healthy4u: Jon Patrick

On Hypervigilance Due to Bad Health IT: "Texting While Doctoring: A Patient Safety Hazard"

An Opinion piece "Texting While Doctoring: A Patient Safety Hazard" appeared in the Annals of Internal Medicine of 3 December 2013, authored by Christine A. Sinsky, MD and John W. Beasley, MD.  Dr. Sinsky is known to me to be what some would call a "heatlhcare IT iconoclast" (more accurately represented by the term "healthcare IT gadfly/realist" IMO). In the piece the authors comment on the distractions caused by the technology, leading to doctors missing important cues in the exam room and to and impaired problem-solving.  This is part of a larger phenomenon that has been called "skill-degrading" or "de-skilling", e.g., see my April 16, 2010 post "Health Information Technology Basics From Calif. Nurses Association and National Nurses Organizing Committee" at <a href="http://hcrenewal.blogspot.com/2010/04/health-information-technology-basics.html">http://hcrenewal.blogspot.com/2010/04/health-information-technology-basics.html</a>).   These effects are likely to be further worsened as more and more clerical tasks such as order entry, the authors point out, get shifted to medical professionals.  To new readers: note that computerized order entry is often a complex and convoluted process; the CPOE systems are most decidedly NOT mere "typewriters for orders."  See, for instance, part 6 of my series on "Mission-hostile health IT" at <a href="http://hcrenewal.blogspot.com/2009/02/it-makes-healthcare-easier-is-this.html">http://hcrenewal.blogspot.com/2009/02/it-makes-healthcare-easier-is-this.html</a>. Most of the Annals article is available as a free preview at <a href="http://annals.org/article.aspx?articleid=1784295">http://annals.org/article.aspx?articleid=1784295</a> as of this writing and is worth reviewing. <table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjCxGx3pchjD96z40o0nvd5V3ajmX-dfcQBAPJ3lg1DDvKwmpnSqlwNwHplkPhWZ4m9BCQYD8leE9-tNRfWS_Yy-QB0G5Y4Jp4VYFBEumMmTb3XZmw1lWhMv8yk8L67VrNiGJW0eY_3ukK4/s1600/sinsky1.gif" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjCxGx3pchjD96z40o0nvd5V3ajmX-dfcQBAPJ3lg1DDvKwmpnSqlwNwHplkPhWZ4m9BCQYD8leE9-tNRfWS_Yy-QB0G5Y4Jp4VYFBEumMmTb3XZmw1lWhMv8yk8L67VrNiGJW0eY_3ukK4/s400/sinsky1.gif" width="305" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Article preview, click to enlarge</td></tr></tbody></table> I found one passage in particular striking, though.  In my ongoing discussions with computer scientist/informaticist/polymath Dr. Jon Patrick at U. Sydney (<a href="http://www.healthll.com.au/?page_id=440">http://www.healthll.com.au/?page_id=440</a>) , the issue of hypervigilance necessitated by bad health IT came up, and we arrived at the definition of same seen at my teaching site at <a href="http://cci.drexel.edu/faculty/ssilverstein/cases/">http://cci.drexel.edu/faculty/ssilverstein/cases/</a>: <blockquote class="tr_bq">Bad Health IT ("BHIT") is defined as IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.  </blockquote> Note this passage in Dr. Sinsky and Beasley's opinion piece: <table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtHLHXSyRd0Dyolv6mcgLfhmp4J-4oYYVf3u2-ztDbSt0oW2ogHT3vz5rhAcr89y8SNkWv1ZAQB1_WZ5CH4mA7paPhsT8IpQBP_dFwsL5qNya5qnQ8OK6k6Y78jVn0Qsll6PrUa1LgR2o8/s1600/sinsky.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtHLHXSyRd0Dyolv6mcgLfhmp4J-4oYYVf3u2-ztDbSt0oW2ogHT3vz5rhAcr89y8SNkWv1ZAQB1_WZ5CH4mA7paPhsT8IpQBP_dFwsL5qNya5qnQ8OK6k6Y78jVn0Qsll6PrUa1LgR2o8/s320/sinsky.jpg" width="313" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">"I am always multitasking ... I am entering orders, checking labs, downloading information while I talk to the patient.  It requires chronic hypervigilance, which is exhausting and demands conscious effort to stay in the 'present' with the patient" (Day S., Personal communication.)  Click to enlarge.</td></tr></tbody></table> I don't know if Dr. Day had seen my materials, but I suspect the exhausting hypervigilance is all too common, just not much publicized due to the secretive, closed, retaliatory-towards-whistleblowers nature of the healthcare IT sector. I ask:  is this what we really want, in pursuit of some uncertain cybernetic miracle? I note that the healthcare IT experiment (and the technology is experimental), long usurped from the Medical Informatics pioneers who trained me and put in the hands of commercial interests and those of a mercantile/manufacturing/management computing background, is increasingly a failure. -- SS

On Hypervigilance Due to Bad Health IT: "Texting While Doctoring: A Patient Safety Hazard"

An Opinion piece " Texting While Doctoring: A Patient Safety Hazard" appeared in the Annals of Internal Medicine of 3 December 2...

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Wisdom from the Medical Journal of Oz: "Good HIT and bad HIT"

The recognition and partitioning of "good health IT" from "bad health IT" is now a mainstream meme.  I have few comments about this new article; it reflects views frequently expressed here at Healthcare Renewal (indeed, one of its references is to this blog and this author): <blockquote class="tr_bq"><a href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit" target="_blank">Good HIT and bad HIT</a> Jon D Patrick and Susan Ieraci Medical Journal of Australia 2013; 198 (4): 205.</blockquote><div class="ui-tabs-panel ui-widget-content ui-corner-bottom" id="article"><blockquote></blockquote><div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><blockquote><div class="Intro">First and foremost, do no harm. Second, do some good</div><div class="Intro"> </div></blockquote><div class="field field-name-field-provenance field-type-text field-label-above"><blockquote><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_elementId-1140662" name="0_elementId-1140662"></a> <div class="P">O<a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1140078" name="0_pgfId-1140078"></a>ne of the key issues for high-volume, high-risk workplaces like hospital emergency departments (EDs) is the struggle of conflicting aims. While hospital managers need information systems for data collection and storage, clinicians need efficient clinical documentation, data retrieval and order-entry systems that save time rather than steal it from the patient. The work of clinicians is aided by reliable data but impaired by the delays of real-time input, difficult system navigation, suboptimal presentation of information, and other problems in the user experience of health information technology (HIT).<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#1">1</a></div><div class="P"> </div><div class="P"><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1139847" name="0_pgfId-1139847"></a>Mohan and colleagues’ study of the impact of an electronic medical record information system on ED performance had some limitations.<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#2">2</a> It was retrospective and unable to control for all confounders, and therefore could only show a correlation with ED delays, not causation. However, the premise for the study delivers an important message — the work required to use the information system was perceived by the ED staff to directly conflict with time spent with patients.</div><div class="P"> </div><div class="P"><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1139851" name="0_pgfId-1139851"></a>Another study has shown that the same electronic medical record information system is perceived to have had a negative impact on the care of patients, as well as the productivity and morale of staff, in six EDs in New South Wales.<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#3">3</a> The need to be hypervigilant about the accuracy of the information supplied by the electronic health record compounds an already stressful clinical environment, which in turn leads to resentment towards the technology and the people who have imposed it. This makes it “bad” HIT. Unless this is corrected, HIT efforts will overuse precious health care resources, will be unlikely to achieve claimed benefits for many years to come, and may actually cause harm.<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#4">4</a>,<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#5">5</a></div><div class="P"> </div><div class="P"><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1139861" name="0_pgfId-1139861"></a>The large HIT corporations produce a type of technology that is best categorised as enterprise resource planning (ERP), which has its roots in the manufacturing industry. It is based on the idea that all processes within an organisation can be standardised, and that all processes of the same type should have their information modelled and processed in the same manner. If this high degree of standardisation were considered the best way to process and model information derived from clinical activity, then ERP would be a favoured technology to adopt, as has happened in many places.</div><div class="P"> </div><div class="P"><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1139862" name="0_pgfId-1139862"></a>However, there is an alternative, almost contradictory, perspective on the nature of clinical work: that it is non-deterministic and performed by a group of diverse staff working in an ecologically stable network of people that has to respond to diverse medical needs and diseases. The ecology model accommodates staff joining and leaving the process, with differing needs emerging at different times, so that the other individuals in the network have to adapt and modify their behaviour and improvise in an unpredictable manner. Amid all this variability is the ever-demanding imperative to improve the processes of care and attention to the patient, while also increasing staff productivity.<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#6">6</a></div><div class="P"> </div><div class="P"><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1139866" name="0_pgfId-1139866"></a>Where the ERP model has been imposed in the clinical setting, staff may be coerced into an approach to their work that is at odds with established best practices. This could only be considered “good” HIT if it brought greater staff productivity with at least no loss (and, preferably, improvement) of patient safety and services and staff morale.</div><div class="P"> </div><div class="P"><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1139867" name="0_pgfId-1139867"></a>It is not enough just to identify problems: effort must be invested in transforming bad HIT into good HIT. This process must identify and optimise all the operative factors: human behaviour, system design, equipment performance, skills of the IT participants, and the operational policy framework.<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#7">7</a> Good HIT should include clinician control of the interface design for content, dataflow and workflow. It includes the ability to change the system in real time, and it incorporates inbuilt data analytical capability, natural language processing, and native interoperability and clinical coding.<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#8">8</a> Finally, there must be an appropriate opportunity to test systems for useability, effectiveness and suitability before their release.</div><div class="P"> </div><div class="P"><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1139874" name="0_pgfId-1139874"></a>There must be a move away from standardised processing models and towards improving the user experience in the clinical setting. Clinicians should not have to shoehorn their activity into predefined, externally imposed work processes that do not reflect actual activity and will not improve efficiency. A true patient-focused system aligns all its components towards the same aim. Like a good clinician, good HIT does no harm — to patients or staff.</div></blockquote></div><div class="field field-name-field-provenance field-type-text field-label-above"> American medical / HIT journals are perhaps a bit too beholden to industry to directly commit such health IT heresy.  Thank the stars those Down Under are a bit more bold.</div></div></div></div><div class="field field-name-field-provenance field-type-text field-label-above"> </div><div class="field field-name-field-provenance field-type-text field-label-above">-- SS</div></div>

Wisdom from the Medical Journal of Oz: "Good HIT and bad HIT"

The recognition and partitioning of "good health IT" from "bad health IT" is now a mainstream meme. I have few commen...

