healthy4u

YouTube Symphony Orchestra winners are announced

(Cross-posted from the <a href="http://www.youtube.com/blog?entry=Hc0bh6GiXlw">YouTube Blog</a>) Today we are proud to announce the winners of the world's first online collaborative orchestra. The global YouTube community and a judging panel containing members of the world's most renowned orchestras have selected over 90 talented musicians to be part of the YouTube Symphony Orchestra. Together, these professional and amateur musicians play 26 different instruments and come from 30+ countries and territories on six continents. To grasp the level of talent we’re talking about, just take a look at the stellar string section: <object height="385" width="480"><param name="movie" value="http://www.youtube.com/p/AE38CDDE6DAA23CC&hl=en"> <embed src="http://www.youtube.com/p/AE38CDDE6DAA23CC&hl=en" type="application/x-shockwave-flash" height="385" width="480"></embed></object> The selected musicians will travel from around the world to New York City to participate in a collaborative summit for classical music on April 12-15, 2009, concluding with a concert at Carnegie Hall under the direction of <a href="http://www.youtube.com/michaeltilsonthomas">Michael Tilson Thomas</a>, San Francisco Symphony Music Director, New World Symphony Founder and Artistic Director, and London Symphony Orchestra Principal Guest Conductor. All the winning audition videos are on the <a href="http://www.youtube.com/symphony">YouTube Symphony Orchestra Channel</a>; please share your congratulations with these musicians in the comments section, and don’t forget to stay tuned as we follow them on the road to Carnegie Hall. (If you’d like to cheer them on in person, tickets are on sale now at <a href="http://www.carnegiehall.org/article/box_office/events/evt_13015.html?selecteddate=04152009"> www.carnegiehall.org</a>.) Cue the congratulatory strings! Posted by Michele Flannery, YouTube Music

YouTube Symphony Orchestra winners are announced

(Cross-posted from the YouTube Blog ) Today we are proud to announce the winners of the world's first online collaborative orchestra. Th...

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Where Is Our Medical Leadership on the Death Traps Known as Misdesigned Healthcare IT?

In my series on health IT (<a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-idiots-part-1.html">starting here</a>) whose human engineering is ill conceived, philistine and presents clinicians with a mission hostile user experience, I have kept a neutral stance regarding the role of our so-called professional society representatives. If we were pilots or police officers or even bus drivers asked to use such seriously impaired devices, we and our unions would have declared war long ago. (I worked some years ago as Medical Programs Manager for the regional transit authority in Philadelphia, and say this quite confidently. <a href="http://www.twu.com/about/officers/lombardo.html">Mr. Lombardo</a> would likely agree.) Right next to my Feb. 18 <a href="http://online.wsj.com/article/SB123492035330205101.html">Wall Street Journal letter to the editor</a> on HIT was a letter from the President-elect of the American Medical Association, J. James Rohack, M.D. Dr. Rohack wrote to the WSJ (emphases mine): <blockquote style="font-family: arial;">You admit in your editorial "<a class="" href="http://online.wsj.com/article/SB123431432273870909.html">A Health-Tech Monopoly</a>" (Feb. 11) that electronic medical records "might do some actual good." We agree, and that is why we support the health information technology provisions of the economic stimulus bill. The economic stimulus bill being considered will create important national HIT interoperability standards. These standards are essential to achieve the promise HIT holds to help increase patient safety, improve care coordination and reduce unnecessary paperwork. As is true in other industries, basic standards will provide the essential foundation on which the private sector can build innovative commercial products. Competition and innovation are bedrocks of America's economic system, as they should be in health care. The HIT provisions in the bill maintain this vision, while building on existing federal efforts to encourage HIT adoption. This bill does not authorize the government to dictate clinical guidelines or national coverage decisions. Medical treatment decisions remain in the hands of physicians. The bill also provides physicians with significant financial assistance for HIT purchases. This critical support is needed so that physicians can make HIT purchases [why would they want to buy defective and hard to use cybernetic monstrosities at any price? - ed.], and patients can then begin to reap the benefit.</blockquote> Where's the innovation in vendor HIT products, whose user interaction even after decades of information science, computer science, biomedical informatics, HCI and other research looks like it was designed by high schoolers? Interoperability standards and financial incentives are, I'm going to venture to say, nearly irrelevant to the poor acceptance of HIT by the average physician in 2009. Our medical leaders seem to be becoming parrots, repeating the irrelevant (in the near term, to 'Joe the Doctor' and 'Rosie the RN') mantras about standards and interoperability, seeing the galaxy while missing the Black Hole whose event horizon they are nearing. Again, I speak from experience. When I was CMIO, we were getting quite good results from our HIT efforts at Christiana Care a decade ago, long before standards were as well formulated as today, for example as seen at the <a href="http://www.hhs.gov/healthit/chiinitiative.html">Consolidated Informatics Initiative</a> site at HHS. Completely lacking in this relatively milquetoast letter to the WSJ is the issue of the mission hostile user experience presented to clinicians by most current HIT applications, designed as inventory systems by MIS-inclined mindsets rather than as clinical tools (if you don't believe me, then believe the U.S. <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=NRC">National Academies</a> and National Research Council, and its informatics pioneers Stead and Barnett): <blockquote> 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. ... Most importantly, current health care IT systems offer little cognitive support; clinicians spend a great deal of time sifting through large amounts of raw data (such as lab and other test results) and integrating it with their medical knowledge to form a whole picture of the patient. Many care providers told the committee that data entered into their IT systems was used mainly to comply with regulations or to defend against lawsuits, rather than to improve care. As a result, valuable time and energy is spent managing data as opposed to understanding the patient</blockquote><o:p></o:p> I encourage clinicians injured and offended by the hostile products they are being coerced to use, organizationally and now nationally, to write to our medical leadership. I wrote the following to <a href="mailto:James.Rohack@ama-assn.org">Dr. Rohack</a>: <blockquote>Dear Dr. Rohack, I wish to call your attention to my series on the site of the Foundation for Integrity and Responsibility in Medicine, the multi author blog Healthcare Renewal. The series outlines the major problems with today's healthcare information technology: poor design and vendor freedom from accountability and information sharing on defects. The series starts <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-idiots-part-1.html" target="blank">here </a>. </blockquote> Thus the AMA leadership is informed of these issues. They can ignore them (after all, I'm just a nobody <a href="http://hcrenewal.blogspot.com/2008/09/mhra-report-on-influence-of-healthcare.html">writing on a godforsaken corner of the digital gutter known as the blogosphere</a>), or they can represent their profession. I encourage others to write their medical leadership as well. -- SS

