healthy4u: matthew holt

Kaiser Health News/Philadelphia Inquirer on InformaticsMD: "The flaws of electronic records"

At my Dec. 2012 post "<a href="http://hcrenewal.blogspot.com/2012/12/upcoming-profile-of-informaticsmd-in.html" target="_blank">How an interview for Kaiser Health News rekindled memories of health IT dysfunction in the 90's that persist in the 10's</a>" I mentioned an interview by a reporter from the Kaiser Health Foundation regarding health IT flaws. His article appeared in both the <a href="http://www.philly.com/philly/entertainment/20130218_The_flaws_of_electronic_records.html" target="_blank">Philadelphia Inquirer</a> and <a href="http://www.kaiserhealthnews.org/Stories/2013/February/18/Scot-Silverstein-health-information-technology.aspx" target="_blank">Kaiser Health News</a> today under the title "The flaws of electronic records": <blockquote class="tr_bq">Philadelphia Inquirer / Kaiser Health News Feb. 18, 2013 <h5 class="byline">Jay Hancock, KAISER HEALTH NEWS</h5><a href="http://www.philly.com/philly/entertainment/20130218_The_flaws_of_electronic_records.html" target="_blank">The flaws of electronic records</a> Drexel University's Scot Silverstein is a leading critic of the rapid switch to computerized medical charts, saying the notion that they prevent more mistakes than they cause is not proven.   <div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_8NHZXfqJrMOagNsDryhPIBfqkCL6Fpg0AV_7cXGpvSysrGf5LNS4vuXZ7bHr0FvlxiN9_8QDMVh7JtYnhDxeQ9XkUACF_VE4yC5XetVqe3I7aWif1W7wxpor32l3xF1SPfZxrg-mSG9S/s1600/silverstein_fixing_computer.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="205" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_8NHZXfqJrMOagNsDryhPIBfqkCL6Fpg0AV_7cXGpvSysrGf5LNS4vuXZ7bHr0FvlxiN9_8QDMVh7JtYnhDxeQ9XkUACF_VE4yC5XetVqe3I7aWif1W7wxpor32l3xF1SPfZxrg-mSG9S/s1600/silverstein_fixing_computer.JPG" width="320" /></a></div> Scot Silverstein of Lansdale, one of the most ardent critics of electronic medical records, works on an antique computer. A growing collection of evidence suggests poorly designed medical software can obscure clinical data, generate incorrect treatment orders, and cause other problems. <div class="photo_area" style="width: 600px;"><div class="photocaption"> RON TARVER /Staff Photogapher </div></div> Jay Hancock, KAISER HEALTH NEWS Posted: Monday, February 18, 2013, 3:01 AM Computer mistakes like the one that produced incorrect prescriptions for thousands of Rhode Island patients are probably far more common and dangerous than proponents of electronic medical records believe, says Drexel University's Scot Silverstein. Flawed software at Lifespan hospital group printed orders for low-dose, short-acting pills when patients should have been taking stronger, time-release ones, the Providence-based system disclosed in 2011. Lifespan says nobody was harmed. But Silverstein, a physician and adjunct professor of health-care informatics who is making a name for himself as a strident critic of electronic health records, says the Lifespan breakdown is part of a much larger problem. "We're in the midst of a mania right now" as traditional patient charts are switched to computers, he said in an interview in his Lansdale home. "We know it causes harm, and we don't even know the level of magnitude. That statement alone should be the basis for the greatest of caution and slowing down."</blockquote> In an ethical world, it would be.  Medicine, though, is in the throes of a loss of ethics, as many stories at this site and many others attest to. <blockquote class="tr_bq">Use of electronic medical records is speeding up, thanks to $10 billion and counting in bounties the federal government is paying to caregivers who adopt them. The consensus among government officials and researchers is that computers will cut mistakes and promote efficiency. So 4,000 hospitals have installed or are installing digital records, the Department of Health and Human Services said last month. Seventy percent of doctors surveyed in September by research firm CapSite said they had switched to digital data. But the notion that electronic charts prevent more mistakes than they cause just isn't proven, Silverstein says. Government doesn't require caregivers to report problems, he points out, so many computer-induced mistakes may never surface.</blockquote> The recent ECRI "deep dive" study of "EHR events" (<a href="http://hcrenewal.blogspot.com/2013/02/ecri-institute-pso-uncovers-health.html" target="_blank">link</a>) is just the latest to raise red flags on that point. Even Dr. David Blumenthal, former chair of the Office of the National Health IT Coordinator (ONC) in HHS seems to have <a href="http://hcrenewal.blogspot.com/2010/05/david-blumenthal-on-health-it-safety.html" target="_blank">changed his message</a> about reporting of medical problems. From a Feb. 16, 2013 New York Times article "<a href="http://www.nytimes.com/2013/02/17/sunday-review/the-hip-replacement-case-shows-why-doctors-often-remain-silent.html?_r=0" target="_blank">Doctors Who Don’t Speak Out</a>": <blockquote class="tr_bq">....  TRADITIONALLY, doctors have brought problems to the attention of colleagues by conducting research and publishing their findings in a medical journal. The advantage of that system helps ensure the credibility of study data and protects a researcher from random attack, said Dr. David Blumenthal, the president of the Commonwealth Fund, a group that studies health policy issues. But getting a study published can take a year or two; some Johnson & Johnson consultants did publish studies about the hip’s flaws, but they largely appeared after it had been recalled. Dr. Blumenthal said there was probably a need for more immediate ways for doctors to share their concerns, like forums supported by professional medical organizations. </blockquote> Back to the Inquirer article: <blockquote class="tr_bq">He doesn't discount the potential of digital records to eliminate duplicate scans and alert doctors to drug interactions and unsuspected dangers. But the rush to implementation has produced badly designed products that may be more likely to confound doctors than enlighten them, he says. Electronic health records, Silverstein believes, should be rigorously tested under government supervision before being used in life-and-death situations, much like medical hardware or airplanes.</blockquote> In fact, arguments otherwise are specious.  "Harm to innovation" is the one I've heard most often.  Yet, those proffering such claims cannot point out what aspect of regulation - adherence to GMP's (good manufacturing processes), pre-market safety and quality testing, post-market surveillance, etc. - will "harm innovation."  Indeed, they opine as if innovation in medicine without objective safety and quality checks is a virtue, rather than a potential vice. <blockquote class="tr_bq">Silverstein "is an essential critic of the field," said physician George Lundberg, editor at large for MedPage Today and former editor of the Journal of the American Medical Association. "It's too easy for those of us in medicine to get excessively enthusiastic about things that look like they're going to work out really well. Sometimes we go too far and don't see the downside of things."