healthy4u: healthcare IT usability

Australian Medical Association on EHR rollout: 'Hard to use, increases workload, hard to find data, we just don't seem to have got the outcome we were looking for.'

Some familiar themes from the Australian Medical Association on their attempt at a National Programme for Health IT: <blockquote class="tr_bq">Electronic health records rollout has not met expectations, Australian Medical Association says <a href="http://www.abc.net.au/news/2013-11-04/ama-says-rollout-of-electronic-health-records-needs-work/5066680">http://www.abc.net.au/news/2013-11-04/ama-says-rollout-of-electronic-health-records-needs-work/5066680 </a> <div class="published">Updated Mon 4 Nov 2013, 8:59am AEDT </div> <div class="first">The Australian Medical Association says the rollout of electronic health records has not met expectations.</div> Federal Health Minister Peter Dutton has announced an independent review of the project to see how it can be improved. AMA national president Dr Steve Hambleton, one of the panel members for the review, says e-health records need to be made easier for doctors to use.</blockquote> Ease of use seems a constant, unremitting problem.  An independent review (if truly independent) is a wise move - and sorely needed in this country, where the narrative is controlled by the industry and its government sponsors/cheerleaders. A bit of wisdom comes to mind, from (of all people) weapons inventor Mikhail Kalashnikov:  "All that is too complex is unnecessary, and it is simple that is needed." (Satirically speaking, would it be helpful  if health IT designers, when suffering from, say, acute renal colic, or Bornholm disease a.k.a. devil's grip, <a href="http://en.wikipedia.org/wiki/Bornholm_disease">http://en.wikipedia.org/wiki/Bornholm_disease</a>, were made to wait for treatment until the doctors and nurses navigated every single tab, menu, pulldown, selection list, etc. to enter all of their data? Perhaps that would be an educational experience for them ... ) <blockquote class="tr_bq">"It's certainly timely to actually have a look at the e-health records and just see where it is, where it's going, whether it's actually achieved what it set out to do and what we need to do to actually make it work," he said. </blockquote> I think the question of  "whether it's actually achieved what it set out to do" was meant as rhetorical. <blockquote class="tr_bq">"The profession's always supported this, we just don't seem to have got the outcome we were looking for."</blockquote> That's because the profession - both in Australia and the U.S. - has abdicated leadership of healthcare informatics efforts, instead delegating it to those without domain expertise, and/or the incompetent. This is a sure path to the results we now are getting both here and Down Under. From a recent essay at the "Sultan Knish" Blog by writer Daniel Greenfield (<a href="http://sultanknish.blogspot.com/2013/10/government-is-magic.html">http://sultanknish.blogspot.com/2013/10/government-is-magic.html</a>) on competence and the Obamacare insurance website debacle: <blockquote class="tr_bq">... Modernity has to be built. It has to be constructed brick by bit by rivet by cable by people who know what they are doing. Modernity without competence is as worthless as the ObamaCare website which looked pretty enough to give the illusion of technocratic modernity, but didn't actually work. Competence is the real modernity and it has very little to do with the empty trappings of design that surround it. In some ways the America of a few generations ago was a far more modern place because it was a more competent place. For all our nice toys, we look like primitive savages compared to men who could build skyscrapers and fleets within a year... and build them well.</blockquote> Unfortunately, there is no easy solution to this problem, since in this industry, failure is an option, and a profitable one at that. <blockquote class="tr_bq">Mr Dutton says a lot of money has been spent on the project, but that the take up rate has been low.</blockquote> In the U.S., the takeup rate has been artificially accelerated by economic incentives and penalties (via the HITECH Act of 2009).  Australia seems to lack such a plan at present. <blockquote class="tr_bq">Concerns were raised in July that the new system, which was trialled in parts of New South Wales, Queensland and Victoria, <a href="http://www.abc.net.au/news/2013-07-16/e-health-flaws-adding-to-gp-stress/4822186" target="_self" title="">makes it difficult for doctors to access updated information</a>. </blockquote> I opine that it takes remarkable incompetence to design software using computers that can store, retrieve and process data at speeds unimaginable just a few years ago, that actually make it difficult for users to access current information. <blockquote class="tr_bq">Doctors also complained that the e-health program, designed to link a patient's medical records between doctors, hospitals and other providers, was increasing their workload.</blockquote> From the linked article "E-Health Flaws Adding to GP Stress", <a href="http://www.abc.net.au/news/2013-07-16/e-health-flaws-adding-to-gp-stress/4822186">http://www.abc.net.au/news/2013-07-16/e-health-flaws-adding-to-gp-stress/4822186</a>: <blockquote class="tr_bq">Many Newcastle GPs say the system is adding to stress levels and making their workloads excessive. They are complaining the E-health program unworkable in its present form and is increasing their workload by up to two hours a day. </blockquote> For little benefit, I add. <blockquote class="tr_bq">... Dr Hambleton says the initial version of the system has several strong aspects and is safe and secure, but that key changes will benefit doctors. "Clinical utility means that it decreases the search time and that we've got accurate information there. Those are the things that'll make clinicians want to use it and be able to use it." </blockquote> Translation: major changes might actually make the systems useful, instead of a time-sapping annoyance (at best), and a danger (at worst). -- SS

Australian Medical Association on EHR rollout: 'Hard to use, increases workload, hard to find data, we just don't seem to have got the outcome we were looking for.'

Some familiar themes from the Australian Medical Association on their attempt at a National Programme for Health IT:Electronic health records rollout has not met expectations, Australian Medical Assoc…

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04 Nov 2013

American Medical Association finally on board with EHR views expressed on this blog since 2004

