healthy4u: good IT/bad IT

The recognition and partitioning of <b>"good health IT"</b> from <b>"bad health IT"</b> 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):<br /><br /><blockquote class="tr_bq"><b><a href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit" target="_blank">Good HIT and bad HIT</a><br />Jon D Patrick and Susan Ieraci<br />Medical Journal of Australia 2013; 198 (4): 205.</b></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"><i>First and foremost, do no harm. Second, do some good</i></div><div class="Intro"><br /></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><br /><div class="P"><span class="DropCap">O</span><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"><br /></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"><br /></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><span class="Sp">,</span><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"><br /></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"><br /></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"><br /></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"><br /></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"><br /></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 <span class="Italic">or</span> staff.</div></blockquote></div><div class="field field-name-field-provenance field-type-text field-label-above"><br />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"><br /></div><div class="field field-name-field-provenance field-type-text field-label-above">-- SS</div></div><br />

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 Healthca…

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At my Aug. 2012 post "<a href="http://hcrenewal.blogspot.com/2012/08/contra-costas-45-million-computer.html" target="_blank">Contra Costa's $45 million computer health care system endangering lives, nurses say</a>", I described how an experimental EHR being forced on clinicians in Contra Costa county, California, was endangering patients who had not consented to its use, and how nurses were reported to be raising hell about it.  I also noted:<br /><br /><blockquote class="tr_bq">... The[se] scenarios [of EHR-created mayhem] are also usually accompanied by <b>amoral misdirection from these personnel away from patient risks... </b><br /><br />Herein is the problem:  <i>the attitude that a clinic full of  non-consenting patients is an appropriate testbed for alpha and beta  clinical software that puts them at risk is medically unethical, based  on the guidelines developed from medical abuses of the past.  </i><b>There is nothing to argue or debate about this.  </b></blockquote><br />Now the affected physicians have their say.<br /><br />These physicians are apparently represented by a union; therefore they likely fear retaliation less than non-union physicians, and thus can be candid:<br /><br /><blockquote class="tr_bq"><a href="http://www.mercurynews.com/news/ci_21575727/county-health-doctors-air-complaints-about-countys-new" target="_blank"><b>Contra Costa County health doctors air complaints about county's new $45 million computer system</b></a><br />By Matthias Gafni<br />Contra Costa Times<br />Posted:   09/18/2012, Updated:  09/19/2012 <br /><br />MARTINEZ -- One of every 10 emergency room patients at the county's public hospitals in September left without ever being seen by a doctor or nurse because of long waits -- a number rising since implementation of Contra Costa's $45 million computer system July 1.<br /><br />One patient waited 40 hours to get a bed.<br /><br />Dr. Brenda Reilly delivered the troubling news Tuesday afternoon to county supervisors. <b>She was one of three dozen doctors in the supervisors' chamber </b>complaining about EPIC, new computer software aimed at integrating all of the county's health departments to create a federally mandated electronic medical record for patients.</blockquote><br />The response, as seen later, were characterized by the typical amoral excuses, mistaken beliefs in technological determinism, (a/k/a quasi-religious computer fanaticism) and misdirection I described above.<br /><br /><blockquote class="tr_bq">To allow for the major computer program installation and conversion, administrators <b>cut doctors' patient loads in half</b>, in turn cutting the number of available appointments in half.<br /><br />In a letter to the supervisors, Dr. Ori Tzvieli -- medical staff president whose union has been negotiating a new contract with the county -- along with 14 doctor co-signers pleaded for administrators <i><b>to continue scaling back physician workloads because doctors are over-stressed. </b></i>Six doctors have left this year, said Dr. Keith White, a 22-year pediatrician.</blockquote><br />I point out that such stress from interacting woth a <a href="http://www.tinyurl.com/hostileuserexper" target="_blank">mission hostile</a> EHR (really, <b>a clinician workflow-control system</b>), and the needed state of <b>hypervigilance</b> to avoid IT-related mistakes that harm patients, lead to burnout and ultimately, a lower quality of patient care.  <br /><br />Patient workloads were reduced by 50%, which is bad enough (and indicative of gross project mismanagement, as I wrote about in another example in my Sept. 2012 post "<a href="http://hcrenewal.blogspot.com/2012/09/the-extremes-to-which-faith-based.html" target="_blank">Lake County (IL) Health Department:  The extremes to which faith-based informatics beliefs can drive healthcare facilities - Depression era soup lines at the clinic?</a>").<br /><br /><b>Yet the 50% reduction, according to the principal end users, was still not enough.</b>  Usability and fitness of the software is surely in question.