healthy4u

The Computer Will See You Now

This in, from the New York Times. Emphases mine: <blockquote>March 6, 2009 Op-Ed Contributor <a style="font-family: arial;" href="http://www.nytimes.com/2009/03/06/opinion/06coben.html?_r=1">The Computer Will See You Now</a> By ANNE ARMSTRONG-COBEN FOR 20 years, I practiced pediatric medicine with a “paper chart.” I would sit with my young patients and their families, chart in my lap, making eye contact and listening to their stories. I could take patients’ histories in the order they wanted to tell them or as I wanted to ask. I could draw pictures of birthmarks, rashes or injuries. I loved how patients could participate in their own charts — illustrating their cognitive development as they went from showing me how they could draw a line at age 2 and a circle at 3 to proudly writing their names at 5. Now that I’ve been using a computer to keep patient records — a practice that I once looked forward to — my participation with patients too often consists of keeping them away from the keyboard while I’m working, for fear they’ll push a button that implodes all that I have just documented. We have all heard about the wonderful ways in which electronic medical records are supposed to transform our broken health care system — by eradicating illegible handwriting and enabling doctors to share patients’ records with one another more easily. The recently passed federal stimulus package provides doctors and hospitals with $17 billion worth of incentive payments to switch to electronic records. The benefits may be real, but we should not sacrifice too much for them. The problem is not just with pediatrics. Doctors in every specialty struggle daily to figure out a way to keep the computer from interfering with what should be going on in the exam room — making that crucial connection between doctor and patient. I find myself apologizing often, as I stare at a series of questions and boxes to be clicked on the screen and try to adapt them to the patient sitting before me. I am forced to bring up questions in the order they appear, to ask the parents of a laughing 2-year-old if she is “in pain,” and to restrain my potty mouth when the computer malfunctions or the screen locks up. I advise teenagers to limit computer time as I sit before one myself for hours each day until my own eyes twitch and my neck starts to spasm. In short, the computer depersonalizes medicine. It ignores nuances that we do not measure but clearly influence care. In the past, I could pick up a chart and flip through it easily. Looking at a note, I could picture the visit and recall the story. Now a chart is a generic outline, screens filled with clicked boxes. Room is provided for text, but in the computer’s font, important points often get lost. I have half-joked with residents that they could type “child has no head” in the middle of a computer record — and it might be missed. A box clicked unintentionally is as detrimental as an order written illegibly — maybe worse because it looks official. It takes more effort and thought to write a prescription than to pull up a menu of medications and click a box. I have seen how choosing the wrong box can lead to the wrong drug being prescribed. So before we embrace the inevitable, there should be more discussion and study of electronic records, or at a minimum acknowledgment of the downside. A hybrid may be the answer — perhaps electronic records should be kept only on tablet computers, allowing the provider to write or draw, and to face the patient. The personal relationships we build in primary care must remain a priority, because they are integral to improved health outcomes. Let us not forget this as we put keyboards and screens within the intimate walls of our medical homes. Anne Armstrong-Coben is an assistant clinical professor of pediatrics at Columbia.</blockquote> What Dr. Armstrong-Coben is describing is what I term a "mission hostile user experience" (<a href="http://tinyurl.com/hostileuserexper">link to my series on this point</a>), but she goes further, recognizing the paradigm change between paper and IT. She questions the wisdom of this still-exploratory change in medical practice. Interestingly, renowned Merck scientist emeritus Dr. Maurice Hilleman, inventor of most of the vaccines we received as kids, also expressed similar concerns to me regarding biomedical research IT (<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/scotsilverstein/hilleman.jpg">link</a>). I've seen the following wisdom on the web as well by Scott Haig at Time.com<a href="http://www.time.com/time/health/article/0,8599,1883002,00.html?xid=rss-fullhealthsci-yahoo"></a>. I think it sums up the controversy over this attempted paradigm change well: <blockquote><a href="http://www.time.com/time/health/article/0,8599,1883002,00.html?xid=rss-fullhealthsci-yahoo">Electronic Medical Records: Will They Really Cut Costs?</a> ... the doctors I know wince whenever electronic medical records are held up as some kind of silver bullet. Before we had them on every countertop, computers held such promise for us in medicine: doctors and patients live in a world of painful, pressing questions, the answers might be in there. Or so we thought. Twenty nine years from the night I first sat in a hospital in front of a computer screen the questions persist. And I still don't see the profit-maximizing, cost-controlling physician with his nationwide computer treating patients any better than the great physicians I've known have. With pen and paper, personal commitment to each patient and judgment born of practical experience. None of which I have found in a machine.. </blockquote>Indeed. I emphasize that I am an advocate for healthcare IT ... but only if that HIT is done well. That means not just technically, but operationally in real world settings, taking into account the clinical, social and organizational ramifications and realities of these technologies in clinical settings. It's those two words "done well" that truly exemplify the old saying that the devil is in the details. -- SS Addendum: the NY Times <a href="http://www.nytimes.com/2009/03/11/opinion/l11medical.html?_r=1&scp=5&sq=The%20Computer%20Will%20See%20You%20Now&st=cse">published letters from a varied audience</a> in response to Dr. Armstrong-Coben's piece, largely agreeing with the issues above.