<div style="text-align: center;">- Posted on the Healthcare Renewal Blog May 17, 2013 -</div> It seems to have taken awhile, but organized medicine seems to finally be recognizing that today's commercial health IT is not quite the revolutionizing, transformative, plug-and-play panacea to healthcare's ills it is often touted as: <blockquote class="tr_bq">AMA Wire May 15, 2013 <a href="http://www.ama-assn.org/ams/pub/amawire/2013-may-15/2013-may-15-general_news1.shtml">AMA board chair: HHS should address EHR usability issues immediately</a> The government needs to act quickly to remedy the impaired usability of electronic health records (EHR) if the technology's touted benefits are to be realized, AMA Board of Trustees Chair Steven J. Stack, MD (left), told officials during a federal hearing last week. "The AMA and most physicians believe that, done well, EHRs have the potential to improve patient care," Dr. Stack, an emergency physician in Lexington, Ky., said during his 30-minute <a class="pdf" href="http://www.ama-assn.org/resources/doc/washington/ehr-meaningful-use-testimony-03may2013.pdf" target="_blank">testimony</a>. "At present, however, these EHRs present substantial challenges to the physicians and other clinicians now required to use them." He emphasized that many of today's EHR systems require significant changes before they can deliver the promised outcomes. Referring to Medicare's meaningful use program, he pointed to undesired consequences of pushing EHR systems on physicians before the technology was completely ready for prime time.</blockquote> "Immediately" is strong language. I note that the phrase "health IT done well" is a term I've been using since 1998 at my now-Drexel-based health IT teaching website at <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases">http://www.ischool.drexel.edu/faculty/ssilverstein/cases</a>, as well as at this blog. Penned by me at my aforementioned Drexel graduate teaching site, originally housed on AOL, in 1998 and still appearing in its main essay: <blockquote class="tr_bq"><div class="MsoNormal">... While clinical IT is now potentially capable of achieving many of the benefits long claimed for it such as improved medical quality and efficiency, reduced costs, better medical research and drugs, earlier disease detection, and so forth, there is a major caveat and essential precondition:  the benefits will be realized only if clinical IT is done well.  For if clinical IT is not done well, as often occurs in today’s environment of medical quick fixes and seemingly unquestioning exuberance about IT, the technology can be injurious to medical practice and biomedical R&D, and highly wasteful of scarce healthcare capital and resources.  </div><div class="MsoNormal"> </div>Those two short words “done well” mask an underlying, profound, and, as yet, largely unrecognized (or ignored) complexity.  This website is about the meaning of "done well" in the context of clinical computing, a computing subspecialty with issues and required expertise quite distinct from traditional MIS (management information systems, or business-related) computing.</blockquote> (I have more recently switched to the easier-to-parse terminology of "good health IT" vs. "bad health IT" after discussions with Dr Jon Patrick at U. Sydney during my visit Down Under last summer, <a href="http://hcrenewal.blogspot.com/2012/08/my-presentation-to-health-informatics.html">http://hcrenewal.blogspot.com/2012/08/my-presentation-to-health-informatics.html</a>.) I've also heard "not ready for prime time" before.  It is a phrase I used in speaking with a New York Times reporter that then appeared in the Oct. 8, 2012 NYT article "The Ups and Downs of Electronic Medical Records" (<a href="http://www.nytimes.com/2012/10/09/health/the-ups-and-downs-of-electronic-medical-records-the-digital-doctor.html?pagewanted=2">http://www.nytimes.com/2012/10/09/health/the-ups-and-downs-of-electronic-medical-records-the-digital-doctor.html?pagewanted=2</a>) by Milt Freudenheim, October 8, 2012, where I am quoted and this blog cited: <blockquote class="tr_bq">... Critics are deeply skeptical that electronic records are ready for prime time. “The technology is being pushed, with no good scientific basis,” said Dr. Scot M. Silverstein, a health I.T. expert at Drexel University who reports on medical records problems on the blog <a href="http://hcrenewal.blogspot.com/">Health Care Renewal</a>. He says testing these systems on patients without their consent “raises ethical questions.” </blockquote> The AMA Board chair went on to opine: <blockquote class="tr_bq">"Attempting to transform the entire health system in such a rapid and proscriptive manner has compelled providers to purchase tools not yet optimized to the end-user's needs and that often impeded, rather than enable, efficient clinical care," he said. He noted that physicians are "prolific technology adopters" but that adoption of EHR systems has required federal incentives because the technology still is "at an immature stage of development."</blockquote> My near-exact terminology has been that the technology is still experimental. <blockquote class="tr_bq">"EHRs have been and largely remain clunky, confusing and complex," he said.</blockquote> Perhaps he read my ten-part series on the health IT mission hostile user experience at this blog, at <a href="http://www.tinyurl.com/hostileuserexper">http://www.tinyurl.com/hostileuserexper</a>. <blockquote class="tr_bq">According to a <a class="external" href="http://www.americanehr.com/blog/2013/03/himss13-ehr-satisfaction-diminishing/" target="_blank">recent survey</a> by AmericanEHR Partners, physician dissatisfaction with EHR systems has increased. Nearly one-third of those surveyed in 2012 said they were "very dissatisfied" with their system, and 39 percent said they would not recommend their EHR system to a colleague—up from 24 percent in 2010.</blockquote> A survey I posted about in Jan. 2010 is here:  "An Honest Physician Survey on EHR's", <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> <blockquote class="tr_bq">Dr. Stack spoke at a "listening session" hosted by the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC), a division of the U.S. Department of Health and Human Services (HHS). The agencies coordinated the session to examine how a marked increase in code levels billed for some Medicare services might be tied to the increased use of EHRs. Dr. Stack noted that some Medicare carriers have begun denying payment for charts that are too similar to other records. "In this instance, even when clinicians are appropriately using the EHR, a tool with which they are frustrated and the use of which the federal government has mandated under threat of financial penalty, they are now being accused of inappropriate behavior, being economically penalized, and being instructed ‘de facto' to re‐engineer non‐value‐added variation into their clinical notes," he said. "This is an appalling Catch‐22 for physicians."</blockquote> "Mandated under threat of financial penalty" has been one of my stated "cart before the horse" issues with HITECH (e.g., <a href="http://hcrenewal.blogspot.com/2010/10/cart-before-horse-again-institute-of.html">http://hcrenewal.blogspot.com/2010/10/cart-before-horse-again-institute-of.html</a>). <blockquote class="tr_bq">Dr. Stack advised officials that three key actions are necessary to rectify these issues with EHR systems: <ul type="disc"><li>The ONC promptly should address EHR usability concerns raised by physicians and add usability criteria to the EHR certification process.</li><li>CMS should provide clear and direct guidance to physicians concerning use of EHRs for documentation, coding and billing. </li><li>Stage 2 of the meaningful use program should allow more flexibility for physicians to meet requirements as EHR systems are improved. </li></ul>The AMA will continue to work with federal agencies to improve EHR systems and the Medicare meaningful use program.</blockquote> I've been calling for usability evaluation to be added to the certification process, including in comments during public comment periods to HHS, for some time. What the AMA Board Chair is apparently missing, though, is health IT safety.  They should perhaps read my post on the recent ECRI Institute Deep Dive Study on health IT risk - itself based on a report in their own AMNews (<a href="http://amednews.com/" target="_blank">amednews.com)</a> publication ("Peering Underneath the Iceberg's Water Level: AMNews on the New ECRI Deep Dive Study of Health IT Events", <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>). I don't think any prudent person would consider a 9-week study of 36 hospitals with volunteered reports of 171 health information technology-related problems, where eight of the incidents reported involved patient harm and three may have contributed to patient deaths, information to ignore. -- SS

American Medical Association finally on board with EHR views expressed on this blog since 2004

- Posted on the Healthcare Renewal Blog May 17, 2013 -It seems to have taken awhile, but organized medicine seems to finally be recognizing that today's commercial health IT is not quite the revolutio…

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17 May 2013

Far more concern about Linux user experience than the EHR user experience, and your life does not depend on the former

I find this ironic and striking: During my informatics postdoc I used a SparcStation-2 running UNIX and an old X Windows user interface.  Then a few years later, in the Windows 95 days, I installed Linux (an open-source UNIX-like operating system) on a PC and used various X Windows user interfaces on that, too.  There was a lot of debate on which features of which user interface made for the best usability, and more broadly, <a href="http://en.wikipedia.org/wiki/User_experience_design" target="_blank">user experience</a>. This debate continues as Linux in its multiple versions continues to be extremely popular. If the health IT sellers put as much time into considering the user experience presented by their products as does the Linux community and were as candid, as, say, the Ubuntu Linux community as <a href="http://en.wikipedia.org/wiki/Unity_%28user_interface%29" target="_blank">here</a>, there might not be physician rebellion groups like Twitter's <a href="http://hcrenewal.blogspot.com/2013/03/twitter-ehr-revolt-ehrbacklash.html" target="_blank">#EHRbacklash</a> springing up. -- SS

Far more concern about Linux user experience than the EHR user experience, and your life does not depend on the former

I find this ironic and striking:During my informatics postdoc I used a SparcStation-2 running UNIX and an old X Windows user interface. Then a few years later, in the Windows 95 days, I installed Lin…

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10 Mar 2013

AMIA: Enhancing patient safety and quality of care by improving the usability of EHR systems, but ... no sympathy for victims of bad health IT?

