Does "Highly wired" Correspond to "Diligence in Following Guidelines" for Care?

One might think the hospitals that have spent tens or hundreds of millions of dollars on healthcare IT would fare the best in performance measures, i.e., adherence to guidelines (irrespective of whether those measures reflect better outcomes, a topic for another time).

Yet, once again that does not appear to be the case. This might seem paradoxical at first glance.

However, as I tell my students, there are no paradoxes - only false assumptions:

Report Finds Improved Performance by Hospitals
New York Times
By KEVIN SACK
Published: September 14, 2011

In the latest advance for health care accountability, the country’s leading hospital accreditation board, the Joint Commission, released a list on Tuesday of 405 medical centers that have been the most diligent in following protocols to treat conditions like heart attack and pneumonia. Almost without exception, most highly regarded hospitals in the United States, from Johns Hopkins in Baltimore to the Mayo Clinic in Rochester, Minn., did not make the list.

The "most highly regarded" hospitals tend to also be "the most wired." One would think that all that hardware would improve "diligence in following protocols" compared to paper-based hospitals. But this is apparently not the case.

... “Reputation and performance on important measures of quality do not always correlate,” said Dr. Mark R. Chassin, the Joint Commission’s president.

As an example, none of the 17 medical centers listed by U.S. News & World Report on its “Best Hospitals Honor Roll” this year are on the Joint Commission’s list of 405 hospitals that received at least a 95 percent composite score for compliance with treatment standards. About one-third of a hospital’s score in the U.S. News methodology is based on its reputation as gauged by a survey of physicians.

These results are not inconsistent with reports such as:

• The 2009 National Research Council report on Health IT, that found that IT even at some of the "best" computerized centers "did not support physicians' cognitive needs";

• The Impact of eHealth on the Quality and Safety of Health Care: A Systematic Overview. Black AD, Car J, Pagliari C, Anandan C, Cresswell K, et al. PLoS Medicine 8(1): e1000387 (Jan. 18, 2011). doi:10.1371/journal.pmed.1000387, that found that "There is a large gap between the postulated and empirically demonstrated benefits of eHealth technologies. In addition, there is a lack of robust research on the risks of implementing these technologies and their cost-effectiveness has yet to be demonstrated, despite being frequently promoted by policymakers and “techno-enthusiasts” as if this was a given";

• Hospital Computing and the Costs and Quality of Care: A National Study. Himmelstein. Wright, Woolhandler. The American Journal of Medicine, Volume 123, Issue 1 , Pages 40-46, January 2010, that found "Hospitals on the “Most Wired” list performed no better than others on quality, costs, or administrative costs";

• Electronic Health Records and Clinical Decision Support Systems: Impact on National Ambulatory Care Quality. Max J. Romano, BA; Randall S. Stafford, MD, PhD, Arch Intern Med. Published online Jan. 24, 2011. doi:10.1001/archinternmed.2010.527, that found that there was "no consistent association between EHRs and CDS and better quality. These results raise concerns about the ability of health information technology to fundamentally alter outpatient care quality";

• Electronic Health Record Use and the Quality of Ambulatory Care in the United States. Linder, Ma, Bates et al. Arch Intern Med. 2007;167:1400-1405, that found that "as implemented, EHRs were not associated with better quality ambulatory care";

• Other articles compiled at my post "An updated reading list on heath IT" at this link.
  

In fact, it is my belief further investigation is needed to measure the distracting effects of information technology on the delivery of healthcare.

... The Joint Commission list, at www.jointcommission.org, omitted the Cleveland Clinic; Massachusetts General Hospital in Boston; Duke University Medical Center in Durham, N.C.; Ronald Reagan U.C.L.A. Medical Center; and the University of California San Francisco Medical Center, among others. It did not include a single hospital in New York City, or the most prominent centers in Chicago and Houston.

“It’s pretty glaring that they’re not there,” said Dr. Peter J. Pronovost, the senior vice president for patient safety and quality for Johns Hopkins Medicine.

Rather, the Joint Commission list of top performers included a disproportionate share of small and rural hospitals, as well as 20 Veterans Affairs medical centers. About 14 percent of roughly 3,000 eligible hospitals made the cut.

Small and rural hospitals may have clinicians who are able to remain focused on the business of healthcare - patient care - rather than the business of bureaucracy - notably, performing the task of data entry clerks for payers, and being subject to the whims of the mission hostile user experience (link) of commercial health IT that can cause injury (link) and even kill (link).

In my own personal experience, the care provided to my mother in her final months of life by a small local hospital in my area - using paper - was superior in terms of ensuring basics of good care were followed, to that of the highly computerized behemoth that maimed my mother. The smaller hospital provided more individualized care and attention, because the clinicians were not distracted by balky technology and the "legible gibberish" output by these systems.

Unfortunately, the small hospital was then acquired by the behemoth. I was there during the rollout of the EHR from the parent. It was not pretty, and I soon found the small hospital's nurses and physicians as distracted as those at the large center, for example in dealing with risky informational abominations such as grossly defective allergy lists (link).

Perhaps the toxic effects of today's commercial health IT need to be taken into account in the Joint Commission's future studies.

-- SS