The Computer Will See You Now

This in, from the New York Times. Emphases mine: March 6, 2009 Op-Ed Contributor The Computer Will See You Now By ANNE ARMSTRONG-COBEN FOR ...

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Power down for the planet

Do you leave your fridge door open after grabbing what you need? Do you leave your vacuum cleaner running when you aren't cleaning? Of course not. The idea of doing either of these things sounds silly, yet many people don't think to turn off their computers after using them. By using <a href="http://www.climatesaverscomputing.org/learn/saving-energy-at-home/">power management tools</a> on your computer and buying <a href="http://www.climatesaverscomputing.org/tools/smarter-computing-catalog/">more efficient computers</a>, you can save nearly half a ton of CO2 and more than $60 a year in personal energy costs. To do our part, Google co-founded the <a href="http://www.climatesaverscomputing.org/">Climate Savers Computing Initiative</a> (CSCI) to promote a smarter, greener computing future. The simple changes above can have a HUGE collective impact; our goal is to reduce carbon dioxide emissions by 54 million tons per year by 2010 — the equivalent of taking 11 million cars off the road. The biggest obstacle we face is not technological, it's awareness. That's why we're excited that CSCI has launched the Power Down for the Planet <a href="http://www.powerdownfortheplanet.org/video/">video contest</a>, a challenge to you and your friends to develop original and creative videos that educate, entertain, and inform others about the importance of energy efficient computing. So pick up a camera and make a video telling your own Climate Savers Computing story. How will the environment benefit from advances in computer power management? How do poor computing practices waste energy? What does a sustainable computing future look like to you? Let your imagination go wild. <a href="http://www.climatesaverscomputing.org/individual-join/">Join us</a>, <a href="http://www.powerdownfortheplanet.org/promote/tellafriend/">gather some friends</a>, and broadcast your vision of efficient computing. The team with the most compelling video can win up to $5,000 and energy efficient laptops; students at <a href="http://www.powerdownfortheplanet.org/about-the-challenge/participating-universities/">participating universities</a> are also eligible to win $5,000 and <a href="http://www.specialized.com/bc/SBCBkModel.jsp?spid=40433&eid=178">Specialized Globe bicycles</a>. We can't wait to see what you create. <object height="295" width="480"><param name="movie" value="http://www.youtube.com/v/jABb8L89G44&hl=en&fs=1"></param><param name="allowFullScreen" value="true"></param><param name="allowscriptaccess" value="always"></param><embed src="http://www.youtube.com/v/jABb8L89G44&hl=en&fs=1" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" width="480" height="295"></embed></object> Posted by Bill Weihl, Green Energy Czar

Power down for the planet

Do you leave your fridge door open after grabbing what you need? Do you leave your vacuum cleaner running when you aren't cleaning? Of...

