Another Sign The EHR Experiment is Producing Undesired (But Predictable) Results: ED EHRs Produce No Efficiency Gains

Adverse results that run counter to the industry meme of healthcare IT exceptionalism are coming fast and furious.  It's hard for me to keep up with it all.<br /><br />In addition to my post today "<b>EHR Exceptionalism Debunked: Care Quality Variances Among VA Hospitals Suggest the True Value of Health IT Has Been Grossly Exaggerated</b>" (<a href="http://hcrenewal.blogspot.com/2014/06/ehr-exceptionalism-debunked-care.html">http://hcrenewal.blogspot.com/2014/06/ehr-exceptionalism-debunked-care.html</a>), here's another.<br /><br />I won't comment on this very much:<br /><br /><blockquote class="tr_bq"><a href="http://www.jwatch.org/na34646/2014/05/30/electronic-charting-less-efficient-paper-charting">http://www.jwatch.org/na34646/2014/05/30/electronic-charting-less-efficient-paper-charting</a><br /><br />May 30, 2014<b> </b><br /><br /><b>Is Electronic Charting Less Efficient Than Paper Charting?</b><br />Daniel J. Pallin, MD, MPH reviewing Ward MJ et al. Ann Emerg Med 2014 Jun.<br /><br />Operational performance was similar before and after computerization at 23 community emergency departments.<br /><br />The federal government has provided $17 billion in incentives to computerize healthcare. The potential benefits include improved error checking, decision support, better billing, and more data for research. However, some research has suggested that going paperless adversely affects productivity.<br /><br />To further examine this issue, investigators measured operational efficiency 6 months before and 6 months after implementation of an electronic health record system at 23 community emergency departments. <b>No significant differences between the two time points were found in all efficiency factors that were measured, including time to provider, lengths of stay, walkouts, patient satisfaction, patients seen per provider per hour, and significant return visits.</b><br /><br />Citation(s):<br /><br />Ward MJ et al. The effect of electronic health record implementation on community emergency department operational measures of performance. Ann Emerg Med 2014 Jun; 63:723. (<a href="http://dx.doi.org/10.1016/j.annemergmed.2013.12.019">http://dx.doi.org/10.1016/j.annemergmed.2013.12.019</a>)</blockquote><br /><i>One might seek to get better results for their $17 billion than, at best, parity to paper.</i><br /><br />Finally, the reader comments at that post suggest ED physicians are the ones helping foot the bill.  As one commenter put it:<br /><br /><blockquote class="tr_bq">"Most quality EM docs won't let a record slow their care up front--especially when quaility metrics are staring us down on time until seen or discharge. <b>So we just chart later and go home later."</b></blockquote><br />We as patients certainly should not find a development like that desirable.<br /><br /><span class="userContent">Note that in my work as a hospital Chief Medical Informatics Officer (CMIO) I recommended simple <b>document imaging solutions</b> for risk-laden ED's (</span><span class="userContent"><span class="userContent">where charts are usually short) </span>to capture and make </span><span class="userContent"><span class="userContent">the paper chart content </span>available anywhere/anytime ... not full-blown digital electronic medical records systems.</span><br /><br />-- SS <br /><br /><div id="stcpDiv" style="left: -1988px; position: absolute; top: -1999px;">Most quality EM docs won't let a record slow their care up front--especially when quaility metrics are staring us down on time until seen or dischage. So we just chart later and go home later. - See more at: http://www.jwatch.org/na34646/2014/05/30/electronic-charting-less-efficient-paper-charting#sthash.WCiV8FQg.dpuf</div><div id="stcpDiv" style="left: -1988px; position: absolute; top: -1999px;">Most quality EM docs won't let a record slow their care up front--especially when quaility metrics are staring us down on time until seen or dischage. So we just chart later and go home later. - See more at: http://www.jwatch.org/na34646/2014/05/30/electronic-charting-less-efficient-paper-charting#sthash.WCiV8FQg.dpuf</div><div id="stcpDiv" style="left: -1988px; position: absolute; top: -1999px;">Most quality EM docs won't let a record slow their care up front--especially when quaility metrics are staring us down on time until seen or dischage. So we just chart later and go home later. - See more at: http://www.jwatch.org/na34646/2014/05/30/electronic-charting-less-efficient-paper-charting#sthash.WCiV8FQg.dpuf</div><div id="stcpDiv" style="left: -1988px; position: absolute; top: -1999px;">Most quality EM docs won't let a record slow their care up front--especially when quaility metrics are staring us down on time until seen or dischage. So we just chart later and go home later. - See more at: http://www.jwatch.org/na34646/2014/05/30/electronic-charting-less-efficient-paper-charting#sthash.WCiV8FQg.dpuf"</div>

Another Sign The EHR Experiment is Producing Undesired (But Predictable) Results: ED EHRs Produce No Efficiency Gains

Adverse results that run counter to the industry meme of healthcare IT exceptionalism are coming fast and furious.  It's hard for me to keep up with it all.In addition to my post today "EHR Exceptiona…

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EHR Exceptionalism Debunked: Care Quality Variances Among VA Hospitals, Perhaps The Most Wired Hospitals in the World, Suggest the True Value of Information Technology in Healthcare Has Been Grossly Exaggerated