</blockquote> (Dr. Lundberg mentioned me in Nov. 2011 at MedPage today in a piece entitled "Health IT: Garbage In, Garbage Out" as <a href="http://hcrenewal.blogspot.com/2011/11/george-lundberg-promise-of-health-it.html" target="_blank">here</a>.) The patients - including ourselves and our own family members, I might add - are the ones who pay the price of our hyper-enthusiasm. <blockquote class="tr_bq">... The FDA's Jeffrey Shuren, a neurologist, has said such cases "likely reflect a small percentage of the actual events that do occur."</blockquote> "Tip of the iceberg" were his exact words (<a href="http://hcrenewal.blogspot.com/2010/02/fda-on-health-it-adverse-consequences.html" target="_blank">link</a>). <blockquote class="tr_bq">... At conferences and working from home on the "Health Care Renewal" blog, Silverstein chronicles digital failures and criticizes hospitals in the same dogged way he applied himself to building the 1970s-era Heathkit computers [and amateur radio equipment - ed.] he still keeps in his home, say people who know him. "His message has been consistent": Health IT "provides far less benefit than is claimed by its proponents and opens new, sometimes potent, routes to failure," said Richard I. Cook, a medical error expert at the University of Chicago who sat on a panel examining electronic record safety at the authoritative Institute of Medicine. "No one wants him to be visible. But his message and tone have not wavered."</blockquote> Dr. Cook wrote the lone dissent to milquetoast IOM recommendations on health IT risk - the magnitude of which IOM itself admitted is unknown - in their 2012 report "Health IT and Patient Safety: Building Safer Systems for Better Care" available <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/Patient%20Safety%20and%20Health%20IT%20prepub.pdf" target="_blank">here</a>.  See Appendix E. The last scientific conference at which I chronicled these failures was at the Health Informatics Society of Australia's HIC2012, as a keynote speaker on health IT trust (<a href="http://hcrenewal.blogspot.com/2012/08/my-presentation-to-health-informatics.html" target="_blank">link</a>).  I would have been at HIC2011, to which I had been originally invited, but was helping care for a relative injured by bad health IT at that time.  Her death freed me to travel Down Under in 2012. I have presented at a number of plaintiff attorney's meetings since then, however, such as the American Association for Justice Winter Convention (AAJ, formerly the Trial Lawyer's Association) just last week (<a href="http://www.justicewinterconvention.org/" target="_blank">link</a>).  Trial lawyers don't seem to mind a very direct approach to the issues, unlike many so-called scientists who, as author Michael Crichton once warned (<a href="http://www.goodreads.com/quotes/344539-i-want-to-pause-here-and-talk-about-this-notion" target="_blank">link</a>), seem to believe in "consensus" rather than science. <blockquote class="tr_bq"> The HIMSS Electronic Health Record Association, an industry group, declined to comment on Silverstein. A spokesman for the Office of the National Coordinator for Health Information Technology, the administration's proponent of digital records, said: "It's important to listen to all the voices" in the discussion of the subject.  </blockquote> Some voices, unfortunately, are louder than others and backed by lobbyists and big money.  See, for instance, the May 2009 Washington Post article by Robert O'Harrow Jr. "The Machinery Behind Health-Care Reform: How an Industry Lobby Scored a Swift, Unexpected Victory by Channeling Billions to Electronic Records" (link to the article and my essay about it is <a href="http://hcrenewal.blogspot.com/2009/05/machinery-behind-healthcare-reform-how.html" target="_blank">here</a>). I do point out, however, for the benefit of those at HIMSS and ONC, that knowing of risks, while doing nothing substantive while "listening to all voices in the discussion" can be seen as gross negligence. <blockquote class="tr_bq">Trained as an internist and in medical information technology [Medical Informatics- ed.] as a Yale University postdoc, Silverstein, 55, served as Merck & Co.'s director of scientific information in the early 2000s and then as a full-time Drexel professor, shifting in recent years to part-time teaching and working on medical liability cases for plaintiff attorneys. His insistent warnings about digital health risks over more than a decade have effectively barred him from a lucrative career at a hospital or software vendor.</blockquote> Perverse as that reality may be, it's also the reverse:  I would not want to work for a hospital or software vendor in 2013, where effecting change to protect patients from bad health IT is hard if not impossible, e.g., as at <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=lawsuit" target="_blank">link</a>, <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=clinical%20computing%20problems%20in%20ICU" target="_blank">link</a>, and <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story" target="_blank">link</a>, and at the other case examples at that site.  I find it a far more effective use of my time to help enact change from the outside - and avoiding the pathological individuals who make such scenarios possible. <blockquote class="tr_bq">"I'm sure Scot would be better off by keeping his mouth shut and getting a job with a hospital that's just put in a big . . . system," said Matthew Holt, a Silverstein critic and cochairman of Health 2.0, which organizes health technology conferences.</blockquote> I note that the raison d'être for this blog is the impact of many people doing just that sort of thing - "keeping their mouth shut" and making money, no matter what the ethical implications.  (The patients killed by such behaviors are, unfortunately, unavailable for comment.) <blockquote class="tr_bq"> Many say he comes on too strong. Even admirers cringed when he began blogging about the 2011 death of his mother, which he blames in a lawsuit on a computer error that allegedly caused Abington Memorial Hospital to overlook a key medication. (Both he and the hospital said they couldn't comment on a pending suit.) Personalizing his campaign, some thought, made him seem less objective.</blockquote> I'm at a loss here.  "Too strong" - on matters of life and death that affect everyone?  A proficient writer, who had been writing about health IT problems since 1998, should have kept silent about a first hand story of HIT harm in 2010 of potential great relevance towards public safety?  Writing about the incident 'lessens objectivity'?  That makes little sense, and is perverse.  Those who opined as such have their priorities in serious disarray. Such personalized accounts are common and have caused great change.  <a href="http://en.wikipedia.org/wiki/Libby_Zion_law" target="_blank">Libby Zion's death</a> due to hospital neglect, and her father's making the issues quite public, comes to mind, as do the many laws enacted that are named after people who've gone public after personal tragedy: <blockquote class="tr_bq">... Grieving the loss of their child, Zion's parents became convinced that their daughter's death was due to inadequate staffing at the teaching hospital.  