the American Medical Association:

http://cnsnews.com/news/article/susan-jones/doctors-dissatisfaction-ehrs-may-be-early-warning-deeper-quality-problems-0

Doctors' Dissatisfaction With EHRs May Be 'Early Warning of Deeper Quality Problems'
October 18, 2013 - 10:17 AM
By Susan Jones

Electronic health records (EHRs) are a source of frustration to many physicians, says a new study conducted by the RAND corporation and commissioned by the American Medical Association.

Electronic health records are a source of frustration to many physicians, according to a study on physician satisfaction sponsored by the American Medical Association.

The findings could serve as an "early warning of deeper quality problems developing in the health care system," the AMA said.

The study, conducted for AMA by the RAND Corporation, found that doctors who perceived themselves or their practices as providing high-quality care reported better professional satisfaction.

Electronic health records (EHRs) were a source of both promise and frustration, the Rand study found.

Although physicians tend to like the concept of EHRs, those surveyed said that current EHR technology interferes with face-to-face discussions with patients; requires physicians to spend too much time performing clerical work; and degrades the accuracy of medical records by encouraging template-generated doctors' notes.

I believe the title should have been "Doctors' Dissatisfaction With EHRs Is A Warning of Deeper Quality Problems".  The academic-style fudge words "may be" and "early" are disposable.

"Physicians [i.e., all of them - ed.] believe in the benefits of electronic health records, and most do not want to go back to paper charts," said Dr. Mark Friedberg, the study's lead author and a RAND scientist. "But at the same time, they report that electronic systems are deeply problematic in several ways. Physicians are frustrated by systems that force them to do clerical work or distract them from paying close attention to their patients."

Dr. Friedberg commits a faux pax symptomatic of an amateur scientist (or of a politician).  That is, making a statement that seems to speak for all physicians, and then for "most" physicians.  Clearly he didn't interview "most" physicians.  I know many who see the EHR as bureaucratic invasion of little clinical utility, and would gladly dump the poorly-engineered EHRs foisted on them that "interfere with face-to-face discussions with patients; require physicians to spend too much time performing clerical work; and degrade the accuracy of medical records" for good old-fashioned paper, supplemented perhaps with document imaging systems that make the notes available anywhere, anytime.

... Health and Human Services Secretary Kathleen Sebelius has said that EHRs will lead to "more coordination of patient care, reduced medical errors, elimination of duplicate screenings and tests, and greater patient engagement in their own care."

Sebelius is parroting others; there is little or no robust evidence supporting such a grandiose assertion (or, typical of today's politicians, she's simply lying; the reader can decide which).

For 2014, some commonsense observations and recommendations on EHRs:

1) The pioneers in the 1950's and 1960's developed systems and experimented with their use in an environment far freer of the bureaucratic need for massive amounts of ultra-taxonomized data than today, where visits were not forced to be time-limited for "productivity", and where clinical notes were pithy and terse, as they were for patient care, not bureaucratic satiation.  The pioneers likely could not have conceived of what clinicians are being called on to enter manually, in 2014.  (I was taught Medical Informatics by some of those pioneers.)

2) The pioneers never intended to add uncompensated burdens onto clinicians.  They intended to help clinicians practice medicine more smoothly, not in a time-starved and robotic, slave-to-the-machine fashion.

3) The health IT industry and its health IT designers, and the largely medically-incompetent data processing/merchant computing personnel in hospital IT departments, appear to have not cared less about these real-world HIT issues - as evidenced by their products - until the pressure was put on by users, resulting in studies of IT safety by the Institute of Medicine (http://hcrenewal.blogspot.com/2010/10/cart-before-horse-again-institute-of.html) and of IT usability by NIST (http://hcrenewal.blogspot.com/2010/12/nist-provides-healthcare-it-industry.html) in just the past few years.

With these factors in mind:

... AMA noted that some medical practices are experimenting with ways to reduce physician frustration by hiring additional staff members to perform many of the tasks involved in using electronic records, such as data entry.

Actually, the use of clinicians as computer data-entry clerks was the real experiment, an experiment whose failure is becoming increasingly apparent. 

The "experiments" with hiring of data entry clerks should be made official healthcare policy as follows: 

1)  Physicians and nurses should be relieved of the burden of data entry into computer interfaces (as opposed to merely viewing) nearly entirely.  Data entry cannot be done under the real-world conditions of patient care in 2014, for most specialties, without compromising the focus on patient care (let alone clinician morale).  

2) Considering the hundreds of millions per organizations spent on theses systems, a pool of data entry clerical staff can well be afforded, hired and trained to transcribe data into computers from clinicians' paper notes, using specialized forms where necessary.  

3) Those same paper notes can be rapidly imaged into a document management system (e.g., Documentum, http://www.emc.com/enterprise-content-management/documentum-platform.htm; I managed a pharmaceutical department of ~55 people and a $13 million budget using such a system) and made available before transcription.  The note images can also serve as a supplement to data viewing screens in the EHR, which at least in 2014 are themselves poorly engineered from the perspective of optimal presentation of information.