Where Is Our Medical Leadership on the Death Traps Known as Misdesigned Healthcare IT?

In my series on health IT ( starting here ) whose human engineering is ill conceived, philistine and presents clinicians with a mission ho...

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Information Technology Makes Healthcare Easier? Is This Industry Trying to Harm Patients? Part 7 of a Series

This post is part 7 of a series on the stunningly poor human engineering of production healthcare IT from major vendors, in use today at major medical centers. These devices provide a decidedly mission hostile user experience, yet with an almost religious fervor are being touted as cybernetic miracles to cure healthcare's ills. (Note: Part 1 of this series is <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-idiots-part-1.html">here</a>, part 2 is <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-testers-and.html">here</a>, part 3 is <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-testers-and_24.html">here</a>, part 4 is <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-testers-and_26.html">here</a>, part 5 is <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-testers-and_27.html">here</a>, part 6 is <a href="http://hcrenewal.blogspot.com/2009/02/it-makes-healthcare-easier-is-this.html">here</a>, part 7 is <a href="http://hcrenewal.blogspot.com/2009/03/information-technology-makes-healthcare.html">here</a>, and part 8 is <a href="http://hcrenewal.blogspot.com/2009/03/malpractices-of-multitudes-mission.html">here</a>. 2011 addendums: a post that can be considered part 9 is <a href="http://hcrenewal.blogspot.com/2011/04/special-k-red-berries-mission-hostile.html">here</a>, part 10 is <a href="http://hcrenewal.blogspot.com/2011/12/ehr-mission-hostile-user-experience.html">here</a>.) Want to make a doctor or nurse miserable? Want to up the odds for error? Simply force them to review lab results on a screen as sloppily designed and cluttered as this one: <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgDLFQ-PAS3aBLCVpAFdakpdwVOpeaoSkPuHFl7j_-U6pBkcU-KNdT7tNiDDHvIVFp21KL_4A72ciatUwGdBpqB0B1Ao8Ho2RgSiUDkj8ogNzauKXTipo3TdAheaQqA5M7v_SWTVQrJ5VxO/s1600-h/labclutter.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5308468215143121762" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgDLFQ-PAS3aBLCVpAFdakpdwVOpeaoSkPuHFl7j_-U6pBkcU-KNdT7tNiDDHvIVFp21KL_4A72ciatUwGdBpqB0B1Ao8Ho2RgSiUDkj8ogNzauKXTipo3TdAheaQqA5M7v_SWTVQrJ5VxO/s320/labclutter.jpg" style="cursor: pointer; display: block; height: 216px; margin: 0px auto 10px; text-align: center; width: 392px;" /></a>(click to enlarge)</div> What technical genius programmed this monstrosity? The clutter is enough to impair the best clinicians who have to use such screens day in and day out on their often substantial patient loads. How is such a screen better than paper? Does the clinician really need to see subcomponents of panels such as General Chemistry split up all over the place, into sections of columns? Perhaps monolithic columns and horizontal scrolling would be less cognitively taxing? More columns, of course, could be placed in the available screen width if space were not wasted by ... units and Abn's! Does the clinician really need to see "Abn" as opposed to, say, "A" for abnormals? (At least the abnormals are actually marked in this application, unlike <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-testers-and.html">here</a> in "Warning! No warnings!) Does the clinician need to see units such as mg/dL (milligrams pre deciliter) and mEq/L (milliequivalents per liter) on each and every lab value? Correction - on ANY lab value? Could not that information be placed - once - in the column or row headers? (Oh, wait ... as shown <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-testers-and_26.html">here</a>, those headers in some products have a tendency to scroll away, forcing the "track the value with your finger" method of medical error prevention!) <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhTPpUz3d7SAmGmxAKZzZozBebb5LKK7E-XY4wSyAV7v42lxdq871V9RZfDEh7izPrg2ShhoTlDf116cfpPVNIqvoV-7k_zXYopKDRryp3YYpNXhIDmyo6Q14tigqUDeJrZ81YI2nPYain2/s1600-h/scroll2.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5308453800556330290" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhTPpUz3d7SAmGmxAKZzZozBebb5LKK7E-XY4wSyAV7v42lxdq871V9RZfDEh7izPrg2ShhoTlDf116cfpPVNIqvoV-7k_zXYopKDRryp3YYpNXhIDmyo6Q14tigqUDeJrZ81YI2nPYain2/s320/scroll2.jpg" style="cursor: pointer; display: block; height: 276px; margin: 0px auto 10px; text-align: center; width: 372px;" /></a>(click to enlarge)</div> Then there's this, just in from Down Under on clinical decision support, touted as one of the most important benefits of HIT: <div class="Ti"></div><blockquote><div class="Ti"><a href="http://www.mja.com.au/public/issues/190_05_020309/swe11286_fm.html">Quality of drug interaction alerts in prescribing and dispensing software</a></div><div class="By"><a href="http://www.blogger.com/blogger.g?blogID=9551150" name="0_elementId-1095765"></a><a href="http://www.blogger.com/blogger.g?blogID=9551150" name="0_pgfId-1101519"></a>Sweidan et al., Medical Journal of Australia 2009; 190 (5): 251-254</div> <div class="Abs"><a href="http://www.blogger.com/blogger.g?blogID=9551150" name="0_elementId-1095776"></a>Objective: To investigate the quality of drug interaction decision support in selected prescribing and dispensing software systems, and to compare this information with that found in a range of reference sources. </div><div class="Abs"><a href="http://www.blogger.com/blogger.g?blogID=9551150" name="0_pgfId-1091820"></a> Design and setting: A comparative study, conducted between June 2006 and February 2007, of the support provided for making decisions about 20 major and 20 minor drug interactions in six prescribing and three dispensing software systems used in primary care in Australia. Five electronic reference sources were evaluated for comparison </div><div class="Abs"><a href="http://www.blogger.com/blogger.g?blogID=9551150" name="0_pgfId-1091821"></a></div><div class="Abs"><a href="http://www.blogger.com/blogger.g?blogID=9551150" name="0_pgfId-1091822"></a> Results: Six of the nine software systems had a sensitivity rate ≥ 90%, detecting most of the major interactions. Only 3/9 systems had a specificity rate of ≥ 80%, with other systems providing inappropriate or unhelpful alerts for many minor interactions. Only 2/9 systems provided adequate information about clinical effects for more than half the major drug interactions, and 1/9 provided useful management advice for more than half of these. The reference sources had high sensitivity and in general provided more comprehensive clinical information than the software systems. </div><div class="Abs"><a href="http://www.blogger.com/blogger.g?blogID=9551150" name="0_pgfId-1091823"></a> Conclusions: Drug interaction decision support in commonly used prescribing and dispensing software has significant shortcomings.</div></blockquote><div class="Abs"></div> More in part 8. -- SS