A panel of experts from the American Medical Informatics Association have written a paper "Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA." The paper is publicly available <a href="http://jamia.bmj.com/content/early/2013/01/24/amiajnl-2012-001458.full.pdf+html" target="_blank">at this link</a> in PDF. The authors are  Blackford Middleton (Harvard Medical School),  Meryl Bloomrosen (AMIA),  Mark A Dente (GE Healthare IT),  Bill Hashmat (CureMD Corp.), Ross Koppel (Dept. of Socology, Univ, of Pennsylvania), J Marc Overhage (Siemens Health Services), Thomas H Payne (U. Washington IT Services),  S Trent Rosenbloom (Vanderbilt Informatics), Charlotte Weaver (Gentiva Health Services) and Jiajie Zhang (University of Texas Health Science Center at Houston). The paper states what has been obvious to this author - and many others - for many years: <blockquote class="tr_bq">ABSTRACT:  In response to mounting evidence that use of electronic medical record systems may cause unintended consequences, and even patient harm, the AMIA Board of Directors convened a Task Force on Usability to examine evidence from the literature and make recommendations. This task force was composed of representatives from both academic settings and vendors of electronic health record (EHR) systems. After a careful review of the literature and of vendor experiences with EHR design and implementation, the task force developed 10 recommendations in four areas: (1) human factors health information technology (IT) research, (2) health IT policy, (3) industry recommendations, and (4) recommendations for the clinician end-user of EHR software. These AMIA recommendations are intended to stimulate informed debate, provide a plan to increase understanding of the impact of usability on the effective use of health IT, and lead to safer and higher quality care with the adoption of useful and usable EHR systems.</blockquote> The paper is a respectable start at acknowledgement of the issues ... albeit years late. That said: I noted some typical language in the article characteristic of the reluctance of the health IT industry and its friends to directly confront these issues.  I wrote a letter to the authors that, as I indicate below, not unexpectedly went unanswered except for one individual -- not even a physician -- who's gone out on a limb professionally in the interest of patient's rights, and as a health IT "iconoclast" (i.e., patient advocate) suffered for doing so (<a href="http://www.modernhealthcare.com/article/20130126/MAGAZINE/301269955" target="_blank">link</a>).  The lack of a response to the letter is itself representative, in my opinion, of a pathology that renders more rights to the healthcare computer and its makers than patients.   More on this below. First, I note I am rarely if ever cited by the academics.  They are not prohibited from doing so.  I've probably been writing on these issues -- poorly done health IT, improper leadership, the turmoil created, etc., publicly for longer than anyone else in the domain. I also note that the paper is somewhat in the form of an analytical debate.  Analytical debates are relatively ineffective in this domain.  They are like popcorn thrust against a battleship.  The paper, also, appearing as it does in a relatively obscure specialty journal (Journal of the American Medical Informatics Association), will probably get more exposure from this blog post than the entire readership of that journal.  The authors need to be relating these issues in forums that are widely read by citizens and government, not in dusty academic journals - that is, assuming they want the messages to widely diffuse. In my review of the article, I note the following: <blockquote class="tr_bq"><div>... In an Agency for Healthcare Research and Quality (AHRQ) workshop on usability in health IT in July 2010, all eight participating vendors agreed that usability was important and many suggested it was a competitive differentiator, although some considered that usability was in the eye of the beholder and that the discipline of usability evaluation was an imperfect science, with results that were not useful.</div></blockquote><div></div><div> A paper like this should have clearly repudiated antiquated viewpoints like that, not merely made note of them.   Not taking a stand is a sign of weakness...or sympathy.</div><div> As a matter of fact, if leaders such as this had paid attention to the 'iconoclasts' and their 'anecdotes', my own mother might not have gone through horrible suffering and death, with me as sad witness as I related to them in my letter below. <blockquote class="tr_bq">... End-users of EHR systems are ultimately accountable for their safe and effective use, like any tool in clinical care. </blockquote> I see a linguistic <a href="http://en.wikipedia.org/wiki/Sleight_of_hand" target="_blank">sleight of hand</a> via use the word "tool" to describe HIT and trying to blend or homogenize this apparatus with other "tools" in clinical care.  The HIT "tool" is unlike any other since no transaction of care can occur without it going through this device, and as such, all care is totally dependent on it.  Further, unlike pharma and medical devices, this "tool" is unvetted and unregulated but its use forced upon many users. <blockquote class="tr_bq">... [AMIA] subcommittees reviewed the literature on usability in health IT, current related activities underway at various US Federal agencies, lessons learned regarding usability and human factors in other industries, and current federally funded research activities.</blockquote></div><div> <div></div> <div>Did they speak with the source of the most candid information?  The plaintiff's and defendant's Bars? Need I even ask that question?</div><div></div><div> <blockquote class="tr_bq"><div>... Recent reports describe the safe and effective use of EHR as a property resulting from the careful integration of multiple factors in a broad sociotechnical framework</div></blockquote> This is not merely 'recent' news.  The field of Social Informatics (<a href="http://www.dlib.org/dlib/january99/kling/01kling.html" target="_blank">link</a>), that has studied IT in its social contexts for decades now, has offered observations on the importance of considering multiple factors in a broad sociotechnical framework.   The authors all know this - or should know this, or should have made it their business to know this.  The statement sounds somewhat protective of the HIT and hospital industries for their longstanding negligence towards those issues. <div dir="ltr"></div> <blockquote class="tr_bq"><div dir="ltr">... User error may result in untoward outcomes and unintended negative consequences. These may also occur as a result of poor usability, and may also be an emergent property only demonstrated after system implementation or widespread use.</div></blockquote></div><div> I note the use of the term "user error" and lack of the term "use error" with significant disdain.  As I wrote <a href="http://hcrenewal.blogspot.com/2011/11/two-opposing-views-of-ehr-1.html" target="_blank">here</a> regarding the views of a HIT industry exexcutive holding the mystical "American Medical Informatics Certification for Health Information Technology",  NIST itself now defines "use error" (as opposed to "user error") as follows: <blockquote class="tr_bq">“Use error” is a term used very specifically by NIST to refer to user interface designs that will engender users to make errors of commission or omission. It is true that users do make errors, but many errors are due not to user error per se but due to designs that are flawed, e.g., poorly written messaging, misuse of color-coding conventions, omission of information, etc. From "NISTIR 7804: Technical Evaluation, Testing and Validation of the Usability of Electronic Health Records." It is available at <a href="http://www.nist.gov/healthcare/usability/upload/Draft_EUP_09_28_11.pdf" rel="nofollow">http://www.nist.gov/healthcare/usability/upload/Draft_EUP_09_28_11.pdf</a> (PDF).</blockquote><div dir="ltr"></div><div dir="ltr"> In the article, indefinites were exchanged with what should have been stronger, declarative statements, and vice versa: <blockquote class="tr_bq">User error ... may also represent a potential health IT-related error yet to happen.</blockquote></div><div dir="ltr"></div><div dir="ltr"> I most decidedly wish they'd stop this "may" verbiage in policy papers like this.</div><div dir="ltr"></div> <blockquote class="tr_bq"><div dir="ltr">... Anecdotal reports suggest that these application differences [where clinicians use more than one commercial EHR system] result in an increased training burden for EHR users.</div></blockquote><div dir="ltr"></div><div dir="ltr"> "Anecdotal"?  How about "obvious to a third grader?"  "Anecdotal" in academic papers often is a term of derision for inconvenient truths such as reports of health IT problems.  Its use often reflects a need for authors using the term (per a senior clinician from Victoria, Australia on the 'anecdotes' issue, <a href="http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html" target="_blank">link</a>) "to attend revision courses in research methodology and risk management."</div><div dir="ltr"></div> <blockquote class="tr_bq"><div dir="ltr">... Some suggest that the expected gains sought with the adoption of EHR are not yet realized.</div></blockquote><div dir="ltr"></div><div dir="ltr"> "Some"?  How about "credible experts?"  "Suggest?"  They merely hint at it?  How about "opine?"   </div><div dir="ltr"></div><blockquote class="tr_bq"><div dir="ltr">... The design of software applications requires both technical expertise and the ability to completely understand the user’s goal, the user’s workflow, and the socio-technical context of the intent</div></blockquote><div dir="ltr"></div><div dir="ltr"> In the meantime, AMIA has been promoting national rollout of a technology where, most often, the latter does not apply.