Sidney Zion questioned the staff's competence for two reasons. The first was the administration of meperidine, known to cause fatal interactions with phenelzine, the antidepressant that Libby Zion was taking. The second issue was the use of restraints and emergency psychiatric medication. Sidney's aggrieved words were: "They gave her a drug that was destined to kill her, then ignored her except to tie her down like a dog." To the distress of the doctors, Zion began to refer to his daughter's death as a "murder." Sidney also questioned the long hours that residents worked at the time. In a New York Times op-ed piece he wrote: "You don't need kindergarten to know that a resident working a 36-hour shift is in no condition to make any kind of judgment call—forget about life-and-death." The case eventually became a protracted high-profile legal battle, with multiple abrupt reversals; case reports about it appeared in major medical journals.</blockquote> An alternate explanation is that, lacking other credible means, this is an ad hominem reaction (of those "some") seeking an angle to attack the message ... and the messenger ... or is simply a reaction of, to put it bluntly, castrati who are more at home in a country club than in the world of ideas. For a bona fide example of "coming on too strong", there's this: <div class="PlainText">In the NEJM article "The 'Meaningful Use' Regulation for Electronic Health Records", David Blumenthal, M.D., M.P.P. (ONC Chair) and Marilyn Tavenner, R.N., M.H.A. (10.1056/NEJMp1006114, July 13, 2010) available <a href="http://healthcarereform.nejm.org/?p=3732&query=home">at this link</a>, the opening statement is (emphases mine): </div><blockquote dir="ltr" style="margin-right: 0px;"><div class="PlainText">The widespread use of electronic health records (EHRs) in the United States is inevitable. EHRs will improve caregivers’ decisions and patients’ outcomes. Once patients experience the benefits of this technology, they will demand nothing less from their providers. Hundreds of thousands of physicians have already seen these benefits in their clinical practice.</div></blockquote><div class="PlainText"> I think it fair to say those are grandiose statements and predictions presented with a tone of utmost certainty in one of the world's most respected scientific medical journals.  Even though it is a "perspectives" article, I once long ago learned that in writing in esteemed scientific journals of worldwide impact, statements of certainty were at best avoided, or if made should be exceptionally well referenced. I note the lack of footnotes showing the source(s) of these statements. Another bona fide example of "coming on too strong": <blockquote class="tr_bq">“We have the capacity to transform health with one thunderous click of a mouse after another,” said (former) HHS Secretary Michael Leavitt - <a href="http://www.himss.org/ASP/ContentRedirector.asp?ContentId=65039&type=HIMSSNewsItem">2005 HIMSS Summit</a> </blockquote> <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/AVvXsEi81rMzS-WFiPrb91_Guccc9_kcbOUplIvRl6eAqyOYRwvsQoibE1PA5rhERJ-q54ZC1TCcdeuJH1o7Ecm_5F5wI4yqIzw4j7xvllLz7pS9-fYIc6we-mJokTLmpLZsggAjGOMJS-veYpb3/s1600/lightning.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi81rMzS-WFiPrb91_Guccc9_kcbOUplIvRl6eAqyOYRwvsQoibE1PA5rhERJ-q54ZC1TCcdeuJH1o7Ecm_5F5wI4yqIzw4j7xvllLz7pS9-fYIc6we-mJokTLmpLZsggAjGOMJS-veYpb3/s1600/lightning.jpg" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">We shall transform health (into what, exactly, is not specified) one thunderous mouse click after another!</td></tr></tbody></table></div> It doesn't get any stronger than that, unless, perhaps, the thunderous wrath of God is invoked. Back to the Inquirer once again: <blockquote class="tr_bq">"His refusal to temper his message makes it sometimes difficult to hear," said Ross Koppel, a University of Pennsylvania sociologist and digital health record skeptic.</blockquote> As per a recent article by Joe Conn in Modern Healthcare entitled "Health IT Iconoclasts" (<a href="http://hcrenewal.blogspot.com/2013/02/modern-healthcare-health-it-iconoclasts.html" target="_blank">link</a>), which wrote of Dr. Koppel, Deborah Peel, Lawrence Weed and me, Dr. Koppel has firsthand experience at his message being found "difficult to hear" by the hyper-enthusiasts: <blockquote class="tr_bq">... Researcher Ross Koppel started an uproar in 2005 when he and a colleague coauthored an article in the Journal of the American Medical Association that found a first-generation computerized physician order entry system (CPOE) at the Hospital of the University of Pennsylvania was simultaneously creating new errors even as it reduced others. Koppel’s bombshell—he’s now an adjunct professor of sociology at the University of Pennsylvania— brought down the wrath of information technology boosters. The Healthcare Information and Management Systems Society, a health IT trade group, challenged the study’s “methodology and its subsequent outcomes,” and criticized its authors for their “limited view” and not “looking at the big picture.”  [Others wrote that his work was 'disingenuous', although it had similar findings to my own observation of the very same CPOE system at Yale-New Haven Hospital ... in 1992 - ed.] ... In 2009, he revealed in another JAMA article that health IT vendors’ contracts included “hold harmless” clauses that shielded software developers from legal liability for medical errors their systems caused, even if the developers had been warned about the defects. “That got me major upheaval,” the worst of his career, Koppel recalls.</blockquote> Koppel, a sociologist, has probably done more for health IT transparency and safety than the physicians of the entire academic medical and medical informatics community combined. <blockquote class="tr_bq">... But Silverstein says his position today is the same as it has always been. He believes in the potential power of electronic records for good, he says. But any doctor who feels bound by the Hippocratic oath's injunction to "first, do no harm," he adds, should balk at what's going on. "Patients are being harmed and killed as a result of disruptions to care caused by bad health IT," he said. "I'm skeptical of the manner and pace" of implementation, "not of the technology itself. . . . My only bias is against bad medicine. And my bias is against people with complacent attitudes about bad medicine."</blockquote> The issues are actually relatively simple, using terminology coined by <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhGiHKiF08nosKVU7uTAYFAuZg0tzy09D_tVjFrfb2sJmv6LrJlm_Pv-vazJeH5joFN8HbBEAGFJRgS9EIIr5grSxultREvX8Uycje6Tgf0cYzN6BfLqgbHbKFxor9o14guSy_qimQdUwou/s1600/jon_IMG_1038a.jpg" target="_blank">Dr. Jon Patrick of U. Sydney</a> at the aforementioned HIC2012 meeting in Australia during our discussions.  Bad health IT must be removed from the market, and good health IT must replace it. <blockquote class="tr_bq">Good Health IT ("GHIT") is defined as IT that provides a good user experience, enhances cognitive function, puts essential information as effortlessly as possible into the physician’s hands, keeps eHealth information secure, protects patient privacy and facilitates better practice of medicine and better outcomes. Bad Health IT ("BHIT") is defined as IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.   </blockquote>   It is this author's opinion that this change will not happen by "going along to get along" or "listening to all the voices in the discussion of the subject" (especially those with Big Money and Big Lobbyists behind them) while doing nothing. I also note that "complacent attitudes about bad medicine" are not the sole province of IT personnel or healthcare management.  Physicians and nurses who acquiesce to bad health IT are part of the problem. -- SS