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Michael Millenson and "the adamant refusal by hospitals and doctors to adopt electronic records no matter what the evidence"

Over at Health Beat by Maggie Mahar appears a piece critical of NYT reporter Julie Creswell's Feb. 20, 2013 article "<a href="http://www.nytimes.com/2013/02/20/business/a-digital-shift-on-health-data-swells-profits.html" target="_blank">A Digital Shift on Health Data Swells Profits in an Industry</a>."  (The piece was also cross-posted at The Health Care Blog.)  There have been several responses highly critical of the NYT article recently in various venues. The Health Beat piece "<a href="http://www.healthbeatblog.com/2013/03/the-health-it-scandal-the-ny-times-didnt-cover/" target="_blank">The Health IT Scandal the NY Times Didn’t Cover</a>" is by Michael L. Millenson, president of Health Quality Advisors LLC in Highland Park, IL, and the author of the critically acclaimed book, <a href="http://www.amazon.com/Demanding-Medical-Excellence-Accountability-Information/dp/0226525880" target="_blank">Demanding Medical Excellence: Doctors and Accountability in the Information Age</a> published in 2000. I bought and read that book at the time. The posting at Health Beat contains the following statement: <blockquote class="tr_bq">The actual scandal is more complicated and scary. It has to do with the adamant refusal by hospitals and doctors to adopt electronic records no matter what the evidence.  </blockquote> I am profoundly disappointed by this statement in view of issues (frequently written about here and elsewhere) such as: <ul><li>The <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=readinglist" target="_blank">conflicting literature</a> by credible and responsible parties on health IT's real-world value and risks as it exists today;  </li><li>Fiduciary obligations of hospital executives to maintain safe operating conditions; </li><li>Legal and ethical obligations of physicians to resist technology they find or believe harmful without rigorous proof of its beneficence and efficacy (which includes the absence of major evidence conflicts); </li><li>The evidence of major and frequent <a href="http://hcrenewal.blogspot.com/2011/01/maude-and-hit-risk-mother-mary-what-in.html" target="_blank">flaws, bugs</a> and "<a href="http://hcrenewal.blogspot.com/search/label/glitch" target="_blank">glitches</a>", some of which are alarming; </li></ul>not to mention: <ul><li>The 500+ reader comments in response to Creswell's article, many by clinicians describing why they don't like today's health IT; </li><li>Examples of unintended adverse consequences such as <a href="http://hcrenewal.blogspot.com/2011/06/babys-death-spotlights-safety-risks.html" target="_blank">here</a> (plus at least 5 other IT-related crippling injuries and/or deaths of infants I know of but cannot speak about), and <a href="http://hcrenewal.blogspot.com/2011/09/sweet-death-that-wasnt-very-sweet-how_24.html" target="_blank">here</a>, and <a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html" target="_blank">here</a>; </li><li>Other factors as at this blog and at my teaching site <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/" target="_blank">here</a>.</li></ul> I am trying to find a polite term for the statement, and struggling to do so in view of the author's prior work, which I admired. The statement really is saying: <blockquote class="tr_bq">... It [the "scandal"] has to do with the adamant refusal by hospitals and doctors to adopt electronic records no matter what the evidence ... which is all exceptionally robust and positive, leaving no room whatsoever for reasonable doubt or caution. </blockquote> Regrettably, here is the most polite term I can come up with describing the statement: <a href="http://thesaurus.com/browse/preposterous" target="_blank">Preposterous</a>. If anyone takes offense to that term, please suggest a more precise one. Perhaps a book needs to be written entitled "Demanding Information Technology Excellence: Health IT and Accountability in the Information Age." -- SS Mar. 4, 2013 addendum: In a response to a reader's comment to the cross-posting of this piece at The Health Care Blog (<a href="http://thehealthcareblog.com/blog/2013/03/03/the-health-it-scandal-the-ny-times-didnt-cover/" target="_blank">link</a>), Millenson responds: <blockquote class="tr_bq">"platon20: my point, that EMRs were available in the 1970s but never changed their interface because doctors never cared enough to demand it, is not refuted by your argument, but confirmed."</blockquote> This is bizarre and inconsistent with my experience and that of other Chief Medical Informatics Officers I've mentored or spoken with.  Since my entry into the domain of Medical Informatics 21 years ago I've heard many physicians, myself included [1], demand that health IT sellers and/or hospital IT departments "improve the user interface", among other areas for improvement.  Based on my own observations and that of others (e.g., via reader comments at my teaching site dating to <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/informaticsmd/opinions1.htm" target="_blank">at least 1999</a>), these pleas have often fallen on the deaf - and in some cases ill-informed and/or incompetent - ears of hospital senior and IT executives and industry pundits.  The latter have often responded by accusing the physicians of being "Luddites" or technophobes, and the advocates for change such as myself "anti-health IT." The most stunning example regarding this phenomenon is the industry pushback against Prof. Jon Patrick at U. Sydney, and the ignoring of his work (on both the user experience and the fundamental software engineering quality) sitting on a University server for several years now, regarding a major U.S. ED EHR <a href="http://sydney.edu.au/engineering/it/~hitru/index.php?option=com_content&task=view&id=91&Itemid=146" target="_blank">slated for rollout in an entire state of Australia</a>.   With usability issues now being forced of the industry for reconsideration by HHS via NIST, the industry response has been to claim that "<a href="http://ehrdecisions.com/2011/05/11/from-the-chair-usability-still-in-the-eye-of-the-beholder/" target="_blank">usability is in the eye of the beholder</a>" and other frivolous claims, up to and including <a href="http://hcrenewal.blogspot.com/2012/09/from-what-i-can-tell-epic-was.html" target="_blank">interference in the the public comments period on Meaningful Use via ghostwriting</a>, and possibly <a href="http://hcrenewal.blogspot.com/2010/05/did-epic-ceo-judy-faulkner-of-epic.html" target="_blank">outrageous statements</a> (although that issue became anechoic), to get their way, which is to do little or nothing on that score. I remind Millenson that "improving the user experience" of health IT cuts into the bottom line. [1] e.g.,  in a project initiated 20 years ago <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story" target="_blank">by the clinicians themselves</a> - in a critical care area no less - in which I had to take over through force of will from the hospital's own IT department and COO and  re-engineer not just the commercial user interface but the entire dataset itself.  The project ultimately proved successful after my intervention, but the mid-level executive who facilitated my takeover to do that, and I, were punished by our superiors for our efforts. -- SS

Michael Millenson and "the adamant refusal by hospitals and doctors to adopt electronic records no matter what the evidence"

Over at Health Beat by Maggie Mahar appears a piece critical of NYT reporter Julie Creswell's Feb. 20, 2013 article " A Digital Sh...

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Guest post by Dr. Jon Patrick, U. of Sydney: On the ECRI Institute's recommendations following a "deep-dive" study of HIT-related events

At my Feb. 9, 2013 post "<a href="http://hcrenewal.blogspot.com/2013/02/ecri-institute-pso-uncovers-health.html" target="_blank">ECRI Institute PSO Uncovers Health Information Technology-Related Events in Deep Dive Analysis</a>", I wrote about an ECRI Institute study of well-defined client data submitted over a 9-week period (a "deep dive" study) on EHR problems.  Risk-creating events at a level that should be a significant concern to patients and clinicians fell into the following categories:  <ul><li>inadequate data transfer from one HIT system to another </li><li>data entry in the wrong patient record</li><li>incorrect data entry in the patient record</li><li>failure of the HIT system to function as intended </li><li>configuration of the system in a way that can lead to mistakes </li></ul> Dr. Jon Patrick at U. Sydney, a scientist and medical informatician who sees the issues from a number of unique perspectives (<a href="http://rp-www.cs.usyd.edu.au/~jonpat/CV/CV_brief.html" target="_blank">link to bio</a>), has offered the following critique of the key recommendations made by the ECRI Institute as a result of this study of health IT events (see aforementioned post for the text of those recommendations).  One caveat is that neither he nor I have the full report as of this writing in part due to expense: <blockquote class="tr_bq">The ECRI has produced a report on HIT errors. I was concerned about the manner in which the Key Recommendations minimised, generalised or failed to concretise important issues that I offer these comments. On ECRI Key Recommendations: 1. Enlist leaders’ commitment and support for the organization’s health IT projects. JP: This is clearly a comment from one level of  management to those levels above it. It doesn't seem to be a comment about the nature of the HIT itself but more about the internal processes to getting it established. There is really not much to say here because if upper management don't want to do anything about the introduction of HIT then engaging in the task is probably futile, hence it was difficult to understand why it was included. 2. Involve health IT users in system planning, design, and selection. JP: yes, this is crucial to successful solutions. 3. Conduct a review of workflow and processes to determine how they must be modified. JP: the missing clause at the end of this sentence is "to fit the introduced HIT system". This is putting the cart before the horse. The notion that a piece of software designed by engineers should have priority over the team of clinicians who are experts in their business is highly naive. Also this statement is in contradiction to point 2 above. The privileging of the functioning of  the IT system as the expert over that of the clinical team, AND making a recommendation in contradiction to an earlier recommendation is absurd enough by itself  to undermine the credibility of  the report. 4. Evaluate the ability of existing IT systems within the organization to reliably exchange data with any health IT system under consideration. JP: And after the evaluation what should be done. This is hardly an informative recommendation. It is of the form "Do Something, it doesn't matter what you do, just do something."  A more compelling statement that would have enhanced the credibility of the authors and demonstrate their knowledge of the industry would have been: " Establish unambiguously and conclusively that any health IT system under consideration has the ability to reliably exchange data with existing IT systems within the organization". Note the focus needs to be on the incoming system being the object of conformity not the incumbent systems. 5. Conduct extensive tests before full implementation to ensure that the health IT system operates as expected. JP: this is a clearly a desirable goal and applies to point 4 above as well as all other aspects of the system functions. 6. Provide user training and ongoing support; educate users about the capabilities and limitations of the system. JP: This is a motherhood statement that does nothing to contribute to the nub of training issues in the use of HIT. Training is an ongoing issue for two reasons: staff change and new staff come on to the roster and need to be trained, and, these systems are complex and expert advice and skill needs to be available to staff as an ongoing service so that work is not delayed due to confusion on how to use the IT. An alternative proposal to reduce training costs and investment would be to design the system so that it matches current best practice of the clinical team so that learning the system is minimised because it fits seamlessly into their work processes. Surely the issue of educating users about the capabilities and limitations of the system is independent of the training topic. The users will discover on their own bat the limitations of the system as they try to use it. 7. Closely monitor the system’s ease of use and promptly address problems encountered by users. JP:This is a quite inadequate description of the action that needs to be taken. The real consideration is for them to have an effective avenue for expressing the limitations in a manner that is acceptable and they are NOT chastised as malcontents [or Luddites or technophobes - ed.] AND that the unnecessary or dangerous limitations are addressed promptly. 8. Introduce alterations to a health IT system in a controlled manner. JP: It is hard to understand what is meant by this statement. Firstly I would have said "introduce alterations to the clinical processes  in a controlled manner". Secondly, alterations to the HIT system need to be done promptly  when it is defective. Once again, as in point 3 above the technology is being preferenced over the clinical processes which I argue is back-to-front. 9. Monitor the system’s effectiveness with metrics established by the organization. JP: This is definitely something that should be done but it also needs a more directed purpose. It is easy to say to assess patient safety but most systems don't readily capture relevant data or supply analytical devises to easily draw a picture of patient  safety. However there is an equally important factor in care that is often overlooked and that is staff productivity and by implication morale. There is a need to understand better ways of assessing staff productivity in positive ways and the effect a CIS has on staff morale.  Typical comments about CISs is that they cost staff  up to 20% more time to maintain the patient record. Staff wouldn't mind giving up that time if it was returned in some other form, but it isn't, so they feel the time is stolen from them or from their patients. 10. Require reporting of health IT- related events and near misses. JP: This is poorly stated and is probably meant to read "health IT - related adverse events". This is a positive recommendation but does not go far enough. A more comprehensive statement would be "Install a process and technology for reporting adverse events and establish methods for evaluating the reports and recommending changes to clinical practice, or technology functionality and implementing them. 11. Conduct thorough event analysis and investigation to identify corrective measures. JP: This  goes some way to dealing with my point in item 10 above. Its weakness is in not identifying the types of problems and taking a firm stance on completing the correct action. SOME of the Items that have been OVERLOOKED 1. The system needs to be alterable at any time by the clinical leadership so as to immediately emplace revised work practices when they are approved. 2. The system needs to have native analytics so that the clinical leadership can monitor the activities of their teams and provide evidenced based feedback to support continuous process improvement. 3. The system needs highly accurate natural language processing so that the search for required content though the clinical record can be fast, efficient and reliable. Professor Jon Patrick Chair of Language Technology School of Information Technologies Faculty of Engineering University of Sydney Health Information Technologies Research Laboratory <a href="http://www.it.usyd.edu.au/~hitru">http://www.it.usyd.edu.au/~hitru</a></blockquote> This is excellent advice coming from perhaps the only computing expert in the world who's conducted a forensic analysis of a major commercial EHR product, one intended for high-risk ED's.  His analysis of that product, intended for government-mandated rollout in public hospitals in Dr. Patrick's Australian state of New South Wales, is at this link. This work has largely been ignored by the health IT industry and the academic Medical Informatics community.  However, I can assure the industry and the academic community that the report will not be ignored by those in the legal community if (perhaps I should say when) patients are injured or killed by the system's deficiencies. -- SS

Guest post by Dr. Jon Patrick, U. of Sydney: On the ECRI Institute's recommendations following a "deep-dive" study of HIT-related events

At my Feb. 9, 2013 post " ECRI Institute PSO Uncovers Health Information Technology-Related Events in Deep Dive Analysis ", I wrot...

