From Parallel Universes? Dueling Accounts of VA/DoD EHR Integration

At a March 2010 post "<a href="http://hcrenewal.blogspot.com/2010/03/will-it-take-luminosity-of-dozen.html" target="_blank">VA / DoD EHR Interface Debacle: Will It Take the Luminosity Of A Dozen Supernovas To Shed Light On The Obvious About Healthcare IT?</a>" I wrote about problems with ongoing efforts to integrate the Veteran Administration's EHR and the Dept. of Defense (active military) EHR.<br /><br />Now there appears to be two dueling accounts of the task's progress:<br /><br /><b>Account One:</b><br /><blockquote class="tr_bq"><span id="ctl00_ContentPlaceHolder_Body_lblArticleContent" style="display: inline-block; width: 600px;"></span><br /><b><a href="http://www.defense.gov/news/newsarticle.aspx?id=119206" target="_blank">DOD, VA to Speed Integration of Health Records</a></b><br />By Jim Garamone<br />American Forces Press Service<br /><br />WASHINGTON, Feb. 5, 2013 – The secretaries of Defense and Veterans Affairs announced their departments <b>will speed implementation of the Integrated Electronic Health Record program</b>, allowing service members and veterans better access and more importantly, better medical care.<br /><br /><br />This approach is affordable, achievable, and if we refocus our efforts we believe we can achieve the key goal of a seamless system for health records between VA and DOD on a <b>greatly accelerated schedule</b>,” said Defense Secretary Leon E. Panetta following a meeting with Secretary of Veterans Affairs Eric Shinseki at VA headquarters here.<br /><br />The departments are able to step up the records program because of advances in information technology while working with existing platforms. <b>The original goal was to have the system deployed by 2018. Now the expectation is by the end of next year.</b><br /><br />The goal is to provide one set of electronic records from entry into the military through veteran status. The program is designed to allow service members or veterans to download information and present it to doctors or other health care providers without delays.<br /><br />Previously, service members had to hand carry paper files from DOD facilities to Veterans Affairs. Once complete, the record program will provide DOD and VA clinicians with the complete medical records of more than 18 million service members, veterans and their beneficiaries.<br /><br />“We’ve agreed to improve interoperability before the end of this year by standardizing health care data,” Shinseki said. The two departments will also accelerate the exchange of real-time data by September. The departments are upgrading the graphical user interface to display the new standardized VA and DOD healthcare data <b>by the end of this year,</b> Shinseki said.<br /><br />... “By this summer, DOD and VA will field and begin conducting a pilot program on the common interface for doctors at seven joint rehab centers across the country and we’ll also expand its use at two other sites,” Panetta said. “All of these facilities will be interoperable by the end of July 2013, so fast time track, but we think we can get it done.”</blockquote><blockquote>“Rather than building a single, integrated system from scratch, we will focus our immediate efforts on integrating VA and DOD health data as quickly as possible by upgrading our existing systems,” Panetta said.</blockquote>  <br /><span id="ctl00_ContentPlaceHolder_Body_lblArticleContent" style="display: inline-block; width: 600px;"></span><br /><b>Account Two:</b><br /><br /><blockquote class="tr_bq">IMMEDIATE RELEASE: February 6, 2013 CONTACT: Curt Cashour (202) 225-3527<br /><br /><span style="font-size: small;"><b><a href="http://www.sanders.senate.gov/newsroom/news/?id=39d4cb1d-1653-4c0e-9ce5-8e389dbe1e64" target="_blank">Senate and House Veterans’ Committee Leaders Fault VA and DoD on Integrated Health Record System</a></b></span><br /><br />WASHINGTON, D.C. – The chairmen and ranking members of the Senate and House Committees on Veterans’ Affairs today faulted the Pentagon and Department of Veterans Affairs for <b>backing off plans to create a single computer system to integrate electronic medical records for troops and veterans.</b><br /><br />Senate Committee on Veterans’ Affairs Chairman Bernie Sanders (I-Vt.) said: “I am deeply disappointed by the VA and Defense Department decision<b> to back away from a commitment to develop and implement a truly integrated, single, electronic health record. </b>President Obama charged the departments with creating a seamless system of integration so that service members transitioning from active duty to civilian life don’t have to worry about whether their health records will be lost or their claims delayed. An integrated record would allow for a streamlined and timely claims process, faster decisions on benefits, less duplication in medical testing and more efficient, cost-effective treatment for both physical and mental health needs. Now more than ever we need greater cooperation between the departments to solve the serious challenges that continue to confront our service members and veterans. I will continue to work to achieve better coordination by the departments and to ensure that the needs of veterans are met.”<br /><br />House Committee on Veterans’ Affairs Chairman Jeff Miller (R-Fla.) said: “The decision by DOD and VA<b> to turn their backs on a truly integrated electronic health record system is deeply troubling.</b> The need for a record system integrated across all DOD and VA components has been universally accepted for years, and until yesterday, both agencies have given us nothing but assurances they were working toward that goal.<br /><br /><b>Previous attempts by DOD and VA to use disparate computer systems to produce universal electronic health records have failed, and unfortunately it appears they are repeating past mistakes.</b> <span style="color: red;"><i><b> [This seems the "focal point" of the apparent discrepancy, one system vs. two that are interfaced - ed.]  </b></i></span>When DOD and VA take shortcuts, the veterans and service members under their care will be shortchanged.”<br /><br />Sen. Richard Burr (R-N.C), the ranking member of the Senate committee, said: “The fact that VA and DoD would reverse course on a plan they have been working towards for years that would create a coordinated electronic health record system between the two agencies is concerning and disappointing. I am concerned about what this means for our nation’s service members and veterans, particularly those who will be transitioning from active duty service to civilian life in the near future. We owe it to our nation’s defenders to do all we can to care for them and provide the most effective, efficient service we can, and coordination and communication between these two agencies is absolutely vital.”<br /><br />Rep. Mike Michaud (D-Maine), ranking member of the House committee, said: “This is a huge setback and completely unacceptable. For years we have been told by both agencies that progress was made and that things were on track. I’m disappointed that our nation’s two largest government agencies – one of which is the world’s foremost developer of high-tech machines and cyber-systems – could not come together on something that would have been so beneficial to those that served. <b>We have just witnessed hundreds of millions of dollars go down the drain.”</b><br /><br />Additional Contacts:<br />Michael Briggs (Sanders) 202 224-5141<br />David Ward (Burr) 202 228-2971<br />Ed Gilman (Michaud) 202 225-6306 </blockquote><br />So, some are touting a marvelous effort ready for prime time in 2014, and others are speaking of hundreds of millions of dollars down the drain with nothing to show for it.<br /><br />As Captain Kirk said to Mr. Spock in the award-winning Star Trek episode "<a href="http://en.wikipedia.org/wiki/The_City_on_the_Edge_of_Forever" target="_blank">The City on the Edge of Forever</a>" about conflicting accounts of the early 1930's death of <a href="http://penciledin.com/wp/wp-content/uploads/2006/12/edith_keeler_and_jim_kirk.jpg" target="_blank">Edith Keeler</a>, played by a pre-Dynasty Joan Collins, vs. Keeler's mid-to-late-1930's rise to national fame and her becoming the cause of World War Two being lost ...<b> </b><span style="font-family: inherit;"><span style="font-size: small;"><b>"They both can't be true."  </b></span></span><br /><br /><blockquote class="tr_bq"><span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;">(Using the clock-mender's tools, Spock gets an image on his tricorder screen of a newspaper report. <b>Edith Keeler, social worker from 21st Street Mission was killed today, it says</b>. Kirk enters.) <br />KIRK: How are the stone knives and bearskins? <br />SPOCK: I may have found our focal point in time. <br />KIRK: You may also find you have a connection burning someplace. <br />SPOCK: Yes. I'm overloading those lines. I believe we'll have our answer on this screen. <br />KIRK: Good. <br />SPOCK: And, Captain, you may find this a bit distressing. <br />KIRK: Let's see what you have. <br />SPOCK: I've slowed down the recording we made from the time vortex. <br />KIRK: <b>February 23rd, 1936. Six years from now. (reading below the headline FDR confers with slum area 'angel') The President and Edith Keeler conferred for some time today </b><br />(Then the whole thing goes up in flames.) <br />KIRK: How bad? <br />SPOCK: Bad enough. <br />KIRK: The President and Edith Keeler. <br />SPOCK: It would seem unlikely, Jim. A few moments ago, I read a 1930 newspaper article. <br />KIRK: We know her future. Within six years from now, she'll become very important. Nationally famous. <br />SPOCK: Or Captain, Edith Keeler will die - this year. I saw her obituary. Some sort of traffic accident. <br />KIRK: <b>You must be mistaken. <i>They both can't be true. </i> </b></span></blockquote><br />Based on the points I raised in the aforementioned March 2010 post about current IT leadership and organizational structures (not to mention <a href="http://en.wikipedia.org/wiki/Beltway_bandits" target="_blank">Beltway Bandit</a> IT consultants), I am skeptical that either plan - monolithic vs. interfaced - has a snowball's chance of success.<br /><br />Edith Keeler dies in either scenario. <br /><br />Let's just hope a war is not lost because of this cybernetic "how to do health IT poorly" feud.<br /><br />-- SS<br /><br /><b>Feb. 7, 2013  Addendum:</b><br /><br />I've received a comment that this post is a bit "geeky" but droll.<br /><br />My response is a word often used by another highly popular SF character:  <a href="http://www.youtube.com/watch?v=xYnzZ2rczSo" target="_blank">Indeed</a>.<br /><br />-- SS