The Wall Street Journal somehow managed to get access to internal VA patient care quality data and published the following article:<br /><blockquote class="tr_bq"><br /><a href="http://online.wsj.com/articles/veterans-affairs-hospitals-vary-widely-in-patient-care-1401753437">http://online.wsj.com/articles/veterans-affairs-hospitals-vary-widely-in-patient-care-1401753437</a></blockquote><blockquote><b>Veterans Affairs Hospitals Vary Widely in Patient Care</b><br /><i>Internal Records Show Facilities Such as Phoenix Have Far Higher Death Rates Than Peers</i><br />Thomas M. Burton and Damian Paletta<br />June 3, 2014 <br /><br />The Phoenix facility at the heart of the crisis at the Department of Veterans Affairs is among a number of VA hospitals that show significantly higher rates of mortality and dangerous infections than the agency's top-tier hospitals, internal records show.<br /><br />The criticism that precipitated last week's resignation of VA Secretary Eric Shinseki has focused largely on excessive wait times for appointments across the VA's 150-hospital medical system.<br /><br />But a detailed tabulation of outcomes at a dozen VA hospitals made available to The Wall Street Journal illustrates a deeper challenge: vastly disparate treatment results and what some VA doctors contend is the slippage of quality in recent years at some VA facilities.<br /><br />Some of the discrepancies are stark, especially for an agency known for offering high-quality care in 50 states.</blockquote><br />Yet, these are highly wired hospitals, perhaps the most highly wired in the world, with one EHR, VistA CPRS, allegedly among the best EHRs in the world developed over decades, and allegedly used by 100% of the clinicians.<br /><br />How can this be?  <br /><br /><blockquote class="tr_bq">... Scott McRoberts, spokesman for the Phoenix VA Health Care System, said on Monday the database "is an internal measurement system to benchmark our improvement, and is not for public consumption."<br /><br />The rate of potentially lethal bloodstream infections from central-intravenous lines was <b>more than 11 times as high among patients at the Phoenix facility than it was at top VA hospitals</b>, data from the year ended March 31, 2014, show.<br /><br />... The findings come from a nonpublic VA database called Strategic Analytics for Improvement and Learning, known as SAIL. SAIL tracks procedure outcomes and ranks VA hospitals on a scale of five stars, the best, to one star, the lowest. <br /><br />... In other examples of variations in care, the Atlanta VA Medical Center, a two-star hospital for quality, has more than <b>three times the rate of central-IV infections than the average</b> of five-star VA hospitals. Houston's VA hospital, ranked as a two-star hospital, had a <b>47% higher acute-care mortality rate than the five-star hospital rate.</b></blockquote><br />A 47% higher acute-care mortality rate?<br /><br />Hospitals are willing to go into tens of millions of dollars of debt and knowingly endanger patients (see e.g. "<b>In Fixing Those 9,553 EHR "Issues", Southern Arizona’s Largest Health Network is $28.5 Million In The Red</b>" at <a href="http://hcrenewal.blogspot.com/2014/06/in-fixing-those-9553-ehr-issues.html">http://hcrenewal.blogspot.com/2014/06/in-fixing-those-9553-ehr-issues.html</a>), and even attempt to stifle clinician conversation on drawbacks (e.g. see "<b>Words that Work</b>" at <a href="http://hcrenewal.blogspot.com/2013/10/words-that-work-singing-only-positive.html">http://hcrenewal.blogspot.com/2013/10/words-that-work-singing-only-positive.html</a>), to attain this technology on the stated reason of "improving patient safety" and "saving money."<br /><br />Former ONC Chair Blumenthal stated explicitly in <span style="font-size: 100%;">the NEJM article "<span style="font-weight: bold;">The 'Meaningful Use' Regulation for Electronic Health Records</span>", Blumenthal</span> and Tavenner (10.1056/NEJMp1006114, July 13, 2010):<br /><div class="PlainText" style="font-family: arial;"><span style="font-size: 100%;"><br /></span></div><blockquote dir="ltr" style="font-family: arial; margin-right: 0px;"><div class="PlainText"><span style="font-size: 100%;">... EHRs <u><b>will</b></u> improve caregivers’ decisions and patients’ outcomes. Once patients experience the benefits of this technology, they <u><b>will demand</b></u> nothing less from their providers. </span></div></blockquote><br />There is no doubt expressed there. <br /><br />The industry itself has convinced the Federal Government to spend tens of billions of taxpayer dollars on this technology via HITECH incentives, and to start penalizing non-adopters via Medicare cuts.  The Government has bought into the hyper-enthusiasm hook, line and sinker, when the same money might have been spent elsewhere such as on care of the underserved...or on our Veterans.<br /><br />Yet the data from a highly-computerized organization like the VA <b>show that these systems cannot be all they are made out to be</b>.  They do not automatically "improve caregivers' decisions and patients' outcomes." This is an on its face observation.<br /><br />They are simply a tool, and in absence of appropriate human staffing, expertise, and conducive work environment, <b>they mean significantly "less than advertised</b>" in terms of improving care quality and outcomes.  <br /><br />Finally, as the VA has gotten busier due to factors such as the return of veterans from recent wars, one must also ask if the loss of productivity, cognitive burden, and other factors caused by needing to interact with a computer rather than paper has made the computer systems more of an impediment to good care rather than a facilitating tool.<br /><br />I think it's time the Government start to reform the industry hype surrounding this technology with far more sober predictions that would facilitate far more cautious implementations.<br /><br />No "revolutions" are happening soon, at least not due to information technology in healthcare. <br /><br />Finally, note that EHR oversell and <i>exceptionalism</i> has been going on for <b>decades.   </b>Donald A. B. Lindberg M.D. (<a href="http://www.nlm.nih.gov/od/roster/lindberg.html">http://www.nlm.nih.gov/od/roster/lindberg.html</a>), Medical Informatics pioneer and Director of the U.S. National Library of Medicine at NIH, observed in 1969 that:<br /><blockquote class="tr_bq"><br />"The [second] reason for the dearth of significant success of computers in medicine has been the <b>flagrant and consistent "over sell" of capability on the part of manufacturers and computer enthusiasts."  </b></blockquote><br />Read his full quote by clicking on the page below, from Morris Collen's book "<a href="http://www.amazon.com/History-Medical-Informatics-United-States/dp/0964774305">A History of Medical Informatics in the United States: 1950 to 1990</a>."<br /><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/AVvXsEjrRIuVMu4XQOTRYpbyXb2-IXrnM019VAdbzcR3D8wVVCDQtXDkhG6UlZTWtBpmUKH7s4QnIHjxuyp65kccko4iKwx6nGV3Cxu8kZ75Fss742dcTMln77zZw4tJOu25MXPfH9Oq1F-i5egc/s1600/collen168.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrRIuVMu4XQOTRYpbyXb2-IXrnM019VAdbzcR3D8wVVCDQtXDkhG6UlZTWtBpmUKH7s4QnIHjxuyp65kccko4iKwx6nGV3Cxu8kZ75Fss742dcTMln77zZw4tJOu25MXPfH9Oq1F-i5egc/s1600/collen168.jpg" width="263" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Informatics pioneer Dr. Donald Lindberg's 1969 observations on health IT oversell.  Click to enlarge.</td></tr></tbody></table><br /><br />Sadly, nothing has changed in health IT, at least since the year we landed on the Moon.<br /><br />-- SS<br /><br />

EHR Exceptionalism Debunked: Care Quality Variances Among VA Hospitals, Perhaps The Most Wired Hospitals in the World, Suggest the True Value of Information Technology in Healthcare Has Been Grossly Exaggerated

The Wall Street Journal somehow managed to get access to internal VA patient care quality data and published the following article:http://online.wsj.com/articles/veterans-affairs-hospitals-vary-widely…

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Words that Work: Singing Only Positive - And Often Unsubstantiated - EHR Praise As "Advised" At The University Of Arizona Health Network