Kaiser Health News/Philadelphia Inquirer on InformaticsMD: "The flaws of electronic records"

At my Dec. 2012 post " How an interview for Kaiser Health News rekindled memories of health IT dysfunction in the 90's that persist...

Đọc thêm »

My Presentation to the Health Informatics Society Of Australia: "Critical Thinking on Building Trusted, Transformative Medical Information: Improving Health IT as the First Step"

In early 2011 I was invited to present at the annual convention of the <a href="http://www.hisa.org.au/" target="_blank">Health Informatics Society of Australia </a>(HISA) by its CEO, Louise Schaper, PhD.  HISA was aware of my writings and thought a presentation at their conference would be of interest to the Australian informatics and healthcare governance community. Dr. Schaper wrote: <blockquote class="tr_bq">From: Louise Schaper Sent: Thursday, March 24, 2011 10:50 AM To: Scot Silverstein Subject: HIC invitation to deliver a keynote presentation Hi Scot, I trust this email finds you well and I hope spring is bringing you some warmer weather and cheer. I wanted to let you know that the Health Informatics Conference committee met recently and expressed a high level of interest in having you deliver a keynote address at HIC and also to form part of a panel presentation.  I know you may not be able to make a commitment to come to Australia in August, but I wanted to let you know what we would love to have you, if circumstances permit you being here.  I’m confident we could have your trip sponsored (providing you don’t mind spending some face-time with the sponsoring organisation) and generate some media coverage around your visit. The preliminary program will be advertised in the next few weeks and at the moment I’m leaving a ‘spot’ for you in the hope that you may be able to join us.  I know you are in difficult and upsetting circumstances so please know that I’m not intending to add to any pressure – I just wanted to let you know that we would be honoured if you are able to deliver an address at HIC this year and I will keep a speaking spot reserved for you if you think you may be able to accept our invitation. Thanks for your time Scot.  I look forward to hearing from you. Kindest regards, Louise</blockquote> Sadly, the "difficult and upsetting circumstances" she mentioned were my involvement in caring for my mother, seriously injured in May 2010 in a healthcare information technology-related medical misadventure and, by this time, dying. I was thus unable to attend. My mother<a href="http://www.findagrave.com/cgi-bin/fg.cgi?page=gr&GRid=88446972" target="_blank"></a> <a href="http://hcrenewal.blogspot.com/2011/06/my-mother-passed-away.html" target="_blank">passed away</a> June 6, 2011 of her injuries. In January 2012, Dr. Schaper was gracious enough to re-invite me to the annual 2012 conference in Sydney.  I accepted. I attended <a href="http://www.hisa.org.au/page/hic2012/" target="_blank">HIC 2012</a>, held in the Darling Harbour Convention Centre in Sydney 30 July - 2 August 2012. <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/AVvXsEiWaQumA9bnkpcHhBU8MKD0wQmepK_Ff_pkUrwUn5RsdzU6gMtDCcSComDCL6LM-_3OhVxpFBfzQj3aBVvMmAHgLL_ZOqnnELJcKyAcpMq6FHbg6Q8trfGKOsJWChvkQWypa6bmqOxAEJRV/s1600/sydney_IMG_1099a.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiWaQumA9bnkpcHhBU8MKD0wQmepK_Ff_pkUrwUn5RsdzU6gMtDCcSComDCL6LM-_3OhVxpFBfzQj3aBVvMmAHgLL_ZOqnnELJcKyAcpMq6FHbg6Q8trfGKOsJWChvkQWypa6bmqOxAEJRV/s400/sydney_IMG_1099a.jpg" width="400" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">I enjoyed taking pictures like this with my trusty (and portable) Canon SX110 IS.  Click to enlarge.  More photos <a href="http://www.facebook.com/media/set/?set=a.4025347084034.2161136.1592238231&type=3&l=a25989ee6e" target="_blank">here</a>.</td></tr></tbody></table> My powerpoint slides for the presentation entitled "Critical Thinking on Building Trusted, Transformative Medical Information:  Improving Health IT as the First Step" are <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/HISA2012_Final.ppt" target="_blank">at this link</a>. <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/AVvXsEinCZFwCFISDK3ycGg0vjvj5b9c863NRP159A_d8cAi_rtzPyjh66R6knd8UFRf-tGAng31fM5hmjWu8Y6UZXuhoLYDUEcmpbWYzpWFF6cSmj8_4Tv0-wY76MVrD1MhjArEpCn_mNO4J9r9/s1600/convention_center_0729121059-00.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEinCZFwCFISDK3ycGg0vjvj5b9c863NRP159A_d8cAi_rtzPyjh66R6knd8UFRf-tGAng31fM5hmjWu8Y6UZXuhoLYDUEcmpbWYzpWFF6cSmj8_4Tv0-wY76MVrD1MhjArEpCn_mNO4J9r9/s400/convention_center_0729121059-00.jpg" width="400" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Darling Harbour Convention Centre, Sydney, Australia. Click to enlarge.</td></tr></tbody></table> Australia has embarked on a national <a href="http://www.nehta.gov.au/ehealth-implementation/what-is-a-pcher" target="_blank">Personally Controlled Electronic Health Record (PCEHR) project</a> under the auspices of Nehta, the <a href="http://www.nehta.gov.au/" target="_blank">National E-Health Transition Authority</a>.  I find this an interesting approach to national health IT; unlike the U.S., whose project is top-down (centrally controlled records), Australia seems to have learned from our mistakes and is initiating health IT as a bottom-up (patient-controlled) initiative. At the conference last week, I delivered a keynote address on the theme of improving health IT as an essential step in leveraging the capabilities of the technology. Being that I am anti-"bad IT" and pro-"good IT", implicit in my address was the issue of the technology's untrustworthiness in 2012, largely due to the unregulated free-for-all its market represents and the poor engineering that is the result. I also participated in a Panel Discussion led by Australian investigative journalist and popular political TV program host <a href="http://www.abc.net.au/tv/qanda/" target="_blank">Tony Jones</a>.  Mr. Jones hosts the Australian Broadcasting Corporation's "Q&A - Adventures in Democracy." <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/AVvXsEhSeK96cHUjMoamPlGqBBh34-upflUg4XEjcvrsQhxtLKeQj_pL73pgvfQI6h_F9LsSehtv58g4zsMcyVOVHgqSLLmnvbpuGZSn-_qA77q1T76bu-NjlU9ec7xSG0h4sgNtpLI9u6DB9PuC/s1600/scot_panel.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhSeK96cHUjMoamPlGqBBh34-upflUg4XEjcvrsQhxtLKeQj_pL73pgvfQI6h_F9LsSehtv58g4zsMcyVOVHgqSLLmnvbpuGZSn-_qA77q1T76bu-NjlU9ec7xSG0h4sgNtpLI9u6DB9PuC/s400/scot_panel.JPG" width="400" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Panel discussion moderated by Australian political commentator Tony Jones, who hosts the show "Q&A" on the Australian Broadcasting Corporation.  Click to enlarge.</td></tr></tbody></table> I will highlight several key points I made in my keynote and on the panel: <ul><li>Critical thinking is essential at all times in healthcare ... or your patient's dead.</li><li>Critical thinking is not mindless criticism; on the contrary, it is reflective, inquisitive, logical thinking that is focused on deciding what to believe or do.</li><li>Health IT must be trusted by users and patients [and be free of major downsides] - as a primary step before HIT can optimally benefit healthcare </li><li>I pointed out I am not suggesting anything new and that, in fact, I am suggesting something old:  "First, do no harm."