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Harvard Medical Students Against Marketing in the Guise of Medical Education

An article by Duff Wilson <a href="http://www.nytimes.com/2009/03/03/business/03medschool.html">in the New York Times </a>this week provided a new look at the pervasiveness of financial relationships among academic medicine and health care corporations, and the beginnings of resistance to them. The Scope of the Relationships <blockquote> Many individual Harvard Medical faculty members receive tens or even hundreds of thousands of dollars a year through industry consulting and speaking fees. Under the school’s disclosure rules, about 1,600 of 8,900 professors and lecturers have reported to the dean that they or a family member had a financial interest in a business related to their teaching, research or clinical care. The reports show 149 with financial ties to Pfizer and 130 with Merck. The rules, though, do not require them to report specific amounts received for speaking or consulting, other than broad indications like 'more than $30,000.' Some faculty who conduct research have limits of $30,000 in stock and $20,000 a year in fees. But there are no limits on companies’ making outright gifts to faculty — free meals, tickets, trips or the like. Other blandishments include industry-endowed chairs like the three Harvard created with $8 million from sleep research companies; faculty prizes like the $50,000 award named after Bristol-Myers Squibb, and sponsorships like Pfizer’s $1 million annual subsidy for 20 new M.D.’s in a two-year program to learn clinical investigation and pursue Harvard Master of Medical Science degrees, including classes taught by Pfizer scientists. </blockquote> Academic Medical Leaders' Defense of Their Relationships with Industry <blockquote> Dr. Flier, who became dean 17 months ago, previously received a $500,000 research grant from Bristol-Myers Squibb. He also consulted for three Cambridge biotechnology companies, but says that those relationships have ended and that he has accepted no new industry affiliations. </blockquote> So maybe it is not surprising that: <blockquote> Dr. Flier says that the Harvard Medical faculty may lead the nation in receiving money from industry, as well as government and charities, and he does not want to tighten the spigot. 'One entirely appropriate source, if done properly, is industrial funds,' Dr. Flier said in an interview. </blockquote> But, <blockquote> That is in contrast to his predecessor as dean, Dr. Joseph B. Martin. Harvard’s rules allowed Dr. Martin to sit on the board of the medical products company Baxter International for 5 of the 10 years he led the medical school, supplementing his university salary with up to $197,000 a year from Baxter, according to company filings. Dr. Martin is still on the medical faculty and is founder and co-chairman of the Harvard NeuroDiscovery Center, which researches degenerative diseases, and actively solicits industry money to do so. Dr. Martin declined any comment. </blockquote> Note that we discussed Dr Martin's directorship of Baxter on Health Care Renewal <a href="http://hcrenewal.blogspot.com/2006/08/disclosing-conflicts-of-interest-story.html">here</a> in 2006, and that we also found that he was on the board of biotechnology company Cytyc. Note also that we have discussed how serving on the board of a health care corporation can produce particularly intense conflicts of interest for academic medical leaders, since such board service implies not just warm and fuzzy feelings for the company, but "unyielding loyalty" to the financial interests of the company and its stockholders (e.g., see <a href="http://hcrenewal.blogspot.com/2009/03/meet-new-boss-same-as-old-boss-health.html">this post</a>). Unsurprisingly, faculty who have their own lucrative relationships with industry are all for more of the same: <blockquote>Encouraging them is Dr. Thomas P. Stossel, a Harvard Medical professor who has served on advisory boards for Merck, Biogen Idec and Dyax, and has written widely on academic-industry ties. 'I think if you look at it with intellectual honesty, you see industry interaction has produced far more good than harm,' Dr. Stossel said. 'Harvard absolutely could get more from industry but I think they’re very skittish. There’s a huge opportunity we ought to mine.' </blockquote>Note that Dr Stossel defended academic-industry "interaction," but did not explain why such interaction seems always to generate large money flows from industry to academic institutions and their individual faculty members. People can surely interact without paying each other. Note further that Dr Stossel may have even more financial relationships with industry than appeared in the NY Times article. When we analyzed some of the logical fallacies Dr Stossel employed in favor of industry payments to physicians <a href="http://hcrenewal.blogspot.com/2007/04/can-people-with-conflicts-of-interest.html">in 2007</a>, we cited Stossel's <a href="http://content.nejm.org/cgi/reprint/353/10/1060.pdf">attck</a> on the rigorous conflicts of interest rules re-imposed on the US National Institutes of Health (NIH) in which Stossel had to disclose "having received consulting fees from <a href="http://zymequest.com/">ZymeQuest</a>, owning stock options in ZymeQuest and Biogen, and having pending and issued patents, owned by Brigham and Women's Hospital, some of which are licensed to ZymeQuest." [Stossel TP. Regulating academic-industrial research relationships - solving problems or stifling progress? N Engl J Med 2005; 353: 1060-1065.] In this <a