From Parallel Universes? Dueling Accounts of VA/DoD EHR Integration

At a March 2010 post "VA / DoD EHR Interface Debacle: Will It Take the Luminosity Of A Dozen Supernovas To Shed Light On The Obvious About Healthcare IT?" I wrote about problems with ongoing efforts …

Đọc thêm »

If Our Honored Military Personnel's Medical Care Was Not Involved, This WSJ Letter Might Have Been Considered Oddly Funny

In the WSJ today, a letter to the editor was published extolling the major strides made by the U.S. military in voice recognition technology for electronic health records:<br /><br /><span style="font-weight: bold; color: rgb(255, 0, 0); font-style: italic;">[</span><span style="font-weight: bold; color: rgb(255, 0, 0); font-style: italic;">Note: this is not to denigrate the military, and I am very thankful to all who serve and defend our country and freedoms. Health IT problems seem unfortunately universal - ed.</span><span style="font-weight: bold; color: rgb(255, 0, 0); font-style: italic;">]</span><br /><blockquote><a href="http://online.wsj.com/article/SB10001424052748703467304575383621906130434.html"><br /><strong>Shared Information Can Give Better Medical Results</strong></a><br />Wall Street Journal<br />JUly 26, 2010<br /><br />There is no question that medical information, notes and all, belong to both the patient and the provider, helping each of them to manage a medical condition ("The Informed Patient: What the Doctor Is Really Thinking," Personal Journal, July 20).<br /><br />In the U.S. Army in Europe, we are taking the concept a little further, from "what the doctor is really thinking" to "what the doctor is saying."<span style="font-weight: bold;"> For the last two years, we have been evaluating voice-recognition technology to improve the provider's experience with our electronic medical record. </span>During the process, we came across a wonderful discovery: As doctors dictate medical notes into the record during patient visits, patients are paying much more attention to what doctors are saying, prompting them to ask important follow-up questions, add statements about something else that may be bothering them, or, most importantly, correcting the doctor when a dictation error is made. It's the type of patient-safety feedback loop that would otherwise be absent.<br /><br />The more we allow our patients behind the curtain to see and hear how we work, the more we will see patients become true partners in their own health care.<br /><br />Robert Walker, M.D.<br />Chief Medical<br />Information Officer<br />Europe Regional<br />Medical Command<br />Heidelberg, Germany </blockquote><br />Here's the problem, as I outlined at my July 1, 2010 post "<a href="http://hcrenewal.blogspot.com/2010/07/4-billion-military-emr-ahlta-to-be-put.html">$4 Billion Military EMR "AHLTA" to be Put Out of Its Misery? Also, Does the VA Have $150 Million to Burn on IT That Was Never Used?</a>":<br /><br /><blockquote>I have heard from numerous reliable sources that the military's $4 billion+ EMR known as "<span style="font-style: italic;">Armed Forces Health Longitudinal Technology Application</span>" (<a style="font-weight: bold;" href="http://dhims.health.mil/userSupport/ahlta/about.aspx">AHLTA</a>) is to be declared a failure, and replaced.<br /><br />I'd written about AHLTA's considerable problems at the post "<span style="font-weight: bold;">If The Military Can't Get Electronic Health Records Right, Why Would We Think Conflicted EHR Companies And IT-Backwater Hospitals Can?</span>" at <a href="http://hcrenewal.blogspot.com/2009/06/if-military-cant-get-electronic-health.html" target="_blank">http://hcrenewal.blogspot.com/2009/06/if-military-cant-get-electronic-health.html</a> .<br /><br />From that post:<br /><blockquote><br />[AHLTA has been described as] difficult for physicians to use. Intolerable. Slow. Unreliable. Frequently crashes. Near mutiny. Morale. Affecting patient care, decreasing patient load. Can it get worse?<br /><br />Yes ... When the Army's Surgeon General observes that clinicians "spend as much or more time <span style="font-weight: bold;">working around</span> the system as they do <span style="font-weight: bold;">with</span> the system", and that the superusers are not enthusiastic about the system, and a Congressional hearing is held entitled "where do we go from here?" (it's clear to this author that they have no clue), one should start to very critically question basic assumptions about health IT.<br /></blockquote><br /></blockquote>Read my June 2009 post on the AHLTA failure at <a href="http://hcrenewal.blogspot.com/2009/06/if-military-cant-get-electronic-health.html" target="_blank">http://hcrenewal.blogspot.com/2009/06/if-military-cant-get-electronic-health.html</a>, and the May 2009 piece I referenced from "<span style="font-weight: bold;">US Medicine - the Voice of Federal Medicine</span>" entitled "<span style="font-size:100%;"><a href="http://www.usmedicine.com/articles/electronic-records-system-unreliable-difficult-to-use-service-officials-tell-congress.html">Electronic Records System Unreliable, Difficult to Use, Service Officials Tell Congress</a>" by Sandra Basu,<i> </i></span>in their entirety.<br /><br />Extolling voice recognition advances in a failed $4+ billion EMR debacle due to severe unusability of most of the information system is akin to extolling the virtues of improving screen-door aesthetics on submarines being flooded by water entry. It could almost be considered funny, in a dark-humor sort of way - except the results are anything but humorous. "Dead serious" is a more apt term.<br /><br />Finally, while "shared information can give better medical results",<span style="font-weight: bold; color: rgb(255, 0, 0); font-style: italic;"> there seems to be little shared information about others' healthcare IT failures</span>.<br /><br />Organizations seem to be constantly re-learning that which others have learned years or decades in the past, repeating the same IT mistakes.<br /><br />The cost of this self-education is not at all cheap.<br /><br />(This failure to learn from others is one reason I write that <span style="font-weight: bold;">health IT lacks the science and rigor of the field it ostensibly serves: medicine</span>.)<br /><br />-- SS

If Our Honored Military Personnel's Medical Care Was Not Involved, This WSJ Letter Might Have Been Considered Oddly Funny

In the WSJ today, a letter to the editor was published extolling the major strides made by the U.S. military in voice recognition technology for electronic health records:[Note: this is not to denigra…

Đọc thêm »

Jurassic Attitudes about Medical Informatics: in the U.S. Navy?