</div><div dir="ltr"></div> <blockquote class="tr_bq"><div dir="ltr">To ... transform our healthcare delivery system ... clinicians need to use usable, efficient health IT that enhances patient safety and the quality of care.</div></blockquote><div dir="ltr"></div><div dir="ltr"> This is the typical hyperenthusiast mantra.  Where's the proof?  And, transform into what, exactly?  Vague rhetoric like this in allegedly scientific papers is most unwelcome.</div><div dir="ltr"></div> <blockquote class="tr_bq"><div dir="ltr">Some experts suggest that improving the usability of EHR may be critical to the continued successful diffusion of the technology.</div></blockquote><div dir="ltr"></div><div dir="ltr"> More weak talk.  Why not come right out and say "Credible experts opine that ...."?</div><div dir="ltr"></div> <blockquote class="tr_bq"><div dir="ltr">... While some EHR vendors have adopted user-centered design when developing health information technologies, the practice is not universal and may be difficult to apply to legacy systems.</div></blockquote><div dir="ltr"></div><div dir="ltr"> From the patient advocacy perspective, that's their problem...it's a risk of being in this business.  Patients should not be expected to be used as experimental subjects while IT sellers figure out what other industry sectors have long mastered.   Further, they should be held accountable for failures that result in harm.  Another risk of doing business in this sector that clinicians have long learned to live with...</div><div dir="ltr"></div> <blockquote class="tr_bq"><div dir="ltr">... Some believe it is difficult or impossible to reliably compare one product with another on the basis of usability given the challenges in assessment of products as implemented.</div></blockquote><div dir="ltr"></div><div dir="ltr"> Nothing is "impossible" and again, if it's "difficult", that's the industry's problem.  There is risk of being in the business of medicine or medical facilitation; nobody promised a rose garden, and a rose garden should not be expected. </div> <blockquote class="tr_bq"><div dir="ltr">... Many effects of health IT can be considered to be ‘emergent’ or only discovered after monitoring a system in use</div></blockquote><div dir="ltr"> One might ask,  where's the industry and AMIA been regading postmarket surveillance (common in other health sectors) for the past several decades?</div><div dir="ltr"></div> <blockquote class="tr_bq"><div dir="ltr">... AMIA believes it is now critical to coordinate and accelerate the numerous efforts underway focusing on the issue of EHR usability.</div></blockquote><div dir="ltr"></div><div dir="ltr"> Only "now?"</div><div dir="ltr"></div> <blockquote class="tr_bq"><div dir="ltr">... Establish an adverse event reporting system for health IT and voluntary health IT event reporting</div></blockquote><div dir="ltr"></div><div dir="ltr"> No, no, no ...voluntary reporting doesn't work.  Even mandatory reporting is flawed, but it's better than voluntary. I am invariably disappointed by recommendations like this.  I've observed repeatedly, for example, that "volunatary reporting" of EHR problems already exists - in the form of the FDA MAUDE database - and most HIT sellers' reports are absent.  See my posts on MAUDE <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=MAUDE">here</a>, <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=maude_death">here</a> and <a href="http://hcrenewal.blogspot.com/2011/01/maude-and-hit-risk-mother-mary-what-in.html" target="_blank">here</a>.  (Also, the only one that seems to report may have <a href="http://hcrenewal.blogspot.com/2010/04/healthcare-it-corporate-ethics-101.html" target="_blank">ulterior motives</a>, i.e., restraint of trade.)</div><div dir="ltr"></div> <blockquote class="tr_bq"><div dir="ltr">... A voluntary reporting process could leverage the AHRQ patient safety organizations (PSO) ... This work should be sponsored by the AHRQ.</div></blockquote><div dir="ltr"></div><div dir="ltr"> These folks clearly don't want any teeth in this.  AHRQ is a research-oriented government branch, not a regulator, nor does it have regulatory expertise.</div><div dir="ltr"> <div>AMIA recommends: </div><blockquote class="tr_bq"><div dir="ltr"><h4>Research and promote best practices for safe implementation of EHR</h4></div></blockquote>In 2013 this is valuable information in the same sense that advice to use sterile technique during neurosurgery is valuable. <div dir="ltr"></div> <div dir="ltr">"Promoting best practices" has been done for decades.  Not mentioned is avoiding worst practices.   I've long written these are not the same thing, as toleration of the inappropriate leadership by health IT amateurs (a term I use in the same sense that I am a Radio Amateur, not a telecommunications professional), politics, empire-building and other dysfunction that goes on in health IT endeavors negates laundry lists of "best practices." </div> What is required is to research and abolish worst practices, including the culture and dynamics of the 'health IT-industrial complex.'  I made this point in my very first website in 1998.  It appears the authors don't get it and/or won't admit to the dysfunction that goes on in health IT projects.   </div><div dir="ltr"></div><blockquote class="tr_bq"><div id="divRpF57737" style="direction: ltr;">... The adoption of useful and usable EHR will lead to safer and higher quality care, and a better return on investment for institutions that adopt them.</div></blockquote><div style="direction: ltr;"></div><div style="direction: ltr;"> "Will?"  With respect to my observation above about the paper's prominent misuse of indefinites vs. stronger declarative terms, the word "may" would have been the appropriate term here.  As I wrote about similar statements from ONC in the NEJM in my 2010 post "<a href="http://hcrenewal.blogspot.com/2010/07/new-england-journal-on-meaningful-use.html" target="_blank">Science or Politics? The New England Journal and The 'Meaningful Use' Regulation for Electronic Health Records</a>", I'm quite disappointed seeing speculation and PR presented as fact from alleged scientists and scientific organizations. Finally, I wrote the following email letter to the authors, to which (except for Ross Koppel) I received no reply.  While Dr. Koppel (a PhD) graciously expressed sympathy for my me and mother, the others (many MD's) were silent.</div><div style="direction: ltr;"> Perhaps the silence is the best indicator of their concern for the rights of computers and HIT merchants relative to the rights of people: </div><blockquote><div style="direction: ltr;">Mon, Jan 28, 2013 at 1:12 PM </div></blockquote><blockquote><div style="direction: ltr;">Dear authors, I've reviewed the new paper "Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA" and wanted to express thanks for it. It's a good start.  Late, but a good start at returning the health IT domain to credibility and evidence-based practice. It's too bad it didn't come out years earlier.  Perhaps my mother would not have gone through a year of horrible suffering and death, with me as sad witness, due to the toxic effects of bad health IT.  Perhaps you should hear how horrible it was to hear my mother in an extended agitated delirium; to hear her cry hysterically later on when the rehab people told her that her weight was 95 pounds; to have to make her a "no code" and put her on hospice-care protocols, and then to have watched her aspirate a sleeping pill when she was agitated, and die several days later of aspiration pneumonia and sepsis ... in the living room of my home ... and then watch the Hearse take her away from my driveway...as a result of bad health IT. I will be writing more thoughts on your article at the Healthcare Renewal blog, of course, but wanted to raise three issues: 1.  The use of "may" and "will" is reversed, and conflating the term "anecdote" with risk management-relevant case reports.  <ul><li>They may also represent a potential health IT-related error yet to happen.  --->  They likely represent a potential health IT-related error yet to happen</li></ul><ul><li>Anecdotal reports suggest that these application differences result in an increased training burden for EHR users.  ---> Credible reports indicate...</li></ul><ul><li>Some suggest that the expected gains sought with the adoption of EHR are not yet realized. ---> Credible experts opine ....</li></ul><div dir="ltr"><ul><li>Some experts suggest that improving the usability of EHR may be critical to the continued successful diffusion of the technology. --->  "Credible experts opine that ..."</li></ul></div><div dir="ltr"><ul><li>The adoption of useful and usable EHR will lead to safer and higher quality care, and a better return on investment for institutions that adopt them. ---> The adoption of useful and usable EHR may lead to safer and higher quality care</li></ul></div> You really need to show more clarity ... and guts ... in papers like this, and drop the faux academic weasel words. 2.  You neglected to speak to the best source for information on EHR-related harms, evidence spoliation, etc... med mal attorneys. 3.  You also neglected to speak to, or cite, the writings of a Medical Informaticist on bad health IT now going back 15 years - and whose mother was injured and died as a result of the issues you write about - me.  In fact I am rarely cited or mentioned by anyone with industry interests. An apparent contempt for 'whistleblowers' such as myself makes me wonder ... what kind of people are the leaders of health IT, exactly?  Do they value computer's rights over patients'? It is not at all clear to me which has been the primary motivator of many of the health IT leaders. I think the rights which I value are quite clear. Sincerely, Scot Silverstein</div></blockquote></div></div> I neglected to mention the horror of seeing my mother put in a Body Bag before being taken to the Hearse in my driveway. -- SS