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Australia and Health IT: Will Government Officials Ever Learn?

Perhaps New Zealand professor Shaun Goldfinch's article "Pessimism, Computer Failure, and Information Systems Development in the Public Sector" should be required reading in their neighboring continent due northwest: <blockquote>Pessimism, Computer Failure, and Information Systems Development in the Public Sector. (Public Administration Review 67;5:917-929, Sept/Oct. 2007, Shaun Goldfinch, University of Otago, New Zealand). Cautionary article on IT that should be read by every healthcare executive documenting the widespread nature of IT difficulties and failure, the lack of attention to the issues responsible, and recommending much more critical attitudes towards IT. <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/Goldfinch_pessimism_PAR.pdf">link</a> to pdf</blockquote> Here's what's about to "go down" (no pun intended) Down Under, this time in the Australian state of <a href="http://en.wikipedia.org/wiki/Queensland">Queensland</a>: <blockquote> <a style="font-weight: bold;" href="http://www.couriermail.com.au/news/queensland/health-software-on-the-sick-list/story-e6freoof-1226142181877">Queensland Health eyes software system despite red flags </a> Koren Helbig From: The Courier-Mail September 21, 2011 12:00AM QUEENSLAND Health is poised to sign a multimillion-dollar contract for computer software similar to that labelled "defective" by an IT expert who audited its use in southern hospitals. University of Sydney's Professor Jon Patrick said electronic medical records systems built by Cerner Corporation for the NSW Government crashed frequently and risked patient safety. A similar Cerner system installed by the Victorian health department also has been plagued by glitches and is five years behind schedule.</blockquote> Dr. Jon Patrick's detailed forensic analysis of a Cerner ED system is <a href="http://sydney.edu.au/engineering/it/%7Ehitru/index.php?option=com_content&task=view&id=91&Itemid=146">at this link</a> and has been a subject of numerous posts on this blog. <blockquote>"I don't think there's any reason for optimism that they can be improved," Prof Patrick said. Leaked internal documents have surfaced detailing problems already looming within Queensland, as bureaucrats negotiate with US-based Cerner to build a $243 million electronic medical records system in Queensland hospitals. Technical information for the proposed Cerner system and existing IT platforms that it must work with was "often incomplete, not-comprehensive, inaccurate and out-of-date", a leaked position paper found. Another email addressed to chief information officer Ray Brown, released to the State Opposition under Right to Information laws, warned of the increasing need to document potential risks "even if we can't find the resources to remove them" in case of disaster and patient death.</blockquote> I guess dead patients can't complain about that, unless provided with underground megaphones. <blockquote>"The no-surprises rule may be applicable and would help in a Coroner's Court," the clinical adviser wrote. But, in a written statement, Mr Brown last night backed Cerner, which he said had successfully operated systems at the Royal Brisbane and Women's and Princess Alexandra hospitals for more than a decade.</blockquote> A few anecdotes of success, let's ignore those pesky anecdotes of problems, and - WHAM! - let's spend billions and roll this out statewide/nationwide. The problem with this (il)logic was well-explained by another physician Down Under who chooses to remain anonymous. See my August 2011 post "From a Senior Clinician Down Under: Anecdotes and Medicine, We are Actually Talking About Two Different Things" <a href="http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html">at this link</a>. Read it carefully.... <blockquote>Mr Brown said Queensland had learnt from interstate problems and would implement an "end-to-end solution", rather than trying to marry different systems across hospitals. Independent experts had verified the rollout and more than 4000 staff had been consulted, indicating their support for Cerner software, he said. The debate came after The Courier-Mail yesterday detailed Opposition claims that Queensland Health bureaucrats deliberately changed an independent report to favour Cerner when hunting for software suppliers in 2009, which QH vehemently denied. Prof Patrick, chair of Language Technology at the university's School of IT, said problems with Cerner's NSW and Victorian systems were well documented in 2009. He said Queensland bureaucrats likely knew of the faults, which should have served as "red flags". Cerner did not respond to a call for comment.</blockquote> May I suggest that "red flags" often get ignored when the color green is present, at least in the U.S. (I don't know the colors of Australian currency.) <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiHLTMH1usG4D_gk7S1KF2vxfi2nsRdQGPHK9P7YUhyphenhyphen8STBFJf-NZ-HN9pvkfeW9VgUFkbuXktE-bog-sEHeBK4-Eb-OhOa5B12sVmgfJU5mG_eyj_VqR8BM6yqsS6K3Di9nyyfyyParK99/s1600/100k.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5654573291010095522" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiHLTMH1usG4D_gk7S1KF2vxfi2nsRdQGPHK9P7YUhyphenhyphen8STBFJf-NZ-HN9pvkfeW9VgUFkbuXktE-bog-sEHeBK4-Eb-OhOa5B12sVmgfJU5mG_eyj_VqR8BM6yqsS6K3Di9nyyfyyParK99/s320/100k.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 381px; height: 161px;" /></a>Who cares about "Red flags" when you can have wads of these? </div> -- SS Addendum: Dr. Patrick notes this at his aforementioned university page: <blockquote>3.13 Statement on 22nd August 2011. I attended the HIC conference in Brisbane in the beginning of August and at a dinner hosted by IBM on the 2nd August I met Mr Greg Wells, the CIO of HSS, and the person responsible for the FirstNet roll out in NSW. He stated that Cerner had provided new software that would solve all of the User Interface problems and it was being rolled at the present time in the Northern Area Health Service region. He said all installations across the state would have this solution by Christmas this year. We shall watch with interest. </blockquote> I guess solving problems <a href="http://sydney.edu.au/engineering/it/%7Ehitru/index.php?option=com_content&task=view&id=120&Itemid=116">like these</a> simply takes a lot of pizzas and Coca-Cola. -- SS

Australia and Health IT: Will Government Officials Ever Learn?

Perhaps New Zealand professor Shaun Goldfinch's article " Pessimism, Computer Failure, and Information Systems Development in the P...

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"Real" Medical Informatics: What Does a Problem List of Typical Health IT Look Like, Part 2

At my Mar. 15, 2011 post "<a href="http://hcrenewal.blogspot.com/2011/03/what-does-problem-list-of-typical.html">What does a "problem list" of typical health IT look like?</a>" I displayed a chart by Jon Patrick at U. Sydney on the ill-suited nature of an American EHR system for use in Emergency Dept. settings. That system had been mandated for rollout in public ED's in the entire Australian state of New South Wales. As it turns out, that chart was just preliminary. A new chart is up entitled "Analysis of Problems Defined by ED Directors", divided into four sections: <blockquote>1. Workarounds and Abandonments (27 elements) 2. Functions Lost from the Pre-FirstNet System or Desirable Functions (31 elements) 3. Processes with Added Risk to the Integrity of the EMR (11 elements) 4. General Problem List - What is the Potential for Resolution? (60 elements)</blockquote> The entire chart can be viewed at this link (best with browsers other than MS Internet Explorer): <a href="http://sydney.edu.au/engineering/it/%7Ehitru/index.php?option=com_content&task=view&id=120&Itemid=116">http://sydney.edu.au/engineering/it/~hitru/index.php?option=com_content&task=view&id=120&Itemid=116</a> . It is lengthy, detailed and - stunning. Prof. Patrick concludes (emphases mine): <blockquote>Reviewing this compendium of difficulties and obstacles created for staff makes it entirely unsurprising that the patient throughput of most EDs dropped by 50% on the day FirstNet was introduced and now some years later throughputs are only just beginning to recover as staff have been able to instigate work practices to minimise the worst aspects of the system. [A spectacular waste of clinician energy - ed.] The workarounds and abandonments give an expression of the frustration of staff and their strategy for retaining equilibrium in their work practices despite FirstNet's presence. In a number of cases we have seen the practice guidelines of NSWHealth surrendered by the imperatives of the technology with the imposition of the HSS. It is astounding that practices defined from years of clinical experience can be discarded so whimsically. [As I have written, the IT industry has invaded the healthcare sector, and this is the absolutely non-whimsical result - ed.] Fortunately, in the case of one pathology laboratory, patient safety was put ahead of the technological imperative lest it jeopardise the registration of the laboratory. The described function-losses with FirstNet compared to the pre-FirstNet systems, and the functionality needs expressed by the staff indicate that they are acutely aware of the value of good technology and have a strong desire to be equipped with something that works properly without creating unacceptable risks to patients and a draconian reduction in their efficiency. The risks posed by the system to maintaining the integrity of the medical record is something that staff are acutely concerned about as they feel it fails to fulfil their legal obligations.Emergency Departments are too important to have to endure these stressful and unproductive conditions. [This is a first principle, as as such is not open to debate - ed.] It is time that the knowledge and experience of the Directors and their staff were listened to and taken seriously [actually, six decades or so into the "computer revolution", I'd say that time was long ago - ed.] for the sake of improving our hospitals's use of technology. After all we have to ask: What business would commit to an interloping "integrated" system whose services are being necessarily dismembered piecemeal as a matter of survival by the users? This is a system whose pieces are not used by the staff, but rather are shadow mirrored by them, not for redundancy but primacy. Who would want a system that is progressively de-activated by the staff to overcome the hazards and operational inefficiencies it has introduced? [My answer: those who profit handsomely, and at no liability to themselves, from this arrangement. I leave it to the reader to decide who might fit in that category - ed.] </blockquote> As a physician and medical informatics specialist myself, I would not want my ED care or that of my family interfered with by such IT. Several questions: <ul><li>How did a government for an entire state of a major country come to allow themselves to believe an EHR system such as this would improve conditions in the most mission critical section of their hospitals, the ED's?</li></ul><ul><li>What testing and validation of the software was done by officials and representatives of said government, and who were they, exactly?</li></ul><ul><li>What experience and background did the validators possess?</li></ul><ul><li>How were clinician complaints during implementation, which has apparently been underway for several years now, handled?</li></ul><ul><li>What other countries are going down the same path?</li></ul><ul><li>Why is not all health IT subject to the same type of government regulator-led validation as this system was put under by a private academic researcher? (Note that the U.S., pharma IT validation is led by the FDA, but that same agency has essentially shied away from healthcare IT validation.) </li></ul><ul><li>Would a country buy software as ill suited to purpose for, say, mitigating disaster risk in their nuclear power facilities? </li></ul> Finally, I ask: If the purpose of Medical Informatics is the improvement of healthcare (as opposed to career advancement of a small number of academics through publishing obscure articles about HIT benefits while ignoring downsides in rarified, echo-chamber peer reviewed journals), then: <ul><li>Who are the "real" medical informatics specialists, and; </li></ul><ul><li>Who are the poseurs?</li></ul> I opine that researchers like Jon Patrick who address real-world issues of great import to patients on HIT risks, and further go public on the web with their work without the full blessings of some dusty journal (and those like Ross Koppel who also directly address the downsides, and others who make available to the public material such as on blogs like <a href="http://www.emrupdate.com/">this</a> and <a href="http://hcrenewal.blogspot.com/">this</a>, papers <a href="http://www.scribd.com/doc/28747771/Remediating-an-Unintended-Consequence-of-Healthcare-IT-A-Dearth-of-Data-on-Unintended-Consequences-of-Healthcare-IT">like this</a> and sites <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/">like this</a>) are the former. Those who deem only "peer reviewed" articles worthy of daylight, and everything else - especially and particularly reports of downsides - "anecdotal" (the <a href="http://hcrenewal.blogspot.com/2010/09/dangers-of-critical-thinking-in.html">anecdotalists</a>) are the latter. -- SS