</li><li>I pointed out the "revolutions" usually have downsides, and IT always produces winners...and losers (per the empirical research of <a href="http://rkcsi.indiana.edu/" target="_blank">Social Informatics</a>). </li></ul> <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/AVvXsEgPv_7EmRu2YtyP9cxNypfcaChsqerNMmjCXd-uI09od0RJU_Zktp0xI9EunbKc2LDOuBNh8Goc7viOA4MRC5LlZf0MLk0A9bYC_YS80j0l5_hSnRNZtoMavZ_eEWydN4H4u7Dk6BgjXWG_/s1600/me_presenting_1.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="291" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgPv_7EmRu2YtyP9cxNypfcaChsqerNMmjCXd-uI09od0RJU_Zktp0xI9EunbKc2LDOuBNh8Goc7viOA4MRC5LlZf0MLk0A9bYC_YS80j0l5_hSnRNZtoMavZ_eEWydN4H4u7Dk6BgjXWG_/s400/me_presenting_1.jpg" width="400" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Me presenting my keynote, driving home the point that IT on its own won't "revolutionize" healthcare; it is a tool to facilitate the true enablers of healthcare - clinicians - a point that should never be forgotten.  Click to enlarge. From the excellent multimedia piece on the conference <a href="http://www.youtube.com/watch?v=DZg_46wY0E0" target="_blank">at this link</a>.<a href="http://www.youtube.com/watch?v=DZg_46wY0E0" rel="nofollow nofollow" target="_blank"></a></td></tr></tbody></table> I then posed a series of questions of great relevance to understanding health IT realities.  Click to enlarge: <div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh-uFWvUdZ7PTw56nSsNDqoOIzOKbQMTNSkCWnge6Jw5jy9AOfTMdThxjDyse4rBY7U4pj8f7LIy4qeY47qG6b3D_9obbuPx-64XZ_R3At5AjaQ2eJtpmGGRIau2IsxpfpmO4WKw0r-g0QT/s1600/slide1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh-uFWvUdZ7PTw56nSsNDqoOIzOKbQMTNSkCWnge6Jw5jy9AOfTMdThxjDyse4rBY7U4pj8f7LIy4qeY47qG6b3D_9obbuPx-64XZ_R3At5AjaQ2eJtpmGGRIau2IsxpfpmO4WKw0r-g0QT/s400/slide1.jpg" width="400" /></a></div> <div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEguSttqZabxxoQiCzP7yl_9FMlW4rnT3ZUx8twTf_sbazNcDGy1VvW5AD2QVpiB9d7Rxutxc9EThK9yudU0GIgnu8pj87tk5xTGuQ8uekuXnqhnD997iwv2No8GIPQZ_ChffLyWFSXdV5yG/s1600/slide2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="298" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEguSttqZabxxoQiCzP7yl_9FMlW4rnT3ZUx8twTf_sbazNcDGy1VvW5AD2QVpiB9d7Rxutxc9EThK9yudU0GIgnu8pj87tk5xTGuQ8uekuXnqhnD997iwv2No8GIPQZ_ChffLyWFSXdV5yG/s400/slide2.jpg" width="400" /> </a> </div><div class="separator" style="clear: both; text-align: center;"> </div><div class="separator" style="clear: both; text-align: center;"> </div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhPbKHlg3AxGIQY_lDXaX3W8fcI437J7j9-ZVsKHA73pY54kZP-0-lFicIkLX2_E0iGZhHPxNLQSI4u_b9idCvIi39VSoO_giCa5T5b_k3ZwivLYeMLD42hdREkpli3DhDNbA3cJpKLBA3G/s1600/slide3.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhPbKHlg3AxGIQY_lDXaX3W8fcI437J7j9-ZVsKHA73pY54kZP-0-lFicIkLX2_E0iGZhHPxNLQSI4u_b9idCvIi39VSoO_giCa5T5b_k3ZwivLYeMLD42hdREkpli3DhDNbA3cJpKLBA3G/s400/slide3.jpg" width="400" /> </a></div><div class="separator" style="clear: both; text-align: center;"> </div><div class="separator" style="clear: both; text-align: center;"> </div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhFj5OyTIR1JrS5wAhg3S8L1upwQVP-0gcC41xQDZij5-4-Gdies1yLqqrvUmSYSeof8FOelUBTIumhMCTQTSceMp88svBZ_i9wDAWMvIaW2utox0lBIhyphenhyphenzFHVIC1tFsQFtjQUuEJJAyFZP/s1600/slide4.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhFj5OyTIR1JrS5wAhg3S8L1upwQVP-0gcC41xQDZij5-4-Gdies1yLqqrvUmSYSeof8FOelUBTIumhMCTQTSceMp88svBZ_i9wDAWMvIaW2utox0lBIhyphenhyphenzFHVIC1tFsQFtjQUuEJJAyFZP/s400/slide4.jpg" width="400" /></a></div><div class="separator" style="clear: both; text-align: center;"> </div><div class="separator" style="clear: both; text-align: center;"> </div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpCb_UzFD6Zxw7EECp2tTOj_AGFsBGuWOUNE0IH4dwDhDV0DKBRZEoiw4NdAuwtdsg6X4XBlu9X9LxELJ3UnXPJPRSaXnkRZrLnecHBBYPostxJpYoeCKszw4-s3-Qs0DdAt9eePf1W6Ay/s1600/slide5.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="298" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpCb_UzFD6Zxw7EECp2tTOj_AGFsBGuWOUNE0IH4dwDhDV0DKBRZEoiw4NdAuwtdsg6X4XBlu9X9LxELJ3UnXPJPRSaXnkRZrLnecHBBYPostxJpYoeCKszw4-s3-Qs0DdAt9eePf1W6Ay/s400/slide5.jpg" width="400" /></a></div><div class="separator" style="clear: both; text-align: center;"> </div><div class="separator" style="clear: both; text-align: center;"> </div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitCex1mQm8nkOlg7pSBqCoEqn6CRp4NMqum4pm8vWLFyj2jJMLSMRQSrs7w3zGw5yg34KkpLGP10uBexfKCHNfczJkYEzGmwKms7eQP0yX-ylLWr777G4n40FpZKS1VYBI2Lymyz8F2DG-/s1600/slide6.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="298" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitCex1mQm8nkOlg7pSBqCoEqn6CRp4NMqum4pm8vWLFyj2jJMLSMRQSrs7w3zGw5yg34KkpLGP10uBexfKCHNfczJkYEzGmwKms7eQP0yX-ylLWr777G4n40FpZKS1VYBI2Lymyz8F2DG-/s400/slide6.jpg" width="400" /></a></div><div class="separator" style="clear: both; text-align: center;"> </div> I left it to the audience to answer these questions. I then posed the question "Is health IT being done well?" I provided links to various evidence that it was not, such as the <a href="http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572" target="_blank">National Research Council 2009 report</a> on health IT; AMIA's report on its <a href="http://hcrenewal.blogspot.com/2009/03/health-it-project-success-and-failure.html" target="_blank">workshop on healthcare IT failure</a>, the 2012 U.S. <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/Patient%20Safety%20and%20Health%20IT%20prepub.pdf" target="_blank">IOM report on safety</a>, the 2012 U.S. <a href="http://www.nist.gov/healthcare/usability/upload/Draft_EUP_09_28_11.pdf" target="_blank">NIST report on usability</a>, work by <a href="http://sydney.edu.au/engineering/it/%7Ehitru/index.php?option=com_content&task=view&id=91&Itemid=146" target="_blank">Australian Professor Jon Patrick of U. Sydney</a> on health IT defects, and other sources as aggregated <a href="http://hcrenewal.blogspot.com/2011/02/updated-reading-list-on-health-it.html" target="_blank">at this link</a>. Again, I did not impose views on the audience.  I didn't need to, as that corpus speaks for itself. I also clarified terminology that reduces essential caution, such as the terms "electronic medical record" (EMR) and "electronic health record" (EHR) - a source of endless, wasted contention on definitions of which is which - being anachronisms from an earlier age of IT.  I pointed out that in 2012 what these innocuous terms somewhat deceptively and disarmingly represent are in reality complex enterprise clinical resource management and clinician workflow control systems – where many, many things can go wrong. <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/AVvXsEhZumc0y9_28FXWfsMcfOZqyJHKP9kdpAvJtKu8gq5MYqMOko6WQ3rD5TH_C0OiNEi9JTfP7ELdGbN_PllfwHjkE1kgDP1xEoti46ZeQ_xLs0tw3IQI5x4FK4o8Y-nmfvl_FxRgJncN0KpR/s1600/slide7.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZumc0y9_28FXWfsMcfOZqyJHKP9kdpAvJtKu8gq5MYqMOko6WQ3rD5TH_C0OiNEi9JTfP7ELdGbN_PllfwHjkE1kgDP1xEoti46ZeQ_xLs0tw3IQI5x4FK4o8Y-nmfvl_FxRgJncN0KpR/s400/slide7.jpg" width="400" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">"EHR":  an innocuous "file cabinet" for records, or something else entirely?  Click to enlarge.</td></tr></tbody></table> I asked if case reports of health IT unintended consequences (UC’s) were “anecdotal” and to be played down, while studies of health IT benefits to date solid science.  