AMIA: Enhancing patient safety and quality of care by improving the usability of EHR systems, but ... no sympathy for victims of bad health IT?

A panel of experts from the American Medical Informatics Association have written a paper "Enhancing patient safety and quality of care by improving the usability of electronic health record systems: …

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30 Jan 2013

Siemens Healthcare on solving EHR usability problems: you can just call up your pal at the next hospital

In my Aug. 2009 post "<a href="http://hcrenewal.blogspot.com/2009/08/why-siemens-healthcare-fails.html">Why Siemens Healthcare Fails</a>", I wrote: <blockquote>I note that I used to admire German engineering rigor, but after seeing ill conceived, misguided position ads like the following from Siemens Healthcare, I am having sincere doubts about that country's current prowess in that domain.</blockquote> My admiration fell another notch. I now see this, in a Feb. 1, 2012 article from HealthData Management entitled "<a style="font-weight: bold;" href="http://www.healthdatamanagement.com/issues/20_2/user-unfriendly-43946-1.html">User Unfriendly</a>" on the flaws in commercial health IT that present a poor user interface/user experience (at the expense, ultimately, of you, the patient). The article's browser title bar somewhat subliminally reads "Physicians gripe that EHR's are not easy to use but improvements are coming": <blockquote> ... There's also no mechanism for publicizing problems with EHR interfaces, unlike the FDA's process for issues with medical devices. [User interface expert Prof. Ben] <a href="http://www.cs.umd.edu/%7Eben/">Shneiderman</a> describes a case where a physician found a bug in an EHR that created a danger to patients. "He contacted the supplier because he thought it was something other users should know about, and the response was, 'Oh, we know-we're working on it,'" Shneiderman says. "The physician said, What? You know about it and you haven't notified everyone?' Contrast that with the Federal Aviation Administration, where problems with airplanes are publicized within hours." The IOM report calls for substantial loosening of those contractual restrictions. "The committee views prohibition of the free exchange of information to be the most critical barrier to patient safety and transparency," the report says. "The committee urges the [HHS] Secretary to take vigorous steps to restrict contractual language that impedes public sharing of patient safety-related details. Contracts should be developed to allow explicitly for sharing of health I.T. issues related to patient safety." The report also says there should be a central place to report and publicize known issues with EHR software.</blockquote> Siemens apparently has a different idea on taking responsibility for the user interfaces of their products: <blockquote>Siemens Healthcare Chief Medical Officer Don Rucker, M.D., says the secrecy issue is overblown. "There are trailer loads of information out there on each of these big systems, and there are so many end users that you can just call up your pal at the next hospital."</blockquote> There are trailer loads of information out there, and it's up to the end user physician to find the information and sort through it? ... Sounds perfectly reasonable to me. /not/ There are so many end users that you can just call up your pal at the next hospital [for guidance on user interface complexities and errors]? Also sounds perfectly reasonable. /not/ ... Except, I think most EMR vendors and user-organizations sort-of disable Remote Assistance, Remote Desktop and similar programs. Even "print screen" is usually either disabled or forbidden from sharing with that "pal at the other hospital." Might have something to do with security and IP protection. Ever try to guide someone through a complex computer interface over the phone, blind, with no real-time mutually viewed visuals? It's not easy, but ... physicians and nurses have PLENTY of time for such fritter, what with the little other work they have to do. I also think saying busy physician, nurse and other clinical customers should "depend on their pals at the next hospital" for information on health IT difficulties is a rather condescending and patronizing statement to make (to be charitable), a backyard-mechanic attitude, but that's just me. Why does Siemens fail? This type of statement is a very good clue. -- SS