"Real" Medical Informatics: What Does a Problem List of Typical Health IT Look Like, Part 2

At my Mar. 15, 2011 post " What does a "problem list" of typical health IT look like? " I displayed a chart by Jon Patr...

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Why The Overambitious, Cavalier Approaches of the Healthcare IT Industry Are Harmful To Health: Guest Post by Dr. Jon Patrick, U. Sydney

Apparently Holland is now veering away from a national project for health information exchange. From a researcher at Erasmus University Rotterdam: <blockquote style="font-family:arial;"> While failures of IT implementation in the UK and more recently the Cerner implementation in Australia has been dissected by [U. Sydney Professor] Jon Patrick, the Dutch initiative for a national health IT infrastructure for exchanging patient data that would start with a medication record and a summary record is about to be voted down in the upper house (Senate) of the Dutch parliament. It means that the trajectory to get this infrastructure and which lasted thirteen years will grind to a halt. Unfortunately this implementation has been poorly documented in scientific journals (to my knowledge only one paper describing the infrastructure was published in Methods of Information in Medicine).</blockquote> I wrote about the exposé by Prof. Jon Patrick of U. Sydney of poor software engineering practices, poor usability, unreliability, and dangers posed by a commercial health IT product slated for the ED's of the Australian state of <a href="http://en.wikipedia.org/wiki/New_South_Wales">New South Wales</a> (NSW) at my Mar. 5, 2011 post "<a href="http://hcrenewal.blogspot.com/2011/03/on-emr-forensic-evaluation-from-down.html">On an EMR Forensic Evaluation by Professor Jon Patrick from Down Under: More Thoughts</a>". Prof. Patrick offers the following additional pithy and highly insightful commentary, reposted here with his permission (emphases mine): <blockquote style="font-family:arial;"><div>Colleagues, Since the publication of my long report on the discontent with and weaknesses of Cerner Firstnet/Millenium in Australia (see <a href="http://www.it.usyd.edu.au/%7Ehitru/index.php?option=com_content&task=view&id=91&Itemid=146" target="_blank">http://www.it.usyd.edu.au/~hitru/index.php?option=com_content&task=view&id=91&Itemid=146</a>) I have been pondering the issue of how we can better define the "EMR" and its functions. I certainly think that the notion of an EMR in terms of current popular discussions in AMIA-WGs [American Medical Informatics Association work groups - ed.] and blogs [such as this one - ed.], government policy and vendor publicity is defined at too high a level of generalisation for analysts to create an adequate specification of it and likewise for the engineers to understand the requirements so that they can build such a system. <div>This position is further justified by the failures to create such systems in the UK, NSW and Victoria (Australia) and the loss of political support in Holland. A counterpoint to this are the successes in New Zealand, Denmark and Scotland with systems of smaller ambition and scale targeted at particular problems. </div> <div>I offer this thesis for deliberation: that large scale enterprise software implementations are an over generalisation of the EMR problem so that their lack of ability to capture local context and their intrinsically weak engineering base demonstrate that the advocates of large scale EMR don't know how to do it, have failed to do it in the past at great cost to various communities, and will continue to fail until they understand and define the task properly and in great detail of what has to be done and how to do it.</div></div></blockquote><div style="font-family:arial;"><div> In other words, the healthcare IT industry itself - starting with its leadership - does not know what it's doing and may itself be ill-suited to purpose, the purpose of facilitating better healthcare. Its overall brute-force, mass-scale, ham-fisted ideologies and approaches cannot succeed except in wasting billions of healthcare dollars. Or, more precisely, transferring that wealth to the IT sector and leaving little to show for it in the health sector. <div>I agree with Prof. Patrick's "thesis." At my own HIT website now at <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/" target="_blank">http://www.ischool.drexel.edu/faculty/ssilverstein/cases/</a> years ago I wrote similar words: </div> <blockquote style="margin-right: 0px;" dir="ltr"> <div> <div style="margin-top: 0px; margin-bottom: 0px;">Healthcare information technology (HIT) holds great promise towards improving healthcare quality, safety and costs ... however, this potential has been largely unrealized. Significant factors impeding HIT achievement have been false assumptions concerning the challenges presented by this still-experimental technology, and underestimations of the expertise essential to achieve the potential benefits of HIT. This often results inclinician-unfriendly HIT design, and HIT leaders and stakeholders operating outside (often far outside) the boundaries of their professional competencies. Until these issues are acknowledged and corrected, HIT efforts will unnecessarily over-utilize precious healthcare resources, will be unlikely to achieve claimed benefits for many years to come, and may actually cause harm.</div></div></blockquote> </div></div>Once again, you heard it here first. I also reiterate, our own "National Program for Health IT in the HHS" needs the same treatment that Prof. Patrick recommends for his own state of NSW, as at my Mar. 8, 2011 post "<a style="font-family: arial;" href="http://hcrenewal.blogspot.com/2011/03/future-pathways-for-e-health-in-nsw.html">The Future Pathways for e-Health in NSW</a>." -- SS

Why The Overambitious, Cavalier Approaches of the Healthcare IT Industry Are Harmful To Health: Guest Post by Dr. Jon Patrick, U. Sydney

Apparently Holland is now veering away from a national project for health information exchange. From a researcher at Erasmus University Rot...

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The Future Pathways for e-Health in NSW

Prof. Patrick has now added a new section to his <a href="http://hcrenewal.blogspot.com/2011/03/on-emr-forensic-evaluation-from-down.html">report on health IT in NSW Australia</a>, entitled "The Future Pathways for e-Health in NSW." It is available <a href="http://sydney.edu.au/engineering/it/%7Ehitru/essays/Things%20we%20should%20change%20in%20NSW-v4.pdf">at this link</a> (PDF). It inoculates against most of the 'Ten Plagues' that bedevil health IT projects (such as the IT-clinical leadership inversion, lack of transparency, suppression of defects reporting, magical thinking about the technology, and lack of accountability of the bureaucrats). Emphases mine: <blockquote>In Short Term ( 0-3 months) 1. Halt further rollouts of Firstnet or other CIS systems. The current roll-out programs use significant efforts in training staff for a system that is counterproductive to patient well being. 2. Complete a full and thorough risk assessment analysis and usability of the software. The CIS report indicates there are a number of risks in the current software that are not likely to have been assessed in the past. 3. Address the current problems before doing anything else. There are a number of problems that appear solvable in the short term that would improve the situation for current users, such as providing needed reports. 4. Create the NSW IT Improvement Panel composed of ED Directors, IT-savvy clinical and quality improvement staff responsible for advising on the preparedness and process of the rollout. 5. Create an effective error and bug reporting mechanism that is viewable by all ED directors and with the display of the priority of each entry and expected completion time. 6. Initiate a high profile campaign to encourage staff to lodge fault records on anything they discover wrong, problematic or inefficient in using the system. In the longer term (3-12 months) 1. Review the Health Support Services and make it clinically accountable by appointing a clinical head with an IT education. 2. Create a culture change in the HSS. The current operation of the HSS seems to be devoid of influence from the clinical community. 3. All NSW CIS system procurement should be guided by an IT Advisory Board of IT experienced clinical, academic and medical software industry experts. 4. Create pathways for hospitals that wish to be early adopters and take a lead role in the development of new methods for using and deploying IT systems. 5. Support innovation within the Australian medical software communities that contribute to a culture of innovation and continuous quality improvement. 6. Adopt transparency rules in all new healthcare information acquisitions. Secrecy has bedevilled the efforts of staff and management to get improvements in the CIS systems and hold service agents accountable for their failure to comply to service level agreements. All agreements about a signed contract should be available to the ED Directors. 7. Replace the State Based Build policy with a policy of providing a technology to match the technology experience of the individual departments so that leaders are not dragged backwards with inappropriate technology installation </blockquote>The de facto "National Program for IT in the HHS" here in the United States needs a similar inoculation. I can only add that our own ONC office (Office of the National Coordinator for Health IT of the Dept. of HHS) had more granular recommendations about expertise levels required for leadership roles in such undertakings. I wrote about them at my Dec. 2009 post "<a style="font-weight: bold;" href="http://hcrenewal.blogspot.com/2009/12/onc-defines-taxonomy-of-health-it.html">ONC Defines a Taxonomy of Robust Healthcare IT Leadership</a>." --SS

The Future Pathways for e-Health in NSW

Prof. Patrick has now added a new section to his report on health IT in NSW Australia , entitled " The Future Pathways for e-Health in ...

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Are Those Sockpuppers From Down Under?