4) The workflows for such arrangement are known to me; I created such an environment in a busy invasive cardiology department, a critical care area performing more than 6000 procedures/year and responsible for 25% of the organization's revenues - fortunately having been able to neutralize and marginalize an IT department seemingly hellbent, perhaps through ignorance, on sabotaging the effort.  See "Essential Value of Medical Informatics Expertise in High-Risk Areas: an Invasive Cardiology Example" at http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story.  The offloading of data entry by clinicians into the computer, and the use of special paper forms for the clinicians, worked exceptionally well in allowing the clinicians to focus on what really matters most - patient care.

5) If healthcare organizations insist on direct clinician data entry, then clinicians' time doing so should be fairly compensated.  Lawyers generally earn from $250/hr and up for profession-related clerical work, like creating legal briefs and letters.  I think physicians should do at least as well.  (If readers believe clinicians should take on this considerable burden and not be fairly compensated, I'd like to hear why.)

6) If healthcare organization leaders truly believe the EHR hyper-enthusiasts, the expense of the clericals will be far offset by the "billions and billions" saved by these systems.

       a) If they don't believe the EHR hyper-enthusiasts, they should be far more skeptical of implementing such systems and imposing the mission-robbing burdens on their clinicians in the first place.

7) These measures will free industry resources for doing what really matters most in clinical care, namely, health IT robustness (freedom from error, security, etc.) and optimal presentation of information customized for the needs of the many different clinical specialties and subspecialties.

-- SS

Yet Another "Anecdote" - Inpatient Results of Electronic Prescribing "Disappointing"

Many of those in the Medical Informatics community, especially the academics in the upper echelons of the American Medical Informatics Association, are not of a risk recognition / risk management mindset.  Typical of academics, they are often also hostile towards dissent from the party line, as you can read about at my post "The Dangers of Critical Thinking in A Politicized, Irrational Culture" at http://hcrenewal.blogspot.com/2010/09/dangers-of-critical-thinking-in.html.

The academics, with a few exceptions, have repeatedly conflated scientific anecdotes of supposed positive results from health IT with risk management-relevant incident reports of bad outcomes and 'near misses', as an Australian colleague wrote about, via me, on August 17, 2011 at "Anecdotes and Medicine, We are Actually Talking About Two Different Things" at http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html).

They dismiss the latter incident reports, even when from well-qualified observers, while giving great attention and credence to the former [a few years as a safety manager in a large urban transit authority disabused me of that type of behavior - ed.], when the former conveniently fit their most cherished beliefs about the beneficence and efficacy of today's health IT.  Further, quality or lack thereof of the former type of evidence is often not considered.  See for instance my post of March 9, 2011 "ONC: The Benefits Of Health Information Technology: A Review Of The Recent Literature Shows Predominantly Positive Results" at http://hcrenewal.blogspot.com/2011/03/benefits-of-health-information.html for a stunning example of this phenomenon directly from the national leadership of health IT.

In my view, this phenomenon has led to a substantial loss of focus on health IT realities needed in order to remediate the industry and realize the true benefits of which the technology is capable.

Now there's yet another "anecdote" at Med Page Today.com for the experts to chomp on:

http://www.medpagetoday.com/MeetingCoverage/ASHP/43400?utm_source=cardio-meetings&utm_medium=email&utm_content=mpt&utm_campaign=DCH

E-Prescribing: Inpatient Results Disappointing
Published: Dec 12, 2013
By Sarah Wickline , Contributing Writer, MedPage Today

ORLANDO -- Electronic prescription order entry and medication reconciliation reduced some errors in hospital settings but increased others, and did not meet overall expectations, researchers reported here.

After implementation of a computerized prescriber order entry (CPOE) system, one hospital experienced a 29.2% increase in medication dispensation errors (P less than 0.05), Ramadas Balasubramanian, PharmD, PhD, of the Carolinas Medical Center-Pineville in Charlotte, N.C., and colleagues reported at the midyear meeting of the American Society of Health-System Pharmacists.

It is likely these are qualified observers who in fact might be expected to be biased towards showing good results of this technology.

In a second study, another hospital experienced a 12% improvement in accuracy (P less than 0.001) after implementation of electronic medication reconciliation charts, according to Jill Covyeou, PharmD, of Ferris State University in Big Rapids, Mich., and colleagues.

For the tens of millions of dollars likely spent to achieve a mere 12% improvement, one wonders if a far less expensive investment in experienced human resources might not have accomplished the same results or even far better.

For their study, Balasubramanian and colleagues looked at the impact of CPOE on medication errors in a community hospital setting.

At the end of 2011, when the Carolinas Medical Center-Pineville hospital had only 119 beds, officials there implemented the CPOE-CANOPY system. In early 2012, the hospital nearly doubled in capacity to 210 beds and opened the pharmacy to 24-hour operation. The researchers looked at medical errors from October 2008 through October 2012.