href="http://muse.jhu.edu/journals/perspectives_in_biology_and_medicine/v050/50.1stossel.html">paean</a> to a laissez-faire approach to conflicts of interest, Stossel also disclosed that he "is a member of the Board of Directors of Zymequest Inc, and the Scientific Leadership Advisory Board of Merck & Co. The author is a founding scientist of Critical Biologics Corporation and a consultant to Boston Scientific, Inc., and Gerson-Lehrman, Inc." [Stossel TP. Regulation of financial conflicts of interest in medical practice and medical research. Perspect Biol Med 2007; 50: 54-71. ] Another defender of the status quo also has her own major relationships with industry: <blockquote> Merck built a corporate research center in 2004 across the street from Harvard’s own big new medical research and class building. And Merck underwrites plenty of work on the Harvard campus, including the immunology lab run by Dr. Laurie H. Glimcher — a professor who also sits on the board of the drug maker Bristol-Myers Squibb, which paid her nearly $270,000 in 2007. Dr. Glimcher says industry money is not only appropriate but necessary. 'Without the support of the private sector, we would not have been able to develop what I call our ‘bone team’ in our lab,' she said at a recent student and faculty forum to discuss industry relationships. Merck is counting on her team to help come up with a successor to Fosamax, the formerly $3 billion-a-year bone drug that went generic last year. </blockquote> Note that Dr Glimcher now seems to view her role not as someone seeking to discover and disseminate the truth, but as someone seeking to develop commercial products. Again, maybe that is not surprising, since she is supposed to have an "unyielding loyalty" to the prominent pharmaceutical company on whose board she sits. The NY Times article did not quote anybody in favor of financial relationships between academic medicine and industry who did not themselves have such relationships. I don't believe I have ever seen a defense of these relationships not authored by someone who was not already personally profiting from such relationships. The Revolt of the Medical Students While he documented how Harvard faculty who also lead huge pharmaceutical firms have no qualms about industry pouring money into medical academics, Mr Wilson found that medical students seem to have figured out the downside of being taught by pharmaceutical, biotechnology and device company employees: <blockquote>In a first-year pharmacology class at Harvard Medical School, Matt Zerden grew wary as the professor promoted the benefits of cholesterol drugs and seemed to belittle a student who asked about side effects. Mr. Zerden later discovered something by searching online that he began sharing with his classmates. The professor was not only a full-time member of the Harvard Medical faculty, but a paid consultant to 10 drug companies, including five makers of cholesterol treatments. 'I felt really violated,' Mr. Zerden, now a fourth-year student, recently recalled. 'Here we have 160 open minds trying to learn the basics in a protected space, and the information he was giving wasn’t as pure as I think it should be.' Mr. Zerden’s minor stir four years ago has lately grown into a full-blown movement by more than 200 Harvard Medical School students and sympathetic faculty, intent on exposing and curtailing the industry influence in their classrooms and laboratories, as well as in Harvard’s 17 affiliated teaching hospitals and institutes. They say they are concerned that the same money that helped build the school’s world-class status may in fact be hurting its reputation and affecting its teaching. </blockquote> Note that the example, while anecdotal, shows how financial relationships could lead to biased education. The students have made surprising progress: <blockquote> The Harvard students have already secured a requirement that all professors and lecturers disclose their industry ties in class — a blanket policy that has been adopted by no other leading medical school. (One Harvard professor’s disclosure in class listed 47 company affiliations.) 'Harvard needs to live up to its name,' said Kirsten Austad, 24, a first-year Harvard Medical student who is one of the movement’s leaders. 'We are really being indoctrinated into a field of medicine that is becoming more and more commercialized.' David Tian, 24, a first-year Harvard Medical student, said: 'Before coming here, I had no idea how much influence companies had on medical education. And it’s something that’s purposely meant to be under the table, providing information under the guise of education when that information is also presented for marketing purposes.' The students say they worry that pharmaceutical industry scandals in recent years — including some criminal convictions, billions of dollars in fines, proof of bias in research and publishing and false marketing claims — have cast a bad light on the medical profession. And they criticize Harvard as being less vigilant than other leading medical schools in monitoring potential financial conflicts by faculty members. </blockquote> Unfortunately, many academics of my generation have become so used to making some extra dollars by working part-time for companies selling health care goods or services that they cannot see how these relationships have distracted them from the academic mission and their professional ideals. Maybe the rising generation of students, now living in a time when the consequences of arrogance, greed, and corruption among our leaders has become so apparent, will put professionalism ahead of personal enrichment.