<style title="owaParaStyle">P { MARGIN-TOP: 0px; MARGIN-BOTTOM: 0px } BODY { SCROLLBAR-ARROW-COLOR: #3f52b8; SCROLLBAR-DARKSHADOW-COLOR: #fafafa; SCROLLBAR-BASE-COLOR: #f7f7f7; SCROLLBAR-HIGHLIGHT-COLOR: #cecfce; SCROLLBAR-TRACK-COLOR: #fffbff } </style><div dir="ltr" style="font-family:arial;"><span style="color: rgb(0, 0, 0);font-size:100%;" >The message below to a listserv for Chief Medical Informatics Officers and related positions was recently forwarded to me by a colleague. I cannot believe what I am reading, as it reflects attitudes I'd thought were extinct by the late 1990's ("I don't see the value of clinical informatics").<br /><br />The last time I'd heard such nakedly Jurassic views, and other anti-physician informatics attitudes <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/informaticsmd/tactics.htm">as in this 1999 essay</a> I penned, was from the C-level officers of the hospital where I was CMIO in that time frame, Christiana Care Health System in Delaware.<br /><br /><br /></span><blockquote><span style="font-size:100%;"><span class="undefined"><span style="color: rgb(0, 0, 0);">From: (Withheld)<span dir="ltr"></span><br />Date: Sun, Jul 4, 2010 at 9:24 AM<a href="http://www.blogger.com/redir.aspx?C=c4065bc8add74dd197a9b92ea9c445cf&URL=mailto%3aAMDIS%40home.ease.lsoft.com"></a></span><br /></span><br />Hi All,<br /><br />I was recently told by one of our senior leaders that </span> <span style="font-size:100%;"><strong>he saw no value to Clinical Informatics</strong> and followed that up by <span style="font-weight: bold;">disbanding the Clinical Informatics Directorate at the BUMED (Headquarters of Navy Medicine) level</span>.<br /><br />I successfully countered that argument with a more senior leader, but I tried to find objective evidence of the value of Clinical Informatics without success. As an academic family physician who lives, eats and breathes evidence-based medicine, I try to make all my decisions and arguments for and against positions/programs based on the best available evidence. In this case, all I could use was potential value and logic.<br /><br />My question is this: Does anyone out there (and I have already discussed</span> <span style="font-size:100%;">this with [<span style="font-style: italic;">name redacted - ed.</span>]) have any objective evidence that shows the value of clinical informatics to the Enterprise (which has multiple definitions, but suffice it to mean across an entire health care system.however large)? I have already talked with [<span style="font-style: italic;">name redacted - ed.</span>] about including a survey of CEO's/COO's/CMO's/CIO's as to the value they see in clinical informatics, but that is some time in the future. I really need some data now. Anyone have anything? Any and all assistance is greatly appreciated.<br /><br /></span><span style="font-size:100%;"></span></blockquote></div> <div dir="ltr" style="font-family:arial;"><span style="font-size:100%;"></span> </div> <div dir="ltr" style="font-family:arial;"><span style="font-size:100%;"><br />In the face of the apparent spectacular failure of AHLTA (<a href="http://hcrenewal.blogspot.com/2010/07/4-billion-military-emr-ahlta-to-be-put.html" target="_blank">$4 Billion Military EMR "AHLTA" to be Put Out of Its Misery? Also, Does the VA Have $150 Million to Burn on IT That Was Never Used?</a>), I certainly view such statements as extraordinary, and in a very negative sense.<br /><br />It has become my opinion that Jurassic attitudes about medical informatics are virtually <strong>unremediable</strong>; they suggest an underlying technical and mental deficit in those who proffer such opinions that is not correctible by evidence and logic. (I can predict with a good degree of certainty that this "senior leader" had a role in AHLTA's demise.)<br /><br /></span></div> <div dir="ltr" style="font-family:arial;"><span style="font-size:100%;"></span> </div> <div dir="ltr" style="font-family:arial;"><span style="font-size:100%;">I suggest a different approach: surely patients received suboptimal care (and perhaps suffered injury) under AHLTA. The freebie newspapers serving the soldiers such as I have seen in my visits to Fort Dix, where my mother has commissary/PX privileges as a result of my father's service-connected injuries and disability, might find such a story "interesting."<br /><br /></span></div> <div dir="ltr" style="font-family:arial;"><span style="font-size:100%;"></span> </div> <div dir="ltr" style="font-family:arial;"><span style="font-size:100%;">In the meantime, I am doing a <a href="http://en.wikipedia.org/wiki/John_Galt">John Galt</a> regarding persons espousing the "I don't see the value of informatics" view. I'm frankly tired that such people remain in the healthcare workforce. While I could provide a lot of material supporting the value of informatics (actually, its essential nature) that I and others have written over the years, I choose to no longer do so.<br /><br /></span></div> <div dir="ltr" style="font-family:arial;"><span style="font-size:100%;"></span> </div> <div dir="ltr"><span style=";font-family:arial;font-size:100%;" >The military person proffering this view is apparently a "senior leader"; it's their responsibility and indeed obligation to make the Navy better. Let them lead.<br /><br />And let the pieces fall where they may.<br /><br /></span><span style="font-size:100%;"><span style="font-family:arial;">-- SS</span></span><br /></div>

Jurassic Attitudes about Medical Informatics: in the U.S. Navy?

P { MARGIN-TOP: 0px; MARGIN-BOTTOM: 0px } BODY { SCROLLBAR-ARROW-COLOR: #3f52b8; SCROLLBAR-DARKSHADOW-COLOR: #fafafa; SCROLLBAR-BASE-COLOR: #f7f7f7; SCROLLBAR-HIGHLIGHT-COLOR: #cecfce; SCROLLBAR-TRA…

Đọc thêm »

$4 Billion Military EMR "AHLTA" to be Put Out of Its Misery? Also, Does the VA Have $150 Million to Burn on IT That Was Never Used?