We at Healthcare Renewal have had experience with the healthcare sock puppets. They are shills, a person or group working on behalf of a company or other special interest. They attempt to use distraction, ad hominem, misdirection and other psyops tactics to attack points of view they don't like. They also plant memes they or their sponsor deem desirable. They are universally anonymous in their postings. One got careless and got nailed via IP forensics, as at my Jan. 2010 post "<a href="http://hcrenewal.blogspot.com/2010/01/more-on-perversity-in-hit-world.html">More on Perversity in the Healthcare IT World: Is Meditech Employing Sockpuppets?</a>" and my semi-satirical followup post a few days later, "<a href="http://hcrenewal.blogspot.com/2010/01/socky-meditech-sockpuppet-on-vacation.html">Socky the Meditech Sockpuppet on Vacation?</a>" after he/she disappeared after exposure. A Healthcare Renewal reader with an MBA at that time non-anonymously related the following (emphases mine): <blockquote>In reading this thread of comments I have to believe IT Guy [the Sock puppet - ed.] is a salesperson. My only question is: Were you assigned this blog or did you choose it? We had this problem a number of years ago where a salesperson was assigned a number of blogs with the intent of using up valuable time in trying to discredit the postings. In my very first sales class we learned to focus on irrelevant points, constantly shift the discussion, and generally try to distract criticism. I would say that HCR is creating heat for IT Guy’s employer and the industry in general. I find it sad that a company would allow an employee to attack anyone in an open forum. IT Guy needs to check with his superiors to find out if they approve of this use of his time, and I hope he is not using a company computer, unless once again this attack is company sanctioned. Steve Lucas</blockquote> It seems this foul type of creature is starting to crawl out of the woodwork regarding Prof. Jon Patricks' analysis of an ED EHR system mandated by the state's government of NSW for public hospitals, as I wrote about in my posts such as on Mar. 5, 2011 at "<a href="http://hcrenewal.blogspot.com/2011/03/on-emr-forensic-evaluation-from-down.html">On an EMR Forensic Evaluation by Professor Jon Patrick from Down Under: More Thoughts.</a>". They may be corporate, they may be government. They likely have a financial stake in the ED EHR project as well. For instance, the sockpuppet/shill comments are starting to appear at the Australian Health Information Technology blog of Dr David More MB, PhD, FACHI at <a href="http://aushealthit.blogspot.com/">http://aushealthit.blogspot.com</a>: <blockquote>This blog has only three major objectives. The first is to inform readers of news and happenings in the e-Health domain, both here in Australia and world-wide. The second is to provide commentary on what seems to have become the lamentable state of e-Health in Australia and to foster improvement. The third, sadly, is now to try and force accountability for the actions of, and the funds spent, by NEHTA. [National E-Health Transition Authority <a href="http://www.nehta.gov.au/about-us/contact-us">as at this link</a> - ed.] </blockquote> (Sounds like a kindred mission relative to HC Renewal.) For instance at Dr. More's post "<a href="http://aushealthit.blogspot.com/2011/03/prof-patrick-has-really-hit-bullseye-it.html">Prof Patrick Has Really Hit the Bullseye It Would Seem. Lots of Supportive Comments From All Over!</a>" we see the following sock puppet-like comments rearing their holey (not holy) woven head: <blockquote>... It seems that the heuristic axiom of Ockham’s Razor (as presented by Jon) is the design criteria by which Jon thinks NSW Health should have selected their CIS ... unbelievable! Unfortunately Jon has not proposed any practical alternatives in his papers. His papers are full of opinions, unfounded claims and incorrect facts (not to mention the countless flaws in his research methodologies). </blockquote>and <blockquote>Dr Patrick - you are so misinformed. There are so many untruths in what you report. Why is this? Because you interviewed 7 people. Being Directors, what is the likelihood they are hands on with the system? Minimal I would say from experience in the EDs. Call yourself a researcher - huh! It is a totally biased report which reflects the opinions of those with an axe to grind. Why don't you talk to some nurses,clerical staff and junior doctors? There are hundreds of them working in EDs across the state. Their opinion should matter as they are the ones caring for our patients. You should be ashamed of yourself! I certainly would not hire you to do a research project if this is the biased and blatantly incorrect rubbish that you come up with. Shame on you!! </blockquote> and the ever-so-common refrain of: <blockquote> Has Dr Patrick ever completed (or even been involved in) an implementation of an EMR (at all or of any scale)? Can someone tell us what makes him an authority the subject? [I, OTOH, have done so, authoring, implementing, managing for hospitals and major pharma - ed.] ... His view is unbalanced and his paper is clearly bias. How Sydney University tolerates papers of such poor quality and biasness (being published by their professors) is beyond me. [Paper is 'clearly bias'? Biasness? This person needs a grammar lesson - ed.] </blockquote> Ink is never put to specifics of the supposed transgressions in these largely <a href="http://www.nizkor.org/features/fallacies/ad-hominem.html">ad hominem</a>, anonymous attacks. If those who wrote them had the fortitude to identify themselves, perhaps they might be somewhat credible. However that rarely if ever is the case. In my humble opinion, such comments are risible, not even worth the electrons they're written with. Except for amusement: <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg3DtCGREf4I9i7ZUFKWW3kCq2yWxsrw3okOy0YckEIFo4dqu0qNZkdqiOwcKXBoV3ptTR9LjEJ3yg5dBmYoDv9qBXxNd8hFXNWAKUsUb8xEG4keQovVddB6Oj0ZWsvlFynC5Keh5eqlxJG/s1600/sockpuppet2.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5581573263825574290" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg3DtCGREf4I9i7ZUFKWW3kCq2yWxsrw3okOy0YckEIFo4dqu0qNZkdqiOwcKXBoV3ptTR9LjEJ3yg5dBmYoDv9qBXxNd8hFXNWAKUsUb8xEG4keQovVddB6Oj0ZWsvlFynC5Keh5eqlxJG/s320/sockpuppet2.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 129px; height: 148px;" /></a>Socky the Health IT Sockpuppet. Click to enlarge. </div> p.s. an ED EHR-injured relative of mine has a message to the sockpuppets of the world. It's not fit for a public site, but it has to do with travel to a very hot, deep, sulfurous place in the earth. -- SS

Are Those Sockpuppers From Down Under?

We at Healthcare Renewal have had experience with the healthcare sock puppets. They are shills, a person or group working on behalf of a co...

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EHR ED's in New South Wales. Will the Problems Magically "Disappear?"

It occurs that one could look at Prof. Jon Patrick's recent <a href="http://hcrenewal.blogspot.com/2011/03/on-emr-forensic-evaluation-from-down.html">health IT forensic analysis</a> as a kind of "indictment" of the industry. He can be seen as suggesting the industry needs to be "put on trial" (figuratively) regarding "crimes" (again, figuratively speaking) they've committed with regard to IT robustness and reliability. The latter translate directly to patient safety. In a lawsuit such as a medical malpractice trial, obvious as well as potential evidence is put under "legal hold." For instance, if an EHR defect is suspected, metadata, audit trails, and patient data are asked (or should be asked) to be frozen or archived in the state they were in at the time of the alleged accident. It can take a page or three (or more) of specifications simply to define what information, exactly, needs to be put on legal hold. My former staff were frequently required to place myriad materials on legal hold at Merck Research Labs, for example, baed on the lawsuit du jour. Once frozen, discovery and forensic analysis of these now-static data can then proceed. In fact, cases can be lost on the basis of evidence of an archiving omissions, destruction or tampering when information holds are requested. It occurs to me that Prof. Patrick has given the industry a detailed look into factors they could start to remediate, without publicity and without telling anyone. While this would be a net plus for patients, it might result in less of a learning experience to the industy than that industry needs, to motivate the industry to avoid future product engineering and quality issues and put quality (not simply margin) as priority #1. I therefore would believe a "hold" put on the present state of these ED EMR systems, or a "snapshot" of their current state (i.e., an evaluation environment mirrored from the present operational one) would allow a careful evaluation of the impact of the issues noted in the study. Such an evaluation would be far more difficult with a cybernetic moving target. The "snapshot" idea would allow evaluation of system risk levels, intermittent "glitches", interference with workflows, etc. in a controlled testing environment, using mock data or data drawn from actual cases. The "snapshot" approach would also allow incremental remediation of the "live" system that comes out of safe, controlled testing, rather than sticking with what exists now until the studies could be completed on the as-is system, and then applying all the fixes as one or more large "upgrades." I, for one, would be interested in studying this "built by software professionals" system and comparing it to health IT systems we "academic nerds" <a href="http://ycmi.med.yale.edu/trialdb/">were authoring</a>, say, 10-15 years ago. -- SS

EHR ED's in New South Wales. Will the Problems Magically "Disappear?"

It occurs that one could look at Prof. Jon Patrick's recent health IT forensic analysis as a kind of "indictment" of the indu...

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Australian ED EHR Study: An End to the Line "Your Evidence Is Anecdotal, Thus Worthless?"

At my Sept. 2010 post "<a href="http://hcrenewal.blogspot.com/2010/09/dangers-of-critical-thinking-in.html">The Dangers of Critical Thinking in A Politicized, Irrational Culture</a>" I lamented that while my early mentor in biomedicine Victor P. Satinsky MD taught the wise credo "critical thinking always, or your patient's dead" in the 1970's, our culture had become so perverse that this credo had been largely supplanted with: <blockquote>"Critical thinking anytime, and your career's dead." </blockquote>That post was in reaction to continued heckling on a professional mailing list, the American Medical Informatics Association (AMIA) Clinical Information Systems Working Group (cis-wg). On this list, Oregon Health Sciences University professor <a href="http://www.billhersh.info/">William Hersh</a> expounded on how the evidence of health IT dangers was largely "anecdotal" therefore to be discounted, and how I, specifically, "didn't know the literature on health IT." In that post I put the lie to the latter figment. On the former prevarication Dr. Jon Patrick, author of the recent thorough dissection of problems with the ED EHR system being rolled out in public hospitals in New South Wales, Australia (see my Mar. 5, 2011 post "<a href="http://hcrenewal.blogspot.com/2011/03/on-emr-forensic-evaluation-from-down.html">On an EMR Forensic Evaluation by Professor Jon Patrick from Down Under: More Thoughts</a>"), hit the ball out of the park: <blockquote>Prof. Patrick to AMIA cis-wg: I think such defences are particularly unuseful especially with respect to the dismissal of personal stories and experiences as "anecdotes", hence committing them to the realm of folklore. I offer these notions as a counterpoint. Discounting Anecdotes: 1. Is a perfidious and specious act. 2. It denies early warning signs of problems. 3. It denies a voice and disempowers the working clinical community who have to operationalise decisions made by others. 4. It denies a route to process improvement within an institution - which is most important for EBM and incremental review of local processes. 5. It defends software manufacturers from fault rectification - cuts off even a need to deliberate on it. Critics of the value of anecdotes are squarely on the side of the faulty and deficient manufacturer. 6. A rule of project management is that projects consist of 3 components, cost, quality and time and if their needs to be a compromise it has to be on quality. Anecdotes are early warning signs of such a compromise. </blockquote><blockquote> </blockquote>Prof. Patrick had to once again put the lie to this refrain at a comment on the HISTalk blog yesterday, where the anonymous proprietor <a href="http://histalk2.com/2011/03/06/monday-morning-update-3711/">had written in a review of Patrick's EHR study</a>: <blockquote>... On the other hand, I wouldn’t say it’s [Prof. Patrick's Cerner FirstNet study] necessarily unbiased, it focuses on implementation of a single department application that didn’t go well for a variety of reasons (despite many successful FirstNet implementations elsewhere), it uses the unchallenged anecdotal comments of unhappy users who make it clear they liked their previous EDIS better, and it nitpicks (I wasn’t moved to find a pitchfork when I learned that the primary keys in the Millennium database aren’t named consistently). [Considering the complexity and changeability of healthcare and the corresponding software lifecycle, I duly note that that latter attitude about 'failing to find pitchforks' regarding breaches of sound software engineering practices seems to be a symptom of the larger health IT disease that Prof. Patrick writes about - ed.] </blockquote> Dr. Patrick then knocked the ball out of the Southern Hemisphere with a <a href="http://histalk2.com/2011/03/06/monday-morning-update-3711/#comment-14097">comment of his own</a> about anecdotalism and a link to an expansion of the aforementioned ideas he'd shared on "discounting anecdotes": <blockquote>Prof. Patrick to HISTalk owner: Your Comment “it uses the unchallenged anecdotal comments of unhappy users ” is not only unfair but unreasonably inaccurate. The comments made by the users are the Directors of 7 EDs and so they have a right to carry authority by virtue of the experience but also the number of 6 out 7 presenting a view of Firstnet as unfit for purpose has numeric validity, which they justify with about 20+ pages of their comments – see Part 2 Appendix 2. I would also point readers to my editorial about the role of personal experiences being the most useful information to understand the nature of socio-technical failures. <a href="http://aci.schattauer.de/en/contents/archive/issue/1124/manuscript/15463/show.html" rel="nofollow">http://aci.schattauer.de/en/contents/archive/issue/1124/manuscript/15463/show.html</a></blockquote> The essay at that link, "The Validity of Personal Experiences in Evaluating HIT", is an editorial in Johns Hopkins informaticist Chris Lehmann's brilliant new journal "<a href="http://aci.schattauer.de/en/contents/archive.html">Applied Clinical Informatics</a>." The editorial is available free, and is a must-read for anyone in a decision-making or managerial role in mission critical domains, including our elected representatives. In the editorial Dr. Patrick concludes. similarly to his earlier AMIA mailing list opinion: <blockquote> ... the denial of recounted personal experiences in discussion and analysis of HIT is biased and specious and has the effect of: 1. Denying early warning signs of problems. 2. Denying a voice for the working clinical community who have to operationalise decisions made by others and thus disempowers them. 3. Denying process improvement within an institution – which is most important for Evidence Based Medicine and incremental review of local processes. 4. Discourages staff from engaging in any form of process improvement hence worsening the sense of disenchantment. Every legitimate personal experience of a HIT deserves to be considered on its merits lest we wish to retreat from process and product improvement. Mechanisms of censorship both implicit due to contrived processes of disinformation and disempowerment or explicit due to contractual specifications will lead to more waste, lost productivity, contempt for the providers, and distress among frontline staff rather than increased productivity and improved patient health and safety as we all desire. </blockquote> In my view, the drivers or motivators for the "anecdotalist" accusation are these, singly or in combination: <ul><li>Too much "education" to see the nose on one's face, as in, to think zebras and unicorns instead of horses when hearing hoofbeats outside one's midwest U.S. abode (eggheads); </li><li>Too little common sense (fools), as in <a href="http://www.morgantownbrights.com/2009/09/10/you-are-wrong-because/">Scott Adams' example</a>: "IGNORING ALL ANECDOTAL EVIDENCE - Example: I always get hives immediately after eating strawberries. But without a scientifically controlled experiment, it’s not reliable data. So I continue to eat strawberries every day, since I can’t tell if they cause hives"; </li><li>Too much concern for the possible interruption of flow of money or power in one's direction (<a style="font-weight: bold;" href="http://www.thefreedictionary.com/gonif">gonifs</a>). </li></ul> In conclusion, the anecdotalist refrain of "your evidence is anecdotal" [therefore of little or no value] when used repetitively against competent observers is the refrain of eggheads, fools and gonifs. In healthcare, the end result is "your patient's dead." My "anecdotal relative" injured in a mid-2010 HIT mishap is sadly an example. [June 2011 addendum: <a href="http://hcrenewal.blogspot.com/2011/06/my-mother-passed-away.html">my relative</a>, after much suffering, has now died of complications of the "anecdotal HIT mishap" - ed.] As for myself, I am a Markopolist (see my Sept. 2010 post "<a href="http://hcrenewal.blogspot.com/2010/09/health-it-on-anecdotalism-and.html">Health IT: On Anecdotalism and Totalitarianism</a>"). -- SS