The categories of medication errors included: drug omission, administration at the wrong time, unauthorized drug, wrong dose, and wrong form of dose.

Any of which, of course, can harm or kill, I note.

There was a 57% increase in medication doses from prior to the CPOE system to after implementation, but even after volume adjustments, the number of errors per 1,000 dispensed medications still increased by 29.2% (P less than 0.05).

Bad health IT such as CPOE systems designed for (per Joan Ash) "calm and solitary office environments" would be expected to perform more poorly as caseloads increase and clinicians have less time for computer fritter.

Unauthorized drug dispensation and improper dose of medication decreased post-CPOE, but drug omission and administration at the wrong time were responsible for the increase.

Those seem to match the expressed concerns of another large group of "anecdote-profferers", e.g., the nurses at my Nov. 17, 2013 post "Another 'Survey' on EHRs - Affinity Medical Center (Ohio) Nurses Warn That Serious Patient Complications 'Only a Matter of Time' in Open Letter" at http://hcrenewal.blogspot.com/2013/11/another-survey-on-ehrs-affinity-medical.html:

From those nurses' Open Letter to management on health IT risks:

... Some of the concerns that nurses have brought to the attention of management include:

• Medication errors/scanning issues - perhaps the biggest concern of all RNs
• RNs unable to access patient records for hours at  a time
• Incorrect descriptors and inaccurate drop-down menus
• Incorrect calculations in the I&O and MAP [mean arterial pressure - ed.] portions of the chart 
• Inaccurate medication times and the inability of RNs to ensure medications are scheduled correctly
• Endless loops of computer prompts that are unable to be dismissed by RNs in an emergency

Back to the current Med Page Today.com article:

The use of CPOE software created a time cut-off issue that explained the wrong time of administration increase, the study authors told MedPage Today. If drugs were ordered 5 minutes after the cut-off for the morning medication administration, they would not make it to the patient until the evening rounds unless a special alert was sent to the nurse staff.

That is, a time-eating and fragile (and thus potentially dangerous} workaround.  I note that one does not have to work around something that is not standing in their way.

Balasubramanian and colleagues suggested that the lack of flexibility in the CPOE software was responsible for the drastic increase in medication errors, despite the fact that they thought it would improve error rates across the board.

In other words, the software is not truly fit for purpose.  See definition of "bad health IT" below.

... The authors suggested that electronic prescribing would be better with electronic medical records. "[E]lectronic prescribing alone may fail to increase medication list accuracy to the extent we would like," Covyeou wrote.

Replace "may fail" with "in our case, did fail."

The point about adding an EHR is certainly in the category of "wishful thinking."

If the EHRs are bad health IT, I opine the situation would likely get even worse (cf. Affinity Health, above).

From my site at http://cci.drexel.edu/faculty/ssilverstein/cases/: 

Bad Health IT ("BHIT") 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, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.

In summary, the technology is not a panacea, and can in fact be worse than paper.  Those who blindly ignore that reality and push for mass rollout of this still-experimental technology "no matter what" do not share, in my opinion, the ethics I was taught in Medical School.

-- SS

Sickness in the Information Technology Sector: Technical problems, discord plagued Maryland health care site

Eye-opening, ground-level, no-holds-barred accounts of IT mismanagement and mayhem are too rare, considering the stakes in 2013.  The behind-the-scenes crap that goes on needs a great deal of sunlight. Below is such an account of great merit, in the Baltimore Sun.

First, I note physicians and nurses are generally able to collaborate to take care of sick patients.  They are natural "team players"; taking care of patients is their professional calling.  I did it all the time in my patient care years, especially in critical care settings, where lack of collaboration with colleagues could lead to dead patients.

IT personnel are another species entirely.  It's all about territory, competition, self-promotion, empire-building, drinking from the ever-flowing fountain of money, etc.; process matters more than results; and to hell with the end users, let alone patients.

Here is, in macro form, the Fifty Shades of Mass Dysfunction I've often encountered when my professional work intersected with IT personnel, whether in hospitals or industry.  And I was supposed to simply "shut up" about this crap - i.e., go along to get along:

Technical problems, discord plagued Maryland health care site
http://www.baltimoresun.com/health/bs-hs-exchange-woes-20131207,0,6559272.story 

By Meredith Cohn and Andrea K. Walker, The Baltimore Sun 10:50 p.m. EST, December 7, 2013

Although state officials have provided the public scant detail about the troubled launch of Maryland's version of Obamacare, emails and documents show that the project was beset behind the scenes for months by an array of technical issues, warring contractors and other problems.

Since Maryland's online health exchange opened Oct. 1 for people to buy insurance under the Affordable Care Act — and immediately crashed — the two main companies in charge of the website have taken their fight to court, a corporate project manager was replaced and a high-powered consulting firm was quietly brought in to restore order. Though state officials initially said the crash of the online exchange was an unexpected and fixable problem, emails and documents obtained by The Baltimore Sun through state open-records laws outline serious issues before and after the launch.