I have heard from numerous reliable sources that the military's $4 billion+ EMR known as "<span style="font-style: italic;">Armed Forces Health Longitudinal Technology Application</span>" (<a style="font-weight: bold;" href="http://dhims.health.mil/userSupport/ahlta/about.aspx">AHLTA</a>) is to be declared a failure, and replaced.<br /><br />I'd written about AHLTA's considerable problems at the post "<span style="font-weight: bold;">If The Military Can't Get Electronic Health Records Right, Why Would We Think Conflicted EHR Companies And IT-Backwater Hospitals Can?</span>" at <a href="http://hcrenewal.blogspot.com/2009/06/if-military-cant-get-electronic-health.html" target="_blank">http://hcrenewal.blogspot.com/2009/06/if-military-cant-get-electronic-health.html</a> .<br /><br />From that post:<br /><blockquote><br />[AHLTA has been described as] difficult for physicians to use. Intolerable. Slow. Unreliable. Frequently crashes. Near mutiny. Morale. Affecting patient care, decreasing patient load. Can it get worse?<br /><br />Yes ... When the Army's Surgeon General observes that clinicians "spend as much or more time <span style="font-weight: bold;">working around</span> the system as they do <span style="font-weight: bold;">with</span> the system", and that the superusers are not enthusiastic about the system, and a Congressional hearing is held entitled "where do we go from here?" (it's clear to this author that they have no clue), one should start to very critically question basic assumptions about health IT.<br /></blockquote><br />One wonders if anyone responsible for AHLTA ever read my now decade-old site on health IT dysfunction, now at <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/">this link</a> at Drexel University, or its many hyperlinks to additional resources.<br /><br />Meanwhile, the VA is having its own problems as noted on the HISTalk blog:<br /><blockquote><br />[<a href="http://histalk2.com/2010/06/29/news-63010/">HISTalk News 6/30/1</a><a href="http://histalk2.com/2010/06/29/news-63010/">0</a>] Back in <a href="http://histalk2.com/2010/03/16/news-31710/" target="_blank">March</a>, I dug out a juicy nugget from an internal VA report: it was <span style="font-weight: bold;">scrapping a $150 million patient scheduling system without ever bringing it live</span>. The GAO weighs in with its <a href="http://www.gao.gov/new.items/d10579.pdf" target="_blank">official report</a> (warning: PDF), pegging the cost at $127 million and saying “VA has not implemented any of the planned system’s capabilities and is essentially starting over.” The contractor that developed the system with “a large number of defects” walks away with $65 million. GAO finds much to criticize about the VA’s involvement: lack of competitive bidding, sloppy specs, unreliable status reports, and lack of action by project oversight groups when the project started tanking. </blockquote><br />The linked PDF report from the U.S. Government Accountability Office (<a href="http://www.gao.gov/">GAO</a>), entitled "<a href="http://www.gao.gov/new.items/d10579.pdf">INFORMATION TECHNOLOGY - Management Improvements Are Essential to VA’s Second Effort to Replace Its Outpatient Scheduling System</a>", reveals errors that cause me to question whether the project leadership ever passed their introductory undergraduate IT courses (assuming they had any).<br /><br />From that report:<br /><br /><blockquote>VA’s efforts to successfully complete the Scheduling Replacement Project were hindered by weaknesses in several key project management disciplines and a lack of effective oversight that, if not addressed, could undermine the department’s second effort to replace its scheduling system:<br /><br /><ul><li>VA did not adequately plan its acquisition of the scheduling application and did not obtain the benefits of competition.</li><li>VA did not ensure requirements were complete and sufficiently detailed to guide development of the scheduling system.</li><li>VA performed system tests concurrently, increasing the risk that the system would not perform as intended, and did not always follow its own guidance, leading to software passing through the testing process with unaddressed critical defects.</li><li>VA’s project progress and status reports were not reliable, and included data that provided inconsistent views of project performance.</li><li>VA did not effectively identify, mitigate, and communicate project risks due to, among other things, staff members’ reluctance to raise issues to the department’s leadership.</li><li>VA’s various oversight boards had responsibility for overseeing the Scheduling Replacement Project; however, they did not take corrective actions despite the department becoming aware of significant issues.<br /></li></ul><br />The impact of the scheduling project on the HealtheVet initiative cannot yet be determined because VA has not developed a comprehensive plan for HealtheVet that, among other things, documents the dependencies among the projects that comprise the initiative.<br /></blockquote><br /><style title="owaParaStyle">P { MARGIN-TOP: 0px; MARGIN-BOTTOM: 0px } BODY { SCROLLBAR-ARROW-COLOR: #3f52b8; SCROLLBAR-DARKSHADOW-COLOR: #fafafa; SCROLLBAR-BASE-COLOR: #f7f7f7; SCROLLBAR-HIGHLIGHT-COLOR: #cecfce; SCROLLBAR-TRACK-COLOR: #fffbff } </style><div dir="ltr">My question is:<br /><br /></div> <div dir="ltr"> </div> <div dir="ltr"><span style="font-family:times new roman;">By </span>what miracle of God will the military's AHLTA's and the VA's scheduling system "replacements" be any better than what now exists? Through reliance on commercial EMR vendors and management consultant "experts", perhaps?<br /><br />If so, I wish the military and VA the best of luck. They will need it.<br /><br />The problems with computing in complex settings such as medicine are pervasive, far beyond the military. It is increasingly clear that the leadership of the <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=ecosystem">healthcare IT ecosystem</a> (and probably even the broader IT ecosystem) consists of <span style="font-weight: bold;">recycled incompetents</span>, never held accountable for project failures, even massive ones, instead moving on to wreak mayhem elsewhere. This has certainly been my own experience in both the hospital and pharma sectors.<br /><br />Competent experts who actually try to do meaningful work (a.k.a. "rock the boat" or "non-team players" in the parlance of the incompetent and/or the power seekers) have become hopelessly marginalized - or unemployed. See the post "<a href="http://hcrenewal.blogspot.com/2010/06/edwin-lee-on-tiger-we-are-now-riding.html">Edwin Lee on the Tiger We Are Now Riding</a>" by Roy Poses. <strong style="font-weight: normal;">Our economy and even society is falling apart as a result of these leadership problems; Lee's post "</strong><span style="font-weight: bold;">Lightweight oil executives produce worthless disaster plans</span>" as linked above is <a href="http://en.wikipedia.org/wiki/Pathognomonic">pathognomonic</a> of these failures<strong style="font-weight: normal;">. Writes Lee:<br /><br /></strong><blockquote>... This week the executives of the other major oil companies (besides BP) presented their oil spill contingency plans to Congress. Several things were immediately evident: the plans were all grossly inadequate and carelessly done, they were all developed by the same outside consulting firm and they were essentially carbon copies of BP’s nearly useless plans. In other words, they were empty “cover your ass” documents rather than serious contingency plans. Some people may find this surprising. From my experience, it’s what we can and should expect from the vast majority of large, public institutions<span style="font-weight: bold;"> because of a universal and deeply flawed process for selecting their leaders.<br /><br />... </span>Those who are chosen to lead fit a mold: mediocre, short term thinkers with similar work experiences, outlooks, temperaments and personal incentives. Disaster response, creative thinking and fundamental changes are outside their limited range of interests or competencies.<br /></blockquote><br /></div> <p dir="ltr">Here is the major problem in a nutshell: no real accountability where it matters.<br /></p><p dir="ltr"><strong><br /></strong></p><p dir="ltr"><strong><span style="font-weight: normal;">What follows from this is a first principle: </span><br /></strong></p><p dir="ltr"><strong><br /></strong></p><p dir="ltr"><strong>Recycled incompetents will never produce good information systems.<br /></strong></p><p dir="ltr"><strong><br /></strong> </p> <p dir="ltr"><span style="font-family:times new roman;"></span> </p> <p dir="ltr">Major health IT commercial vendor CEO's have been reported as making statements that <span style="font-style: italic;">health IT usability </span>-- <span style="font-weight: bold;">one of AHLTA's major deficiencies</span> - "<span style="font-style: italic;">will be part of certification over her dead body</span>" (as described in my post at <a href="http://www.blogger.com/redir.aspx?C=bbea8e4243b540e08b9cb5507a83da5b&URL=http%3a%2f%2fhcrenewal.blogspot.com%2f2010%2f05%2fdid-epic-ceo-judy-faulkner-of-epic.html" target="_blank">http://hcrenewal.blogspot.com/2010/05/did-epic-ceo-judy-faulkner-of-epic.html</a>).<br /><br />Why don't we recycle physicians with track records of killing patients? Better yet, make them Chairs of clinical departments? </p> <p dir="ltr"> </p> <p dir="ltr">The answer is obvious, but the IT culture seems immune to such considerations.</p><p dir="ltr"><br /></p><p dir="ltr">The UK's National Programme for IT in the NHS (NPfIT) is AHLTA on a national scale:</p><br /><br /><blockquote>The UK Public Accounts Committee report on disastrous problems in their £12.7 billion national EMR program is <a href="http://www.publications.parliament.uk/pa/cm200809/cmselect/cmpubacc/153/15304.htm">here</a>.<br /><br />Gateway reviews of the UK National Programme for IT from the Office of Government Commerce (OGC) are <a href="http://www.connectingforhealth.nhs.uk/about/foi">here</a> (released under the UK’s Freedom of Information Act), and a summary of 16 key points is <a href="http://www.computerweekly.com/blogs/tony_collins/2009/06/16-key-points-in-gateway-revie.html">here</a>.</blockquote><br /><p></p><p dir="ltr"><br /></p><p dir="ltr">My prediction is this:</p><p dir="ltr"><br /></p><p dir="ltr">I do not believe health IT has advanced enough beyond the experimental stage for clinically efficacious, safe, cost effective mass dissemination.<br /></p><p dir="ltr"><br /></p><p dir="ltr">Further, I do not believe that the human capital necessary to make such dissemination happen in a clinically efficacious, safe, cost effective manner exists in the IT industry.</p><p dir="ltr"><br /></p><p dir="ltr">Talent management in that industry -- based on cheap, just-in-time, "programming language/platform du jour", "smart people cannot or should not learn but should be declared obsolete", and Bart Simpson-style attitudes about ability and expertise -- does not allow the needed human capital to exist. A remarkable and revealing example comes from an article about health IT leadership a number of years ago in the journal “<a href="http://www.healthcare-informatics.com/">Healthcare Informatics</a>”:<br /></p><blockquote style="font-family: arial;"><br /><b style=""><i style="">I don't think a degree gets you anything</i></b><i style="">," says healthcare recruiter Lion Goodman, president of the <a href="http://www.goodmangroup.com/">Goodman Group</a> in <st1:place st="on"><st1:city st="on">San Rafael</st1:city>, <st1:state st="on">California</st1:state></st1:place> about CIO's and other healthcare MIS staffers. Healthcare MIS recruiter Betsy Hersher of <a href="http://www.hersher.com/">Hersher Associates</a>, <st1:place st="on"><st1:city st="on">Northbrook</st1:city>, <st1:state st="on">Illinois</st1:state></st1:place>, agreed, stating "There's nothing like <b style="">the school of hard knocks</b>."<span style=""> </span>In seeking out CIO talent, recruiter Lion Goodman "<b style="">doesn't think clinical experience yields [hospital] IT people who have broad enough perspective</b>. Physicians in particular make poor choices for CIOs. They don't think of the business issues at hand because they're consumed with patient care issues," according to Goodman.</i></blockquote><p dir="ltr"><br /></p><p dir="ltr">The "management improvements" sought by the VA may simply not be possible, until the IT field undergoes something comparable to the "Flexner report" that the medical professions and their educational programs underwent a century ago.</p><p dir="ltr"><br /></p><p dir="ltr">And perhaps until health IT leadership personnel begin to lose their homes and fortunes in court to harmed patient plaintiffs, to the point where the leadership start begging competent, marginalized professionals who actually know what they're doing to save their sorry asses.<br /></p><p dir="ltr"><br /></p><p dir="ltr">-- SS</p><p style="font-weight: bold;" dir="ltr"><br /></p><p dir="ltr"><span style="font-weight: bold;">7/6 addendum:</span><br /></p><p dir="ltr"><br /></p><p dir="ltr">For more on the topic of dinosaur-era attitudes about Medical Informatics that lead to such debacles, see my July 5, 2010 post "<a href="http://hcrenewal.blogspot.com/2010/07/jurassic-attitudes-about-medical.html">Jurassic Attitudes about Medical Informatics: in the U.S. Navy?</a>"</p>

$4 Billion Military EMR "AHLTA" to be Put Out of Its Misery? Also, Does the VA Have $150 Million to Burn on IT That Was Never Used?