I then asked if the reality might be that studies of health IT benefits to date were mostly anecdotal (e.g., in specialized settings; weak observational studies vs. randomized clinical trials) while reports of UC’s <a href="http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html" target="_blank">are risk management-relevant incident report “red flags”</a> pointing to possible systemic problems. I pointed out the common seller marketing memes of beneficence and deterministic efficacy, and asked if these were realistic.  I also pointed out the need for transparency about HIT risks, and the impediments to this transparency. Finally, I indicated what was the likely problem affecting all countries involved in EHR projects: that the rigor, ethics and skepticism of medical science itself not applied in the domain of health IT. I suggested a simple solution:  a paradigm shift in thinking about health IT as another medical device, that needed to be subject to the same methodologies and ethical considerations applicable for decades (or more) in the healthcare delivery sector such as medical devices, pharmaceuticals, and research (and other risk-prone industries e.g., aviation and automotive). My goal was to provoke thinking about these issues, to circumvent blank, uncritical acceptance of industry and industry-supporter memes. I believe I succeeded.  Feedback I received was that the audience, including government officials, found many new things to consider as they embark on their national health IT projects. I also heard that some HIT seller representatives were squirming a bit.  That was not unexpected.  I was taking "control of their message" away from them. <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/AVvXsEhGiHKiF08nosKVU7uTAYFAuZg0tzy09D_tVjFrfb2sJmv6LrJlm_Pv-vazJeH5joFN8HbBEAGFJRgS9EIIr5grSxultREvX8Uycje6Tgf0cYzN6BfLqgbHbKFxor9o14guSy_qimQdUwou/s1600/jon_IMG_1038a.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhGiHKiF08nosKVU7uTAYFAuZg0tzy09D_tVjFrfb2sJmv6LrJlm_Pv-vazJeH5joFN8HbBEAGFJRgS9EIIr5grSxultREvX8Uycje6Tgf0cYzN6BfLqgbHbKFxor9o14guSy_qimQdUwou/s400/jon_IMG_1038a.jpg" width="400" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">University of Sydney Professor Jon Patrick presenting on computational linguistics.   Jon is the author of a treatise on health IT defects (at <a href="http://sydney.edu.au/engineering/it/%7Ehitru/index.php?option=com_content&task=view&id=91&Itemid=146" target="_blank">this link</a>), mentioned numerous times on this blog.  Dr. Patrick graciously hosted me at his Sydney home for several days after the conference and he and his wife gave me a wonderful tour of the city.  Click to enlarge.</td></tr></tbody></table> Finally, I had a question from the audience, from fellow blogger <a href="http://thehealthcareblog.com/blog/category/matthew-holt/" target="_blank">Matthew Holt of the Health Care Blog</a>.  (I've had some online debate with him before, such as in the comment thread at my April 2012 post <a href="http://hcrenewal.blogspot.com/2012/04/allscripts-shares-plunge-on-weak.html" target="_blank">here</a>.) Matthew asked me a somewhat hostile question (perhaps in retaliation for the thrashing he received at the end of my May 2009 post on the WaPo's HIT Lobby article <a href="http://hcrenewal.blogspot.com/2009/05/machinery-behind-healthcare-reform-how.html" target="_blank">here</a>), that I was well prepared for, expecting a question along these lines from the seller community, actually.  The question was preceded by a bit of a soliloquy of the "You're trying to stop innovation through regulation" type, with a tad of Merck/VIOXX ad hominem thrown in (I ran Merck Research Labs' Biomedical libraries and IT group in 2000-2003). His question was along the lines of - you were at Merck; VIOXX was bad; health IT allowed discovery of the VIOXX problem by Kaiser several years before anyone else; you're trying to halt IT innovation via demanding regulation of the technology thus harming such capabilities and other innovations. The audience was visibly unsettled.  Someone even hollered out their disapproval of the question. My response was along the lines that: <ul><li>VIOXX was certainly not Merck at its best, but regulation didn't stop Merck from "revolutionizing" asthma and osteoporosis via Singulair and Fosamax;</li><li>That I'm certainly not against innovation; I'm highly pro-innovation;</li><li>That our definitions of "innovation" in medicine might differ, in that innovation without adherence to medical ethics is not really innovation.  It is exploitation.</li></ul> (I forgot to mention that I gave an invited presentation to Merck's Drug Surveillance department in 2006, PPT <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/silverstein_merck_informatics_nov2006.ppt" target="_blank">here</a>, long after I was their employee, on the potential use of EHR data to detect drug adverse events sooner than traditional phase IV studies or ad-hoc reporting allowed.) When I spoke of medical innovation requiring ethics, nearly the full audience at my keynote address - hundreds of people - broke out in applause. <div class="O"><div style="mso-char-wrap: 1; mso-kinsoku-overflow: 1; mso-line-spacing: "100 20 0"; mso-margin-left-alt: 216;">•</div></div>I knew at that point that my talk was a success. <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/AVvXsEhEK2U60to_tB_kXJTSf-Qe5ZaNpx9W1QcfYdeVVUzfgg9vdWregrtDUXPVsD6jdwSqMw_stc3jSUIQBxskqnK83HsNBcQ5WgC1MKocdAnrl_OABrk9RSJ4PXDJOcgG_gprdRB3kiIItMRb/s1600/Louise_Scot_HIC2012_080212.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhEK2U60to_tB_kXJTSf-Qe5ZaNpx9W1QcfYdeVVUzfgg9vdWregrtDUXPVsD6jdwSqMw_stc3jSUIQBxskqnK83HsNBcQ5WgC1MKocdAnrl_OABrk9RSJ4PXDJOcgG_gprdRB3kiIItMRb/s320/Louise_Scot_HIC2012_080212.jpg" width="240" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">This author with HISA CEO Louise Schaper , PhD. Click to enlarge.</td></tr></tbody></table> More photos of my trip are <a href="http://www.facebook.com/media/set/?set=a.4025347084034.2161136.1592238231&type=3&l=a25989ee6e" target="_blank">here</a>. -- SS Addendum:  Another added pleasure in my visit Down Under. As Australia and the U.S. respect each other's amateur radio licenses, I was able to operate my handheld radio as "KU3E portable Victor-Kilo." VK is the international radio prefix for Oz.  Contacting Australia from the U.S. is considered a "holy grail" of ham radio.  It was interesting to hear amateur radio "from the other end." <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/AVvXsEgLNBtEIJGKFAAofrv5VhAkUXCgQjPqCfV3aD9E1JI5XmIPE-TwuVC09JJB_Eat7S0tMY3QgeDD2gNiKu1XtJn2lNSrjn91D6BURD6nhahGjbh3HVWTs0XoESuw-9Pr1tuX88OeL_XLNTlK/s1600/vx3.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgLNBtEIJGKFAAofrv5VhAkUXCgQjPqCfV3aD9E1JI5XmIPE-TwuVC09JJB_Eat7S0tMY3QgeDD2gNiKu1XtJn2lNSrjn91D6BURD6nhahGjbh3HVWTs0XoESuw-9Pr1tuX88OeL_XLNTlK/s200/vx3.jpg" width="110" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Yaesu VX-3 Multiband Transceiver</td></tr></tbody></table> -- SS Aug. 11, 2012 Addendum: An excellent multimedia video of HIC 2012 produced as the conference proceeded has been posted on YouTube at <a href="http://www.youtube.com/watch?v=DZg_46wY0E0">http://www.youtube.com/watch?v=DZg_46wY0E0</a>.  It was finished and shown immediately after the conference's conclusion. -- SS