When clinicians are told to promote a technology in no uncertain terms, that puts a chilling effect on critical thinking and discourse.  In effect, when under orders to only speak positively about a hospital or its technology, saying anything bad could very likely get clinicians labeled as 'troublemakers' or 'disruptive clinicians.'  Sometimes - in a sadly real example at Affinity Health - it may even get threats of having complaints plastered to one's forehead (see <a href="http://hcrenewal.blogspot.com/2013/07/hows-this-for-patient-rights-affinity.html">http://hcrenewal.blogspot.com/2013/07/hows-this-for-patient-rights-affinity.html</a>), a threat answered to by a judge.<br /><br />The 'disruptive' label usually does not have a good effect on one's evaluations and job (or, for doctors, even career) longevity.  See, for example, the resources at <a href="http://www.aapsonline.org/index.php/article/sham_peer_review_resources_physicians/">http://www.aapsonline.org/index.php/article/sham_peer_review_resources_physicians/</a> on <b>sham peer review.</b><br /><br />At <a href="http://www.uahealth.com/">University of Arizona Health Network (UAHN)</a>, clinicians are being told to promote the EPIC EHR.<br /><br />The campaign is under the aegis of executives who know, should know, or should have made it their business to know the mayhem caused at other medical centers by EPIC and other major clinical IT systems (see for example query links <a href="http://hcrenewal.blogspot.com/search/label/EPIC">http://hcrenewal.blogspot.com/search/label/EPIC</a> and <a href="http://hcrenewal.blogspot.com/search/label/healthcare%20IT%20difficulties">http://hcrenewal.blogspot.com/search/label/healthcare%20IT%20difficulties</a>).<br /><br />Here's what clinicians are bring told in the Oct. 3, 2013 "Weekly update for UAHN employees":<br /><blockquote class="tr_bq"><br /><h1 style="color: #606060 !important; display: block; font-family: Helvetica; font-size: 40px; font-style: normal; font-weight: bold; letter-spacing: -1px; line-height: 125%; margin: 0; text-align: left;"> <span style="font-size: 18px;"><span style="color: #1c3e71; font-family: verdana, 'helvetica neue', helvetica, sans-serif; line-height: 18px;">Words that Work </span></span></h1><div style="color: #505050; line-height: 13px;"><br />Talking positively to our patients about our new Electronic Health Record system is important! Here are some key words and phrases you can use to emphasize the many benefits of the new system:</div><ul><li style="color: #505050; line-height: 13px;"> Electronic health record (not ‘Epic’ or ‘EHR’)</li><li style="color: #505050; line-height: 13px;"> One comprehensive record</li><li style="color: #505050; line-height: 13px;"> Coordinated care</li><li style="color: #505050; line-height: 13px;"> Improves patient safety & quality</li><li style="color: #505050; line-height: 13px;"> Convenient, easy patient portal </li><li style="color: #505050; line-height: 13px;"> Private and secure</li></ul><div style="color: #505050; line-height: 13px;"><a href="https://www.uahealth.com/pdf/Epic_Words_That_Work.pdf" style="color: #1c3e71; font-weight: normal; text-decoration: underline; word-wrap: break-word !important;" target="_self"><b>Click here</b></a> for more words and behaviors to inspire confidence in our patients (and ourselves) as we transition to this new system.</div></blockquote><br />The link to "more words" produced this PDF:<br /><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/AVvXsEj_OOVivF_6D2GEFgUm6ujfKdJjMf4UMwoxX7ZECU7351gCph46CpKY7tryUY2qq63Q7Snl9fy1SNKk9QOxUyXfhgON7lm2W2MO_Sgin5pPxl4Rf6OR78MIdzjuQrxPDCBQ4ri6BeN3YxKn/s1600/words+that+work.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_OOVivF_6D2GEFgUm6ujfKdJjMf4UMwoxX7ZECU7351gCph46CpKY7tryUY2qq63Q7Snl9fy1SNKk9QOxUyXfhgON7lm2W2MO_Sgin5pPxl4Rf6OR78MIdzjuQrxPDCBQ4ri6BeN3YxKn/s400/words+that+work.jpg" width="311" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><b>"Words that Work"</b> - If I worked there, I would be concerned that that using "words that don't work" about a project that probably cost hundreds of millions of dollars would likely injure my career. <b> Click to enlarge.</b></td></tr></tbody></table><br />This is shameless.  Many of these claims are unsubstantiated or in significant doubt in the literature.<br /><br />First:<br /><br />They left out issues such as these:<br /><br /><blockquote class="tr_bq">• The software is tested and validated for safety by nobody, including traditional medical device safety testers.<br /><br />• No postmarket surveillance for problems, either.<br /><br />• Transparency about problems that can cause patient harm is severely impeded by systematic impediments to information flow (as per <b>IOM's 2012 study of health IT safety</b> at <a href="http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html">http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html</a>, <b>FDA via their leaked Internal Memo</b> on HIT safety as at <a href="http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html">http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html</a>, the <b>Joint Commission in their Sentinel Events Alert on Health IT </b>as at <a href="http://hcrenewal.blogspot.com/2008/12/joint-commission-sentinel-events-alert.html">http://hcrenewal.blogspot.com/2008/12/joint-commission-sentinel-events-alert.html</a>, and others.)<br /><br />• Problems known are only the <b>"tip of the iceberg"</b> (FDA, ECRI Institute), as at <a href="http://hcrenewal.blogspot.com/2010/02/fda-on-health-it-adverse-consequences.html">http://hcrenewal.blogspot.com/2010/02/fda-on-health-it-adverse-consequences.html</a> and <a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html">http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html</a> </blockquote><blockquote class="tr_bq"><b>(Mar. 2014 addendum:</b> add to that list the revelations of med mal insurer CRICO, that EHR technology has contributed to a substantial fraction of the medical malpractice suits in Massachusetts: <a href="http://hcrenewal.blogspot.com/2014/02/patient-safety-quality-healthcare.html">http://hcrenewal.blogspot.com/2014/02/patient-safety-quality-healthcare.html</a>)</blockquote><br />Of the claims they do make:<br /><br /><blockquote class="tr_bq">• <span style="color: red;"><b><i>Efficient</i></b></span> - see aforementioned links as well as "Common Examples of Healthcare IT Difficulties" at <a href="http://cci.drexel.edu/faculty/ssilverstein/cases/">http://cci.drexel.edu/faculty/ssilverstein/cases/</a><br /><br />• <span style="color: red;"><b><i>Convenient</i></b></span> - as above.  According to whom?  Compared to what?  Pen and paper?<br /><br />• <span style="color: red;"><b><i>Improves patient safety and quality</i></b></span> - see IOM report post at <a href="http://hcrenewal.blogspot.com/2011/11/iom-report-on-health-it-safety-nix-fda.html">http://hcrenewal.blogspot.com/2011/11/iom-report-on-health-it-safety-nix-fda.html</a> .  We as a nation <b>are only now studying safety of this technology</b>, and the results are not looking entirely convincing, e.g.<b> ECRI Deep Dive Study</b> of health IT safety at <a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html">http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html</a>.  171 health IT mishaps in 36 hospitals, voluntarily reported over 9 weeks, with 8 reported injuries and 3 reported possible deaths is not what I would call something that "improves patient safety and quality" without qualifications.<br /><br />• <i><span style="color: red;"><b>The Cadillac of its kind</b></span></i> - according to whom?<br /><br />• <i><span style="color: red;"><b>Patients at hospitals using this system love it</b></span> </i>-  Do most patients even know what it, or any EHR, looks like?  Have they provided informed consent to its use?<br /><br />• <span style="color: red;"><i><b>Exciting </b></i></span>- clinician surveys such as by physicians at <a href="http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html">http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html</a> and by nurses at <a href="http://hcrenewal.blogspot.com/2013/07/candid-nurse-opinions-on-ehrs-at.html">http://hcrenewal.blogspot.com/2013/07/candid-nurse-opinions-on-ehrs-at.html</a> shed doubt on that assertion.  </blockquote><blockquote class="tr_bq">(<b>Addendum:</b> also see what nurses think about these systems at "<b>Another 'Survey' on EHRs - Affinity Medical Center (Ohio) Nurses Warn That Serious Patient Complications Only a Matter of Time in Open Letter</b>", <a href="http://hcrenewal.blogspot.com/2013/11/another-survey-on-ehrs-affinity-medical.html">http://hcrenewal.blogspot.com/2013/11/another-survey-on-ehrs-affinity-medical.html</a>)<br /><br />• <span style="color: red;"><i><b>The best thing for our patients</b></i></span> - again, according to whom?<br /><br />• <b><span style="color: red;"><i>Sophisticated new system</i></span></b> - "New"?  Not so much, just new for U. Arizona Health.  "Sophisticated", as if that's a virtue?  Too much "sophistication" is in part what causes clinician stress and burnout, raising risk; see this summary of a new, not-free JAMIA article "<b>Electronic medical records and physician stress in primary care: results from the MEMO Study</b>", J Am Med Inform Assoc amiajnl-2013-001875 at <a href="http://www.beckershospitalreview.com/healthcare-information-technology/the-relationship-between-emrs-and-physician-stress.html">http://www.beckershospitalreview.com/healthcare-information-technology/the-relationship-between-emrs-and-physician-stress.html</a>.   From that summary:<br /><br /><blockquote class="tr_bq">... Compared with physicians at clinics with low-function EMRs,<b> physicians at clinics with moderate-function EMRs experienced significantly more stress and had a higher rate of burnout. </b>Additionally, physicians at clinics with moderate- or high-function EMRs felt less satisfied with their current position overall. </blockquote>and:<br /><blockquote class="tr_bq">... Results also showed a significant relationship between time pressure and physician stress in the cohort with high-function EMRs, and only in this cohort, <b>suggesting physicians at these clinics may be particularly pressured for time during patient encounters in the face of a large number of EMR functions</b>. "This 'made sense' to us in thinking about the possibility that those in the high-use group had more to do in the EMR" [say the authors].<b> </b></blockquote><br />• <span style="color: red;"><b><i>Smartest program out there</i></b></span> - "Smartest" meaning what, exactly?  According to whom?  Who performed the comparison?<br /><br />• <i><b><span style="color: red;">Streamlined</span></b> </i>- compared to what?<br /><br />• <b><span style="color: red;"><i>Thank you for your patience</i></span></b> - even if the effects on clinicians gets you or your loved ones maimed or killed?<br /><br />• <span style="color: red;"><b><i>Safe and secure network</i></b></span> - really?  No break ins, ever, considering multiple breach stories like those at <a href="http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy">http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy</a>?<br /><br />• <span style="color: red;"><b><i>Keeping you informed is our priority</i></b></span> - informed of what?<br /><br />• <span style="color: red;"><b><i>Specially trained staff</i></b></span> - like these:  <a href="http://hcrenewal.blogspot.com/2010/08/epics-outrageous-recommendations-on.html">http://hcrenewal.blogspot.com/2010/08/epics-outrageous-recommendations-on.html</a>?</blockquote><br />and this:<br /><br /><blockquote class="tr_bq">• <span style="color: red;"><i><b>Take Responsibility</b></i></span> - I ask, should clinicians "take responsibility" for IT-related disruptions that impair care such as "use error" (as opposed to user error), i.e., what the National Institute of Standards and Technology has called operator error due to poor usability and other features of bad health IT?  (See "<b>NIST on the EHR Mission Hostile User Experience</b>" at <a href="http://hcrenewal.blogspot.com/2011/10/nist-on-ehr-mission-hostile-user.html">http://hcrenewal.blogspot.com/2011/10/nist-on-ehr-mission-hostile-user.html</a>.)  What about <b>"glitches"</b> and bugs that corrupt or lose data?  Should clinicians also 'take responsibility' for those?  (See for example the posts on the wild things that happen when IT malpractice leads to clinical mayhem at <a href="http://hcrenewal.blogspot.com/search/label/glitch">http://hcrenewal.blogspot.com/search/label/glitch</a>.)</blockquote><br />It appears to me that this vendor is using its client hospitals' management to enforce an "acceptable point of view" clinicians must proffer to patients about EHRs (which they must call "health" records), despite well-known contradictory findings.  This is, in effect, forced marketing of a device.<br /><br />Trying that for a drug or a conventional medical device (e.g., a particular stent) would be on its face unethical and likely illegal.<br /><br />Finally, critical thinking is what keeps patients alive and safe.  Marketing measures like this (some might call it "propaganda"), espousing and enforcing 'EHR exceptionalism', in my opinion, damage critical thinking and expression, and are thus unacceptable to push on clinicians and on patients.<br /><br />I add that requiring clinicians to promote deceptive propaganda the clinicians themselves know is untrue, from painful experience, is degrading, intimidating and destroys morale.  It is axiomatic that clinicians (or anyone) operating under such conditions cannot perform at their best.<br /><br />Thus the management geniuses who came up with these instructions (if not outright vendor-ghostwritten as at the Aug. 2012 "<b>Health IT Vendor EPIC Caught Red-Handed: Ghostwriting And Using Customers as Stealth Lobbyists</b>", <a href="http://www.tinyurl.com/epic-stealth">http://www.tinyurl.com/epic-stealth</a>) are by their actions increasing risk of patient harm. <br /><br />The nurses' unions at at <a href="http://hcrenewal.blogspot.com/2013/07/rns-say-sutters-new-electronic-system.html">http://hcrenewal.blogspot.com/2013/07/rns-say-sutters-new-electronic-system.html</a> have it right, in my view:  complain about the disruptions this technology causes, and complain loudly, if at the very least to make sure the problems are out in the open.<br /><br />-- SS<br /><br /><b>Note: </b>also see the followup Nov. 2013 post "<b>We’ve resolved 6,036 issues and have 3,517 open issues: extolling EPIC EHR virtues at University of Arizona Health System</b>" at <a href="http://hcrenewal.blogspot.com/2013/11/weve-resolved-6036-issues-and-have-3517.html">http://hcrenewal.blogspot.com/2013/11/weve-resolved-6036-issues-and-have-3517.html</a><br /><br />