I have heard from numerous reliable sources that the military's $4 billion+ EMR known as "Armed Forces Health Longitudinal Technology Application" (AHLTA) is to be declared a failure, and replaced.I…

Đọc thêm »

VA / DoD EHR Interface Debacle: Will It Take the Luminosity Of A Dozen Supernovas To Shed Light On The Obvious About Healthcare IT?

<div style="text-align: center;"><span style="font-size:85%;">(Note: Academic/military readers of this post, I would enjoy your comments. Email </span><span style="font-weight: bold;font-size:85%;" >sms88</span><span style="font-size:85%;"> AT </span><span style="font-weight: bold;font-size:85%;" >drexel</span><span style="font-size:85%;"> DOT </span><span style="font-weight: bold;font-size:85%;" >edu</span><span style="font-size:85%;">. Thank you -- SS.)</span><br /></div><div style="text-align: center;"><span style="font-size:85%;"><br />(Dec. 2010 note: I have observed a large number of "hits" on this post from multiple offices of the Mitre Corporation in the past several weeks. Dear Mitre, I ask that if you use my materials in your proposals or writings, that you please let me know. Thank you. My email address is in my profile under "Contributors." -- SS)<br /></span></div><br />The VA and DoD have been working for a number of years on interfacing the VistA EHR system and the military's EHR, AHLTA (why anyone would want to interface to AHLTA <a href="http://hcrenewal.blogspot.com/2009/06/if-military-cant-get-electronic-health.html">in its present state</a> is of concern to me, but...)<br /><br /><span style="font-style: italic; font-weight: bold; color: rgb(255, 0, 0);">[</span><span style="font-style: italic; font-weight: bold; color: rgb(255, 0, 0);">Note: this is not to denigrate the military, and I am very thankful to all who serve and defend our country and freedoms. HIT problems seem unfortunately universal - ed.</span><span style="font-style: italic; font-weight: bold; color: rgb(255, 0, 0);">]</span><br /><br />The interface attempt, likely done by the usual actors in the traditional "business IT" manner has resulted in the predictable:<br /><br /><blockquote><a style="font-weight: bold;" href="http://www.nextgov.com/nextgov/ng_20100304_9977.php?oref=topstory">Glitch prompts VA to shut e-health data exchange with Defense</a><br />NextGov.com<br />By Bob Brewin 03/04/2010<br /><br />The Veterans Affairs Department closed off access to the Defense Department's huge electronic health record system on Monday because it found errors in some patients' medical data clinicians downloaded from the Defense network, according to a departmental patient safety alert, which Nextgov obtained.<br /><br />Although no patient was injured, <span style="font-weight: bold;">the errors shed light on how software glitches could affect the accuracy of electronic medical records</span> and a planned national system that has been backed by the Bush and Obama administrations.</blockquote><br />"<span style="font-style: italic;">Shed light on how software glitches could affect the accuracy of electronic medical records?</span>"<br /><br />As my early medical mentor, Hahnemann cardiothoracic surgery pioneer Victor P. Satinsky would have said about purveyors of such wisdom: they are <span style="font-weight: bold;">Masters of the Obvious</span>.<br /><br />I ask:<br /><br />Why do we keep needing to "<span style="font-weight: bold;">shed light</span>" on the blatantly obvious, in your face, computer science 101 reality about electronic information systems? The light was shed when the first stored-program computers <a href="http://en.wikipedia.org/wiki/UNIVAC_I">were developed in the late 1940's</a>.<br /><br />Exactly how much light do we need to shed before IT personnel "get it" about the need for the most extreme diligence in IT-based medical records?<br /><br />Perhaps the light of a dozen <a href="http://www.youtube.com/watch?v=iE_5hqcWT-o">supernovas</a>?<br /><br /><br /><div style="text-align: center;"><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://www.youtube.com/watch?v=iE_5hqcWT-o"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5445180060915623778" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiW8VRMIxeVW719b0j7uAZXO__OGwOUG8YL9fPlUhFbl9KGy5RRmhhqryN-YOQONtQjn9yQw-JdENCo3YThiw77-umpum9EdV1yNSURRliXeAfljqKc19Rd8CTCGfApr3nYrNcsCi3BfxFa/s320/crab.jpg" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 336px; height: 219px;" /></a><span style="font-size:85%;">Is this the amount of light it will take before the IT world "gets it" about the need for the utmost engineering rigor in healthcare IT? (click image to play video).</span><br /></div><br /><br />------------------------------------<br /><span style="font-weight: bold; color: rgb(255, 0, 0);"><br />*** Nov. 2011 addendum:</span><span style="color: rgb(255, 0, 0);"> <span style="font-weight: bold;">I now personally face the aftermath of the worst-case "perfect storm" caused by health IT that began in May 2010, just two months after I wrote this post -</span></span><br /><br /><br /><div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjlTFolp_-A1Gxo803a7L8VUsrFqJgvj7eUgCJ0i5unI6z-9-sbzWJiZf9erCNWiEOWv70OqhfdHlSLbAxrpnjmoeMemFcU0kfJV15moPS0Y5Nb8e8utTBI5hstfBv94s92aquZi6zIKoLK/s1600/Marker.bcs.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5670400994172634594" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjlTFolp_-A1Gxo803a7L8VUsrFqJgvj7eUgCJ0i5unI6z-9-sbzWJiZf9erCNWiEOWv70OqhfdHlSLbAxrpnjmoeMemFcU0kfJV15moPS0Y5Nb8e8utTBI5hstfBv94s92aquZi6zIKoLK/s320/Marker.bcs.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 320px; height: 185px;" /></a><span style="font-size:85%;">Here is what EHR dysfunction caused to me, personally</span><br /></div><br />------------------------------------<br /><br /><br />It's fortunate the error was found in a somewhat less than life-threatening manner:<br /><br /><blockquote>VA first discovered the problem in late February, when one of its doctors accessed the Defense health records system, called AHLTA, to review the prescription information of a female patient. <span style="font-weight: bold;">The data showed a Defense physician had prescribed her an erectile dysfunction drug. </span>The VA doctor suspected the system displayed erroneous information <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">[although females have been known to use these drugs- ed.]</span> and a check with the Defense medical facility that supposedly prescribed the drug informed VA that the data was wrong and the VA query had <span style="font-weight: bold;">returned information for another patient.<br /><br />... </span>When doctors queried the Defense system for patient information, they received no data, a portion of the data, incorrect information, or the complete, correct data for the patient, according to the alert.</blockquote><span style="font-weight: bold;"></span><span style="font-weight: bold; font-style: italic;"><span style="color: rgb(255, 0, 0);"><br />[Where have I seen these types of patient data errors mentioned recently? Perhaps at my recent post "</span></span><a style="font-weight: bold; font-style: italic;" href="http://hcrenewal.blogspot.com/2010/02/fda-on-health-it-adverse-consequences.html">FDA on Health IT Adverse Consequences: 44 Reported Injuries And 6 Deaths In Two Years, Probably Just Tip of Iceberg"</a> <span style="font-weight: bold; font-style: italic;">? <span style="color: rgb(255, 0, 0);">- ed.]</span></span><br /><br /><blockquote>The glitch did not cause harm to any patient, but "<span style="font-weight: bold;">the potential exists for decisions regarding patient care to be made using incorrect or incomplete data</span>," said Jean Scott, director of the Veterans Health Administration's Information Technology Patient Safety Office, in the alert issued on Wednesday.</blockquote><br />Indeed.<br /><blockquote><br />"The VA clinician may see the patient's data during one session, but another session may not display the data previously seen," the alert noted. "This problem occurs <span style="font-weight: bold;">intermittently</span> and has been reported when querying DoD laboratory, pharmacy and radiology reports."</blockquote><br />I would add that "intermittent errors" are by definition <span style="font-weight: bold; font-style: italic;">unpredictable</span>. This is the most dangerous type of IT malfunction of all.<br /><br /><blockquote>Until those systems are reactivated, VA doctors will have to obtain a patients' health information from their <span style="font-weight: bold;">paper medical files</span>, faxes or PDF attachments that are e-mailed to the physicians, Scott said.</blockquote><br />What? That old-fashioned, unreliable <a href="http://en.wikipedia.org/wiki/Papyrus">5,000 year old artifact</a> upon which the foundations of modern medicine were built, and favored by Luddites?<br /><blockquote><br />The errors occurred in the Bidirectional Health Information Exchange, a project started in 2004 that allows clinicians in VA and Defense to view health information in patient files. <span style="font-weight: bold;">Older code in the system became stressed at peak periods</span> when clinicians were making the most number of queries, said Roger Baker, chief information officer at VA. At these times, the system did not clear out a memory cache, resulting in memory leaks "so that information from one patient is presented as it is from another," he explained.</blockquote><br />Good software and information architecture engineering practices call <span style="font-weight: bold;">exactly</span> for testing under stress. Failure to clear caches, memory leaks, etc. are fundamental flaws that should <span style="font-weight: bold;">never be permitted to see the light of day</span> in clinical settings. That is what acceptance testing is designed to do. That's what mission critical software undergoes in other sectors. That is what drug and device clinical trials are designed to do.