<br /><br /><blockquote class="tr_bq">"<b>We were not ready for EPIC</b> and <b>EPIC was not ready for us</b>," White told supervisors. "As a result, the providers are <b>struggling to provide safe and effective care </b>for 100,000 citizens of the county, many of whom are very ill. We often feel that we are failing. We are very tired ... many doctors have left and all are considering leaving."</blockquote><br />It is impossible for people, especially medical professionals, to be "ready" for a system that "is not ready for them", i.e., "<b>bad IT</b>" as defined at my teaching site intro <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/" target="_blank">at this link</a>:<br /><br /><blockquote class="tr_bq"><span style="font-size: small;"><b>Good Health IT ("GHIT"</b>) is defined as<i> IT that provides a good user experience, enhances cognitive function, puts essential information as effortlessly as possible into the physician’s hands, keeps eHealth information secure, protects patient privacy and facilitates better practice of medicine and better outcomes. </i><br />    <br /><i><b>Bad Health IT ("BHIT")</b> </i>is defined as <i>IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, 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. </i></span></blockquote><br />The two phrases "<b>We were not ready for EPIC" </b>and <b>"EPIC was not ready for us</b>" do not belong together in the same sentence.<br /><br />A claim that physicians (and nurses) are "struggling" to provide safe let alone effective care for 100,000 should <b>RAISE ALARM BELLS</b>, not produce a paternalistic, patronizing response from medical and governmental officials as it did, seen below.<br /><br /><blockquote class="tr_bq">Both doctors and administrators agreed Tuesday that creating an integrated electronic health record is important, but a series of white coats stepped to the podium in what they jokingly termed "Doccupy" to share their nightmarish last few months.</blockquote><br />I disagree with the assessment that "creating an integrated electronic health record is important", in that the technology and know-how to do so <i>without endangering the very patients the technology is supposed to protect</i> does not yet seem to exist in the commercial sector.<br /><br />In that sense, <b>regulating EHR technology and subjecting it to controlled clinical trials and refinement </b>(as with any other medical device or drug, and many other types of healthcare-related IT such as MDDS - <a href="http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/MedicalDeviceDataSystems/default.htm" target="_blank">medical device data systems</a>) <b>with consenting subjects is what's important.</b><br /><br />On MDDS, from the FDA link above:<br /><i><br /></i>   <br /><blockquote class="tr_bq"><i>Medical Device Data Systems (MDDS) are hardware or software  products that <b>transfer, store, convert formats, and display medical  device data</b>. An MDDS does not modify the data or modify the display of  the data, and it does not by itself control the functions or parameters  of any other medical device. MDDS are not intended to be used for active  patient monitoring. Examples of MDDS include:</i><br /><ul><li><i>software that stores patient data such as blood pressure readings for review at a later time;</i></li><li><i>software that converts digital data generated by a pulse oximeter into a format that can be printed; and</i></li><li><i>software that displays a previously stored electrocardiogram for a particular patient.</i></li></ul><i><b>The  quality and continued reliable performance of MDDS are essential for  the safety and effectiveness of health care delivery</b>. Inadequate quality  and design, unreliable performance, or incorrect functioning of MDDS  can have a critical impact on public health.</i></blockquote><br />That health IT used on live patients receives special regulatory accommodation in the form of non-regulation, when clearly the  quality and continued reliable performance of EHR systems are essential for  the safety and effectiveness of health care delivery,<b> is inexcusable in 2012.  </b><br /><br />(Of course, stunningly, FDA won't touch the latter, although admitting they are medical devices that should fall under the FD&C Act, because EHRs are a "political hot potato."  See <a href="http://hcrenewal.blogspot.com/2011/04/fda-decides-regulating-implantable.html" target="_blank">this post</a> for the relevant citations.)<br /><br /><blockquote class="tr_bq">... "This has been excruciatingly painful to do what is needed for those people who need it most," said Dr. Rachel Steinhart, an emergency room doctor who worked a graveyard shift ending Tuesday morning, hours before the board meeting. She said she still had to document paperwork for 16 of her patients. <b>"It's going to implode. It can't go on like this."</b></blockquote><br />Patients are surely going to be injured or killed in this setting.  There is likely a "hold harmless" clause with the vendor, so, doctors, I'm sorry to say, despite your complaints, <b>you will very likely be held legally liable.</b><br /><br /><blockquote class="tr_bq">The head of the county's health care system sympathizes, and hopes to work with medical staff to ease the transition for what is a monumental moment in medical history.<br /><br />"We're in an era of massive change right now, not only in our system, but in the system nationwide," said Dr. William Walker, Contra Costa's health services director. "Coming with the rapidity is its throwing people off balance."</blockquote><br />Dr. Walker has just painted a big red <span style="color: #cc0000;"><b>"name me as a defendant for gross negligence and breach of fiduciary responsibilities to patients and clinicians" </b><span style="color: black;">target on his back for glossing over known health IT risks and what appear to be rather profound complaints coming from his constituents.  