Harvard Medical Students Against Marketing in the Guise of Medical Education

An article by Duff Wilson in the New York Times this week provided a new look at the pervasiveness of financial relationships among academic...

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Shaking up earthquake searches

Silicon Valley is well known as the home of technology companies like Google, but it's also one of many regions around the world with frequent earthquake activity. When we in the Bay Area feel an earthquake, we want to know how strong it was and where it occurred, as soon as possible. After all, even a small vibration could be the result of a severe earthquake far away. Traditionally, we've had to wait for answers as reporters scrambled to investigate and spread the news. But thanks to the <a href="http://www.usgs.gov/">US Geological Survey (USGS)</a>, we can get earthquake data straight from the source. Now, when you search for "<a href="http://www.google.com/search?q=earthquakes">earthquakes</a>" on Google, you'll get information on some of the most recent, significant earthquakes from around the world, right on the search results page. From there, you can click through to the <a href="http://earthquake.usgs.gov/eqcenter/">USGS Earthquake Center</a> for more information, or visit the epicenter of any quake on Google Maps. To find earthquakes closer to home, you can add a location to your query, for example: "<a href="http://www.google.com/search?q=earthquakes+California">earthquakes California</a>." <a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj0xcVsbuOAgPRN4R9IRYTu7B3Wq1Nf7yYQR2gZrq2jstnLhujdbrr9NEsMCyHQyDTAnHFOridUry-DBMKuE_2d9xhfTLpiqwXL93WExbuJ4VhIP9u8dusJ0HTjNKEMkNQqzL-5L02z-auf/s1600-h/earthquakes_california_screenshot_2009-03-05a.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5309852190872783554" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj0xcVsbuOAgPRN4R9IRYTu7B3Wq1Nf7yYQR2gZrq2jstnLhujdbrr9NEsMCyHQyDTAnHFOridUry-DBMKuE_2d9xhfTLpiqwXL93WExbuJ4VhIP9u8dusJ0HTjNKEMkNQqzL-5L02z-auf/s400/earthquakes_california_screenshot_2009-03-05a.jpg" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 400px; height: 170px;" /></a>Earthquake search is the latest of Google's special search features, and many others can help you in different ways. If you'd like to know the local time where an earthquake occurred, search for "time" followed by the location (for example, "<a href="http://www.google.com/search?q=time+Japan">time Japan</a>"). Let's say the epicenter was 50km from the coast and you want to know how far that is in miles. Type "<a href="http://www.google.com/search?q=50km+in+miles">50km in miles</a>" into the search box. You can find out about these special features and many more on the <a href="http://www.google.com/help/features.html">Search Features page</a>. Posted by Mike Danylchuk, Software Engineer, Search User Interface team

Shaking up earthquake searches

Silicon Valley is well known as the home of technology companies like Google, but it's also one of many regions around the world with fr...

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Draft Patient Rights Statement and Informed Consent on Use of HIT