<br /><br />At <a href="http://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/20040014965_2004000657.pdf">this link</a>, for example, is <span style="font-style: italic;">NASA's Certification Processes for Safety-Critical and Mission- Critical Aerospace Software</span> from 2003 (PDF). From that document:<br /><br /><blockquote>... Since safety-critical aerospace software is prevalent and important to human life, what is the rationale behind certification of such software? In other words, <span style="font-weight: bold;">how do engineers know when a new software product works properly and is safe</span> to fly? In the United States, software must undergo a certification process described in various standards by various regulatory bodies including NASA and the Requirements and Technical Concepts for Aviation (RTCA) which is enforced by the Federal Aviation Administration (FAA).</blockquote><br />There are no analogous requirements or enforcement in the healthcare IT sector. None.<br /><br />In fact, the VA, of all places, should have been <span style="font-weight: bold;">exceptionally wary of these types of malfunctions</span> and exercised the <span style="font-style: italic;">highest </span>levels of engineering rigor.<br /><br />Why?<br /><br />See "<span style="font-style: italic;">IT Vulnerabilities Highlighted by Errors, Malfunctions at Veterans Medical Centers</span>" <a href="http://hcrenewal.blogspot.com/2009/03/it-vulnerabilities-highlighted-by.html">at this link</a>. From that posting, reflecting a March 4, 2009 JAMA article by the same title by Bridget M. Kuehn (<a href="http://jama.ama-assn.org/cgi/content/extract/301/9/919">JAMA 2009;301(9):919-920)</a>:<br /><br /><blockquote>... After a software update of the electronic medical records system at VA hospitals in August [2008], health care workers at these facilities began to report that as they moved from the records of one patient to those of a second patient, they would sometimes <span style="font-weight: bold;">see the first patient's information displayed under the second patient's name</span>. <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">[If not for the diligence of the users then, that type of error could have led to dead patients -ed.]</span><span style="font-family:arial;"><br /><br />This records-scrambling problem was reported at 41 of the 153 VA medical centers, said Gail Graham, deputy chief officer of Health Information Management at Veterans Health Administration Headquarters in Washington, DC. Graham explained that the jumbling of records was an uncommon occurrence that only occurred after a particular sequence of events.<br /><br />... </span><span style="font-family:arial;">Health care workers at the VA medical centers were notified about this potential problem in October, and on December 20, the centers received a software "patch" to fix the problem.</span><br /><br /><span style="font-family:arial;">Nine VA medical centers reported another type of problem related to their electronic records system: <span style="font-weight: bold;">physician orders to stop medication were missed</span>, causing some patients to receive intravenous medications longer than necessary. The problem occurred because after the software upgrade, physician orders to discontinue such medications, which had previously appeared at the top of the screen, were not displayed.</span><br /><br /><span style="font-family:arial;">In 3 cases, patients received infusions of drugs such as heparin for up to 11 hours after their physician had ordered the drug to be discontinued. Graham said the affected patients were not notified because they had not been harmed by the oversights. This software problem was corrected on December 8.</span> </blockquote><br />As I noted in that post: "... if this type of error occurs once too often,<span style="font-weight: bold;"> your patient's dead</span>."<br /><br />Back to the current VA / DoD interface "glitch":<br /><br /><blockquote>... The VA has fixed the [current] bug and plans to bring the BHIE back online on March 9. Baker emphasized the bug's effect on the medical records of patients that VA and Defense clinicians share was sporadic and <span style="font-weight: bold;">occurred in one out of 100 queries</span>. The glitch caused errors only in the records that VA clinicians accessed. Defense doctors still have access to records Veterans Affairs stores.</blockquote><br />"Only" 1 out of 100? ... that's only 10,000 errors per million EHR queries. Not too bad at all ... how many soldiers are in a military <a href="http://en.wikipedia.org/wiki/Division_%28military%29">division</a>?<br /><br /><blockquote>Baker said the department's response to the glitch showed VA's overall health system worked "<span style="font-weight: bold;">because there is always a doctor in the loop</span>" who checks the accuracy of a patient's health data in combination with a well established patient safety organization that quickly alerts clinicians to any errors.</blockquote><br />The "system worked" because luck prevailed that fallible, busy human clinicians were not deceived by erroneous information provided by a computer? I fall back on <a href="http://hcrenewal.blogspot.com/2010/02/forgotten-first-principles-in.html">first principles of IT</a>:<br /><br /><span style=";font-family:arial;font-size:100%;" ></span><blockquote><span style="font-size:100%;"><span style=";font-family:arial;font-size:100%;" >A computer can free professionals from tedious, repetitive work which does not require judgment. It can provide facts and figures with lightning speed, giving domain experts more time to exercise their judgment thoughtfully </span></span></blockquote><br />The system is <span style="font-weight: bold;">not working</span> when computers add to the tedium, and having to expend precious cognitive capacity in ferreting out computer errors is certainly in that category. This excuse reminds me of a recent quote from our Homeland Security secretary about how the "<a href="http://www.foxnews.com/politics/2009/12/28/napolitano-acknowledges-security-failed-allowing-terror-suspect-plane/">system worked</a>" when an airplane nearly was blown out of the sky.<br /><br />These failure excuses, possibly written by a public relations 'spin doctor' in an effort at damage control, remind me of a humorous sign I bought in a novelty store once, for placing on the wall: "Our policy is to <a href="http://hcrenewal.blogspot.com/2006/01/our-policy-is-to-always-blame-computer.html">always blame the computer</a>."<br /><br />Perhaps clinicians need to stand up for this motto:<span style="font-weight: bold;"> No more alpha and beta software rollouts in healthcare.</span><br /><br /><blockquote>Robert Charette, a risk management consultant and president of the ITABHI Corp. in Fredericksburg, Va., which consults with Defense, said VA was lucky it discovered an error as obvious as prescribing an erectile dysfunction drug for a female patient. He wondered if VA would have detected the error if it were for drugs with similar names, adding that despite the low error rate, "<span style="font-weight: bold;">it's the one out of 100 that can bite you</span>."</blockquote><br />It's also the one out of fifty thousand that can bite you, for instance as <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/scotsilv/vioxx1.htm">Merck recently discovered</a>.<br /><blockquote><br />Baker said the complexity of medical records systems like BHIE would make regulating such networks <span style="font-style: italic;">[by agencies such as FDA - ed.] </span>a daunting task.</blockquote><br />I thought we were just <span style="font-size:100%;"><span style="color: rgb(51, 51, 51);">at the point of</span><span style="color: rgb(255, 0, 0); font-weight: bold; font-style: italic;"> transforming health</span><span style="color: rgb(255, 0, 0); font-weight: bold; font-style: italic;"> with one thunderous click of a mouse after another</span></span> per our prior HHS secretary at the <a href="http://www.himss.org/ASP/ContentRedirector.asp?ContentId=65039&type=HIMSSNewsItem">2005 HIMSS summit</a>. Perhaps not...<br /><br /><blockquote>Dave deBronkart, a patient advocate in Nashua, N.H., who spoke at last week's Health IT Policy Committee meeting, said in an interview with Nextgov that the glitch paralleled the problems he encountered last year when he tried to transfer information from his hospital medical record to Google Health, an online electronic health record database the search giant launched in 2008.</blockquote><br />I wrote about that at "<span style="font-weight: bold;">Should Google Seek the Resignations of Those Responsible for This Healthcare IT Debacle?</span>" <a href="http://hcrenewal.blogspot.com/2009/04/should-google-seek-resignations-of.html">here</a>.<br /><br /><blockquote>If the United States wants to develop a national health electronic record system, it needs to <span style="font-weight: bold;">make sure heath information exchanges work correctly</span>, said deBronkart, who added VA should be commended for reacting quickly to the software problem and issuing the patient safety alert.</blockquote><br />I believe this is not possible under the current leadership, organizational and regulatory structures found in the healthcare IT sector. As I've written before, healthcare cannot be 'reformed' or even improved by IT, until IT and its culture are themselves reformed.<br /><br />For more on these issues, see my site below.<br /><br />-- SS<br /><br /><div style="text-align: justify;"><span style="font-size:100%;"><span style="font-weight: bold;font-size:85%;" ><span style="color: rgb(0, 153, 0);">For more on HIT challenges see "Contemporary Issues in Medical Informatics: Common Examples of Healthcare Information Technology Difficulties" - </span></span></span><a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/"><span style="font-size:85%;">http://www.ischool.drexel.edu/faculty/ssilverstein/cases/</span></a><br /></div>