Words that Work: Singing Only Positive - And Often Unsubstantiated - EHR Praise As "Advised" At The University Of Arizona Health Network

When clinicians are told to promote a technology in no uncertain terms, that puts a chilling effect on critical thinking and discourse.  In effect, when under orders to only speak positively about a h…

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Once Again, on IBM Watson, Cybernetic Miracles and Reductionist Views of Medicine

The cybernetic miracle shamans are at it again:<br /><br /><blockquote><a href="http://www.engadget.com/2011/09/12/ibms-watson-set-to-tackle-health-insurance-takes-diagnosis-fo/">IBM's Watson set to tackle health insurance, takes 'Diagnosis for $1,000'</a><br />via Engadget by Billy Steele on 9/12/11<br /><br />After tackling your tech support woes, the famed Watson is moving on to mop up the health insurance industry. That's right, the IBM showstopper we all know and love for trouncing trivia kings on Jeopardy has been hired by one of the largest health insurance company's in the US. <span style="font-weight: bold;">WellPoint Inc. </span><span style="font-weight: bold; font-style: italic;"><span style="color: rgb(255, 0, 0);">[yes </span>- <a href="http://hcrenewal.blogspot.com/search/label/WellPoint">this</a> <span style="color: rgb(255, 0, 0);">WellPoint, a company that HC Renewal has referenced not just a few times - ed.]</span></span><span style="font-weight: bold;"><span style="color: rgb(255, 0, 0);"> </span>will make use of the system's breakneck speed and healthcare database alongside patient records -- allowing the supercomputer to guide treatment options and prescribe medicines.</span> <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">[Med Mal plaintiff's attorneys: take note - ed.] </span> Once implemented, data will be combined from three sources in a matter of seconds: a patient's chart / records from a doctor, the insurance company's patient history and the medical knowledge that Watson already possesses. A pilot program will roll out next year to a number of cancer facilities, academic medical centers and oncology practices. No word yet on when The Watson School of Medicine will start accepting applications.</blockquote><br /><br /><span style="font-size:100%;">I wrote on these issues quite seriously back in January 2011 at this post: <span style="font-weight: bold;">"</span><a style="font-weight: bold;" href="http://hcrenewal.blogspot.com/2011/01/ibms-watson-jeopardy-and-revolutioning.html">IBM's Watson, Jeopardy, and Revolutionizing Medicine</a><span style="font-weight: bold;">."</span><br /><br />I wrote on a somewhat sarcastic note at this March 2011 post:</span><span style="font-weight: bold;font-size:100%;" > </span><span style="font-size:100%;"><span style="font-weight: bold;">"</span><a style="font-weight: bold;" href="http://hcrenewal.blogspot.com/2011/03/quick-thought-on-cybernetic-medicine.html">Here Comes the Judge! A Quick Thought on Cybernetic Medicine: Why Can't Computers Also Do Law?</a><span style="font-weight: bold;">"</span><br /><br />My views are unchanged since then.<br /><br />Roy Poses adds a good point:<br /></span><ul><li><span style="font-size:100%;">Where are the clinical trials? </span>There is nothing here about actually doing clinical trials to test if Watson is accurate enough to do more good than harm before rolling this out. [As Scot has said a zillion times] This is an experimental technology akin to a new medical device that should be tested as rigorously as any new device or drug should be tested before it is used on patients. </li></ul>To which I further add:<br /><ul><li>Where is the patient informed consent?<br /></li></ul><span style="font-size:100%;">-- SS<br /><br /><span style="font-weight: bold;">Addendum: </span><br /><br />Perhaps Watson should better replace our "they're all the best and brightest" hospital CEO's and managers.<br /><br /></span>

Once Again, on IBM Watson, Cybernetic Miracles and Reductionist Views of Medicine

The cybernetic miracle shamans are at it again:IBM's Watson set to tackle health insurance, takes 'Diagnosis for $1,000'via Engadget by Billy Steele on 9/12/11After tackling your tech support woes, th…

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IBM's Watson, Jeopardy, and "Revolutionizing Medicine"