Information Technology Makes Healthcare Easier? Is This Industry Trying to Harm Patients? Part 7 of a Series

This post is part 7 of a series on the stunningly poor human engineering of production healthcare IT from major vendors, in use today at m...

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We're Only In It for the Money: the Disproportionate Funding of University Administrators by Academic Medicine

We have previously <a href="http://hcrenewal.blogspot.com/2007/04/medical-schools-to-faculty-show-me.html">discussed</a> how academic medical leadership seems to care more about how much money their faculty bring in than their clinical, teaching or research performance. Why academic medicine came to put money ahead of mission has never been clear. However, a little bit of insight has been (probably inadvertently) provided by an announcement of a new university president. After the early resignation of President Trani, under fire for his coziness with tobacco money (see post<a href="http://hcrenewal.blogspot.com/2008/08/after-controversy-over-tobacco-money.html"> here </a>and links backwards), Virginia Commonwealth University (VCU) just announced its new President, Michael Rao. The <a href="http://www.news.vcu.edu/news.aspx?v=detail&nid=2801">official announcement </a>of his appointment included: <blockquote> The VCU Board approved Rao’s salary of $488,500, $176,113 of which is paid by state funds and $312,387 from VCU Health System and private funds, for the positions of VCU president and president of the VCU Health System. His total compensation package, approved by the board, also includes $66,500 in deferred compensation, a $60,000 housing allowance, and use of a car, all paid by private funds. Separate from the compensation package, Rao will receive a signing bonus of $275,000, paid by private funds. He will be required to repay $200,000 if he leaves the university within five years. </blockquote> This announcement is unusual, perhaps unique, in that it breaks down the sources of a university president's salary. Very few universities publish any details about their budgets, and hardly ever explain money flows among their different sub-divisions. What is striking is that 63% of President Rao's salary will come from the health center. However, the health center only accounts for about one-eighth of the university's students. (<a href="http://www.vcu.edu/about/">Total university enrollment </a>is more than 32,000, and 2008 <a href="http://www.healthsciences.vcu.edu/pdfs/FY08QUICKFACTCARD.pdf">Health Sciences enrollment </a>was 4278.) So, the president of a university will derive approximately five times more of his funding from the health sciences division of the university than would be expected by the size of that division. I suspect that this situation is not unique, or even uncommon. What is unique is that VCU has made it public. (Note also that President Rao's total compensation, while far more than that of the average faculty member, is nowhere near as outrageous as that of some other university presidents. Finally, in the interests of disclosure, I should note that I was a full-time faculty member at VCU from 1987-1994, and still serve as an adjunct faculty member there.) In my experience and humble opinion, it seems that the pressure academic leaders put on their faculty to bring in ever increasing amounts of money is out of proportion to the needs of academic medical centers or medical schools, or even the greed of their leaders. Instead, it may be that academic medical centers and medical schools, in turn, are under pressure to be the cash cows of their universities. Many universities have expanded their administrative staffs and budgets, and raised the salaries of their top leaders far more than inflation or increases in enrollment would justify. They have also erected palatial buildings, funded extravagant sports programs, and provided students luxuries unheard of when the baby boomers went off to college. University leaders may well have taken advantage of the abundant money flowing through health care, especially that supplied by pharmaceutical, biotechnology and device companies to generate research and "education" to market their products, and that supplied by a physician and hospital reimbursement system rigged to pay handsomely for an ever increasing number of procedures (see post <a href="http://hcrenewal.blogspot.com/2009/02/what-ruc-again-one-of-worlds-most.html">here</a>). But having become accustomed to this money to fund expansive administrative budgets, it is no wonder that university leaders have pushed for more and more financial production from medical school faculty, no matter what. And funded by their cash cow academic medical sub-divisions, it is no wonder that university leaders have turned a blind eye towards, if not actively encouraged financial entanglements by faculty and administrators that would dull their scruples about the sources and reasons for their outside financial support. If we want universities and their academic medical components to go back to putting their mission before their margins, we need to wean university leaders off the narcotic of surplus funds provided by their academic medical sub-divisions' external financial support.

We're Only In It for the Money: the Disproportionate Funding of University Administrators by Academic Medicine