Siemens Healthcare on solving EHR usability problems: you can just call up your pal at the next hospital

In my Aug. 2009 post "Why Siemens Healthcare Fails", I wrote:I note that I used to admire German engineering rigor, but after seeing ill conceived, misguided position ads like the following from Siem…

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02 Feb 2012

HIMSS and Healthcare IT: We Don't Need A "Usability Maturity Model." We Need - USABILITY - and Less of Cold-Blooded Calculus

Health IT industry consortium HIMSS has followed up its Master of the Obvious, 50-years-too-late paper "Defining and Testing EMR Usability: Principles and Proposed Methods of EMR Usability Evaluation and Rating" (June 2009) that I wrote about in a Dec. 2010 post "<a href="http://hcrenewal.blogspot.com/2010/12/unintended-errors-with-ehr-based-result.html">Unintended errors with EHR-based result management: a case series, and a special pleading for health IT</a>" with a new report: <a href="http://www.himss.org/ASP/ContentRedirector.asp?ContentID=76349"></a><blockquote><a style="font-weight: bold;" href="http://www.himss.org/ASP/ContentRedirector.asp?ContentID=76349">Promoting Usability in Health Organizations: Usability Maturity Model</a> (PDF, Feb. 2011)</blockquote> I knew I was in for a heaping helping of gobbledygook after reading the title itself: “Promoting Usability in Health Organizations: Initial Steps and Progress Toward a Healthcare Usability Maturity Model” A “Healthcare Usability Maturity Model” is a clue that what follows will take simplicity, and expend considerable ink to tangle it into a mess of process mysticism, buzzwords, paradigms, very pretty charts, and other Master-of-the-Obvious-made-to-look-sophisticated, destined-for-the-dusty-shelf consultant report. That is largely what follows. See for yourself.This passage in the Executive Summary is pathognomonic of the amoral, money-over-blood, patients-as-guinea-pigs mentality that inhabits the commercial health IT sector. I find it particularly revealing and revolting: <blockquote> ... Leaders may be reluctant to incorporate usability principles and practices [in a safety-critical technology increasingly mediating all aspects of medical care delivery - ed.] because of perceptions that these methods may slow development and product fielding. However, data exist on usability return on investment (ROI), outlining the value of adopting usability in health organizations. </blockquote> Excuse me? It takes proof of "ROI" to convince these companies to produce usable (which subsumes the concept of "safe") health IT? This is as cold-blooded a calculus as it gets. This is <a href="http://en.wikipedia.org/wiki/Ford_Pinto">Ford Pinto</a> material:<blockquote>... Critics alleged that the vehicle's lack of reinforcing structure between the rear panel and the tank meant the tank would be pushed forward and punctured by the protruding bolts of the <a href="http://en.wikipedia.org/wiki/Differential_%28mechanics%29" title="Differential (mechanics)" class="mw-redirect">differential</a><a href="http://en.wikipedia.org/wiki/Ford_Pinto#cite_note-fordpintocase-14">[15]</a> [by a rear end collision of only 20 mph/32 km/h, causing a fire - ed.]— making the car less safe than its contemporaries.According to a 1977 <a href="http://en.wikipedia.org/wiki/Mother_Jones_%28magazine%29" title="Mother Jones (magazine)">Mother Jones</a> article, Ford allegedly was aware of the design flaw, refused to pay for a redesign, and decided it would be cheaper to pay off possible lawsuits for resulting deaths. The magazine obtained a <a href="http://en.wikipedia.org/wiki/Cost-benefit_analysis">cost-benefit analysis</a> that it said Ford had used to compare the cost of an $11 repair against the monetary value of a human life—what became known as the Ford Pinto Memo.<a href="http://en.wikipedia.org/wiki/Ford_Pinto#cite_note-50worst-12">[13]</a><a href="http://en.wikipedia.org/wiki/Ford_Pinto#cite_note-mother-15">[16]</a><a href="http://en.wikipedia.org/wiki/Ford_Pinto#cite_note-16">[17]</a> An example of a Pinto rear-end accident that led to a lawsuit was the 1972 accident that killed Lilly Gray and severely burned 13-year old Richard Grimshaw. The accident resulted in the court case <a href="http://en.wikipedia.org/wiki/Grimshaw_v._Ford_Motor_Co.">Grimshaw v. Ford Motor Co.</a>,<a href="http://en.wikipedia.org/wiki/Ford_Pinto#cite_note-17">[18]</a> in which the California Court of Appeal for the Fourth Appellate District upheld compensatory <a href="http://en.wikipedia.org/wiki/Damages">damages</a> of $2.5 million and <a href="http://en.wikipedia.org/wiki/Punitive_damages">punitive damages</a> of $3.5 million against Ford, partially because Ford had been aware of the design defects before production but had decided against changing the design. [In more recent years, others said the Ford Pinto scandal was not clear-cut, but health IT unusability increasing odds for medical errors is clear-cut - ed.] </blockquote> <blockquote> </blockquote> Why are these companies and their leadership getting to play God - in a field such as Medicine? <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtYbO9i2jbJhyyQoyesX24vy99i7HmbRi1kxfdWEEBWLpTmLP96_JrM5JI86qwUPQj1Ty9do51aSnNSRNA8dohgaxoRq-xqmtV_BNVjW4U6Bq42Yw3K2gnwf5tK7_mxnnVqOj9KN9r1y6W/s1600/cp.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5579924020893002882" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtYbO9i2jbJhyyQoyesX24vy99i7HmbRi1kxfdWEEBWLpTmLP96_JrM5JI86qwUPQj1Ty9do51aSnNSRNA8dohgaxoRq-xqmtV_BNVjW4U6Bq42Yw3K2gnwf5tK7_mxnnVqOj9KN9r1y6W/s320/cp.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 128px; height: 181px;" /></a>Usability? Those Luddite doctors and crummy patients will get usability over my - er, their - dead bodies, if I don't profit handsomely from it. Finally, I have several meta-observations about this new report: <ul><li>We don't need a "usability maturity model." We need USABILITY. We need the common and longstanding knowledge of software usability in other mission critical sectors to be applied on the development whiteboard and usability testing labs (if any!) at HIT vendors. </li></ul><ul><li>Why is it that health IT usability has to be written about, basically as if from the grade school level, in 2011 - some sixty years into the “computer revolution?” Do we still write treatises on why it’s wise to use sterile technique and good lighting in operating rooms? What is the major malfunction in this industry? </li></ul><ul><li>Why is this treatise not entitled “Promoting Usability in Health IT Vendor Development Shops: A Vendor Responsibility Model”?</li></ul><ul><li>The frequent use of the terminology "user experience" as applied to healthcare IT in this report struck my eye. It has been adopted in this report, but was uncommon regarding health IT until recently, as in my posts about the health IT <a href="http://www.tinyurl.com/hostileuserexper">mission hostile user experience.</a> </li></ul>The terminology is conspicuously absent in the aforementioned earlier 2009 HIMSS report. It would not take Sherlock Holmes to theorize that I might be an <a href="http://www.google.com/search?client=firefox-a&rls=org.mozilla%3Aen-US%3Aofficial&channel=s&hl=en&source=hp&biw=1024&bih=578&q=healthcare+IT+user+experience&btnG=Google+Search#sclient=psy&hl=en&client=firefox-a&hs=q9q&rls=org.mozilla:en-US%3Aofficial&channel=s&biw=1024&bih=578&tbs=ww:1&q=%22mission+hostile+user+experience%22&aq=f&aqi=&aql=&oq=&pbx=1&bav=on.2,or.&fp=6c13b9433fbb516b">unattributed contributor</a> to the new 2011 HIMSS report. If anyone knows differently, I'd be interested to hear about it.-- SS <blockquote> </blockquote>