• 
• 

1. 1
2. 2

• Previous
• Next

VA / DoD EHR Interface Debacle: Will It Take the Luminosity Of A Dozen Supernovas To Shed Light On The Obvious About Healthcare IT?

(Note: Academic/military readers of this post, I would enjoy your comments. Email sms88 AT drexel DOT edu. Thank you -- SS.)(Dec. 2010 note: I have observed a large number of "hits" on this post fr…

Đọc thêm »

If The Military Can't Get Electronic Health Records Right, Why Would We Think Conflicted EHR Companies And IT-Backwater Hospitals Can?

The publication "<a href="http://www.washingtonpost.com/wp-dyn/content/article/2009/05/15/AR2009051503667.html?hpid=topnews">The Machinery Behind Healthcare Reform: How an Industry Lobby Scored a Swift, Unexpected Victory by Channeling Billions to Electronic Records</a>" on May 16 2009 in the Washington Post (my comments <a href="http://hcrenewal.blogspot.com/2009/05/machinery-behind-healthcare-reform-how.html">here</a>) exposes a massive lobby that has grossly over-represented the benefits of healthcare IT, committed a cross-disciplinary invasion of medicine, and created a myth about HIT's supposed transformative powers in curing healthcare's ills.<br /><br />Since its publication in the Post I have become concerned that the research literature that exists extolling healthcare IT may be tainted by corporate influence. The phenomenon of tainted biomedical literature is certainly familiar to readers of Healthcare Renewal and other medical blogs regarding pharmaceuticals and medical devices.<br /><br /><span style="font-weight: bold;">Electronic health records systems can facilitate, not revolutionize, medicine when led by competent experts cross-trained to a meaningful extent</span> (i.e., graduate level or beyond) in both clinical medicine and information science and technology, e.g., biomedical informatics professionals. Even these professionals must often expend much effort in "managing the mismanagement" by incompetent and/or conflicted IT and hospital leadership. (An example of a tightly run and highly specialized project in a high risk medical subspecialty that did have tangible clinical and some financial returns, via identification of poorly performing medical devices -- not something the medical device industry cares for -- is <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=Cardiology%20story">here</a>. This type of project is not easily portable.)<br /><br />Making yet another case for how the concept of national electronic health records is probably a bad idea at this point in time with respect to our understanding of health IT and its social-technical interactions and challenges, it appears the military's EHR system AHLTA is simply a disaster. <span style="font-weight: bold; color: rgb(255, 0, 0); font-style: italic;">[</span><span style="font-weight: bold; color: rgb(255, 0, 0); font-style: italic;">Note: this is not to denigrate the military, and I am very thankful to all who serve and defend our country and freedoms. HIT problems seem unfortunately universal - ed.</span><span style="font-weight: bold; color: rgb(255, 0, 0); font-style: italic;">]</span> All of the preventable elements I've <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/">written about</a> are present: unreliability to due inadequate attention to resilience engineering, a <a href="http://www.tinyurl.com/hostileuserexper">mission hostile user experience</a>, time-wasting, demoralization of clinicians, and a cornucopia of other predictable (to informatics experts) consequences when health IT is managed by anyone other than experts.<br /><br />Just as our economy and culture are now falling apart at the seams as a result of decades of mismanagement and corruption, from micro to macro levels, in most domains (borrowing a phrase from Rev. Jeremiah Wright, "the chickens are coming home to roost"), so the wages of incompetence and corruption in healthcare and healthcare IT are rearing their ugly head. This is the situation in the setting of a relatively constrained patient population (primarily active military personnel and families):<br /><span style="text-decoration: underline;"><br /></span><p></p><blockquote><p><a href="http://www.usmedicine.com/articles/electronic-records-system-unreliable-difficult-to-use-service-officials-tell-congress.html">U.S. Medicine - the Voice of Federal Medicine</a></p><p>May 2009</p><p><span style="font-size:100%;"><b>Electronic Records System Unreliable, Difficult to Use, Service Officials Tell Congress - <i>By Sandra Basu</i></b></span></p>WASHINGTON—AHLTA, the Department of Defense’s $4 million <span style="font-weight: bold; color: rgb(255, 0, 0); font-style: italic;">[sic - that should be $4 billion - ed.]</span> electronic medical record system, continues to be <span style="font-weight: bold;">difficult for military physicians to use</span>, according to top military health leaders who spoke at a House Armed Services subcommittee hearing at the end of March.<br /><br />At a Congressional hearing titled “AHLTA is ‘<span style="font-weight: bold;">Intolerable</span>,’ Where do we go from here?” top Department of Defense and service leaders told members that <span style="font-weight: bold;">medical personnel are hampered by an electronic medical record system that, among other issues, is slow, difficult to use, unreliable and frequently crashes</span>.“Being the first service to vigorously support the fielding of AHLTA five years ago, we faced a near mutiny of our healthcare providers, our doctors, our nurse practitioners, physician assistants and others last summer,” Army Surgeon General Lt. Gen. Eric Schoomaker, MC, USA, told committee members at a joint hearing held by the Military Personnel Subcommittee and the Terrorism, Unconventional Threats and Capabilities Subcommittee.<br /><br />Committee members also voiced concern about how the system was impacting provider morale and patient care. “The committee has heard from military doctors and nurses who use AHLTA that it is <span style="font-weight: bold;">unreliable, difficult to use and has decreased the number of patients they can see each day</span>. We have also heard that medical professionals <span style="font-weight: bold;">leave the military</span> because of their frustration with AHLTA,” said Rep. Joe Wilson, R.-S.C., ranking member of the Military Personnel Subcommittee of the House Armed Services Committee. </blockquote><br />Difficult for physicians to use. Intolerable. Slow. Unreliable. Frequently crashes. Near mutiny. Morale. Affecting patient care, decreasing patient load. Can it get worse?<br /><br />Yes:<br /><p><b></b></p><blockquote><p><b>A Troubled System</b></p>AHLTA is currently deployed worldwide to 70 hospitals, 410 clinics and 6 dental clinics. In addition, the system is used in 14 theater hospitals and 208 forward resuscitative sites.<br /><br />While Army, Navy and Air Forcer medical leaders who testified all stressed the importance of an electronic medical record <span style="font-weight: bold; color: rgb(255, 0, 0); font-style: italic;">[perhaps due to lobby influence and myth-making? - ed.]</span>, they all expressed frustrations with AHLTA. Dr. Schoomaker told committee members that medical personnel, particularly specialists, often “spend as much or more time working around the system as they do with the system.” He said that the services are still not effectively able to seamlessly access complete data of patients from the battlefield between the military treatment facilities and the Department of Defense and the Veteran’s Administration.<br /><br />Last year he said he knew he had a problem when he asked a physician who is a self-described “super user” of the system whether she was a “super fan” of the system and she responded that she was not. “When our best and most faithful users of AHLTA could not admit to being fans of the system, I knew we were really having serious problems,” Dr. Schoomaker said.</blockquote><br />When the Army's Surgeon General observes that clinicians "spend as much or more time <span style="font-weight: bold;">working around</span> the system as they do <span style="font-weight: bold;">with</span> the system", and that the superusers are not enthusiastic about the system, and a Congressional hearing is held entitled "where do we go from here?" (it's clear to this author that they have no clue), one should start to very critically question basic assumptions about health IT. Who said it's a powerful tool to improve healthcare and reduce costs? Who said it's ready for national dissemination? What conflicts do such individuals have with the health IT industry?