Australian ED EHR Study: An End to the Line "Your Evidence Is Anecdotal, Thus Worthless?"

At my Sept. 2010 post " The Dangers of Critical Thinking in A Politicized, Irrational Culture " I lamented that while my early men...

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What to do about the state of the ED EHR's in NSW?

<div dir="ltr" style="font-family:arial;">At my post yesterday "<a href="http://hcrenewal.blogspot.com/2011/03/on-emr-forensic-evaluation-from-down.html">On an EMR Forensic Evaluation by Professor Jon Patrick from Down Under: More Thoughts</a>", I've come down pretty hard on internal and external (i.e., human interface) sloppiness in mission critical IT systems. In my view, the flaws that create randomly-occurring errors, combined with a <a href="http://www.tinyurl.com/hostileuserexper">mission hostile user experience</a> highly and especially inappropriate in the hectic and unpredictable ED environment, turn these systems into slot machines. The jackpot, however, is not wealth. It's injury or death. I've been asked, "So - what to do about the state of the ED EHR in NSW?" Here are some simple initial suggestions: A. For the time being: securing and implementing a paper backup (pen & paper) with scanning and document imaging retrieval system (integrated or standalone) as an 'EHR supplement", in order that really critical info can be steered in that direction. Clinicians are already avoiding the EHR system and not entering or minimizing data, or using other "workarounds." Therefore, informationally and safety-wise, a document imaging/retrieval system for paper would probably be a net plus. ED charts are not Tolstoy novel-length, as a matter of fact. There would not be many pages per patient, but even small morsels of key information collected easily and quickly, then retrieved easily, and presented clearly, cleanly and rapidly, as on a sheet or three of physical, then virtual parchment, can have enormous value. </div> <div style="font-family: arial;" dir="ltr" face="arial"> </div> <div dir="ltr" style="font-family:arial;">B. Clinicians and responsible executives and officials should start demanding that the ED EHR vendor release its full conceptual and logical data models so that others can, competitively (including the original vendor if they wish), cleanse it and redo a user interface that meets the needs of NSW ED's. The latter should be determined collaboratively with the key stakeholders, and developed using agile, iterative and incremental methodologies, not the usual stale Management Information Systems approach. (I.e., the mercantile, manufacturing and management computing paradigms that are ill-fitting to healthcare informatics as further explained at my post <a href="http://hcrenewal.blogspot.com/2008/05/seedie-society-for-exorbitantly.html">here</a>.) That way moving data over to the "redone" new system would not be a nightmare. Or perhaps less of a nightmare than an entirely new extant system from another vendor (which would likely have similar flaws anyway and need similar rework). </div> <div dir="ltr" face="arial"> </div> <div dir="ltr" style="font-family: arial;">The closed-system, locked-in-to-one-vendor paradigm that's apparently holding the ED's of an entire state of the fine country of Australia hostage must end. Let the best organization win. As I also observed in the aforementioned post, the UK, having their own HIT issues (see my Aug. 2010 "Battle of Britain" post <a href="http://hcrenewal.blogspot.com/2010/08/cerners-blitzkrieg-on-london-wheres-raf.html">at this link</a>), apparently learned something, as evidenced in: <blockquote style="font-family:arial;"><a href="http://www.connectingforhealth.nhs.uk/engagement/clinical/occo/safety/dscn14.pdf">Health Informatics — Application of clinical risk management to the manufacture of health software</a>. UK National Health Service, DSCN14 (2009), formerly ISO/TS 29321:2008(E). and <a href="http://www.connectingforhealth.nhs.uk/engagement/clinical/occo/safety/dscn18.pdf">Health informatics — Guidance on the management of clinical risk relating to the deployment and use of health software</a>. UK National Health Service, DSCN18 (2009), formerly ISO/TR 29322:2008(E). <a href="http://www.connectingforhealth.nhs.uk/engagement/clinical/occo/safety/dscn14.pdf"> </a></blockquote>Perhaps those in the U.S. and in VK-land (<a href="http://www.wia.org.au/">amateur-radio speak</a> for Australia; I am <a href="http://www.arrl.org/">KU3E</a> here in the U.S.) can also heed these documents and their recommendations. -- SS Mar. 8, 2011 addendum: Prof. Patrick has added a new section to his report, entitled "The Future Pathways for e-Health in NSW." It is available <a href="http://sydney.edu.au/engineering/it/%7Ehitru/essays/Things%20we%20should%20change%20in%20NSW-v4.pdf">at this link</a> (PDF). It inoculates against most of the 'Ten Plagues' that bedevil health IT projects (such as the IT-clinical leadership inversion, magical thinking about the technology, and lack of accountability): More on the Pathways at my post <a href="http://hcrenewal.blogspot.com/2011/03/future-pathways-for-e-health-in-nsw.html">here</a>. The de facto "National Program for IT in the HHS" here in the United States needs a similar inoculation. --SS </div>

What to do about the state of the ED EHR's in NSW?

At my post yesterday " On an EMR Forensic Evaluation by Professor Jon Patrick from Down Under: More Thoughts ", I've come down...

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On an EMR Forensic Evaluation by Professor Jon Patrick from Down Under: More Thoughts.