Instead, he </span></span><span style="color: #cc0000;"><span style="color: black;"><span style="color: #cc0000;"><span style="color: black;">supplies platitudes, not action to remediate or withdraw the bad IT</span></span>.</span></span><br /><br /><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/AVvXsEinDtXnVAFuOPvRaK5g59iqj2yAbapYdW0lbU6L7m4v_l8DyslOSHCGTuaUi26Zuka7KRKI_XWyHgjZHm4cR_rK7wcnXCy9Ht9Jkl78UnfmwgmfrePkDhIk1fHZ0J0qY76aqXh6PmuYTmJ6/s1600/target.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEinDtXnVAFuOPvRaK5g59iqj2yAbapYdW0lbU6L7m4v_l8DyslOSHCGTuaUi26Zuka7KRKI_XWyHgjZHm4cR_rK7wcnXCy9Ht9Jkl78UnfmwgmfrePkDhIk1fHZ0J0qY76aqXh6PmuYTmJ6/s200/target.jpg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="color: #cc0000;"><b>Name me as a defendant for gross negligence and breach of fiduciary responsibilities to patients and clinicians</b></span></td></tr></tbody></table><span style="color: #cc0000;"><span style="color: black;"><br /></span></span><br />The response is stunning:<br /><br /><blockquote class="tr_bq">To ease the burden, Walker hopes to have<b> teams of medical care providers formed</b> to ease the doctors' paperwork burden, enabling them to return to treating patients.</blockquote><br />It takes teams of physicians to properly see a patient due to the interference of EHRs?  That is remarkable.<br /><br /><blockquote class="tr_bq">The ccLink program has its benefits, some doctors said. Dr. Chris Farnitano, an ambulatory care medical director, described how he retrieved a patient's biopsy results from a different hospital on the spot, whereas in the past it would have taken weeks.<br /><br />However, other doctors called ccLink clunky and time-consuming, designed more for bureaucrats than physicians. Even with doctors cutting their patient load in half -- meaning half as many appointments are available for patients -- doctors complained that they spend more time on their computers than treating patients.</blockquote><br />This is misdirection by the Medical Director.  It's unarguable that the <b>risks far outweigh the benefits.  </b>Further, retrieving a biopsy or other result result instantaneously <b>could easily be done from an innocuous, non-disruptive document imaging system </b>(e.g., Documentum).  The latter would also be many millions of dollars less expensive than an EHR.<br /><br /><blockquote class="tr_bq">"It's a truncation of patient care. The individual patient doesn't get the care they used to get," said David MacDonald, a 22-year family medicine doctor.</blockquote><br />Again, Dr. MacDonald, the liability for adverse outcomes is <i><u>on you</u></i>.<br /><br />You are now, in effectm an indentured servant of an IT company, providing free alpha and beta testing at your expense and peril, using the patients as an even lower level of indentured servant/guinea pig.<br /><br />There's also significant patient-endangering collateral damage from this mayhem:<br /><br /><blockquote class="tr_bq"><b>The lack of appointments has overburdened emergency rooms</b>, which already exceeded emergency room wait benchmarks in a facility built to see 80 patients a day, but often sees <b>more than 200 patients a day</b>. Since ccLink started, the average patient spends four hours in the ER, up an hour from before the computer system transition, which was already over national benchmarks, said Reilly.</blockquote><br />The scenario could not be worse.  The ED's are themselves burdened by EHR's.<br /><br /><blockquote class="tr_bq">The supervisors asked for continued updates, and for patience.<br /><br />"Continuous  improvement means you need continuous change," said supervisor Federal  Glover. "<b>Eventually, it's going to become second nature as it was with  cell phones.</b> We'll wonder how we ever did without it."</blockquote><br />Supervisor Glover has also painted a "defendant" target on his back.  This is the misdirection I was speaking of earlier, consisting of platitudes, logical fallacy and falsehoods:<br /><br /><ul><li>"Continuous improvement" is not what's going on here; </li><li>Such improvement does not mean creating chaos as a precondition; </li><li>Whether this software will become "second nature" is anyone's guess.  That is a hysterical and logically fallacious statement (e.g., an <a href="http://www.nizkor.org/features/fallacies/appeal-to-belief.html" target="_blank">appeal to belief</a>) of an almost quasi-religious fanaticism regarding computing.  This technology could ultimately be scrapped in favor of, say, simpler document imaging systems due to increasing clinician complaints, inherent usability issues in fast-paced medical settings, litigation, costs, harms etc.;</li><li>What of the patients placed at risk, and/or injured/killed as a result of this experimentation?  What of them, and their medical and human rights?</li></ul><br />In effect, a response like this is medically unethical.  The correct response would be a halt in the rollout until problems are substantially remediated in a controlled, risk free setting - <b>not the clinic.</b><br /><br />If that is not possible,<b> the system needs to indeed be scrapped or replaced.</b><br /><br />Continuation of patient endangerment is inexcusable<b> </b>medically, ethically and legally.<br /><br />-- SS <b><br /></b>

In addition to nurses, doctors now air their alarm: Contra Costa County health doctors air complaints about county's new $45 million computer system

At my Aug. 2012 post "Contra Costa's $45 million computer health care system endangering lives, nurses say", I described how an experimental EHR being forced on clinicians in Contra Costa county, Cali…

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