Health IT has been nearly universally touted as "improving the quality of medical care." That implies that HIT also affects outcomes of care, and that if it is defective or malfunctions, it can reduce the quality of medical care and contribute to poor outcomes. A virtual medical tool (i.e., a medical tool that happens to involve computers) that can impact the quality of care and outcomes either positively or adversely seems to me to be a very potent device. I also believe the regulatory definition of "medical device" needs updating; it may have become obsolete with the galloping advances in technology over the past decade or two. Patients currently are subject to the effects upon their care of electronic medical devices known collectively as "clinical IT" (electronic health records, computerized physician order entry, clinical decision support, clinical data repositories, etc.), but are not informed of the nature of this IT nor its possible adverse effects on their care. The consent forms they do sign are, therefore, incomplete. I am proposing a "Patient Rights Statement and Informed Consent on Use of Clinical IT Devices" be required at healthcare organizations using this technology. Here is a draft of such a consent. Note that this draft is a bit tongue in cheek, but not entirely so. There is nothing nonfactual about it: <blockquote style="color: rgb(255, 0, 0);">Patient Rights Statement and Informed Consent on Use of Clinical IT Devices I, ___________, consent to treatment at Acme General Hospital. I understand my rights to the very best care Acme General can provide, and understand that Acme General has taken every feasible step to assure my safety and comfort. I understand that my treatment will be modulated and advised by my doctors' and nurses' interactions with clinical devices still under development in an exploratory fashion known as "electronic health records systems", "clinician order entry systems", "clinical decision support systems" and other computer systems, hereafter "clinical IT devices." I understand that said clinical IT devices are not subject to federal or state evaluation, regulation or approval, as are the drugs I take and the "physical" medical devices that may be used in my care (such as catheters and defibrillators), and were designed by for profit IT companies whose primary leaders and developers lack clinical expertise. I further understand that these clinical IT devices, while believed to be benign and helpful, have never been rigorously and scientifically proven to be safe and effective. I understand that the literature is conflicting on this point, and that patients have been documented to have been harmed or nearly harmed by design problems, defects and malfunctions in these clinical IT devices. I understand the vendor of the clinical IT devices in use at Acme General has a contract with Acme General Hospital that forbids Acme General and its employees and representatives from sharing known defects about the clinical IT devices with other organizations. I also understand that there are currently ____ clinical IT device defects known at Acme General as reported by its staff. Of these defects, ___% fall into the category of affecting revenue, ___ % fall into the category of affecting clinician work efficiency, and ___ % fall into the category of affecting patient safety and outcomes. I understand that of these known defects, ___ % fall into Class 1, "likely to cause patient harm in short term if uncorrected", ___% fall into Class 2, "may cause in patient harm in medium or long term", and ___% fall into Class 3, "not likely to cause patient harm, but may affect operations." I understand the vendor of the clinical IT devices in use at Acme General have granted Acme General 75,000 shares of their stock, and are using Acme General to refine these clinical IT devices for sale to other healthcare organizations and to other clinical IT initiatives in the U.S. and overseas. I also understand the vendors of these clinical IT devices have promised Acme General these defects will be remediated by ______ (date). Finally, I understand that use of these clinical IT devices may cause user fatigue and cognitive overload in clinical users after prolonged exposure, especially if not well designed, making the clinicians more liable to commit medical error. I, however, also understand, since these clinical personnel are "learned intermediaries", that if I suffer injury or die as a result of a clinical IT device problem, the vendor of the clinical IT device is immune from liability. The liability will fall upon the doctors and nurses using it, and upon Acme General. I understand that if I do not consent to use of these clinical IT devices by hospital clinicians during my care, I will be treated by clinicians using paper charts and forms to manage my information, which carries risk but is a proven technology in widespread use in medicine to record detailed clinical information over approximately the past century<a href="http://www.ipst.gatech.edu/amp/collection/museum_invention_paper.htm"></a>. Signed, ________________ (patient name) _________ (date) </blockquote> -- SS

Draft Patient Rights Statement and Informed Consent on Use of HIT

Health IT has been nearly universally touted as "improving the quality of medical care." That implies that HIT also affects outco...

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Health IT Project Success and Failure: Recommendations from Literature and an AMIA Workshop