We have previously discussed how academic medical leadership seems to care more about how much money their faculty bring in than their clin...

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An economist's advice on healthcare information technology

In a Feb. 28, 2009 New York Times article entitled "<a href="http://www.nytimes.com/2009/03/01/business/01unbox.html?_r=2&emc=eta1" style="font-family: arial;">How to Make Electronic Medical Records a Reality</a>", we get advice from the same profession in part responsible for the worst economic downturn since 1982 and perhaps 1929: <blockquote face="arial">... It is scarcely surprising, then, that only about 17 percent of the nation’s physicians are using computerized patient records [to various extents, 13% of that 17% only having basic functionality - ed.], according to a government-sponsored <a href="http://content.nejm.org/cgi/content/full/NEJMsa0802005">survey</a> published last year in The New England Journal of Medicine. "This is really not a technology problem,” observed Erik Brynjolfsson (<a href="http://ebusiness.mit.edu/Erik/">bio</a>), an economist at the Sloan School of Management at the Massachusetts Institute of Technology. “It’s a matter of incentives and market failure.”</blockquote> No, Prof. Brynjolffson, it is a matter of technology - as in, the misuse thereof. It's also a matter of logic failure, incompetence, conflict of interest, and vendor exploitation of <a href="http://hcrenewal.blogspot.com/2007/10/physicians-learned-helplessness.html">physician learned helplessness</a>. Vendors are already getting <a href="http://hcrenewal.blogspot.com/2006/10/70-million-for-electronic-medical.html">$70 to $100 million and up</a> for these products from individual medical centers, enough to build entire new hospitals. What more incentive to produce reasonable, safe, effective products do they need? On the other hand, the incentive you need to get physicians and other clinicians to purchase and use ill conceived, cavalierly designed HIT that saps their time and cognitive focus is not monetary. The necessary incentive is HIT that presents an acceptable user experience and that facilitates real, live clinicians in improving the quality of care. Only in healthcare could products with hundreds or thousands of known defects (known to individual healthcare organizations in isolation, that is, some being critical defects that can kill patients and others merely raising risk of <a href="http://www.pittsburghlive.com/x/pittsburghtrib/news/cityregion/s_611120.html" style="font-family: arial;">clinician cognitive overload that promotes error</a>), be sold to other healthcare organizations without disclosure of such defects. Further, contractually the customers are usually restricted from sharing those known defect lists with other organizations. Only in HC could vendors of defective products also be shielded from liability from their products' defects on "learned intermediary" principles, as if these learned intermediaries cannot be misled or caused to make errors by defective information. As I mentioned in <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-testers-and_27.html">part 5</a> of my series on HIT's mission hostile user experience, I have now become aware of organizations with defects/clinician complaint lists for contemporary HIT including CPOE, EHR etc. amounting to well over a hundred pages in one case, and well over a thousand individual items in another, and a number of unquantified but considerable in-betweens. How many defects lists are concealed? (Perhaps it's time to start calling in the state Attornies General on the basis of sale of known defective and possibly harmful software, without disclosing such defects, in my mind a form of fraud?) One wonders if Prof. Brynjolffson is aware of issues of HIT mission hostile user experiences due to gross violations of the most basic tenets of user centered design such as I've outlined <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-idiots-part-1.html" style="font-family: arial;">starting here</a>. How about vendors using hospitals as guinea pigs for apparently poorly tested products as in this <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/DUCOM_EMR_Complaint.pdf" style="font-family: arial;">Civil Complaint</a> (PDF) against HIT vendor AllScripts? How about the issues at my <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/medinfo.htm" style="font-family: arial;">site on HIT difficulties</a>? My final comment: Economists, please spare the medical profession from your advice. It is not helpful nor wanted. We are getting tired of cross-occupational invasions by biomedical and healthcare informatics dilettantes. If you've not gone to medical school, not done a residency, and/or (for those many competent nonmedical informatics professionals) not had considerable education and experience in information science, computer science, biomedical informatics, social informatics, and other areas, you're an HIT dilettante. Period. No ifs, no buts, no debate. (Such people perhaps need to read "<a href="http://gagne.homedns.org/%7Etgagne/contrib/unskilled.html">Unskilled and Unaware of It: How Difficulties in Recognizing One's Own Incompetence Lead to Inflated Self-Assessments</a>" and stop rendering expert advice in areas in which they lack expertise.) I leave it to other bloggers here to determine if anyone cited in the NY Times article holds financial interests in HIT-related companies. -- SS