My Presentation to the Health Informatics Society Of Australia: "Critical Thinking on Building Trusted, Transformative Medical Information: Improving Health IT as the First Step"

In early 2011 I was invited to present at the annual convention of the Health Informatics Society of Australia (HISA) by its CEO, Louise Sch...

Đọc thêm »

The Machinery Behind Healthcare Reform: How the HIT Lobby is Pushing Experimental and Unsafe Technology on Unconsented Patients and Clinicians

(To those who linked here from "<a href="http://www.thehealthcareblog.com/the_health_care_blog/2009/05/microsoft-google-in-healthy-competition---cnet-news.html">The Health Care Blog</a>", see my footnote at the end of this post. Also, I suggest readers at least peek at each and every hyperlink I've placed in this essay. It takes time, but it's illuminating - ed.) <div><div> In many past posts on Healthcare Renewal I have commented on a bewildering healthcare and IT industry blindness to a growing body of literature and experiences of those "in the trenches" that throw doubts upon Utopian views of health IT as a panacea for healthcare's problems. Those responsible for this literature advise caution and the highest levels of scientific rigor in the large scale adoption of clinical information technology if that technology is to actually improve healthcare, myself included. We know the difficulties and risks. Bad healthcare informatics wastes money and distracts clinicians. <a href="http://iig.umit.at/efmi/badinformatics.htm">Bad healthcare informatics can kill</a>. "Primum non nocerum" is a critical ideology in health IT. I first wrote about these observations <a href="http://www.tinyurl.com/hit-misadventure">a decade ago</a> and was merely standing on the shoulders of those who preceded me with their own critical thoughts and observations regarding cybernetic miracles in medicine. I've also been puzzled about the sudden lurch by the current administration to commit tens of billions of dollars to national HIT, along with eventual penalties for resistance, within the ridiculously short time frame of 2014 and with little public discussion. The provisions seemed to simply "appear" in H.R. 1 EH, a.k.a. the Economic Recovery Act of 2009. I wrote about this <a href="http://hcrenewal.blogspot.com/2009/02/illusions-of-hope-over-experience.html">here</a>. Finally, I was curious about the timing of a remarkable set of reports from highly respected U.S. organizations on HIT issues, such as a Dec. 2008 Sentinel Events Alert from the <a href="http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm">Joint Commission</a> and a Jan. 2009 report from the <a href="http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572">U.S. National Research Council</a>. What motivated their release? The answers to these questions have become bit clearer via a remarkable article from the Washington Post. It reveals an administration heavily influenced by - no surprise - powerful industry lobbyists. (I thought this administration had pledged a different mode of government conduct, but as has been said, campaigning is done with poetry, and governing is done with prose.) Here is an interesting explanation of how medicine has been cross-occupationally invaded by the IT industry, probably ten or more years before that industry really has the depth of understanding, depth of talent and capabilities to make useful, usable, safe, and cost effective national health IT a reality: <blockquote><a href="http://www.washingtonpost.com/wp-dyn/content/article/2009/05/15/AR2009051503667.html?hpid=topnews">The Machinery Behind Health-Care Reform</a> How an Industry Lobby Scored a Swift, Unexpected Victory by Channeling Billions to Electronic Records By Robert O'Harrow Jr. Washington Post Staff Writer Saturday, May 16, 2009 When President Obama won approval for his $787 billion stimulus package in February, large sections of the 407-page bill focused on a push for new technology that would not stimulate the economy for years. The inclusion of as much as $36.5 billion in spending to create a nationwide network of electronic health records fulfilled one of Obama's key campaign promises -- to launch the reform of America's costly health-care system. But it was more than a political victory for the new administration. It also represented a triumph for an influential trade group whose members now stand to gain billions in taxpayer dollars. A Washington Post review found that the trade group, the Healthcare Information and Management Systems Society (HIMSS), had worked closely with technology vendors, researchers and other allies in a sophisticated, decade-long [lobbying] campaign to shape public opinion and win over Washington's political machinery ... At the center of those efforts is the Healthcare Information and Management Systems Society. Started a half-century ago, it represents 350 companies and about 20,000 members. Corporate members include government contractors such as Lockheed Martin and Northrop Grumman, health-care technology giants such as McKesson, Ingenix and GE Healthcare, and drug industry leaders, including the Pharmaceutical Research and Manufacturers of America. With financial backing from the industry, they started advocacy groups, generated research to show the potential for massive savings and met routinely with lawmakers and other government officials.</blockquote> A lot of voices were left out of that trade group's lobbying, including the open source EHR proponents following the traditions of the <a href="http://www.va.gov/cprsdemo/">VistA effort</a>, as one can learn about in the book "<a href="http://www.amazon.com/Medical-Informatics-Electronic-Collaboration-Innovation/dp/0763739251">Medical Informatics 20/20</a>" by VA pioneers Goldstein, Groen et al. These traditions are largely alien to the commercial IT sector as evidenced by the mission hostile clinical IT products they put out (see my series on that issue <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-idiots-part-1.html">starting here</a>) and even known <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/DUCOM_EMR_Complaint.pdf">grossly defective software</a> for use on live patients. The HIMSS trade group's massive conflicts of interest also seem to have blinded it to the longstanding concerns of many experts in medical informatics, social science and related fields that <a href="http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572">current approaches to health IT are insufficient</a> and may impair healthcare quality initiatives (let's be frank about what that really means - it means patient harm). The creation of advocacy groups backed by industry financing also seems eerily similar to many stories on HC Renewal and other blogs about the pharmaceutical industry, as does "generated research." That "research" may also have been industry funded, and it is my belief the impartiality and soundness of such research needs to be critically and impartially re-examined. <blockquote>Their proposals made little headway in Congress, in part because of the complexity of the issues and questions about whether the technology and federal subsidies would work as billed. </blockquote>In other words, Congress was doing its job regarding lobbying by proponents of an experimental technology in which they had a major financial stake. Until... <blockquote>As the downturn worsened last year, advocates helped persuade Obama's advisers to dust off [i.e., uncritically accept lock, stock and barrel - ed.] electronic records legislation that had stalled in Congress -- legislation that the advocates had a hand in writing, the Post review found. Their sudden success shows how the economic crisis created a remarkable opening for a political and financial windfall: the enactment of a sweeping new policy with no bureaucratic delays and virtually no public debate about an initiative aimed at transforming a sector that accounts for more than a sixth of the American economy.</blockquote> Let me add that while the advocates "had a hand" in writing the legislation [i.e., they wrote the legislation - ed.], researchers and critical thinkers regarding the downsides of health IT industry in its present state seem to have had little voice in this legislation. <blockquote>"It was perhaps a once-in-a-generation opportunity to make something happen," said H. Stephen Lieber, the trade group's president. Obama "identified the vehicle that he could use to move his policy agenda forward without the crippling policy debate."</blockquote> I find this simply outrageous. The reason for policy debates in healthcare and especially healthcare IT is to avoid crippling or killing patients. Lieber is not a clinician. Who is he to cheer (and perhaps to have spearheaded) the short circuiting of "policy debate" on health IT? According to his <a href="http://www.himss.org/Content/files/SLieber_bio.pdf">bio</a>, he holds an MA from the School of Social Service Administration at the University of Chicago, a BA in Psychology from the University of Arkansas, and has completed additional course work at the graduate schools of business at both universities and at the Keller Graduate School of Management. <blockquote>... Many technology advocates, including health policy specialists, say that networked electronic patient records that can be transmitted instantly would make health care more efficient and provide valuable insights about costs and care.... Some advocates also say the savings could amount to tens of billions of dollars each year from reduced paperwork, faster communication and the prevention of harmful drug interactions. An equally important benefit, they say, could be to enable researchers to determine the most effective procedures for an ailment. Such an approach would rely on unprecedented data-mining into medical records and the practices of doctors, a kind of surveillance that also would enable insurers to cut costs by controlling more precisely the care that patients receive [Leading to rationing to increase profits? - ed.]</blockquote> These assertions have never been proven in a scientifically robust manner. Further, there is a growing body of literature expressing significant doubts about these predictions of cybernetic miracles from health IT (see short partial lists of examples <a href="http://hcrenewal.blogspot.com/2009/03/reader-on-why-we-have-busywork.html">here</a> and <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=other">here</a>) that has largely been ignored - in the worst traditions of pseudoscience and scientific fraud - by the industry and its lobbyists. In fact, the latter assertion - comparative effectiveness research based on EHR data - may have moved from scientific possibility (e.g., better detection of major adverse drug and therapy events) to anti-scientific pipe dream, as in my essay "<a href="http://hcrenewal.blogspot.com/2009/04/have-we-suffered-complete-breakdown-in.html">Have we suffered a complete breakdown in the scientific method with regard to EHR and clinical IT?