<div style="text-align: center;">Note: the reports to which this post refers are available as a set of PDF's from the University of Sydney, NSW, Australia <a style="font-style: italic;" href="http://www.it.usyd.edu.au/%7Ehitru/essays/Study%20of%20Enterprise%20Health%20IS%20-%20Parts%200-9%20PDF-ARCHIVE.zip">at this link</a> (12 Mb, .zip folder), or at "A study of an Enterprise Health information System" at <a href="http://sydney.edu.au/engineering/it/%7Ehitru/index.php?option=com_content&task=view&id=91&Itemid=146">http://sydney.edu.au/engineering/it/~hitru/index.php?option=com_content&task=view&id=91&Itemid=146</a>. <div style="text-align: center;">March 6, 2011 addendum. Also see my new post "<a style="font-style: italic;" href="http://hcrenewal.blogspot.com/2011/03/what-to-do-about-state-of-ed-ehr-in-nsw.html">What to do about the state of the ED EHR in NSW?</a>" </div></div> Over ten years ago now, 1999 in fact, I started my healthcare IT difficulties website. That site, "Contemporary Issues in Medical Informatics: Common Examples of Healthcare Information Technology Difficulties" now resides on a Drexel University server in Philadelphia, Pennsylvania USA <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/">at this link</a>, and used as a teaching resource. I started the site after observing, for lack of a better description, "crazy stuff" in the commercial healthcare information technology sector. Crazy stuff such as EMR systems for ICU's that <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=clinical%20computing%20problems%20in%20ICU">crashed regularly and spread pathogens around</a>, EMR's for invasive cardiology cath labs <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story">that were an informational jumble and abyss and that also issued regular General Protection Faults and died</a>, lack of Medical Informatics expertise (and actual disdain for it) in healthcare IT projects, grossly incompetent IT leaders, and hospitals uncritically and enthusiastically buying these products as if they were a plug and play, proven technology. To make matters worse, I also observed executives expressing a hostile indifference to glaring deficiencies. My observations about health IT and about responses to my counsel brought to mind the biblical passage: <blockquote>"Give not that which is holy unto the dogs, neither cast ye your pearls before swine, lest they trample them under their feet, and turn again and rend you." - Matthew 7:6 </blockquote> I was never afforded the opportunity to perform a forensic analysis of the internals of these systems, being that I was not allowed to obtain the software or "schematics" of the data structures. In fact, to make the cardiology system usable, I ordered the IT staff to simply discard the internal data dictionary, relational data structures, input screens, and analytic routines, and rebuild them - from scratch - using a proper Medical Informatics-based, cardiology domain expert-driven, iterative and incremental (agile) approach. The result was a resounding success, and was described in a written report as "exceptional" by national specialty association reviewers invited to evaluate the effort. (A success for which, I might add, I and my enlightened executive sponsor <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story">were paradoxically demonized by the IT department and hospital executives</a>; cf. Matthew 7:6.) Now, an Australian researcher of considerable computer and database expertise, <a href="http://sydney.edu.au/engineering/it/%7Ejonpat/">Professor Jon Patrick</a> at the University of Sydney, has put considerable ink to a forensic evaluation of the internals and external reactions to an EMR system "built in America", Cerner Firstnet. Professor Patrick holds a Ph.D. from Monash University. He came to the University of Sydney from Massey University, New Zealand, where he held the foundation Chair of Information Systems. Professor Patrick won Australia's national Eureka science prize in 2005 for developing a natural language processing system that detected financial scams in web pages at the behest of the Australian Government. FirstNet is an ED EHR that government officials decided must be installed in ED's of public hospitals throughout the Australian state of New South Wales. Promo material below, click to enlarge: <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjWv3btAUsn_Umf2ZFMjq6HXIZ6BgHxlc835DJCPhyBPJzoY8PVpBuM_w6id8ohYVEfHWPPvBvQWjowc_kQWlqenx4WezZU_6sWBRcil-j5bO9RUr-N9MOP3r3X0GgM2qAiR_vQu73S2rl5/s1600/p1.png"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5580655476444502130" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjWv3btAUsn_Umf2ZFMjq6HXIZ6BgHxlc835DJCPhyBPJzoY8PVpBuM_w6id8ohYVEfHWPPvBvQWjowc_kQWlqenx4WezZU_6sWBRcil-j5bO9RUr-N9MOP3r3X0GgM2qAiR_vQu73S2rl5/s320/p1.png" style="display: block; margin: 0px auto 10px; width: 247px; cursor: pointer; height: 320px; text-align: center;" /></a>FirstNet promo material, page 1. Click to enlarge. (Hmm ... Is there a subliminal message in the picture of the doctor and nurse?) </div><div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgtd0yVxqvX4M2SebLq7XUMfF-4lum_lGcfgEsmXc75o6s4INr4HJfRIFh7YZPdlj1RqedKjnVVNjIbTvFIZCbybSvpWGIYDV8dqMZf8NqC1c3vDe14bEjjvq-oZeN3R3SOoGA2mTH7ZC1N/s1600/p2.png"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5580655538113430082" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgtd0yVxqvX4M2SebLq7XUMfF-4lum_lGcfgEsmXc75o6s4INr4HJfRIFh7YZPdlj1RqedKjnVVNjIbTvFIZCbybSvpWGIYDV8dqMZf8NqC1c3vDe14bEjjvq-oZeN3R3SOoGA2mTH7ZC1N/s320/p2.png" style="display: block; margin: 0px auto 10px; width: 247px; cursor: pointer; height: 320px; text-align: center;" /></a>FirstNet Promo material, page 2. Click to enlarge. </div> The initiative's been underway for several years, and the result is a group of apparently very unhappy Wal-Mart shoppers. (I guess the correct line would be "unhappy <a href="http://en.wikipedia.org/wiki/Big_W">Big W</a> shoppers" for those Down Under.) Prof. Patrick had written a preliminary essay on the issue entitled, in rhetorical question-style, "The Story of the Deployment of an ED Clinical Information System: Systemic Failure or Bad Luck?" back in 2009. He apparently found himself in considerable hot water for doing so due to 'pushback' as I described at "<a href="http://hcrenewal.blogspot.com/2009/11/academic-freedom-and-ed-ehrs-down-under.html">Academic Freedom and ED EHR's Down Under: An Update</a>". However, his university stood by him in defense of academic freedom (and of the sanctity of those in the healing arts, I might add). He's spent the intervening time expanding the analysis of the ED clinical system and its deployment considerably, right down to the fine nuances of relational database design in complex domains (such as biomedicine). As I wrote in an initial post "<a href="http://hcrenewal.blogspot.com/2011/03/study-of-enterprise-health-information.html">A Study of an Enterprise Health information System - Finally, an Informatics Scientist Does A Rigorous Review of a Commercial EHR System, by Cerner</a>", the TOC of his new analysis are these (the files are available as a .zip archive <a href="http://www.it.usyd.edu.au/%7Ehitru/essays/Study%20of%20Enterprise%20Health%20IS%20-%20Parts%200-9%20PDF-ARCHIVE.zip">at this link</a>): <blockquote>3.0 Part 0 - Executive Summary 3.1 Part 1 - A Critical Essay on the Deployment of an ED Clinical Information System ‐ Systemic Failure or Bad Luck? First published here in Oct 2009, revised Dec 2009. 3.2 Part 2 - Discussions with ED Directors: Are we on the right track? 3.3 Part 3 - Discussions with Software Performance Experts. 3.4 Part 4 - Conceptual Data Modelling. 3.5 Part 5 - Database Relational Schema and Data Tables. 3.6 Part 6 - Coalescing the Analyses of the ER Diagrams, Relational Schemata and Data Tables. 3.7 Part 7 - The Integrated Assessment. 3.8 Part 8 - Future HIT Regulation Proposals. 3.9 Part 9 - Ockham's Razor of Design. Published at the IHI conference, Nov 2010 Washington.</blockquote> I have been reading these sections, and have found the technical sections (parts 4-6) highly informative about a major suspicion I've held for many years. I suspected chaos in the health care IT software engineering process, with inadequate attention to quality, rigor, fine detail, resilience engineering, talent management and other practices essential in development of mission critical products of any type. Prof. Patrick's forensic analysis, while not proof of my concerns, certainly supports them. If Boeing produced aircraft with malfunctioning engines, broken seats, defective flaps, tires that blew on landing, and rust right out of the factory (like the Chevy Vega of old?), one might suspect the development and manufacturing environment could be substantially problematic. The theme of apparent violations of fundamental precepts of relational database design run consistently through his analysis of the FirstNet product. Without getting too technical (which I can, having written successful <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/medinformatic1/saudi.htm">r</a><a href="http://www.ischool.drexel.edu/faculty/ssilverstein/medinformatic1/saudi.htm">elational database-based clinical information systems</a> of considerable complexity for challenging environments, with novel user interaction design besides), I see evidence of developmental chaos. Examples: primary key-foreign key inconsistencies and problematic usages ("keys" are flags used to link sets of information about some object or entity, such as a patient to their diagnoses or meds), internal field nomenclature faux pas (there are best practices on how to do this to enhance software quality and maintenance), cryptic documentation , "stale bits" (old code and data) from past iterations remaining to create "glitches", unreliabilities and new problems, and other technical sins apparently abound. These can be read about in sections 4-6 of Prof. Patrick's analysis. The issues can be summarized as he did in the part 6 Abstract: <blockquote> Consistent weaknesses in sections of the Millenium clinical information System (CIS) are revealed in the combined study of the ERD (entity-relationship diagram), logical schema and the data tables. PK (primary key, i.e., unique identifier) values are not always defined unambiguously at the design level and data tables reveal inconsistencies in declarations and data validation. There is evidence that keys are managed by software within the application rather than by the in-built functions available in the database management system leading to less confidence in data integrity. </blockquote>He goes on to relate: <blockquote> The [technical design] weaknesses in terms of clinical work practices, that have been identified are only likely to show up in occasional circumstances with a combination of processing and data values separated in time. [In other words, the resulting errors are unpredictable, and depend on variable factors about the patient's data and user's attempted actions that cannot be predicted ahead of time - ed.] Staff are not likely to associate one instance of missing or mis-processed data with another. This spasmodic nature tends to lull staff into a false sense of security that the mis-processing is either inconsequential or an accident of their own making. We recommend that each and every mis-processing experience be recorded as accurately as possible so that appropriate computational forensic analysis can correctly identify if weaknesses in the underlying technology have been the source. </blockquote> These are dead-serious matters, literally. One's well being in an ED should not depend on random chance. If you are the "lucky patient" who Wins the Lottery or Hits the Jackpot on health IT mis-processing, or whose clinicians are distracted by user experience flaws, "workarounds", demoralization or other issues, you might end up maimed - or in the grave. <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZ20IJBLu5ePEUKL0bwFA8RSyWPjKFQDm5YHVAcwwbU_9imWz6YVp8pp8QbDpSEoZ1F4TNzVfWia13tgGqFCynsMZviaTQuc2D5QfIgw7u_KsQnbWrPUU3qzkI-r72Grz7kp4Fm32KkBqA/s1600/winner.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5580994204237950722" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZ20IJBLu5ePEUKL0bwFA8RSyWPjKFQDm5YHVAcwwbU_9imWz6YVp8pp8QbDpSEoZ1F4TNzVfWia13tgGqFCynsMZviaTQuc2D5QfIgw7u_KsQnbWrPUU3qzkI-r72Grz7kp4Fm32KkBqA/s320/winner.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 360px; height: 270px;" /></a>The ED EHR Slot Machine. Click to enlarge. You've hit the ED EHR mis-processing jackpot! Perhaps today is a good day to die... </div> I do not believe mission critical software for, say, avionics, or for implantable medical devices, suffers such sloppiness. (In part due to regulation, which health IT lacks entirely in the U.S.). The UK, having their own HIT issues (see my Aug. 2010 "Battle of Britain" post <a href="http://hcrenewal.blogspot.com/2010/08/cerners-blitzkrieg-on-london-wheres-raf.html">at this link</a>), apparently learned something, as evidenced in: <a href="http://www.connectingforhealth.nhs.uk/engagement/clinical/occo/safety/dscn18.pdf"></a><blockquote><a href="http://www.connectingforhealth.nhs.uk/engagement/clinical/occo/safety/dscn18.pdf">Health informatics — Guidance on the management of clinical risk relating to the deployment and use of health software</a>. UK National Health Service, DSCN18 (2009), formerly ISO/TR 29322:2008(E). and <a href="http://www.connectingforhealth.nhs.uk/engagement/clinical/occo/safety/dscn14.pdf">Health Informatics — Application of clinical risk management to the manufacture of health software</a>. UK National Health Service, DSCN14 (2009), formerly ISO/TS 29321:2008(E).