The revelations came just days before Rebecca Pearce, the head of the exchange, resigned. State officials announced that move Friday night and pulled Carolyn Quattrocki from the governor's health reform office to serve as an interim replacement

I am going to reproduce some paragraphs that show just how chaotic are the processes - in any health IT endeavor, whether they be for the exchanges that are essential to getting insured, or to the hospital IT systems that are essential to getting out of the hospital in something other than a pine box.

Emphases mine:

Just two weeks before the launch, Pearce visited the prime contractor's Linthicum headquarters and found a room of empty seats. She fired off an email questioning the company's commitment to resolve problems and reminding the contractors of what was at stake: "Tonight, I am begging. I don't know how else to say it: we have got to make this a reality."

Despite her proddings, in-fighting between contractor Noridian Healthcare Solutions and a key subcontractor, EngagePoint Inc., disintegrated amid finger-pointing and accusations in court papers. At one point, after Noridian severed contractual ties between the companies but continued to ask for help, EngagePoint CEO Pradeep Goel emailed Noridian officials: "Are you people on crack cocaine?"

Contractors, subcontractors, all offering "solutions" in healthcare and all likely to have not a single soul on board with anything beyond a merchant-computing background.

And nice, friendly questions amongst the friendly, collaborative finger-pointing and accusations typical of the IT world when mass mayhem occurs.

And a begging boss?  How lovely.

... Pearce, who was hired in 2011 at a salary of $175,000, declined to comment on problems surrounding the exchange or her resignation.  [If I were her I would have resigned out of disgust with these idiots.  Oh wait - I did leave IT positions for reasons, in part, like that  - ed.]

The emails provided by the state covered the two weeks before and after the website launch. They give only a limited behind-the-scenes view of creating and launching the exchange. Officials withheld an unknown number of emails, saying state law exempts them from disclosure because they involved the decision-making process of high-ranking executive officials.

The troubles in Maryland mirror problems faced by other state exchanges, as well as the federal portal providing insurance options to consumers in 36 states.

 Emails withheld under claims of legal privilege means we'll never know all the dirt.

... In Maryland, Sharfstein said the complexity was compounded because of an aging state Medicaid computer system that needed to be integrated into the exchange. Officials also chose to customize existing technology that proved tougher to retrofit than expected, he said.

"Unlike buying a book online from Amazon, this process is more akin to applying for a passport, buying a home, and receiving an individually calculated tax credit all through a single web portal," O'Malley said Friday night. "We had more user glitches and user problems than we had hoped.

"A longer testing period might have allowed us to prioritize and address more of these problems before the launch date. Time and ultimate success will tell whether the decision to purchase off-the-shelf software and employ multiple contractor entities were good or bad decisions."

"Hope" is not a proper project management technique of which I am aware, especially in a project of the admitted complexity as this one.

"Tougher to retrofit than expected?" Expected by whom?  IT "experts" who believe in unicorns and the tooth fairy?  I point out that in medicine, such mistakes are called "malpractice."

A longer testing period might have allowed us to address more problems?  But they went live anyway?

... In early 2012, the state gave a $71 million contract to develop the website to a Noridian-led team that included Curam Software, IBM and Connecture. To save time in creating the exchange, the Maryland legislature exempted the contract from the normal procurement process, and North Dakota-based Noridian outscored three other bidders.

Sharfstein said Noridian will likely remain at work in its Linthicum offices beyond its contract's year-end expiration. The company has already been paid about $57 million but the state contract allows penalties for delays. State officials declined to comment on whether any penalties will be sought.

Noridian is ultimately responsible for delivering the system, Sharfstein said. EngagePoint, which is based in Calverton, was not included in the original contract and appeared to have been hired without the exchange's knowledge, officials said.

The state first learned of the companies' "deep strains" in the three months before the website launched, according to documents in U.S. District Court in Baltimore. The issues disputed included accounting, project management, intellectual property and payment.

Emails offer a glimpse at how their differences affected efforts to build the site and then fix post-launch problems. Pearce repeatedly questioned the contractors' commitment to the project after Gov. Martin O'Malley announced on national TV that Maryland's site would go live on time.

On Sept. 22, after Sen. Barbara Mikulski echoed the governor in publicly applauding Maryland's readiness, Pearce wrote the contractors: "It's time to get this right. Now. Period."

Noridian was also criticizing the subcontractor it hired. On Sept. 25, Noridian's project manager wrote to Goel, complaining that EngagePoint refused to perform critical work: "EngagePoint is responsible for 'designing and implementing [an exchange] system,'" the project manager wrote.

The 8 a.m. launch was supposed to allow the estimated 800,000 uninsured Marylanders to sign in and browse 45 plans from six insurers. Officials had warned of "bumps in the road," but the site crashed in minutes.

... "As the executives in charge of this program, I would like to understand from you exactly what is happening with the project and what you are doing to address the issues," she wrote to the contractors at 7:56 a.m. on Oct. 2. By 4:10 p.m., she questioned why 85,000 people had hit the "get started" button, but there fewer than 500 accounts had been created.