HIMSS and Healthcare IT: We Don't Need A "Usability Maturity Model." We Need - USABILITY - and Less of Cold-Blooded Calculus

Health IT industry consortium HIMSS has followed up its Master of the Obvious, 50-years-too-late paper "Defining and Testing EMR Usability: Principles and Proposed Methods of EMR Usability Evaluation …

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03 Mar 2011

The National Program for Healthcare IT in the U.S., and the Elephant in the Living Room

<div dir="ltr">The <a href="http://www.nist.gov/index.html">National Institute of Standards and Technology</a> (NIST) has begun to address deficient clinical IT usability. A PDF with presentations on the topic from the recent NIST conference on HIT usability is <a href="http://www.nist.gov/itl/upload/Final-Agenda-Usability-in-Health-IT-2-2.pdf">here</a> (warning: very large, 26 MB). There is a critical "meta-issue" that's being ignored regarding usability, though, yet it is the elephant in the living room. First, I will detail the elephant, then ask the simple, logical question that arises (the "inconvenient" question that nobody seems to be able to give a straight, non-marketing-spin answer to). </div> <div dir="ltr"> </div> <div dir="ltr">Here are the details of the elephant. First, poor usability ---> increased risk to patients. This is a first principle; it is not open to debate. Now: </div> <div dir="ltr"> </div> <div dir="ltr">If NIST is just now getting involved in "improving HIT usability" (the improvement of which should have occurred at least two decades ago); </div> <div dir="ltr"> </div> <div dir="ltr">While HIMSS's former Chairman of the Board admits the <a href="http://hcrenewal.blogspot.com/2010/07/barry-chaiken-md-mph-lets-be-patient.html" target="_blank">technology remains experimental</a>: </div> <div dir="ltr"> </div> <blockquote dir="ltr" style="margin-right: 0px;"> <div dir="ltr">... We’re still learning, in healthcare, about that user interface. We’re still learning about how to put the applications together in a clinical workflow that’s going to be valuable to the patients and to the people who are providing care. Let’s be patient. Let’s give them a chance to figure out the right way to do this. Let’s give the application providers an opportunity to make this better; </div></blockquote> <div dir="ltr"> </div> <div dir="ltr">While HIMSS itself admits <a href="http://www.himss.org/content/files/HIMSS_DefiningandTestingEMRUsability.pdf"> </a><a href="http://www.himss.org/content/files/HIMSS_DefiningandTestingEMRUsability.pdf" target="_blank">in this 2009 PDF</a> that </div> <blockquote dir="ltr" style="margin-right: 0px;"> <div dir="ltr">"Electronic medical record (EMR)!adoption rates have been slower than expected in the United States, especially in comparison to other industry sectors and other developed countries. A key reason, aside from initial costs and lost productivity during EMR implementation, is lack of efficiency and usability of EMRs currently available"; </div></blockquote> <div dir="ltr"> </div> <div dir="ltr">While the National Research Council (the highest scientific authority in the U.S.) last year <a href="http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572" target="_blank">reported that</a> : </div> <div dir="ltr"> </div> <blockquote dir="ltr" style="margin-right: 0px;"> <div dir="ltr">"Current Approaches to U.S. Health Care Information Technology are Insufficient" and that the technology "does not support clinicians' cognitive needs." The study was chaired by Medical Informatics pioneers Octo Barnett (Harvard/MGH) and William Stead (Vanderbilt); </div></blockquote> <div dir="ltr"> </div> <div dir="ltr">While it's not just the user experience that's the problem, either... </div> <div dir="ltr"> </div> <div dir="ltr">Insurers are starting to recognize this, e.g., <a href="http://hcrenewal.blogspot.com/2010/07/norcal-mutual-insurance-company.html" target="_blank">"NORCAL Mutual Insurance Company: "Electronic Health Records: Recognizing and Managing the Risks"</a> ; While hospitals and vendors cannot yet manage the technology reliably - how many medical mistakes have/will occur as a result of screw ups <a href="http://hcrenewal.blogspot.com/2010/07/health-it-and-highest-regulatory.html" target="_blank">like this one</a>, now confirmed to have occurred at a religious-denomination hospital chain headquartered in the Great Lakes region of the U.S.? <a href="http://hcrenewal.blogspot.com/2010/07/maude-database-patient-outcome-death.html" target="_blank">This patient</a> won't get a second chance, either. </div> <div dir="ltr"> </div> <div dir="ltr">The above issues are the elephant in the living room. Or, shall I say, in the Boardrooms and meeting rooms where health IT is planned and discussed? <div style="text-align: center;"><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi372kCKQVR2zneqSKOy61V1bpGev7OclaMtQFd1qq86Elnm_87Jq308yxvhTG3zQFsUPqicO3WbHwA2ZPbIWr2X0vyis_-2D-da5x0p02CFnoeG85MaoBzYQU6pQrWTOK39oUZEvwlt6zm/s1600/elephant-in-the-room.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5496364856603005506" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi372kCKQVR2zneqSKOy61V1bpGev7OclaMtQFd1qq86Elnm_87Jq308yxvhTG3zQFsUPqicO3WbHwA2ZPbIWr2X0vyis_-2D-da5x0p02CFnoeG85MaoBzYQU6pQrWTOK39oUZEvwlt6zm/s320/elephant-in-the-room.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 320px; height: 244px;" /></a>Health IT is great stuff, guys; it might actually work well one day! Let's roll it out nationally and penalize those Luddite doctors who refuse to "use it meaningfully" because it's not very usable. Oh, just ignore that strange creature over there in the corner ... </div></div> <div dir="ltr"> </div> <div dir="ltr"> </div> <div dir="ltr"> </div> <div dir="ltr"> Considering the size and weight of the elephant, here is my question: </div> <div dir="ltr"> </div> <div dir="ltr">Why are we rolling out this technology nationally under penalty of Medicare garnishment? I cannot get a straight, unspun answer to that question. Perhaps we need Bill O'Reilly to ask these questions of health IT officials on his <a href="http://www.foxnews.com/">FOX News</a> program, <a href="http://books.google.com/books?id=b9GRPXrYDPUC&printsec=frontcover&dq=no+spin+zone&hl=en&ei=8ANHTP3CAYL_8Abk6bXhBA&sa=X&oi=book_result&ct=result&resnum=1&ved=0CCkQ6AEwAA#v=onepage&q&f=false">The O'Reilly Factor</a>, where spin is attacked relentlessly (the "No Spin Zone.") -- SS </div>