<br /><br /><blockquote>He blamed the system’s failures on a lack of a clear-cut strategy for implementing AHLTA—a problem he believes still exists. “In my opinion, the failures of AHLTA can be attributed to the<span style="font-weight: bold;"> overall lack of a clear, actionable strategy and poor execution from its genesis. As a result of the MHS’s lack of an information management/information technology strategy up to this point</span>, theArmy Medical Department has been largely frustrated by a number of obstacles that continue to impede the system’s capabilities and functionality,” he said.<br /><br />He also said that the services should have a greater input in decision making regarding AHLTA. “Military health system information technology investments and solutions should be transparent to the services sitting here at the table and should be jointly governed, meaning that we with service input are treated as principal customer clients of the system and that we are heard and acted upon promptly,” he said.</blockquote><br />As a faculty member in a College of Information Science and Technology where undergraduates and graduate students are taught the importance of information science and consideration of the needs of end users as a primary enabler of IT success, how can there be a "lack of an information management/information technology" strategy in this national health IT project? How can there have been a lack of input into decision making by the services in the development and deployment of AHLTA?<br /><br /><blockquote>Leaders from the Navy and Air Force detailed the challenges that their personnel face in using AHLTA. “Almost all of the providers I spoke to relate to the system going down unexpectedly, recently <span style="font-weight: bold;">at least once a week</span>,” Navy Deputy Surgeon General Rear. Adm. Thomas R. Cullison, MC, USN, told committee members. He added that while no one would like to return to paper records, <span style="font-weight: bold;">providers are “largely dissatisfied” with the system and that the system slows down their clinic time.</span> “Most of our providers say they have to stay later in the afternoon to finish up notes simply because it slows down clinic time,” he said.<br /><br />Air Force Deputy Surgeon General Maj. Gen. Charles Bruce Green, USAF, MC, told the committee that Air Force primary care physicians spend about<span style="font-weight: bold;"> 40 percent of their time working with AHLTA versus 60 percent of their time with patients.</span> On the other hand, specialists are “working around the system trying to find new solutions,” since the system does not address the needs unique to their practices. In his written testimony, Dr. Green said that the problems associated with AHLTA have resulted in “<span style="font-weight: bold;">low productivity and provider morale</span>.” </blockquote><br />Forty percent of clinician time spent tinkering with balky computers? This should be astonishing to any reader unfamiliar with these issues, and an eye opener to our governmental representatives not just regarding the military, but regarding the entire lobby-promoted scheme to force clinicians to adopt HIT by 2014 or suffer financial penalties.<br /><br />Specialists "working around" the system (thus risking the <a href="http://hcrenewal.blogspot.com/2008/06/business-v-clinical-computing.html">dangers of workarounds</a> of HIT deficiencies observed by Koppel and others) because it <span style="font-weight: bold;">does not meet the needs of their subspecialties</span>? No surprises here. After reading about issues in development of domain specific healthcare information systems for high risk subspecialties (such as <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=Cardiology%20story">here</a>), it should be obvious that the business IT-dominated health IT industry as it currently exists cannot fill such needs.<br /><br />More importantly, I feel the AHLTA project is an illustration of what will be reproduced, thousands or tens of thousands of times over, in hospitals and physician practices all over this country as we proceed in a national EHR initiative based on false premises borne of the health IT lobby.<br /><br /><b></b><blockquote><b>The Problem</b><br /><br />Then-Assistant Secretary of Defense for Health Affairs S. Ward Casscells, M.D., told committee members that many of the problems that AHLTA has suffered have been “self-inflicted wounds,” due to <span style="font-weight: bold;">software contracts with vendors that were “poorly written.”</span> “We have had, over the past decade, contracts that were poorly written from the standpoint of performance, they have l<span style="font-weight: bold;">oopholes in them that permitted delays</span>. We have, in some instances, lax oversight of some of these contracts,” he said.</blockquote><br />Unbelievable. Hospitals sign HIT contracts putting all liability for system defects on clinicians, and that gag them from disclosing defects outside their organizations. The military's HIT contracts apparently had additional flaws that are probably pervasive in the commercial sector as well.<br /><br /><blockquote>... In moving forward to rectify AHLTA problems, DoD has adopted a Unified Strategy Regional Distribtion Approach, a three-phased plan for reshaping the electronic health system. In written testimony, Dr. Casscells explained this strategy seeks to “improve provider satisfaction, improve reliability and strengthen data sharing throughout DoD and Department of Veterans Affairs healthcare delivery continuum and with private healthcare providers.” The first phase of the approach will focus on “stabilizing performance, reliability and the core infrastructure,” of the system according to Casscell’s written testimony.<br /><br />"I want to be wary of overpromising. We have done that in the past <span style="font-weight: bold; color: rgb(255, 0, 0); font-style: italic;">[indeed, the entire HIT industry has massively overpromised for decades - ed.]</span>, but I am excited about this. I think there is a chance here that we can once again be leaders for the nation in electronic health records, as was the case several decades ago. I would like to think that a year or two from now, you will agree with me that AHLTA has gone from intolerable to indispensible,” Dr. Casscells told committee members.<br /><br />Tommy J. Morris, acting director in DoD’s office of the Deputy Assistant Secretary of Defense for Force Health Protection and Readiness Programs, said that <span style="font-weight: bold;">the only service that nonconcurred with their proposed blueprint to overhaul AHLTA was the Army <span style="color: rgb(255, 0, 0); font-style: italic;">[not exactly an unimportant stakeholder - ed.]</span></span><br /><br /><span style="font-weight: bold;">Dr. Schoomaker, on his part, challenged the notion that there was actually a “strategy” in place for rectifying AHLTA.</span> “Mr. Morris has g<span style="font-weight: bold;">ot a plan</span>, he does not have a strategy. We asked for a strategy. A plan is just one element of a larger strategy. We asked for a strategy and our involvement in that strategy, so with respect, that is what we in a sense partially nonconcurred with,” Dr. Schoomaker said.</blockquote><br />"I've got a plan." How familiar a refrain that is in a time of mass societal mismanagement.<br /><br />If I were a politician examining health IT, I'd really start looking into how our government became convinced health IT was not only a worthwhile investment, but an "economic stimulus." As with our <a href="http://hcrenewal.blogspot.com/2009/05/canadian-health-it-ripoff-is-anyone-in.html">friends up north</a>, it seems to be primarily a stimulus for poseurs and dyscompetents to come out of the woodwork, disrupt healthcare providers, and then collect massive fees for the "favor."<br /><br />In consideration of the above, I ask:<br /><br />If the military, with its internal discipline and ability to take over entire modern countries with just a few thousand soldiers lost, and its constrained patient population (active military personnel and families generally free of complex and chronic illnesses) can't get electronic health records right, why would anyone think inept and sometimes corrupt EHR companies, dyscompetent hospital IT departments, and <a href="http://hcrenewal.blogspot.com/2009/03/health-it-hold-harmless-and-defects-gag.html">reckless and cavalier hospital executives</a> can?<br /><br />I reiterate my concerns that the "<span style="font-weight: bold; font-style: italic;">AHLTA experience</span>" will become all too familiar to hospitals and physician practices throughout this country, unless sanity and rationality is restored to our thinking about health IT.<br /><br />-- SS

If The Military Can't Get Electronic Health Records Right, Why Would We Think Conflicted EHR Companies And IT-Backwater Hospitals Can?

The publication "The Machinery Behind Healthcare Reform: How an Industry Lobby Scored a Swift, Unexpected Victory by Channeling Billions to Electronic Records" on May 16 2009 in the Washington Post (m…

Đọc thêm »