About a half-hour later, she wrote to the contractors, "Can you please provide an update on what is going on right now? Who is on site? What has anyone learned?"

Some of the companies' emails focused on achievements rather than dwelling on worsening problems.

Noridian CEO Tom McGraw wrote to state officials on Oct. 4, "We have seen increases in all aspects of the system performance over the last several hours and anticipate that these will start showing in the next report."

But four days later McGraw notified state officials that the project manager was being replaced.

Conflict, favoritism, fighting, "it's not my job", lies, spin, stonewalling, strife ... chaos.

"Efforts to build the site and then fix post-launch problems" is also typical of the IT world.  In health IT, especially clinical IT, those harmed or killed during the "fixing" process are considered a necessary sacrifice, a "bump in the road."

... Paul von Ebers, CEO of Noridian Mutual Insurance Co., Noridian's parent company, wrote on Oct. 10 that the consultants "expressed concern with ongoing coordination issues between the Noridian and EngagePoint teams." He requested a meeting to resolve "working differences" between the companies.

This was days before Noridian fired EngagePoint, sparking the angry email exchanges and dueling lawsuits between the companies. Noridian then sought to hire EngagePoint workers; EngagePoint sued and was met with a counter-suit.

"We are expected to do piecemeal work for Noridian after contract termination because you just woke up and decided you don't know what you are doing?" Goel wrote Oct. 26. "We are not going to respond to ridiculous emails from Noridian demanding our team members show up for work after being escorted out of the office."

That's the path to progress:  firing subcontractors and attempting to steal their employees, and lawsuits and countersuits.

I could go on, but read the entire postmortem account (itself rare in large IT projects) at the Baltimore Sun link above.

Some of the de-identified cases at my academic site on health IT difficulties reflect this type of discord; some are mine personally such as at http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=clinical%20computing%20problems%20in%20ICU , http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story and http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cultures%20of%20mismanagement%20toxic%20to%20healthcare%20quality.

I was expected to "go along to get along" with this BS, and was deemed "not a team player" when I spoke up for enduser (clinician) and ultimate customer (patient) rights.

In summary, the IT world is demonstrably dysfunctional, with the types of conflict as in the Baltimore Sun story more the rule than the exception, especially where healthcare is concerned.  Good, relatively brief resources for better understanding these issues are the following papers:

Social Informatics.  An introductory essay entitled “Learning from Social Informatics” by R. Kling at the University of Indiana can be found at this link (PDF).  The book “Understanding And Communicating Social Informatics” by Kling, Rosenbaum & Sawyer, Information Today, 2005 (Amazon.com link here) was based on this essay.

Pessimism, Computer Failure, and Information Systems Development in the Public Sector.  (Public Administration Review 67;5:917-929, Sept/Oct. 2007, Shaun Goldfinch, University of Otago, New Zealand).  Cautionary article on IT that should be read by every healthcare executive documenting the widespread nature of IT difficulties and failure, the lack of attention to the issues responsible, and recommending much more critical attitudes towards IT.  linkto pdf

“Defensive climate in the computer science classroom” by Barker et al., Univ. of Denver.  Link here(subscription required).  May help explain the control-seeking culture of IT personnel.   As part of an NSF-funded IT workforce grant, the authors conducted ethnographic research to provide deep understanding of the learning environment of computer science classrooms. Categories emerging from data analysis included 1) impersonal environment and guarded behavior; and 2) the creation and maintenance of informal hierarchy resulting in competitive behaviors. These communication patterns lead to a defensive climate, characterized by competitiveness rather cooperation, judgments about others, superiority, and neutrality rather than empathy.

If a person thinks this technology will "revolutionize" healthcare anytime soon, considering the "people issues" involved let alone the technical ones, then that person is either hopelessly naïve, or needs a mental health evaluation (colloquially, "needs their head examined").

-- SS

Australian Medical Association on EHR rollout: 'Hard to use, increases workload, hard to find data, we just don't seem to have got the outcome we were looking for.'

Some familiar themes from the Australian Medical Association on their attempt at a National Programme for Health IT:

Electronic health records rollout has not met expectations, Australian Medical Association says
http://www.abc.net.au/news/2013-11-04/ama-says-rollout-of-electronic-health-records-needs-work/5066680

Updated Mon 4 Nov 2013, 8:59am AEDT

The Australian Medical Association says the rollout of electronic health records has not met expectations.

Federal Health Minister Peter Dutton has announced an independent review of the project to see how it can be improved.

AMA national president Dr Steve Hambleton, one of the panel members for the review, says e-health records need to be made easier for doctors to use.

Ease of use seems a constant, unremitting problem.  An independent review (if truly independent) is a wise move - and sorely needed in this country, where the narrative is controlled by the industry and its government sponsors/cheerleaders.

A bit of wisdom comes to mind, from (of all people) weapons inventor Mikhail Kalashnikov:  "All that is too complex is unnecessary, and it is simple that is needed."