An economist's advice on healthcare information technology

In a Feb. 28, 2009 New York Times article entitled " How to Make Electronic Medical Records a Reality ", we get advice from the sa...

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Information Technology Makes Healthcare Easier? Is This Industry Trying to Harm Patients? Part 6 of a Series

(Note: Part 1 of this series is <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-idiots-part-1.html">here</a>, part 2 is <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-testers-and.html">here</a>, part 3 is <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-testers-and_24.html">here</a>, part 4 is <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-testers-and_26.html">here</a>, part 5 is <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-testers-and_27.html">here</a>, part 6 is <a href="http://hcrenewal.blogspot.com/2009/02/it-makes-healthcare-easier-is-this.html">here</a>, part 7 is <a href="http://hcrenewal.blogspot.com/2009/03/information-technology-makes-healthcare.html">here</a>, and part 8 is <a href="http://hcrenewal.blogspot.com/2009/03/malpractices-of-multitudes-mission.html">here</a>. 2011 addendums: a post that can be considered part 9 is <a href="http://hcrenewal.blogspot.com/2011/04/special-k-red-berries-mission-hostile.html">here</a>, part 10 is <a href="http://hcrenewal.blogspot.com/2011/12/ehr-mission-hostile-user-experience.html">here</a>.)  This post is part 6 of a series on the stunningly poor human engineering of production healthcare IT from major vendors, in use today at major medical centers. These devices provide a decidedly mission hostile user experience, yet with an almost religious fervor are being touted as cybernetic miracles to cure healthcare's ills. During the Sunday morning talk show "Roundtable" this morning, I saw an <a href="http://www-03.ibm.com/press/us/en/pressrelease/24405.wss">IBM ad touting the fact that they'd surpassed the petaflop mark</a> (built computers that can perform one thousand trillion floating point calculations per second). They touted how such computers will enable weather prediction, medical advances, solutions to social problems, and other cybernetic miracles. (Some of these miracles have been promised since the days of <a href="http://en.wikipedia.org/wiki/ENIAC">ENIAC</a> in the late 1940's.) Now, I am indeed amazed by such machines, and realize their value when utilized by competent domain experts overseeing equally competent analysts and programmers, ideally along with HCI (human computer interaction) experts who can help humans interact effectively with such computational high performance. One would think, though, in a culture where we can perform one thousand trillion calculations per second on large machines, and where consumer machines can perform pretty fast as well that we could do better in the human interface to healthcare IT: <blockquote style="font-family: arial;">As of 2008, the fastest PC <a href="http://en.wikipedia.org/wiki/Microprocessor" title="Microprocessor">processors</a> (quad-core) perform over 37 GFLOPS (Intel QX9775)<a href="http://en.wikipedia.org/wiki/FLOPS#cite_note-15" title=""></a> [that's 37 billion calculations per second - ed.] <a href="http://en.wikipedia.org/wiki/Graphics_processing_unit" title="Graphics processing unit">GPUs</a> in are considerably more powerful, for example, in the <a href="http://en.wikipedia.org/wiki/GeForce_8_Series" title="GeForce 8 Series">GeForce 8 Series</a> the nVidia 8800 Ultra performs around 576 GFLOPS on 128 processing elements ... There are now graphics cards such as the ATi Radeon HD 4870X2 which can run at over 2.4 TeraFLOPS [2.4 trillion calculations per second - ed.]</blockquote> Amazing. I used to support applications running on IBM <a href="http://en.wikipedia.org/wiki/PSeries">POWER</a>-based supercomputers far slower than 1000 trillion FLOPS for drug discovery at Merck, and chatted with those who used these supercomputers in molecular modeling, critical to drug discovery. Today's computing advances are indeed remarkable just a few years later. Here is where my disappointment arises. Health IT seems to be back in the <a href="http://en.wikipedia.org/wiki/TRS-80">TRS-80</a> days in terms of its failure to utilize these levels of computing power to create a mission friendly user experience and safer medical care. <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh3iYkQGuuf2x-7_cRR86BqI9620S4bzH4nRdfw8pkp2JNCdN3t2vcbgN17AR_j6Pnmk_JA4izcj8qYrPjS4DPHyW95nAJPTFS-gzqnXbExtDC3sQhlQQcBhaucYU8a4YagJeIbeTA2DBYC/s1600-h/trs80.