In the news recently was a story about a new supercomputer doing amazing things. In a technological tour de force, IBM's Watson supercomputer research project has reached a milestone, beating a group of contestants in the TV gameshow <a href="http://www.jeopardy.com/">Jeopardy</a>.<br /><div style="text-align: left;"><br /></div><br /><div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi4R5y1uoDll8zLUmx22rZxiqAHl5hq0tvpaRRKSekUIfyB2becLGwwv1vErfjt3RvXL99H1grtWsHE65PN6auQh3CSEw1sBlb-CbQwFZ2FlB7c2hXGq_x_RGso6s4oS2W95riDNqkRtBqg/s1600/jeopardy.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5563164871585166706" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi4R5y1uoDll8zLUmx22rZxiqAHl5hq0tvpaRRKSekUIfyB2becLGwwv1vErfjt3RvXL99H1grtWsHE65PN6auQh3CSEw1sBlb-CbQwFZ2FlB7c2hXGq_x_RGso6s4oS2W95riDNqkRtBqg/s320/jeopardy.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 274px; height: 205px;" /></a><span style="font-size:85%;">The TV game show "Jeopardy"</span><br /></div><br />Will predictions of advancements in medicine follow? Predictably so:<br /><br /><blockquote><a href="http://www.eweek.com/c/a/IT-Infrastructure/IBMs-Watson-Supercomputer-Beats-Humans-in-Jeopardy-Practice-Match-296135/">IBM's Watson Supercomputer Beats Humans in Jeopardy Practice Match</a><br />eWeek.com<br />By: Fahmida Y. Rashid<br />2011-01-13<br /><br />Watson, IBM's latest DeepQA supercomputer, defeated its two human challengers during a demonstration round of Jeopardy on Jan. 13. The supercomputer will face former Jeopardy champions Ken Jennings and Brad Rutter in a two-game, men-versus-machine tournament to be aired in February.<br /><br />However, the Jeopardy match-up was not the "culmination" of four years of work by IBM Research scientists that worked on the Watson project, but rather, "just the beginning of a journey," Katharine Frase, vice president of industry solutions and emerging business at IBM Research, told eWEEK.<br /><br />Supercomputers that can understand natural human language—complete with puns, plays on words and slang—to answer complex questions <span style="font-weight: bold;">will have applications in areas such as health care</span>, tech support and business analytics, David Ferrucci, the lead researcher and principal investigator on the Watson project, said at the media event showcasing Watson at IBM's Yorktown Heights Research Lab.<br /><br />Watson analyzes "real language," or spoken language, as opposed to simple or keyword-based questions, to understand the question, and then looks at the millions of pieces of information it has stored to find a specific answer, said Ferrucci. </blockquote><br />This is undoubtedly a remarkable accomplishment.<br /><br />Indeed, accompanying the announcements we are also seeing predictions that such supercomputers "will have applications in health care."<br /><br />Indexing of the medical literature, and data mining (for better or worse) from free text come to mind.<br /><br />However, the current irrational exuberance about healthcare IT in 2011 is based on several misconceptions. This leads to predictions such as this ...<br /><br /><p></p><blockquote><p>The technology has to process natural language to understand "what did they mean" versus "what did they say," which has a lot of implications in the health care sector, said Frase. <span style="font-weight: bold;">Patients are not using the terms doctors learned in medical school to describe their ailments</span>, but more likely the terms they picked up from their parents growing up, she said. </p></blockquote><br />"<span style="font-weight: bold;">Patients are not using the terms doctors learned in medical school to describe their ailments"?<br /><br /></span>What medical school(s), exactly, are being spoken of here?<br /><br />It seems as if IT folks think medicine was invented just yesterday. In fact, in medical school, internship, residency and practice we learn all about that, and learn how to<span style="font-style: italic;"> 'translate' that information or use it to elicit more information as needed</span> in order to provide care. I'm not sure a multimillion dollar supercomputer is needed for that ...<br /><br />... and related "platform database" predictions such as this:<br /><br /><blockquote><p></p> <span style="font-weight: bold;">... A Watson-like system can take that information and co-relate it against all the medical journals and relevant <span style="font-style: italic; color: rgb(255, 0, 0);">[who decides that? - ed.]</span> information, and say, "Here's what I think <span style="font-style: italic; color: rgb(255, 0, 0);">[think? -ed]</span> and why," </span>while showing its evidence for how it came up with the conclusion, according to Frase.</blockquote><br />(Actually, computers don't think. A more correct statement would be "here are the results of the algorithms that your faithful machine has crunched, using the medical literature as input.")<br /><br />That's quite naïve and idealistic with regard to actual medical decision making. It is a computer technician's oversimplified, reductionist, amateur view regarding biomedicine, a domain of often <a href="http://en.wikipedia.org/wiki/Wicked_problem">wicked complexity</a>.<br /><br />As I intimated above, one key issue is what is "relevant" with regard to information.<br /><br />Consider the issue of the medical literature suffering from numerous conflict of interest and dishonesty-related phenomema making it increasingly untrustworthy, as <strong style="font-weight: normal;">pointed out by Roy Poses in a Dec. 2010 post "</strong><a href="http://hcrenewal.blogspot.com/2010/12/lancet-emphasizes-threats-to-academic.html">The Lancet Emphasizes the Threats to the Academic Medical Mission</a>", at my Aug. 2009 post "<a href="http://hcrenewal.blogspot.com/2009/08/has-ghostwriting-infected-experts-with.html">Has Ghostwriting Infected The "Experts" With Tainted Knowledge, Creating Vectors for Further Spread and Mutation of the Scientific Knowledge Base?</a>" and <a href="http://hcrenewal.blogspot.com/search/label/pseudo-evidence%20based%20medicine">elsewhere</a> on this blog.<br /><br />Then too, there are plausibility issues in medical research, as expressed in the paper "<a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0020124">Why Most Published Research Findings Are False</a>", <span rel="dc:creator"><span>John P. A. Ioannidis</span></span>, PLoS Medicine 2(8): e124, 2005. Dr. Ioannidis observes:<br /><br /><blockquote>There is increasing concern that most current published research findings are false. The probability that a research claim is true may depend on study power and bias, the number of other studies on the same question, and, importantly, the ratio of true to no relationships among the relationships probed in each scientific field. In this framework, a research finding is less likely to be true when the studies conducted in a field are smaller; when effect sizes are smaller; when there is a greater number and lesser preselection of tested relationships; where there is greater flexibility in designs, definitions, outcomes, and analytical modes; when there is greater financial and other interest and prejudice; and when more teams are involved in a scientific field in chase of statistical significance. Simulations show that for most study designs and settings, it is more likely for a research claim to be false than true. Moreover, for many current scientific fields, claimed research findings may often be simply accurate measures of the prevailing bias. </blockquote><br />Dealing with these very real-world issues in patient care requires nothing less than human judgment borne of experience, critical thinking skills (<span style="font-weight: bold;">emphases on </span>"<span style="font-weight: bold;">thinking</span>",<span style="font-weight: bold;"> which computers cannot do, </span><span>sorry all you <a href="http://en.wikipedia.org/wiki/HAL_9000">HAL-9000</a> and <a href="http://en.wikipedia.org/wiki/The_Ultimate_Computer">M5</a> fans</span>) and intuition to manage. "Garbage in, garbage out" applies in the extreme.<br /><br /><br /><div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj54NUfsCx-Pmm61Zbeam-zOBWRhBAgx6qothqp5ellRv_f_oMnXIsWcS8K2Xtr1_2X5vNWPJWPJqcnP0QV6m66Pta0ixSnrGFxZ_kYWLH0Dj1QA55vFYqoRTBvPvonsz5AnDyUuJi2oR1q/s1600/m5.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5575927899141022466" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj54NUfsCx-Pmm61Zbeam-zOBWRhBAgx6qothqp5ellRv_f_oMnXIsWcS8K2Xtr1_2X5vNWPJWPJqcnP0QV6m66Pta0ixSnrGFxZ_kYWLH0Dj1QA55vFYqoRTBvPvonsz5AnDyUuJi2oR1q/s320/m5.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 260px; height: 195px;" /></a><span style="font-size:85%;">(The Ultimate Computer, Dr. Richard Daystrom's mid-23rd century Multitronic unit, M5. Fun to watch it beat up on <a href="http://images.wikia.com/startrek/images/2/29/Constitutions_formation.jpg">starships Excalibur, Hood, Lexington and Potemkin</a> due to malfunction. Even more fun to watch William Shatner talk it into cybernetic suicide via guilt, and yes, as a teen I knew all the ST trivia cold, but I think sci-fi has gone too far into people's heads.)