The National Program for Healthcare IT in the U.S., and the Elephant in the Living Room

The National Institute of Standards and Technology (NIST) has begun to address deficient clinical IT usability. A PDF with presentations on the topic from the recent NIST conference on HIT usabil…

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21 Jul 2010

Meaningful Use Final Rule: Have the Administration and ONC Put the Cart Before the Horse on Health IT?

Meaningful use before meaningful usability? The Dept. of HHS today has released the final version of "Meaningful Use" rules on HIT, which can be seen here: <a title="Article about: Meaningful Use – Final Version Full Text" href="http://histalk2.com/2010/07/13/meaningful-use-final-version-full-text/" rel="bookmark">Meaningful Use – Final Version Full Text</a>. <div dir="ltr">By what category of diligence were the rules for "meaningful use" finalized on the same date that a NIST conference is being held on health IT "usability" ("Usability in Health IT: Technical Strategy, Research, and Implementation", <a href="http://www.nist.gov/itl/usability_hit.cfm" target="_blank">http://www.nist.gov/itl/usability_hit.cfm</a>), implying there's a problem with usability of these experimental devices physicians are supposed to "meaningfully use?" Don't take my word on the issue of usability problems... The <a href="http://sites.nationalacademies.org/NRC/index.htm">National Research Council of the National Academies</a> (considered the highest scientific authority in the U.S.) issued a 2009 report on HIT. In that report, presided over by noted HIT pioneers G. Octo Barnett (Harvard/MGH) and William Stead (Vanderbilt), were findings that current HIT does not support clinicians' cognitive needs as <a href="http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572">here</a>: </div><blockquote dir="ltr">CURRENT APPROACHES TO U.S. HEALTH CARE INFORMATION TECHNOLOGY ARE INSUFFICIENT WASHINGTON -- Current efforts aimed at the nationwide deployment of health care information technology (IT) will not be sufficient to achieve medical leaders' vision of health care in the 21st century and may even set back the cause, says a new report from the National Research Council. The report, based partially on site visits to eight U.S. medical centers considered leaders in the field of health care IT, concludes that greater emphasis should be placed on information technology that provides health care workers and patients with cognitive support, such as assistance in decision-making and problem-solving. </blockquote><div dir="ltr"> How about HIT industry trade/"educational" group <a href="http://www.himss.org/">HIMSS</a> itself? I think reasonable people might conclude the technology is not ready for "meaningful use" on a national scale from their mid 2009 report: </div><blockquote dir="ltr" face="arial"><a href="http://www.himss.org/content/files/HIMSS_DefiningandTestingEMRUsability.pdf">Defining and Testing EMR Usability: Principles and Proposed Methods of EMR Usability Evaluation and Rating</a> (PDF) HIMSS EHR Usability Task Force June 2009 EXECUTIVE SUMMARY Electronic medical record (EMR) adoption rates have been slower than expected in the United States, especially in comparison to other industry sectors and other developed countries. A key reason, aside from initial costs and lost productivity during EMR implementation, is lack of efficiency and usability of EMRs currently available. Achieving the healthcare reform goals of broad EMR adoption and “meaningful use” will require that efficiency and usability be effectively addressed at a fundamental level.</blockquote><div dir="ltr"> These "usability" problems require long term solutions. There are no quick fix, plug and play solutions. Years of research are needed, and years of system migrations as well for existing installations. Yet we now have an HHS Final Rule on "meaningful use" regarding experimental, unregulated medical devices the industry itself admits have major usability problems, along with a growing body of literature on the <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=2009">risks entailed</a>.</div><div dir="ltr"> </div><div dir="ltr">For crying out loud, talk about putting the cart before the horse... </div> <div dir="ltr" style="text-align: center;"><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbxjl-AlGATfarPayjaUYkCOG4sUrulp4D88Nk7_z-eEbaWRl-xi1g0neGKWDhEL1w6-_-FCu4iBoJx9AUlU-bccaAmEcMfmGI1uoa4gTohjch5gzcx5tA9Ru-uMB0Mip6NE0PuUsfDXJ5/s1600/horse-cart.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5493460657310735298" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbxjl-AlGATfarPayjaUYkCOG4sUrulp4D88Nk7_z-eEbaWRl-xi1g0neGKWDhEL1w6-_-FCu4iBoJx9AUlU-bccaAmEcMfmGI1uoa4gTohjch5gzcx5tA9Ru-uMB0Mip6NE0PuUsfDXJ5/s320/horse-cart.jpg" style="display: block; margin: 0px auto 10px; width: 253px; cursor: pointer; height: 168px; text-align: center;" /></a>Something's very wrong here... </div><div dir="ltr"> </div>However, this situation is anything but humorous. How more "cart before the horse" can government get? Poor usability promotes medical error. Medical error puts patients at risk of iatrogenic injury and death<a href="http://hcrenewal.blogspot.com/2010/07/new-england-journal-on-meaningful-use.html"></a>. Are we are entering an era of cybernetic medical assault on our patients (and perhaps criminal negligence and <a href="http://en.wikipedia.org/wiki/Manslaughter">manslaughter</a>, a term I do not use lightly) through irrational exuberance in computing -- and through exuberance about the profits to be made by the HIT industry? Unless we slow down in our exuberance and recklessness on HIT diffusion, my fear is that we very well might be. -- SS Addendum: Also see my followup July 14, 2010 post "<a style="font-weight: bold;" href="http://hcrenewal.blogspot.com/2010/07/new-england-journal-on-meaningful-use.html">Science or Politics? The New England Journal and "The 'Meaningful Use' Regulation for Electronic Health Records</a>." -- SS

Meaningful Use Final Rule: Have the Administration and ONC Put the Cart Before the Horse on Health IT?

Meaningful use before meaningful usability?The Dept. of HHS today has released the final version of "Meaningful Use" rules on HIT, which can be seen here: Meaningful Use – Final Version Full Text.By w…

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13 Jul 2010

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