(Satirically speaking, would it be helpful  if health IT designers, when suffering from, say, acute renal colic, or Bornholm disease a.k.a. devil's grip, http://en.wikipedia.org/wiki/Bornholm_disease, were made to wait for treatment until the doctors and nurses navigated every single tab, menu, pulldown, selection list, etc. to enter all of their data? Perhaps that would be an educational experience for them ... )

"It's certainly timely to actually have a look at the e-health records and just see where it is, where it's going, whether it's actually achieved what it set out to do and what we need to do to actually make it work," he said. 

I think the question of  "whether it's actually achieved what it set out to do" was meant as rhetorical.

"The profession's always supported this, we just don't seem to have got the outcome we were looking for."

That's because the profession - both in Australia and the U.S. - has abdicated leadership of healthcare informatics efforts, instead delegating it to those without domain expertise, and/or the incompetent.

This is a sure path to the results we now are getting both here and Down Under.

From a recent essay at the "Sultan Knish" Blog by writer Daniel Greenfield (http://sultanknish.blogspot.com/2013/10/government-is-magic.html) on competence and the Obamacare insurance website debacle:

... Modernity has to be built. It has to be constructed brick by bit by rivet by cable by people who know what they are doing. Modernity without competence is as worthless as the ObamaCare website which looked pretty enough to give the illusion of technocratic modernity, but didn't actually work.

Competence is the real modernity and it has very little to do with the empty trappings of design that surround it. In some ways the America of a few generations ago was a far more modern place because it was a more competent place. For all our nice toys, we look like primitive savages compared to men who could build skyscrapers and fleets within a year... and build them well.

Unfortunately, there is no easy solution to this problem, since in this industry, failure is an option, and a profitable one at that.

Mr Dutton says a lot of money has been spent on the project, but that the take up rate has been low.

In the U.S., the takeup rate has been artificially accelerated by economic incentives and penalties (via the HITECH Act of 2009).  Australia seems to lack such a plan at present.

Concerns were raised in July that the new system, which was trialled in parts of New South Wales, Queensland and Victoria, makes it difficult for doctors to access updated information. 

I opine that it takes remarkable incompetence to design software using computers that can store, retrieve and process data at speeds unimaginable just a few years ago, that actually make it difficult for users to access current information.

Doctors also complained that the e-health program, designed to link a patient's medical records between doctors, hospitals and other providers, was increasing their workload.

From the linked article "E-Health Flaws Adding to GP Stress", http://www.abc.net.au/news/2013-07-16/e-health-flaws-adding-to-gp-stress/4822186:

Many Newcastle GPs say the system is adding to stress levels and making their workloads excessive. They are complaining the E-health program unworkable in its present form and is increasing their workload by up to two hours a day.

For little benefit, I add.

... Dr Hambleton says the initial version of the system has several strong aspects and is safe and secure, but that key changes will benefit doctors.

"Clinical utility means that it decreases the search time and that we've got accurate information there. Those are the things that'll make clinicians want to use it and be able to use it."

Translation: major changes might actually make the systems useful, instead of a time-sapping annoyance (at best), and a danger (at worst).

-- SS

A new and very interesting EMR "glitch" - no warnings on stopping a medicine that diminishes the effects of a second medication

A new and very interesting EMR "glitch" from a report I received recently:

... I found a glitch with my [name redacted] EMR. It probably happens with all EMRs. I had a patient on primidone (http://en.wikipedia.org/wiki/Primidone) for essential tremor. Later, his primary care put her on warfarin [a "blood thinner" - ed.] for atrial fibrillation. Some time after that, I took her off of primidone.  Her INR jumped to 7 or 8. [High - ed.] What happens is that the EMRs warn a physician pretty well if you START a medicine that interacts with warfarin, but fails to warn if you STOP a medicine that interacts with warfarin. If you are used to relying on your EMR to warn you about drug interactions, you can fall into this trap easily, as I found out. Luckily, the patient was not harmed.

In other words, if a medication that interacts with another medication by suppressing the latter's effects to some degree is discontinued, EMRs may not warn of it.  Stopping the former can accentuate the effects of the latter, and disaster can result.  A primidone metabolite, phenobarbital, decreases INR and the anticoagulant effects of warfarin (http://www.medscape.com/viewarticle/745645_3).  Stop primidone, but continue warfarin, and ... wham.

The alert algorithms were apparently not designed with this eventuality in mind ... probably because the designers never thought of this issue.  Medicine is not as easy as it might appear to the outside, non-expert observer.

-- SS

Louise Schaper, PhD, CEO, Health Informatics Society of Australia: "What's Missing From the Health IT Investment? - Health Informatics"

Louise Schaper, PhD, CEO of the Health Informatics Society of Australia (HISA, http://www.hisa.org.au/), graciously extended an invitation in 2011 that I could not attend, and again in 2012 (that I accepted) to give a keynote presentation at HISA's annual convention, Healthcare Informatics Conference (HIC).  A writeup of my HIC2012 presentation in Sydney is at http://hcrenewal.blogspot.com/2012/08/my-presentation-to-health-informatics.html.