</span><br /></div><br />There are also other computer-vs-human mind issues at play.<br /><br />First, let's look at Watson. Just to play the TV quiz show game show Jeopardy<span style="text-decoration: underline;"></span>, a game largely about the knowledge and recall of trivia, it took the following:<br /><br /><ul><li>Watson is a breakthrough human achievement in the scientific field of Question and Answering, also known as "QA." The <a href="http://www-03.ibm.com/press/us/en/pressrelease/33233.wss">Watson software is powered by an IBM POWER7 server</a> optimized to handle the massive number of tasks that Watson must perform at rapid speeds to analyze complex language and deliver correct responses to <em>Jeopardy!</em> clues. <b>The system incorporates a number of proprietary technologies for the specialized demands of processing an enormous number of concurrent tasks and data while analyzing information in real time</b>.</li></ul><ul><li><a href="http://www-03.ibm.com/innovation/us/watson/research-team/algorithms.html">An entire team of "algorithm specialists"</a> writing algorithms specialized to the purpose of "the special question processing" needed to answer Jeopardy questions, such as: "On Sept. 1, 1715 Louis XIV died in this city, site of a fabulous palace he built", and "To marry Elizabeth, Prince Philip had to renounce claims to this southern European country's crown."</li><li> <p><a href="http://latimesblogs.latimes.com/technology/2011/01/ibm-computer-named-watson-will-battle-jeopardy-champs-for-1-million.html">Watson took about four years to build and is made up of<span style="font-weight: bold;"> 10 racks of <span style="font-style: italic; color: rgb(255, 0, 0);"> [multiprocessor - ed.]</span> IBM servers running Linux with 15 terabytes of memory </span></a><span><a href="http://latimesblogs.latimes.com/technology/2011/01/ibm-computer-named-watson-will-battle-jeopardy-champs-for-1-million.html"><span style="font-weight: bold;"><span style="font-style: italic; color: rgb(255, 0, 0);">[presumably fast-access RAM, not hard disk -ed.]</span></span></a></span>, the report said. <span style="font-style: italic;">[as per the LA Times - ed.]</span> Over those four years, IBM has filled Watson with about 200 million pages' worth of information from encyclopedias, dictionaries, books, news and movie scripts, the AP said.</p></li></ul><br /><br /><div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjllrDkbM4zyrUvmBggvXWfT8H_n5BVjW166X1Q1fRpNWpAR-gdlemHQz0UPPZ-ZtybUndKwKgb7whbaqCKmfhy9DjOYnPnbAEWarzT6EDxISvP5Ybz5vdd46lF-qn1j68bbpkIM5ugay8G/s1600/server_blade.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5563166290700826178" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjllrDkbM4zyrUvmBggvXWfT8H_n5BVjW166X1Q1fRpNWpAR-gdlemHQz0UPPZ-ZtybUndKwKgb7whbaqCKmfhy9DjOYnPnbAEWarzT6EDxISvP5Ybz5vdd46lF-qn1j68bbpkIM5ugay8G/s320/server_blade.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 320px; height: 213px;" /></a><span style="font-size:85%;">A rack-mountable server ("blade").</span><br /><br /><br /></div><br /><div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjLkv9ctR4kO4KZFzY43DlIAVfOwcmPnEyPY9vG-zALrf2xeuYcT0mChTXvDQ-w_THGGNFNWWyDzgXZJfcW_XCYFXNuWZjgi-Z0xJHuMYZ7s_B62nKt1UjkFmEPaJVawb8slDrH1CWUh6uC/s1600/rack_of_servers.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5563161488373887826" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjLkv9ctR4kO4KZFzY43DlIAVfOwcmPnEyPY9vG-zALrf2xeuYcT0mChTXvDQ-w_THGGNFNWWyDzgXZJfcW_XCYFXNuWZjgi-Z0xJHuMYZ7s_B62nKt1UjkFmEPaJVawb8slDrH1CWUh6uC/s320/rack_of_servers.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 320px; height: 302px;" /></a><span style="font-size:85%;">Racks of servers, each with multiple advanced CPU's</span><br /></div><br /><br /><br /><div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjrYT6l_MtNTP0fDPKPAwWphw0r-52n19DGUNTXbOtSI7YtUsD7eMvA3tbXkfpZVL5LCsBrpUMl9W0Mfa5N8t7jSupxZDnsjaE8KlB3v0onZT0owL8e6Fj9ulBloSOuCdLq-WGElDpppC9/s1600/watsonibm.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5563162581131539810" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjrYT6l_MtNTP0fDPKPAwWphw0r-52n19DGUNTXbOtSI7YtUsD7eMvA3tbXkfpZVL5LCsBrpUMl9W0Mfa5N8t7jSupxZDnsjaE8KlB3v0onZT0owL8e6Fj9ulBloSOuCdLq-WGElDpppC9/s320/watsonibm.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 320px; height: 233px;" /></a><span style="font-size:85%;">Racks of servers in IBM's Watson supercomputer, all prettied up, HAL 9000-style</span><br /></div><br /><br />Second, it will be many years indeed before even the current Watson QA capabilities can be tailored to a domain as complex as biomedicine and made widespread for the hundreds of thousands of practicing physicians and the much larger number of allied healthcare professionals in the U.S. or worldwide.<br /><br />Third, there's this from the same LA Times article linked above:<br /><br /><ul><li>Like its human competitors, Watson won't have Internet access<span style="font-style: italic;"> [or access to anything outside its immense local storage - ed.]</span> during the games, so Googling an answer won't be an option, the report said.</li></ul><br />I see a significant degree of machine-human unfairness right there. A computer has 100% reliable access to information in its storage media. The human mind does not. That's appropriate for a TV game show that tries to test a persons' knowledge of trivia, but that's not how medicine works. <span style="font-weight: bold;"><br /><br />What if the match were made more fair, giving the humans error-free access to the same information Watson has stored in its own 15 terabytes and </span><span style="font-weight: bold;">200 million pages</span><span style="font-weight: bold;">?</span><br /><br />Fourth, medicine is not about recalling trivial factoids of information based on parsing natural language queries in the "puzzle format" of Jeopardy. <span>As I wrote <a href="http://hcrenewal.blogspot.com/2011/01/google-ceo-eric-schmidt-on-healthcare.html">here</a> and <a href="http://hcrenewal.blogspot.com/2010/01/does-ceo-of-google-use-google.html">here</a>,</span><span style="font-weight: bold;"> medicine is not a platform database information retrieval problem.</span> (I would argue medicine, except in simple cases, is in large part a matter of filtering the irrelevant, unlikely, and unreliable, of which there is an exponentially increasing amount, from information relevant to the subtleties of a complex medical situation.)<br /><br />Certainly, today's clinical IT will make little dent in healthcare quality and error reduction, as those issues are not in majority due to record keeping problems of paper vs. electronic, as I pointed out in my Dec, 2010 post "<a href="http://hcrenewal.blogspot.com/2010/12/is-healthcare-it-solution-to-wrong.html">Is Healthcare IT a Solution to the Wrong Problem?</a>". The expectations for today's health IT are grossly exaggerated.<br /><br />How about expert systems technology such as Watson? Regarding NLP and fact retrieval 'tours de force' like IBM Watson, medicine is about cognition, about human judgment born of experience in dealing with ambiguity not just of language but of observations, findings, lab data, image interpretation, etc., about human intuition and assemblage and integration of a huge amount of disparate information in ways not well understood even by its practitioners. The end result is not just recall of a piece of information.<br /><br />I consider a statement such as:<br /><br /><span><blockquote>... a Watson-like system can take that information and co-relate it against all the medical journals and relevant information, and say, "Here's what I think <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">[actually, as mentioned previously, here's the results of the algorithms - ed.]</span> and why"</blockquote><br />... to imply just as grandiose a valuation to the technology as the statements I heard a decade ago about the health IT of the day - or even today - "revolutionizing medicine."</span><br /><br />I'm not even sure such a capability would be very useful; we already have <a href="http://dxplain.org/dxp/dxp.pl">DXplain</a> developed by domain experts over decades, and that's not had a major impact on healthcare to date.<br /><br />The real breakthrough will be when a cybernetic expert system can take, say, cases from the Case Records of the Massachusetts General Hospital in the NEJM verbatim, and compete as a peer (e.g., as a peer not recognized to be a machine) with a round-table panel of expert physicians <span style="font-style: italic;">with facile access to the medical literature</span> (e.g., PubMed) on the differential diagnosis, how to establish the diagnosis and to rule out others, the treatment strategies, and the likely outcomes, and then participate in the care.