</a>" I am not even considering massive potential for abuses created by online national health records. <blockquote>"Finally, we're going to have access to millions and millions of patient records online," said Blackford Middleton, a physician, Harvard professor and chairman of the Center for Information Technology Leadership, whose studies have concluded the health-care system could save $77.8 billion each year through the universal use of information technology networks. "This is the biggest step for health-care information technology in this country's history." But others said the case was far from being so clear. Some observers said the projected savings are overly optimistic and that launching such vast computer networks under tight deadlines is risky, a lesson learned by the Bush administration when it botched a variety of homeland security systems rushed into place after the Sept. 11 terrorist attacks. </blockquote> While I respect Blackford Middleton as a former leader of the EHR company from which I selected the EHR for Christiana Care Health System in the late 1990's, I also respect those "others" who say the case is far from clear. It is through science and an open political process that such debates need to be resolved, not through lobbying and utopianism. The potential for adverse, unexpected consequences in such a major social re-engineering effort are simply too great for cavalier attitudes or utopianism. We are already seeing adverse consequences - just the most recent examples are <a href="http://hcrenewal.blogspot.com/2009/05/dangerous-health-it-mismanagement-spin.html">here</a> and <a href="http://hcrenewal.blogspot.com/2009/05/medical-cyber-piracy.html">here</a>. Industry "roll out HIT no matter what, patient and clinician <a href="http://hcrenewal.blogspot.com/2009/03/draft-patient-rights-statement-and.html">informed consent</a> be damned" attitudes also teeter on the precipice of human rights violation. In fact, the corporatization of health IT and the treatment of health IT as if it were any other IT not involving third parties with special rights (i.e., patients) may have already resulted in serious breaches of hospital executive fiduciary responsibilities towards safety and (in the U.S.) of their Joint Commission safety standards obligations as well; see my essay <a href="http://hcrenewal.blogspot.com/2009/03/health-it-hold-harmless-and-defects-gag.html">here</a>. <blockquote>Some proponents said they worry that an over-reliance on technology as a solution could distract the health-care system from difficult questions about quality of care. They said efforts to find a quick technological fix will likely run up against complex cultural challenges.</blockquote> The latter quote sounds like me, stating the obvious. Allow me to translate the applied, real world meaning of "cultural challenges." It means increased political infighting between stakeholders, power grabs, distractions and chaos on the medical floor and in the medical office, and other social and political upheavals within medicine that will likely distract from the ability of already harried clinicians to provide care. <blockquote>"I would like to believe that the effective use of technology to augment health care will lead to substantial savings and improvements in the quality of care," said Mark Frisse, a physician and professor of biomedical informatics at Vanderbilt University, who leads an electronic health record program in Nashville. "But the evidence does not consistently bear this out."</blockquote> Dr. Frisse is quite correct, although I would add that the evidence that does not bear out these beliefs is many, many times stronger than that which, say, caused VIOXX to be pulled off the market. <blockquote> "HIMSS has a very effective grass roots advocacy program that reaches all levels of government," Dave Roberts, a senior executive, said in the group's literature... HIMSS has a "strategic alliance" with the Center for Information Technology Leadership, a nonprofit that produces research reports -- which HIMSS prints and distributes to Congress and elsewhere.</blockquote> I agree with that description. Missing from the description, and one I would not add, is a "scientific organization." <blockquote>After volunteering on John Kerry's presidential campaign in 2004, [now-chairman of the board of HIMSS and their ally, the Center for Information Technology Leadership] Middleton said he was recruited as an Obama volunteer last year and provided information about electronic records to the candidate's health-care policy group. Middleton said he worked with several campaign officials, including David Blumenthal, a colleague at Partners HealthCare and a Harvard professor, who was Obama's health-care adviser and is now the administration's national coordinator for health technology. "We didn't have to go very far to get our information," said one senior Obama adviser, who was not authorized to speak publicly and discussed the campaign on the condition of anonymity. Blumenthal "taught all the rest of us everything we know."</blockquote> He may have taught them "everything they know", but he apparently did not teach them everything that is important to know. Obama's team has seemingly thrown a significant body of literature on HIT drawbacks and risks under the bus. This is the essence of scientific naïveté and quackery. <blockquote>Middleton said he provided many of those details. "I sent them a LOT of stuff, many papers and most of the reports. I probably spoke or communicated with David Blumenthal, David Cutler (the health economist on the team), or Dora Hughes about every other week during the heat of the campaign," Middleton said in an e-mail. </blockquote> While Blumenthal goes on in the article to minimize Middleton's influence, I can only wonder if any of the HIT industry lobbyists sent "<a href="http://iig.umit.at/efmi/badinformatics.htm">this stuff</a>" to the campaign. <blockquote>The stimulus bill suggests that the government will recoup about a third of the spending allocated for electronic health records over the next decade, an assumption that some health-care observers question, in part because of a critical analysis by the Congressional Budget Office last year. The CBO, then led by Orszag, examined the industry-funded study behind the $77.8 billion assertion, among other things, and concluded that it relied on "overly optimistic" assumptions and said much is unknown about the potential impact of health information technology.</blockquote> I can add that not only is there much unknown about the potential, but there is much unknown about the true difficulties of making it all actually work as promised. See <a href="http://www.ctlab.org/documents/Hiding%20in%20plain%20sight.pdf">this seminal short article</a> on why this is so. This is a spectacularly poor way to run major national initiatives costing tens of billions of dollars and upon which patient wellbeing rides. Blindly. <blockquote>Joseph Antos, a health-care policy specialist who has examined the legislation, said the risks of the technology plan are high because of the haste with which it is being implemented and the special interests seeking to profit from it. "This is the real way things get done [and the "real" way true disasters such as our recent world wide financial chaos get initiated - ed.]," said Antos, of the American Enterprise Institute, a Washington think tank. "The stimulus bill looked like a bonanza to an awful lot of people." [I tend to take "awful lot of people" quite literally in this case.]</blockquote> Haste is an understatement. A more reasonable timeframe might have been <a href="http://www.jamia.org/cgi/content/abstract/13/1/106">2024</a>, not 2014. I can add that if this initiative blows up as it has in the UK, then the only triumph will be the financial triumph of the trade group and its apparatchiks. The losers will be the administration, patients, clinicians, and everyone else in the healthcare system. [6/29/09 addendum: it's worse than I thought. The UK's NPfIT in the NHS was suspected to have been doomed from the start, but proceeded anyway; see "<a href="http://www.computerweekly.com/blogs/tony_collins/2009/06/16-key-points-in-gateway-revie.html">16 key points in Gateway Reviews on NHS IT scheme</a>" and the <a href="http://www.connectingforhealth.nhs.uk/about/foi">Gateway Reviews themselves</a>, released under a UK FOI request - ed.] In all seriousness, and with recognition of the harshness of this observation, I add that the patients who might die as a result of hastily and poorly designed and implemented health IT under this rushed "real way" initiative, will have in effect been murdered by this lobby. -- SS Footnote: It is interesting to watch the "circling of the wagons" that is starting over the WaPO story. It is in fact predictable that ad hominem, distortion of views, etc. will follow. For example, Matthew Holt of The Health Care Blog, <a href="http://www.thehealthcareblog.com/the_health_care_blog/2009/05/microsoft-google-in-healthy-competition---cnet-news.html">who writes</a> (emphases mine): <blockquote>I draw your attention to a troika of articles, all of which show how things can be slightly misinterpreted. First, who knew that Blackford Middleton was either the most influential health policy wonk out there, or single-handedly responsible for the Haliburtonization of health IT? If you read <a href="http://www.washingtonpost.com/wp-dyn/content/article/2009/05/15/AR2009051503667.html?sub=AR">the WaPo article about it</a>, it looks as though there was some kind of terrible conspiracy to impose an evil fraud in terms of unnecessary health IT spending on the taxpayer. And for example MedinfomaticsMD over at Health Care Renewal (who appears to have jumped from the position that some health IT installations have real problems to the less tenable one that all EMRs kill) is just one <a href="http://hcrenewal.blogspot.com/2009/05/machinery-behind-healthcare-reform-how.html">going loopy about it</a>.</blockquote> "Loopy?" Merriam-Webster: <blockquote><a href="http://www.merriam-webster.com/dictionary/loopy">Loopy</a>: 1 : having or characterized by loops 2 : <a class="lookup" href="http://www.merriam-webster.com/dictionary/crazy">crazy</a>, <a class="lookup" href="http://www.merriam-webster.com/dictionary/bizarre">bizarre</a> <div class="run_on" mwref="http://www.m-w.com/mwref">— loop·i·ly <a class="audio" href="http://www.merriam-webster.com/cgi-bin/audio.pl?loopi01v.wav=loopily%27" onclick=" popWin('/cgi-bin/audio.pl?loopi01v.wav=loopily'); return false; "><img alt=" Listen to the pronunciation of loopily" src="http://www.merriam-webster.com/images/audio.gif" title=" Listen to the pronunciation of loopily" /></a> \-pə-lē\ adverb </div><div class="run_on" mwref="http://www.m-w.com/mwref">— loop·i·ness <a class="audio" href="http://www.merriam-webster.com/cgi-bin/audio.pl?loopi02v.wav=loopiness%27" onclick=" popWin('/cgi-bin/audio.pl?loopi02v.wav=loopiness'); return false; "><img alt=" Listen to the pronunciation of loopiness" src="http://www.merriam-webster.com/images/audio.gif" title=" Listen to the pronunciation of loopiness" /></a> \-pē-nəs\ noun</div></blockquote><div class="run_on" mwref="http://www.m-w.com/mwref"> </div> Ad hominem (<a href="http://www.nizkor.org/features/fallacies/ad-hominem.html">link</a>) is no substitute for a logical argument, in fact it is a logical fallacy. Further, an over the top statement that I've "jumped to a less tenable position that all EMR's kill" is quite disappointing from someone who clearly has the intellect to know how amateurishly political an attack that is on a physician-informaticist in this field for almost two decades. One who is trying to take a strong pro-patient, ethical stance while balancing the need to develop safe and effective health IT along <a href="http://www.jamia.org/cgi/content/abstract/13/1/106">more reasonable timelines</a>, and without the behind-the-scenes corporate influence we write about at Healthcare Renewal. -- SS 2012 Addendum:  see the end of my post regarding my keynote presentation to the Health Informatics Society of Australia <a href="http://hcrenewal.blogspot.com/2012/08/my-presentation-to-health-informatics.html" target="_blank">at this link</a> for more on Matthew Holt's apparent disdain for my positions regarding HIT ethcs.</div></div>

The Machinery Behind Healthcare Reform: How the HIT Lobby is Pushing Experimental and Unsafe Technology on Unconsented Patients and Clinicians

(To those who linked here from " The Health Care Blog ", see my footnote at the end of this post. Also, I suggest readers at leas...

Đọc thêm »