I unfortunately could not make it Down Under for HIC2013 in Adelaide.  However, HISA has posted videos of a number of presenters.

One of the presenters is Dr. Schaper.  Her presentation "Health Informatics: A megatrend driving investment, careers & delivering the future of healthcare" is at http://www.hisa.org.au/page/hic2014videos (bottom video).  It is well worth watching.

Louise Schaper PhD, CEO, Health Informatics Society of Australia

After reviewing the potential benefits of heathcare IT, Dr. Schaper asks what I consider the most critical question of all.

At 08:20 she asks:  "What's missing from this [multi-billion dollar] investment?"

The answer is "Health Informatics."

Dr. Schaper then indicates the real-world implications of the field of commercial health IT largely missing its critical founding scientific discipline:

At 13:00 she amplifies the point further:  We are not learning our lessons!  The themes of that slide are familiar to readers of this blog, and to current health IT users:

Dr, Schaper then goes on to cover some real-world issues related to impediments to meaningful health informatician engagement in health IT design, implementation and other aspects of leadership.

The presentation is worth watching in its entirety.  The issues in health IT of meaningful involvement and leadership by those with expertise in healthcare informatics (as compared to, for example, those in manufacturing, mercantile, and management computing whose experience is often ill-suited for high-level roles in healthcare projects) are truly international.

Finally, for those in the U.S. not used to Australian accents, Dr. Schaper's is quite enjoyable to listen to.

-- SS

Words that Work: Singing Only Positive - And Often Unsubstantiated - EHR Praise As "Advised" At The University Of Arizona Health Network

When clinicians are told to promote a technology in no uncertain terms, that puts a chilling effect on critical thinking and discourse.  In effect, when under orders to only speak positively about a hospital or its technology, saying anything bad could very likely get clinicians labeled as 'troublemakers' or 'disruptive clinicians.'  Sometimes - in a sadly real example at Affinity Health - it may even get threats of having complaints plastered to one's forehead (see http://hcrenewal.blogspot.com/2013/07/hows-this-for-patient-rights-affinity.html), a threat answered to by a judge.

The 'disruptive' label usually does not have a good effect on one's evaluations and job (or, for doctors, even career) longevity.  See, for example, the resources at http://www.aapsonline.org/index.php/article/sham_peer_review_resources_physicians/ on sham peer review.

At University of Arizona Health Network (UAHN), clinicians are being told to promote the EPIC EHR.

The campaign is under the aegis of executives who know, should know, or should have made it their business to know the mayhem caused at other medical centers by EPIC and other major clinical IT systems (see for example query links http://hcrenewal.blogspot.com/search/label/EPIC and http://hcrenewal.blogspot.com/search/label/healthcare%20IT%20difficulties).

Here's what clinicians are bring told in the Oct. 3, 2013 "Weekly update for UAHN employees":

Words that Work 

Talking positively to our patients about our new Electronic Health Record system is important! Here are some key words and phrases you can use to emphasize the many benefits of the new system:

• Electronic health record (not ‘Epic’ or ‘EHR’)
• One comprehensive record
• Coordinated care
• Improves patient safety & quality
• Convenient, easy patient portal 
• Private and secure

Click here for more words and behaviors to inspire confidence in our patients (and ourselves) as we transition to this new system.

The link to "more words" produced this PDF:

"Words that Work" - If I worked there, I would be concerned that that using "words that don't work" about a project that probably cost hundreds of millions of dollars would likely injure my career.  Click to enlarge.

This is shameless.  Many of these claims are unsubstantiated or in significant doubt in the literature.

First:

They left out issues such as these:

• The software is tested and validated for safety by nobody, including traditional medical device safety testers.

• No postmarket surveillance for problems, either.

• Transparency about problems that can cause patient harm is severely impeded by systematic impediments to information flow (as per IOM's 2012 study of health IT safety at http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html, FDA via their leaked Internal Memo on HIT safety as at http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html, the Joint Commission in their Sentinel Events Alert on Health IT as at http://hcrenewal.blogspot.com/2008/12/joint-commission-sentinel-events-alert.html, and others.)

• Problems known are only the "tip of the iceberg" (FDA, ECRI Institute), as at http://hcrenewal.blogspot.com/2010/02/fda-on-health-it-adverse-consequences.html and http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html 

(Mar. 2014 addendum: add to that list the revelations of med mal insurer CRICO, that EHR technology has contributed to a substantial fraction of the medical malpractice suits in Massachusetts: http://hcrenewal.blogspot.com/2014/02/patient-safety-quality-healthcare.html)

Of the claims they do make:

• Efficient - see aforementioned links as well as "Common Examples of Healthcare IT Difficulties" at http://cci.drexel.edu/faculty/ssilverstein/cases/

• Convenient - as above.  According to whom?  Compared to what?  Pen and paper?