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5308372357322955250" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh3iYkQGuuf2x-7_cRR86BqI9620S4bzH4nRdfw8pkp2JNCdN3t2vcbgN17AR_j6Pnmk_JA4izcj8qYrPjS4DPHyW95nAJPTFS-gzqnXbExtDC3sQhlQQcBhaucYU8a4YagJeIbeTA2DBYC/s320/trs80.jpg" style="cursor: pointer; display: block; height: 210px; margin: 0px auto 10px; text-align: center; width: 320px;" /></a>HIT user experience: trapped in the TRS-80 era?</div> Below is how a major healthcare IT system forces a user to do even a simple task, changing the starting date and time for a common medication.Let's count the steps required for what used to require one step: putting the instrument below to paper. <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiFXj4eVehB764m3ljNBTp3jE-6CxZlw6icBExGfzijZWgtPVJBUvohT404nBN9eDMyBY3qQOlH9qkDLVC2m5imQF9CFSdVFw4MxVA_ir4PKFjt6z-Jk_DcCEGV-6tlg5ZTOX190LD3Xs-W/s1600-h/pen.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5308281877911815090" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiFXj4eVehB764m3ljNBTp3jE-6CxZlw6icBExGfzijZWgtPVJBUvohT404nBN9eDMyBY3qQOlH9qkDLVC2m5imQF9CFSdVFw4MxVA_ir4PKFjt6z-Jk_DcCEGV-6tlg5ZTOX190LD3Xs-W/s320/pen.jpg" style="cursor: pointer; display: block; height: 153px; margin: 0px auto 10px; text-align: center; width: 225px;" /></a> Keep in mind, health IT is touted as improving the quality of healthcare, reducing errors, and reducing costs. Step one in the world of HIT (a world, as I said, of MIS-inspired inventory systems, not clinical tools for use by clinicians) involves hunting for, and then clicking "frequency" on a scrolling list of possible "order details", seen on the left of the screen below: <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg01arsCdU_N-N0lKZkvqOwmppPc-5_m7V9qrMjL23NTQb1kqKIFC_WQGaxV71I20SR5_nRRSa45c2q-Ldm9JJHwRnlgwJvkQMWVM91gsMhGvE_CrTPIE9HU3dmnJ_qlvaW9kUFD0cfBalf/s1600-h/figure1.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5308029627092402370" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg01arsCdU_N-N0lKZkvqOwmppPc-5_m7V9qrMjL23NTQb1kqKIFC_WQGaxV71I20SR5_nRRSa45c2q-Ldm9JJHwRnlgwJvkQMWVM91gsMhGvE_CrTPIE9HU3dmnJ_qlvaW9kUFD0cfBalf/s320/figure1.jpg" style="cursor: pointer; display: block; height: 222px; margin: 0px auto 10px; text-align: center; width: 374px;" /></a>(click to enlarge)</div> The user then clicks on the "ellipsis button" at upper right, which produces a popup to display the "standard times" for B.I.D. (twice a day) meds: <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZa4XLjfFVR0leddg-h8vMJX1mU-APtEqUjDRJwBcukMNXdCHyNXkpMwHI5TQoFkeeV0HDN1Ep2f-nzmXVCE1O4Q9L9CmgFdx4HHmUmgZ6gIz6NTQjQ8qMIjWpiygyXusuvralV1-SFoWe/s1600-h/figure2.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5308029627188284594" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZa4XLjfFVR0leddg-h8vMJX1mU-APtEqUjDRJwBcukMNXdCHyNXkpMwHI5TQoFkeeV0HDN1Ep2f-nzmXVCE1O4Q9L9CmgFdx4HHmUmgZ6gIz6NTQjQ8qMIjWpiygyXusuvralV1-SFoWe/s320/figure2.jpg" style="cursor: pointer; display: block; height: 225px; margin: 0px auto 10px; text-align: center; width: 374px;" /></a>(click to enlarge)</div> On the popup subscreen is a list of "standard medication adminstration times" or SMAT's. Here the BID times are shown as 0900 and 2100 (9 AM and 9 PM). To override these times, more screens, more clicks and more work is needed. The user must click on a "requested start date and time," which has defaulted by programmer edict to the CURRENT data and time. The user is warned in the "User Guide" about how to perform this function as follows- <blockquote style="font-family: arial;">CAUTION: If you do not change the [default] requested start data and time, the first dose will be scheduled for the current date and time.</blockquote> The "current time" here being 11:28 AM as on left: <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgvlkfNul56B1G0YuqcjcdsVJUYoQLViYi36QjsqxsvPUz_Lg01hvfOiuxtSyRwRI_NP9wiqrI8eJc7zvisJqYy4Efv_IyTLnxIF_sZ7f1yOOW1oFT8eKSDC0iriDKYvtOofVw5p64EP1eL/s1600-h/figure3.