<br /><br />When this happens (call this the "NEJM <a href="http://en.wikipedia.org/wiki/Turing_test">Turing Test</a>"), and when such capabilities are affordable and widely available, then medicine will have been revolutionized.<br /><br />Of course, the enormity of the hardware and the algorithmic advances required to make a truly "revolutionary" tool such as this are obviously staggering. Considering that it takes 10 racks of multiprocessor IBM servers with 15 terabytes of memory and a team of varied domain experts writing algorithms for several years to accomplish the NLP advances and lookups to answer Jeopardy-style trivia questions, one can only imagine what a truly useful cybernetic medical assistance system would look like.<br /><br />It should also be remembered that Watson does not think. Humans do. Cybernetic Jeopardy and chess playing accomplishments notwithstanding, I believe a machine even close to passing a "NEJM Turing test" will be a long time in coming. Until then, we should be encouraging better support for human physicians struggling to use their medical expertise in a sea of bureaucracy, stress and overwork (part of which will increasingly be a struggle with <a href="http://www.tinyurl.com/hostileuserexper">mission hostile health IT</a>).<br /><br />Finally, far off as I believe it to be, I do think the hundreds of billions of dollars being devoted to today's health IT would be <span style="font-weight: bold;">better devoted to developing a "Dr. Watson" </span>that can pass a medical Turing test as described above, than deploying mission hostile, primitive HIT and developing an unsustainable mega-bureaucracy to support it as in my post <a href="http://hcrenewal.blogspot.com/2011/01/health-it-and-dr-truth-hurts.html">here</a>.<br /><br />This is not to minimize the wonderful accomplishments of the Watson team. I just wish predictions of cybernetic miracles in medicine would be held in abeyance after the lessons of the past fifty years of computers in medicine.<br /><br />In the meantime, perhaps the current Watson might be useful in remediating our very sclerotic and moribund "mainsteam media," especially in the domain of politics. Its reporters and writers can certainly use cybernetic help in their fact-checking and logic, Jeopardy-style, far more so than physicians.<br /><br />-- SS<br /><br /><span style="font-weight: bold;">Feb. 23, 2011 addendum:</span><br /><br /><a href="http://www.urbandictionary.com/define.php?term=oy%20gevalt">Gevalt!</a><br /><br />From the article "<a href="http://www.computerworld.com/s/article/9209899/IBM_s_Watson_could_usher_in_new_era_of_medicine?taxonomyId=67&pageNumber=2">IBM's Watson could usher in new era of medicine</a>", Sharon Gaudin, Computerworld, February 17, 2011:<br /><blockquote><br />Jennifer Chu-Carroll, an IBM researcher on the Watson project, said the computer system is a <span style="font-weight: bold;">perfect fit for the healthcare field</span> ... Think of some version of Watson being a physician's assistant," Chu-Carroll said. "In its spare time, Watson can read all the latest medical journals and get updated. Then it can go with the doctor into exam rooms and listen in as patients tell doctors about their symptoms.<span style="font-weight: bold;"> It can start coming up with hypotheses about what ails the patient.</span></blockquote><br />Gevalt indeed ... incredible irrational exuberance. We can easily go from Jeopardy to Medicine ... and then to the Moon, in a hot air balloon! (The moon is up, hot air balloons go up, what's the problem?)<br /><br />How many patients has Chu-Carroll seen lately?<br /><br />(Her bio at <a href="http://www.blogger.com/%22Jennifer%20Chu-Carroll,%20an%20IBM%20researcher%20on%20the%20Watson%20project,%20said%20the%20computer%20system%20is%20a%20perfect%20fit%20for%20the%20healthcare%20field%20...%20Think%20of%20some%20version%20of%20Watson%20being%20a%20physician%27s%20assistant,%22%20Chu-Carroll%20said.%20%22In%20its%20spare%20time,%20Watson%20can%20read%20all%20the%20latest%20medical%20journals%20and%20get%20updated.%20Then%20it%20can%20go%20with%20the%20doctor%20into%20exam%20rooms%20and%20listen%20in%20as%20patients%20tell%20doctors%20about%20their%20symptoms.%20It%20can%20start%20coming%20up%20with%20hypotheses%20about%20what%20ails%20the%20patient.%22%22%20%20Gevalt%21%20%20Irrational%20exuberance%20%20--%20we%20can%20easily%20go%20from%20Jeopardy%20to%20Medicine...and%20then%20to%20the%20Moon,%20in%20a%20hot%20air%20balloon%21%20%20%28The%20moon%20is%20up,%20hot%20air%20balloons%20go%20up,%20what%27s%20the%20problem?%29%20%20How%20many%20patients%20has%20Chu-Carroll%20seen%20lately?%20%20%28Her%20bio%20at%20http://researcher.ibm.com/researcher/view.php?person=us-jencc%20is%20down;%20%22The%20server%20at%20researcher.ibm.com%20is%20taking%20too%20long%20to%20respond%22;%20Watson%20must%20be%20taking%20a%20nap%29...">http://researcher.ibm.com/researcher/view.php?person=us-jencc</a> was initially down at this moment; "The server at researcher.ibm.com is taking too long to respond." Watson must be taking a nap. Archive.org says "The connection has timed out. The server at web.archive.org is taking too long to respond." Just like a doctor!)<br /><br />Anyway, it now appears:<br /><blockquote><br />I am a Research Staff Member at <a href="http://www.research.ibm.com/">IBM T. J. Watson Research Center</a>. I also manage the Knowledge Structures group which focuses on improving advanced search technology through the use of natural language processing and machine learning techniques. Prior to joining IBM in 2001, I spent 5 years as a Member of Technical Staff at <a href="http://www.bell-labs.com/">Lucent Technologies Bell Laboratories</a>. My research interests include question answering, semantic search, natural language discourse processing, and spoken dialogue management. </blockquote><br />Please, please, please, computer scientists: STOP MAKING THESE PREDICTIONS OF CYBERNETIC MIRACLES JUST AROUND THE CORNER. YOU'VE BEEN DOING IT SINCE THE VACUUM TUBE-BASED MACHINES.<br /><br /><span style="color: rgb(255, 0, 0);font-size:100%;" >STOP! PLEASE!</span><br /><br />(Maybe first they could give us a computer that does a perfect, lucid, coherent, fluent translation of, say, Russian-to-English, another promise made since the 1950's "<a href="http://en.wikipedia.org/wiki/Robby_the_Robot">Robby the Robot</a>" years?)<br /><br /><br /><div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjldnVE-YxPUg-hkvX4Hd5X5fYKQAXRofzxvC7_HoF3GWZW6hCxJZc9yKQVZXpYEEjMwu0yQFiY5W6i-FoKaviXmgNELU2r9Lz5wJVjzqMANDpVtr3subr_jGV3-lRnKhzl-0i0hYsvmhPq/s1600/Robbie_Forbidden_Planet.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5577003659342042578" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjldnVE-YxPUg-hkvX4Hd5X5fYKQAXRofzxvC7_HoF3GWZW6hCxJZc9yKQVZXpYEEjMwu0yQFiY5W6i-FoKaviXmgNELU2r9Lz5wJVjzqMANDpVtr3subr_jGV3-lRnKhzl-0i0hYsvmhPq/s320/Robbie_Forbidden_Planet.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 320px; height: 162px;" /></a><span style="font-size:85%;">Robby the Robot in "Forbidden Planet." Lost in Space fans will remember Robby as doing battle with the <a href="http://www.lostinspacerobot.com/"><span style="text-decoration: underline;">Class M-3 Model B9, General Utility Non-Theorizing Environmental Control </span></a></span><span style="font-size:85%;"><a href="http://www.lostinspacerobot.com/">Robot</a> ("Danger, Danger, Will Robinson") as well!</span><br /></div><br />I think the essay in today's WSJ by UC Berkeley philosopher <a href="http://en.wikipedia.org/wiki/John_Searle">John Searle</a> is also apropos: <a href="http://online.wsj.com/article/SB10001424052748703407304576154313126987674.html">Watson Doesn't Know It Won on 'Jeopardy!' </a><br /><br />-- SS<br /><br /><span style="font-weight: bold;">Addendum:</span> See my Wall Street Journal Letter to the Editor on these matters <a style="font-weight: bold;" href="http://hcrenewal.blogspot.com/2011/02/medinformaticsmd-in-wsj-again-no.html">at this link</a><span style="font-weight: bold;">.</span><br /><br /><span style="font-size:100%;">I wrote on a somewhat sarcastic note at this March 2011 post:</span><span style="font-weight: bold;font-size:100%;" > </span><span style="font-size:100%;"><span style="font-weight: bold;">"</span><a style="font-weight: bold;" href="http://hcrenewal.blogspot.com/2011/03/quick-thought-on-cybernetic-medicine.html">Here Comes the Judge! A Quick Thought on Cybernetic Medicine: Why Can't Computers Also Do Law?</a><span style="font-weight: bold;">"</span><br /></span><br />Also see my Sept. 2011 followup post <span style="font-weight: bold;">"</span><a style="font-weight: bold;" href="http://hcrenewal.blogspot.com/2011/09/once-again-on-watson-and-reductionistic.html">Once Again, on IBM Watson, Cybernetic Miracles and Reductionist Views of Medicine</a><span style="font-weight: bold;">."</span><br /><br />-- SS