</blockquote> That said, I will now comment in more detail on a part of the analysis readily understandable by 'database laypeople': part 2, "Discussions with ED Directors: Are we on the right track?" (again, probably a rhetorical question). In this section, candid discussions were held with the Directors of seven Emergency Departments in New South Wales public hospitals assessing the impact of the introduction of the FirstNet information system into their ED's. The effort has been ongoing for approximately the last 5 years. Numerous themes remind me of my own observations as in my aforementioned <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/">Drexel health IT difficulties site</a>: <blockquote>The implementation processes of the HSS [governmental Health IT support, a.k.a. Health Support Services - ed.] were criticised for refusing to acknowledge the validity of complaints, failing to fulfil promises, creating an ineffective change process, refusing to consult clinicians, using strategies to disenfranchise participation by clinical staff, and introducing a technology that doesnʼt fit their needs. </blockquote>All of these themes are familiar to me, and are representative of the phenomena of non-clinician, IT-centric arrogant ignorance, paternalism, leadership-pyramid inversion (i.e., the facilitators thinking and acting as if they are the enablers of healthcare), playing nasty politics with clinicians to avoid work, and minimizing job and results-evaluation discomfort for those lucky enough to secure cushy IT jobs in health IT support. <blockquote>In determining the clinical documentation needs of staff, the Directors claim that the HSS ignores the needs of staff. Directors report over-supply of irrelevant information and under-supply of needed information in the clinical interfaces. ["Legible gibberish" - ed.] The environment consists of counter-intuitive interfaces where data is entered by one person in one part of the system so that it is not discoverable by another person. The interfaces have inappropriate sizing of objects, confusing functions, redundant steps, unused functions and cluttered interfaces. These difficulties have resulted in increased time usage on the system resulting in decreased time with patients for no gain in administrative or clinical outcomes. Staff minimise their use of the system to as little as possible with work arounds being constantly developed and improved. Staff morale has been clearly degraded with accompanying loss of respect for the HSS and more generally NSWHealth’s authority. </blockquote> These concepts are described and illustrated in my multi-part essay on the healthcare IT mission hostile user experience <a href="http://www.tinyurl.com/hostileuserexper">at this link</a>. They represent major deviations from good information science, information presentation and human-computer interaction (HCI) precepts. <blockquote>... Workarounds in using the system are the most obvious tangible response of staff to the functions of the system they consider unsatisfactory. The key aspect of workarounds is that they constitute a subversion of the policy processes created by the software that the staff are not prepared to collaborate with. Some of these strategies may even compromise the legal status of the records in the system: such as not signing documents, unrecorded alterations to documents, and test results not attached to patient records. ... Another form of staff protest workaround is the strategy by staff to avoid using the system by either having other people [presumably underlings - ed.] do the work on the system, inserting minimal amounts of information thereby reducing the value of the information and passing information to other staff verbally. </blockquote> Workarounds to IT obstacle courses and booby traps, as noted by Koppel, Wetterneck, Telles & Karsh in "<a style="font-weight: bold;" href="http://jamia.bmj.com/content/15/4/408.abstract">Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes and Threats to Patient Safety</a>", J Am Med Inform Assoc. 2008 Jul-Aug;15(4):408-23, increase, not reduce, the risk of EHR-mediated medical errors. I wrote about their findings at "Business v. clinical computing: Workarounds to Barcode Medication Administration Systems" <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=barcoding">at this link</a>. It should be kept in mind that these are mission-critical systems for use in a fast-paced ED, not tracking systems for widgets - or for lab rats. <blockquote>The lack of appropriate reporting functionality of the system has had a serious impact on the critical work of the Directors on process improvement ... It was evident in talking to the Directors that they have antennae highly tuned to the processes happening in their departments and the public health issues that emerge from their patients. On a daily, weekly and monthly basis they review single cases, collections of common cases, and variations in established disease profiles to understand the success of their work and to detect emerging new trends or potential new disease outbreaks. At an administrative level they are asked to review cases either because of the return of new test results or due to complaints or reviews from other bodies. The FirstNet installation has removed all the reporting functionality the directors had in their previous system EDIS while destroying their information sources for process improvement, and their mechanisms for creating and collaborating in research projects. This, in turn, has led to a loss of motivation to enter data further degrading the value of the data held within the system.</blockquote> Reducing the value of a tool to people, and decreasing their ability to perform their jobs (especially when they take great professional responsibility and pride in those jobs) predictably leads to demoralization, demotivation and a cascading path down a whirlpool of failure. <blockquote> The disadvantages of the system for day to day operations is well demonstrated by the issues around the ordering system. It is stated to be overly complex and requires a large deal of repetitive information to be input for multiple orders on one sample, plus specialist data entry knowledge that requires every joint order to have exactly the same timestamp. Ordering was the first accession where staff recognised that information is sometimes sent to the wrong staff, both arriving where it shouldn’t and not arriving where it should. ... Further mis-processing is seen with the cancellation of orders when a patient is transferred to a hospital ward from the ED. The results of orders, particularly radiology, often need to be checked by senior staff, but the system has no functionality to enable efficient processing of orders that have normal results, and thereby require no further attention.</blockquote> I do recall another EHR system, by the same vendor I believe, where an "upgrade" in the recent past led to orders ending up in the wrong places (<a href="http://hcrenewal.blogspot.com/2010/08/huffington-post-investigative-fund-fda.html">link</a>): <blockquote>... Computers at a major Midwest hospital chain went awry on June 29, posting some doctors’ orders to the wrong medical charts in a few cases and possibly putting patients in harm’s way. The digital records system “would switch to another patient record without the user directing it to do so,” said Stephen Shivinsky, vice-president for corporate communications at Trinity Health System. Trinity operates 46 hospitals, most in Michigan, Iowa and Ohio. [In other words, data entered by clinicians was going into the wrong charts. How many charts were involved? Does the hospital system even know, I wonder? - ed.] Less than two weeks later, an unrelated glitch caused Trinity to shut down its $400 million system for four hours at 10 hospitals in the network because electronic pharmacy orders weren’t being delivered to nurses for dispensing to patients, he said.</blockquote> Not to pick on this vendor; these "glitches" seem to be occurring in many HIT vendor's products. All this, dear readers, is simply madness. <blockquote> ... Patient record retrieval is an important aspect of the staff work with patients, therefore its efficiency and accuracy is of vital importance to the activities of the ED. Staff were particularly pointed about the deterioration of this functionality in FirstNet compared to the previous system EDIS. [ED information system - ed.] There were cases where records could not be found, confusion about where data was stored in the patient record with different staff writing the same information into different parts of the record, and the [manual] rewriting of records [requiring a large amount of additional labor and time, not exactly a commodity in an ED -ed.] due to insertion of content into the wrong record.</blockquote> These are critical issues. If you can't get information out of a computer in a timely fashion, what you have is a very expensive doorstop. I also note that a document imaging system that images hand written charts would not have these problems... Prof. Patrick addresses the oft-heard canard that such complaints are the complaints of "Luddite doctors", old dogs who simply don't want to learn new tricks: <blockquote>The staff in the ED are now generally experienced at using some form of clinical information system, many for over 10 years. This experience gives them a keen sense of what is possible with technology as well as the deficiencies in the existing systems. Combining this experience and knowledge with a sense of professional responsibility for process improvement enables them to judge quite acutely when a system is well designed or not. Hence their observations about elements of systems that are not parsimonious enough for optimal clinical efficiency deserve to be respected. </blockquote> That it even needs to be written that the opinions of experienced medical professionals on the tools they are coerced to use by non-medical outsiders "deserve to be respected" gives testimony to my observation of a cross-disciplinary invasion of healthcare by the IT profession (among others). <blockquote> Workflow and dataflow and the continuity of these processes are vital to the smooth running of a complex socio-technical process. ED staff have shaped these flows over a period of years and socialised all staff into the streaming. The directors have found that with the workflow of staff needing to use both clinical and nursing notes at the same time, their separation in FirstNet is deleterious. One department considered that the many nursing and medical notes accumulated over a day had to be kept in a single continuous sequence in the clinical record. Their workaround was to keep the one note page open for 24 hours to maintain the needed continuity in the patient record and avoid staff using a significant amount of time at the computer searching for needed information. </blockquote>Nemeth and Cook explain how an ED EHR can be developed and marketed that interferes with, not supports, the workflows common in ED"s worldwide, in "<a href="http://www.ctlab.org/documents/Hiding%20in%20plain%20sight.pdf">Hiding in plain sight: What Koppel et al. tell us about healthcare IT</a>", J Biomed Inform. 2005 Aug;38(4):262-3: <blockquote> ... On the surface, healthcare work seems to flow smoothly. That is because the clinicians who provide healthcare service make it so. Just beneath the apparently smooth-running operations is a complex, poorly bounded, conflicted, highly variable, uncertain, and high-tempo work domain. The technical work that clinicians perform resolves these complex and conflicting elements into a productive work domain. Occasional visitors to this setting [i.e., IT personnel, non-medical bureaucrats, etc. - ed.] see the smooth surface that clinicians have created and remain unaware of the conflicts that lie beneath it. The technical work that clinicians perform is hiding in plain sight. [Hiding from the uninformed, that is - ed.] Those who know how to do research in this domain can see through the smooth surface and understand its complex and challenging reality. Occasional visitors cannot fathom this demanding work, much less create IT systems to support it. Progress in healthcare IT systems relies on scientific data on the actual, not the perceived, nature of day-today operations.</blockquote> It increasingly seems the only place the faux-expert, healthcare-facilitor, cybernetic snake oil salespeople are going ot learn this simple lesson is in the courtroom... <blockquote>A recent article in the press has presented evidence that access block times in EDs across the state of NSW are worsening. </blockquote> As regards causality, it perhaps takes being an IS dept. director in a hospital - or holding elected office - to be unable to recognize the nose at the front of one's face. Prof. Patrick wraps up this section of his forensic analysis as follows: <blockquote>A number of conclusions can be drawn from the study: 1. Staff are entirely dissatisfied with the SBB and they feel that the deliverables have significantly failed to match the promises. 2. The Directors see that the HSS have failed in their support of the frontline of emergency care across the Sydney basin and their practices are decidedly lacking in proper engagement with the user community which should be their primary concern. 3. Some of the consequences of the HSS decision not to provide the reports needed by the Directors have lead to them being seriously hampered in being able to monitor the quality of their own department’s practices and wider changes and trends in community health. 4. The inefficiencies introduced by this technology have lead to a litany of complaints about its behaviour that have gone unheeded over the past three years. 5. It has lead to major strategies to work around the system by staff at all levels, to the point of complete avoidance by some staff. The major consequences of these failings in the eyes of the ED directors are: <ul><li>Lost productivity and inefficiencies,</li><li>Increased risks to patients,</li><li>Disillusionment of staff and loss of morale.</li></ul></blockquote>Considering my own relative's injuries originating in an ED EHR mishap, I think I can safely add to Prof. Patrick's final tally an additional item: <blockquote><ul><li>Patients have been harmed. </li></ul></blockquote>This is not a pretty picture. I'm confident the Australian legal system abhors negligence as much as our own here in the U.S. If patients are injured and/or die as a result, considering that the Programme leadership and IT vendors knew - or should have known - of these deficits, it would not surprise me if criminal negligence charges begin to appear. These issues are not exactly rocket science, and an expanding literature base has been appearing in recent years. See, for example, my recent post "An Updated Reading List on Health IT" <a href="http://hcrenewal.blogspot.com/2011/02/updated-reading-list-on-health-it.html">at this link</a>. I can only add that my own relative was nearly killed as a result of a number of the phenomena described in Prof. Patrick's analysis. More on other sections of his report at another time. -- SS March 6, 2011 addendum: Also see my new post "<a href="http://hcrenewal.blogspot.com/2011/03/what-to-do-about-state-of-ed-ehr-in-nsw.html">What to do about the state of the ED EHR in NSW?</a>" -- SS Mar. 8, 2011 addendum: Prof. Patrick has added a new section to his report, entitled "The Future Pathways for e-Health in NSW." It is available <a href="http://sydney.edu.au/engineering/it/%7Ehitru/essays/Things%20we%20should%20change%20in%20NSW-v4.pdf">at this link</a> (PDF). It inoculates against most of the 'Ten Plagues' that bedevil health IT projects (such as the IT-clinical leadership inversion, magical thinking about the technology, and lack of accountability): More on the Pathways at my post <a href="http://hcrenewal.blogspot.com/2011/03/future-pathways-for-e-health-in-nsw.html">here</a>. The de facto "National Program for IT in the HHS" here in the United States needs a similar inoculation. --SS

On an EMR Forensic Evaluation by Professor Jon Patrick from Down Under: More Thoughts.

Note: the reports to which this post refers are available as a set of PDF's from the University of Sydney, NSW, Australia at this link ...

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