• Improves patient safety and quality - see IOM report post at http://hcrenewal.blogspot.com/2011/11/iom-report-on-health-it-safety-nix-fda.html .  We as a nation are only now studying safety of this technology, and the results are not looking entirely convincing, e.g. ECRI Deep Dive Study of health IT safety at http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html.  171 health IT mishaps in 36 hospitals, voluntarily reported over 9 weeks, with 8 reported injuries and 3 reported possible deaths is not what I would call something that "improves patient safety and quality" without qualifications.

• The Cadillac of its kind - according to whom?

• Patients at hospitals using this system love it -  Do most patients even know what it, or any EHR, looks like?  Have they provided informed consent to its use?

• Exciting - clinician surveys such as by physicians at http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html and by nurses at http://hcrenewal.blogspot.com/2013/07/candid-nurse-opinions-on-ehrs-at.html shed doubt on that assertion. 

(Addendum: also see what nurses think about these systems at "Another 'Survey' on EHRs - Affinity Medical Center (Ohio) Nurses Warn That Serious Patient Complications Only a Matter of Time in Open Letter", http://hcrenewal.blogspot.com/2013/11/another-survey-on-ehrs-affinity-medical.html)

• The best thing for our patients - again, according to whom?

• Sophisticated new system - "New"?  Not so much, just new for U. Arizona Health.  "Sophisticated", as if that's a virtue?  Too much "sophistication" is in part what causes clinician stress and burnout, raising risk; see this summary of a new, not-free JAMIA article "Electronic medical records and physician stress in primary care: results from the MEMO Study", J Am Med Inform Assoc amiajnl-2013-001875 at http://www.beckershospitalreview.com/healthcare-information-technology/the-relationship-between-emrs-and-physician-stress.html.   From that summary:

... Compared with physicians at clinics with low-function EMRs, physicians at clinics with moderate-function EMRs experienced significantly more stress and had a higher rate of burnout. Additionally, physicians at clinics with moderate- or high-function EMRs felt less satisfied with their current position overall.

and:

... Results also showed a significant relationship between time pressure and physician stress in the cohort with high-function EMRs, and only in this cohort, suggesting physicians at these clinics may be particularly pressured for time during patient encounters in the face of a large number of EMR functions. "This 'made sense' to us in thinking about the possibility that those in the high-use group had more to do in the EMR" [say the authors].

• Smartest program out there - "Smartest" meaning what, exactly?  According to whom?  Who performed the comparison?

• Streamlined - compared to what?

• Thank you for your patience - even if the effects on clinicians gets you or your loved ones maimed or killed?

• Safe and secure network - really?  No break ins, ever, considering multiple breach stories like those at http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy?

• Keeping you informed is our priority - informed of what?

• Specially trained staff - like these:  http://hcrenewal.blogspot.com/2010/08/epics-outrageous-recommendations-on.html?

and this:

• Take Responsibility - I ask, should clinicians "take responsibility" for IT-related disruptions that impair care such as "use error" (as opposed to user error), i.e., what the National Institute of Standards and Technology has called operator error due to poor usability and other features of bad health IT?  (See "NIST on the EHR Mission Hostile User Experience" at http://hcrenewal.blogspot.com/2011/10/nist-on-ehr-mission-hostile-user.html.)  What about "glitches" and bugs that corrupt or lose data?  Should clinicians also 'take responsibility' for those?  (See for example the posts on the wild things that happen when IT malpractice leads to clinical mayhem at http://hcrenewal.blogspot.com/search/label/glitch.)

It appears to me that this vendor is using its client hospitals' management to enforce an "acceptable point of view" clinicians must proffer to patients about EHRs (which they must call "health" records), despite well-known contradictory findings.  This is, in effect, forced marketing of a device.

Trying that for a drug or a conventional medical device (e.g., a particular stent) would be on its face unethical and likely illegal.

Finally, critical thinking is what keeps patients alive and safe.  Marketing measures like this (some might call it "propaganda"), espousing and enforcing 'EHR exceptionalism', in my opinion, damage critical thinking and expression, and are thus unacceptable to push on clinicians and on patients.

I add that requiring clinicians to promote deceptive propaganda the clinicians themselves know is untrue, from painful experience, is degrading, intimidating and destroys morale.  It is axiomatic that clinicians (or anyone) operating under such conditions cannot perform at their best.

Thus the management geniuses who came up with these instructions (if not outright vendor-ghostwritten as at the Aug. 2012 "Health IT Vendor EPIC Caught Red-Handed: Ghostwriting And Using Customers as Stealth Lobbyists", http://www.tinyurl.com/epic-stealth) are by their actions increasing risk of patient harm.

The nurses' unions at at http://hcrenewal.blogspot.com/2013/07/rns-say-sutters-new-electronic-system.html have it right, in my view:  complain about the disruptions this technology causes, and complain loudly, if at the very least to make sure the problems are out in the open.

-- SS

Note: also see the followup Nov. 2013 post "We’ve resolved 6,036 issues and have 3,517 open issues: extolling EPIC EHR virtues at University of Arizona Health System" at http://hcrenewal.blogspot.com/2013/11/weve-resolved-6036-issues-and-have-3517.html