healthy4u: GAO

A new GAO report has appeared entitled "Health Care Delivery: Features of Integrated Systems Support Patient Care Strategies and Access to Care, but Systems Face Challenges." (Hat tip: saw this in story by Inga at <a href="http://histalk2.com/2010/11/18/news-111910/">HerTALK</a>). The report is available at these links: GAO-11-49 November 16, 2010 <a class="result" href="http://www.gao.gov/highlights/d1149high.pdf">Highlights Page</a> (PDF) <a class="result" href="http://www.gao.gov/new.items/d1149.pdf">Full Report</a> (PDF, 33 pages) <a class="result" href="http://www.gao.gov/htext/d1149.html">Accessible Text</a> One of those strategies, of course, is healthcare IT: <blockquote> IDSs in GAO's sample reported that using electronic health records (EHR), operating health insurance plans, and employing physicians all support strategies to improve patient care. An EHR contains patient and care information, such as progress notes and medications. Some IDSs said that using EHRs supports their patient care strategies such as care coordination, disease management, and use of care protocols by increasing the availability of individual patient and patient population data and by improving communication among providers.</blockquote> Some might take this report as "proof" that healthcare IT is ready for national rollout. However, the following passage lends doubt to that interpretation, in the form of a significant "however" (a common word seen in reports about healthcare IT, along with terms such as "but", "except", "in some cases", "in the next release", the ever-valuable term "glitches", and other similar hedge terms). <blockquote>… However, the information we present is from the perspective of the IDSs in our sample. We relied on data obtained through the Web-based data collection instrument, interviews with system representatives, and published studies and did not conduct independent analyses of the effectiveness of strategies. </blockquote> This report suffers a serious flaw: potential (or might I say likely) self-reporting bias. Caveat emptor.-- SS

GAO report: - Health Care Delivery: Features of Integrated Systems Support Patient Care Strategies and Access to Care (such as HIT)

A new GAO report has appeared entitled "Health Care Delivery: Features of Integrated Systems Support Patient Care Strategies and Access to Care, but Systems Face Challenges." (Hat tip: saw this in s…

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I have heard from numerous reliable sources that the military's $4 billion+ EMR known as "Armed Forces Health Longitudinal Technology Application" (<a style="font-weight: bold;" href="http://dhims.health.mil/userSupport/ahlta/about.aspx">AHLTA</a>) is to be declared a failure, and replaced. I'd written about AHLTA's considerable problems at the post "If The Military Can't Get Electronic Health Records Right, Why Would We Think Conflicted EHR Companies And IT-Backwater Hospitals Can?" 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> . From that post: <blockquote> [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? Yes ... When the Army's Surgeon General observes that clinicians "spend as much or more time working around the system as they do with 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. </blockquote> 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. Meanwhile, the VA is having its own problems as noted on the HISTalk blog: <blockquote> [<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 scrapping a $150 million patient scheduling system without ever bringing it live. 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> 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). From that report: <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: <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. </li></ul> 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. </blockquote> <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: </div> <div dir="ltr"> </div> <div dir="ltr">By 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? If so, I wish the military and VA the best of luck. They will need it. 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 recycled incompetents, 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. 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. Our economy and even society is falling apart as a result of these leadership problems; Lee's post "Lightweight oil executives produce worthless disaster plans" as linked above is <a href="http://en.wikipedia.org/wiki/Pathognomonic">pathognomonic</a> of these failures. Writes Lee: <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 because of a universal and deeply flawed process for selecting their leaders. ... 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. </blockquote> </div> Here is the major problem in a nutshell: no real accountability where it matters. What follows from this is a first principle: Recycled incompetents will never produce good information systems. Major health IT commercial vendor CEO's have been reported as making statements that health IT usability -- one of AHLTA's major deficiencies - "will be part of certification over her dead body" (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>). Why don't we recycle physicians with track records of killing patients? Better yet, make them Chairs of clinical departments? The answer is obvious, but the IT culture seems immune to such considerations. The UK's National Programme for IT in the NHS (NPfIT) is AHLTA on a national scale: <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>. 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> My prediction is this: I do not believe health IT has advanced enough beyond the experimental stage for clinically efficacious, safe, cost effective mass dissemination. 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. 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>”: <blockquote style="font-family: arial;"> I don't think a degree gets you anything," 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 the school of hard knocks." In seeking out CIO talent, recruiter Lion Goodman "doesn't think clinical experience yields [hospital] IT people who have broad enough perspective. 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.</blockquote> 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. 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. -- SS 7/6 addendum: 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>"

$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…

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