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IBM's Watson, Jeopardy, and "Revolutionizing Medicine"

In the news recently was a story about a new supercomputer doing amazing things. In a technological tour de force, IBM's Watson supercomputer research project has reached a milestone, beating a group…

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UK: ISO draft standards for the development, manufacture and deployment of healthcare IT focus on SAFETY

The UK's NHS has not had the best of success to date implementing national health IT, as indicated by reports <a href="http://www.publications.parliament.uk/pa/cm200809/cmselect/cmpubacc/153/15304.htm">here</a> and <a href="http://www.connectingforhealth.nhs.uk/about/foi">here</a>, for example.<br /><br />However, they have appeared to have learned from their mistakes and in fact are on the way to being far ahead of the U.S. in terms of understanding what it truly takes for HIT to be efficacious - and perhaps even more importantly, <span style="font-weight: bold;">as safe as possible.</span><br /><br />From an informatics colleague who informed me of these developments:<br /><br /><span></span><blockquote><span>The UK has recently adopted the ISO draft standards for the development and deployment of HIT. They don't go as far as premarket approval, but do require vendors to develop and deliver to healthcare organizations a formal hazard assessment for their products, require both to continually update their risk assessments, and require care delivery organizations to have an explicit process for identifying & mitigating risks, and formally accepting (or not) the residual risks that remain. The thinking is these standards will be adopted across the EU once the ISO approval process is completed.</span></blockquote><br /><br />These two remarkable documents are available from the UK's NHS:<br /><span style="font-size:100%;"><br /></span><div class="PlainText"><blockquote><a href="http://www.isb.nhs.uk/documents/isb-0160/dscn-18-2009">http://www.isb.nhs.uk/documents/isb-0160/dscn-18-2009</a><br /><span style="font-weight: bold;font-size:130%;" ><br />"Health informatics — Guidance on the management of clinical risk relating to the deployment and use of health software"</span><br />Formerly ISO/TR 29322:2008(E)<br />DSCN18/2009<br /><br />and<br /><br /><a href="http://www.isb.nhs.uk/documents/isb-0129/dscn-14-2009">http://www.isb.nhs.uk/documents/isb-0129/dscn-14-2009</a><br /><br /><span style="font-weight: bold;font-size:130%;" >"Health Informatics — Application of clinical risk management to the manufacture of health software"</span><br />Formerly ISO/TS 29321:2008(E)<br />DSCN14/2009<br /></blockquote><br />From the first of these, the overall intro:<br /><br /><blockquote>ISO (the International Organization for Standardization) is a worldwide federation of national standards bodies (ISO member bodies). The work of preparing International Standards is normally carried out through ISO technical committees. Each member body interested in a subject for which a technical committee has been established has the right to be represented on that committee. International organizations, governmental and non-governmental, in liaison with ISO, also take part in the work. ISO collaborates closely with the International Electrotechnical Commission (IEC) on all matters of electrotechnical standardization.</blockquote><br />Then on to matters at hand:<br /><br /><blockquote><span style="font-weight: bold;">Introduction</span><br /><br /><span style="font-weight: bold;">The threat to patient safety</span><br /><br />There is mounting concern around the world about the substantial number of avoidable clinical incidents which have an adverse effect on patients, of which a significant proportion result in avoidable death or serious disability, see references [1], [2], [3], [4], [5] and [6]. A number of such avoidable incidents involved poor or "wrong" diagnoses or other decisions. A contributing factor is often missing or incomplete information, or simply ignorance, e.g. of clinical options in difficult circumstances or of the cross-reaction of treatments (a substantial percentage of clinical incidents are related to missing or incomplete information).<br /><br />It is increasingly claimed that information systems such as decision support, protocols, guidelines and pathways <span style="font-weight: bold;">could markedly reduce such adverse effects.</span> <span style="font-weight: bold; font-style: italic;"><span style="color: rgb(255, 0, 0);"><br /><br />[As I have written in many places such as</span> <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=2009">here</a> <span style="color: rgb(255, 0, 0);">and</span> <a href="http://hcrenewal.blogspot.com/2010/07/new-england-journal-on-meaningful-use.html">here</a>, <span style="color: rgb(255, 0, 0);">this may or may not be true regarding today's commercial healthcare IT as it is currently designed and deployed. Evidence supporting the assertion, especially robust studies such as randomized controlled clinical trials, is scarce, and evidence contradicting it is growing. The technology remains experimental - ed.]</span></span><br /><br />If for no other reason – and there are others – this is leading to increasing deployment and use of increasingly complex health software systems, such as for decision support and disease management. It can also be anticipated that, due to pressures on time and to medico-legal aspects, clinicians will increasingly rely on such systems, with less questioning of their "output", as a "foreground" part of care delivery rather than as a "background" adjunct to it. Indeed, as such systems become integrated with medical care, any failure by clinicians to use standard support facilities may be criticised on legal grounds.<br /><br />Increased use of such systems is not only in clinical treatment but also in areas just as important to patient safety, such as referral decision-making. Failure to make a "correct" referral, or to make one "in time", can have serious consequences.<br /><br />Economic pressures are also leading to more decision support systems. The area of generic and/or economic prescribing is the most obvious, but achieving economy in the number and costs of clinical investigative tests is another.<br /><br />Thus the use of health software and medical devices in increasingly integrated systems, e.g. networks, can bring substantial benefit to patients. <span style="font-weight: bold;">However unless they are proven to be safe and fit for purpose they may also present potential for harm or at least deter clinical and other health delivery staff from making use of them, to the ultimate detriment of patients.</span> <span style="font-weight: bold; color: rgb(255, 0, 0);">Annex A provides some examples of the potential for harm.</span><br /><br />Harm can of course result from unquestioning and/or non-professional use, although the manufacturers of health software products, and those in health organizations deploying and using such products within systems, can mitigate such circumstances through, for example, instructions for use, training and on-screen presentation techniques, guidance, warnings or instructions.<br /><br />Some of these system deficiencies are <span style="font-weight: bold;">insidious, may be invisible to the end user</span> <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">[an obviously perilous situation - ed.]</span> and are typically out of the sole control of either the manufacturer or the deploying health organization.</blockquote><br />The reports note the obvious, something that the health IT vendors' <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=koppel_kreda">contractual gag clauses</a> and secrecy in the health IT industry make difficult to rigorously evaluate:<br /><br /><blockquote>A necessary pre-cursor for determining and implementing controls to minimize risks to patients, from a health software systems that is manufactured and then deployed and used within a health organization, <span style="font-weight: bold;">is a clear understanding of the risks which the deployed system might present to patients if malfunction or an unintended event were to occur</span>, and the likelihood of such a malfunction or event causing harm to the patient.</blockquote><br />These risks cannot be properly evaluated in an industry where the flows of information are dominated by the vendors.<br /><br />Some examples of potential for harm, from annex (appendix) A, will likely sound quite familiar to readers of Healthcare Renewal:<br /><br /><ul><li>Patient (mis)identification</li><li>Inadvertent accidental prescribing of dangerous drugs (such as methotrexate)</li><li>Incorrect patient details retrieved from radiology information system</li><li>CT and MRI images could not be seen after being moved to PACS</li><li>Drug mapping error</li><li>Pre-natal screening risk computation errors</li><li>Radiotherapy errors</li><li>Slack security</li></ul><br />I especially note the following in the first document (on deployment):<br /><br /><blockquote>5.3 Competencies of personnel<br /><br />Persons performing risk management tasks will need to have the knowledge, experience and competencies appropriate to the tasks assigned to them. This will need to include, where appropriate, knowledge and experience of the particular health software systems (or similar health software products) and applications, the technologies involved and risk management techniques. <span style="font-weight: bold;">This should include appropriate registered clinical input throughout the process. Appropriate competency and experience records will need to be maintained.</span><br /><br />Clinical risk management tasks can, and should, be performed by a project team that contains representatives of each of the functions that are involved in deploying and subsequently using the health software systems or system, with each contributing their specialist knowledge to build both awareness and consensus. <span style="font-weight: bold;">Of particular importance will be clinical input from clinicians who are familiar with the practical realities of the environments within which the software system will be used and the clinical processes to which the software system is directed.</span><br /></blockquote><br />Emphasis on the last sentence is mine. At a time when U.S. CIOs and health IT "talking heads" still find the need to write touchy-feely "Master of the Obvious" articles extolling the virtues of permitting clinicians 'input' into health IT projects, usually under the aegis of unempowered "Directors of Informatics" or "Chief Medical Information Officers" (a.k.a. Directors of Nothing and Chiefs of Nothing, with no true executive presence or authority), the latter direct, definitive sentence is refreshing.<br /><br />Miracle of miracles, even postmarketing surveillance is covered (the pharma and medical device industries have been mandated by regulators to conduct such studies on their products for decades):<br /><br /><blockquote><span style="font-weight: bold;">11 Post-deployment monitoring</span><br /><br />Both manufacturers and organizations deploying and using health software and other products within systems, have a <span style="font-weight: bold;">business need to establish, document and maintain a process to collect and review information about the clinical safety performance of the products and system in the post-deployment phase,</span> at least to help manage their liabilities but also to enable them to optimize their products and systems.</blockquote><br />There is much more in these documents.<br /><br />Download and read the PDF's. I will have more to say in future posts, but thank god someone is considering the risks to patients of this technology, touted as universally beneficent by <span style="font-style: italic;">health IT exceptionalists</span>, in a serious manner.<br /><br />Now if only we can import this thinking into the United States.<br /><br />-- SS<br /><br /></div>

UK: ISO draft standards for the development, manufacture and deployment of healthcare IT focus on SAFETY

The UK's NHS has not had the best of success to date implementing national health IT, as indicated by reports here and here, for example.However, they have appeared to have learned from their mistakes…

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