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5308029628468691810" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgvlkfNul56B1G0YuqcjcdsVJUYoQLViYi36QjsqxsvPUz_Lg01hvfOiuxtSyRwRI_NP9wiqrI8eJc7zvisJqYy4Efv_IyTLnxIF_sZ7f1yOOW1oFT8eKSDC0iriDKYvtOofVw5p64EP1eL/s320/figure3.jpg" style="cursor: pointer; display: block; height: 248px; margin: 0px auto 10px; text-align: center; width: 380px;" /></a>(click to enlarge)</div> Fantastic. The user must then change the requested start data and time to match the SMAT (standard medication administration time) for the first dose. Say they want the first dose to be given at 2100 (9 PM) tonight. In the screen below, the user changed this to 6/5/2006 at 2100 (9 PM) to match the SMAT time. The first dose is to be given at 2100 (9 PM) on the current night. <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgQfrjbyMJ6kb3YgoeKwqA0WO4_F-jdSTMUmKZ0txLa1U65OptDzStPRzToCseARboEnud4PpqVmCfstKa5HZta4DxMdAl6nZG3BshhHGIHNP5un6t6hHJI0_7aVMZQ3kAlMbMPRP51zQmH/s1600-h/figure4.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5308029630499616658" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgQfrjbyMJ6kb3YgoeKwqA0WO4_F-jdSTMUmKZ0txLa1U65OptDzStPRzToCseARboEnud4PpqVmCfstKa5HZta4DxMdAl6nZG3BshhHGIHNP5un6t6hHJI0_7aVMZQ3kAlMbMPRP51zQmH/s320/figure4.jpg" style="cursor: pointer; display: block; height: 182px; margin: 0px auto 10px; text-align: center; width: 350px;" /></a>(click to enlarge)</div> But they're not done yet! After signing the order, the clinician making the change (often a nurse) will need to click the eMAR (Electronic Medication Administration Record) tab. They must verify something called the "eMAR time frame setting" to be certain that this "time frame" is set for something called the "clinical range." See below: <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSc_pFbe3x2tEOSi4PUnW-HJdwjgknrtbsUhwzjpuCSe4LS71OnAdJbvhFLWNskvyeI1INugJm3T_hqNMpiSxsHY7a84Sfr-l1dMz1aAouRqsBJRy6TeQuRm47KeoXeojw4sBRM-mXSyef/s1600-h/figure5.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5308029629886659842" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSc_pFbe3x2tEOSi4PUnW-HJdwjgknrtbsUhwzjpuCSe4LS71OnAdJbvhFLWNskvyeI1INugJm3T_hqNMpiSxsHY7a84Sfr-l1dMz1aAouRqsBJRy6TeQuRm47KeoXeojw4sBRM-mXSyef/s320/figure5.jpg" style="cursor: pointer; display: block; height: 60px; margin: 0px auto 10px; text-align: center; width: 344px;" /></a>(click to enlarge)</div> This act comes with a warning in the instruction manual: <blockquote style="font-family: arial;">CAUTION: Never limit the eMAR to your shift or to today only. Limiting your view of the eMAR may cause you to inadvertently create medication errors. (!) </blockquote>Inadvertently create medication errors? Really? Should be easy to fix with machines capable of trillions of calculations per second, no? No. The user is advised that if the eMAR timeframe is not set to "Clinical Range", all they need do is: Close the patient's chart, and log out of the health IT application. When you log on next time, the time frame will default to Clinical Range. Simple, no? Something we all want our doctors and nurses to be doing day in, day out for just this one simple function, no? Who designed such an interface? What kind of user experience is this, exactly? One designed to make clinical work easier? Perhap the HIT designers might seek a brain transplant or some other procedure to restore brain function, and then utilize the amazing computational power of modern IT and the advances in biomedical informatics, computational lingustics, parsers (used in building computer program compilers), etc. to allow a user to type in a command with an easily learned syntax such as: <blockquote style="color: red; font-family: arial;">> change Amoxicillin bid 0900 2100 start 06/05/2006</blockquote> and have the computer popup a verification window that asks: <blockquote face="arial"> Are you sure you want to change Amoxicillin to twice daily, 0900 and 2100 (9 AM and 9PM), starting Monday June 5 (Yes/no)? </blockquote>Or are such undergraduate level computer science feats beyond what's "a good business case" for the HIT vendors, thereby banking on the cognitive diligence of healthcare providers to make up for HIT stupidities? Are these vendors aware of fifty+ years of computer science, information science, biomedical informatics, HCI and other research? Who, exactly, is creating, testing and approving the clinician user experiences I am illustrating? Clinicians as technophobes when we're talking about poor IT such as presented in this series? My a**. In part 7 and on we shall start to see the "peek a boo, wild goose chase, go find your lab data" screens I've mentioned. -- SS

Information Technology Makes Healthcare Easier? Is This Industry Trying to Harm Patients? Part 6 of a Series

(Note: Part 1 of this series is here , part 2 is here , part 3 is here , part 4 is here , part 5 is here , part 6 is here , part 7 is here ...

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"Buried Data," a "Smoke-and-Mirrors Job" and a "Positive Spin" on a "Cursed Study"

Documents produced on discovery and recently unsealed during litigation suggested how <a href="http://www.astrazeneca-us.com/">AstraZeneca</a> handled clinical research data in the marketing of its atypical anti-psychotic drug <a href="http://www.seroquel.com/">Seroquel </a>(quetiapine). As <a href="http://www.bloomberg.com/apps/news?pid=20601087&sid=aS_.NqzMArG8&refer=home">reported by Bloomberg</a>, <blockquote> AstraZeneca Plc 'buried' unfavorable studies on its antipsychotic drug Seroquel, according to an internal e-mail unsealed as part of litigation over the medicine. The drugmaker failed to publicize results of at least three clinical trials of Seroquel and engaged in 'cherry picking' of data from one of those studies for use in a presentation, an AstraZeneca official said in a December 1999 e-mail unsealed yesterday under an agreement between the company and lawyers for patients. The London-based company faces about 9,000 lawsuits claiming it failed to properly warn users that Seroquel can cause diabetes and other health problems. 'The larger issue is how we face the outside world when they begin to criticize us for suppressing data,' John Tumas, an AstraZeneca publications manager, told colleagues in the e-mail. One unsealed document showed AstraZeneca officials considered Trial 15, one of the studies Tumas described as 'buried,' to be a problem because it didn’t produce favorable results on the issue of weight gain for patients taking the drug. Gaining weight can be a factor in the development of diabetes. Richard Lawrence, an AstraZeneca official, said in a February 1997 e-mail that the company had engaged in a 'great smoke-and-mirrors job' in dealing with U.S. and Canadian investigators on the trial’s results. 'Adopting the approach Don has outlined should minimize (and dare I venture to suggest) could put a positive spin (in terms of safety) on this cursed study,' Lawrence said in the e- mail. It isn’t clear from the e-mail which person Lawrence is referring to. In his December 1999 e-mail, Tumas said that AstraZeneca had 'buried trials 15, 31, 56,' and was considering a study listed as COSTAR. Details of the trials weren’t specified in the e-mail. Tumas chastised colleagues for using favorable data produced by Trial 15 without disclosing the full study results, according to his unsealed e-mail. 'There has been a precedent set regarding ‘cherry picking’ of data,' which was used in “the recent Velligan presentations,' he said. 'Thus far, I am not aware of any repercussions regarding interest in the unreported data.' The publications manager indicated that AstraZeneca had a favorable reputation for engaging in 'ethical behavior' when it came to disclosing study results on its drugs. 'We must decide if we wish to continue to enjoy this distinction,' Tumas wrote. 'The reporting of the COSTAR results will not be easy,' he added. 'We must find a way to diminish the negative findings. But, in my opinion, we cannot hide them.' </blockquote> So here we have more evidence about a big pharmaceutical company suppressing and manipulating data from the clinical research when its results proved unfavorable to its product. The unsealed evidence, when added to many other cases we have discussed, suggest that manipulation and suppression of clinical research data to support companies' vested interests is a common practice by commercial health care firms, including but not restricted to pharmaceutical, biotechnology, and device companies. As we have said before, suppression and manipulation of research amounts to post-hoc abuse of research subjects who volunteered their participation believing that it would advance science and health care. Furthermore, suppression and manipulation of research can deceive physicians into prescribing tests and treatments that will fail to help, or even harm patients, and deceive patients into thinking that they are getting the best possible tests and treatments, when, again what they are getting is ineffective or even harmful. In my humble opinion, there is an increasingly strong argument that clinical research should not be controlled, and probably should not be done at all by organizations with vested interests in the research producing results favorable to their products. See additional comments about the Seroquel litigation on the Clinical Psychology and Psychiatry blog <a href="http://clinpsyc.blogspot.com/2009/02/seroquel-becomes-zyprexa-part-2-but.html">here</a>, and the Carlat Psychiatry Blog <a href="http://carlatpsychiatry.blogspot.com/2009/02/of-seroquel-sex-and-secret-documents.html">here</a>. ADDENDUM (2 March, 2009) - See detailed comments on the apparent manipulation of a meta-analysis of Seroquel versus a "typical" anti-psychotic, haloperidol, <a href="http://clinpsyc.blogspot.com/2009/03/internal-documents-suggest-that.html">on the Clinical Psychology and Psychiatry Blog</a>.

"Buried Data," a "Smoke-and-Mirrors Job" and a "Positive Spin" on a "Cursed Study"

Documents produced on discovery and recently unsealed during litigation suggested how AstraZeneca handled clinical research data in the mar...

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