A preprint article "Health IT Project Success and Failure: Recommendations from Literature and an AMIA Workshop" by Bonnie Kaplan and Kimberly D. Harris-Salamone (doi:10.1197/jamia.M2997) has just been published and made available in the Journal of the American Medical Informatics Association (<a href="http://www.jamia.org/">JAMIA</a>). It will appear in the May/June 2009 issue of JAMIA. [Addendum 1/2010: a link to a free PDF of the published article is <a href="http://jamia.bmj.com/content/16/3/291.full.pdf">here</a>.] There is a history to this publication, that summarizes the findings and recommendations of a surprisingly well attended workshop ironically named "<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failure_workshop_final_revised.doc">Avoiding The F-Word: IT Project Morbidity, Mortality, and Immortality</a>." The workshop was held at the 2006 national meeting of AMIA. Ten years ago, in early 1999 I started a website hosted on AOL, and called at that time "Medical Informatics and Leadership of Clinical Computing: Common Examples of Healthcare IT Failure." A historical version of the site (with a "politically corrected" title) is <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/medinformaticsmd/failurecases.htm">here</a>; the modern site is now <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/">here</a>. The website was unique at the time and today, remarkably, remains nearly so (see <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/content/documents/FINAL_Healthcare%20IT%20Failure_Oct_19_2006.ppt">this pdf poster</a> from AMIA's 2006 annual meeting). Yet I was to soon learn through correspondence about the website that these problems were common as well as international in scope. Healthcare IT failure was (and is) a somewhat "taboo" subject, in no small part because of contractual gag clauses on users and vendor lack of legal accountability for defects, as well as a striking overconfidence in computing and timidity about discussing organizational failure and IT mismanagement. Its open discussion has therefore been severely impaired and minimized. <div> </div><div>I pushed this topic hard among the Medical Informatics community, yet for years there was resistance to bringing this issue to the fore. I took significant "heat" for my views as well, making me somewhat of an outcast in my own professional community and <a href="http://hcrenewal.blogspot.com/2007/03/problems-found-in-uc-davis-emr-project.html">even to one of my former mentees.</a> This phenomenon may have been a combination of academic concerns about a topic that might dilute the field, preferential and understandable focus on successes, conflicts of interest, and other issues. <div> </div><div>[May 2009 addendum: the "taboo" nature of the subject of HIT difficulty and failure might in fact have been engineered by the HIT industry; see the article "<a href="http://www.washingtonpost.com/wp-dyn/content/article/2009/05/15/AR2009051503667.html?hpid=topnews">The Machinery Behind Healthcare Reform: How an Industry Lobby Scored a Swift, Unexpected Victory by Channeling Billions to Electronic Records</a>" by Robert O'Harrow, Jr., May 16, 2009, Washington Post -- ed.]</div><div> I, on the other hand, having been (pre-informatics fellowship) a Medical Review Officer in the medical department of a regional mass transit authority, and observing a fatal subway elevated accident related to drug abuse, was not going to back down. The accident was the worst in perhaps sixty years in Philadelphia, with hundreds of injuries and several deaths in part due to overriding of medical judgment by non-medical personnel on drug testing at time of union-demanded reinstatement of persons known to have problems. This was as a quid pro quo for labor contract approval. Worse, there were IT errors as well -- again with overriding of medical personnel, namely, me. I'd written a program on our departmental PC for random drug test date selection, but by MIS edict, use of that program was overridden in favor of some slop they authored for their machines - which "forgot" to enroll the operator behind the accident in random testing altogether. Months went by with no tests, and then at the time of the accident the operator's cocaine metabolite levels "blew the lid off the GCMS machine", according to the toxicologist performing the test. Having been informed by my earlier transit authority experience (and gaining some lessons in fortitude from the militant mass transit labor unions I had dealings with), I started the HIT difficulties website in late 1998-early 1999 after <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=clinical%20computing%20problems%20in%20ICU">watching ICU patients needlessly being put at risk</a> and the high risk <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story">Invasive Cardiology cath lab being disrupted</a> as CMIO at Christiana Care in Mr. Biden's home state. These problems were once again due to the ill-informed, capricious edicts of overempowered MIS leaders, sanctioned by equally ill-informed executive leadership. In fact, I quit that CMIO role, no longer being able to tolerate being a marginalized "Director of Workarounds to Dangerous Health IT Mismanagement" (as are many of today's CMIOs), unable by management caprice to make even the most basic of corrections to obvious and risky - and grossly negligent, perhaps even criminally negligent - design and implementation errors. With the exception of a period of time in pharmaceutical research IT from 2000-2003, I periodically sought additional case information on healthcare IT difficulties from colleagues via email and AMIA message board postings, but the results were lukewarm at best. I'd hoped upon returning to a focus on the healthcare provider IT sector in late 2003 that conditions in that sector would have improved. I was wrong. I continued to comment on these issues but with results similar to the past. However, as more informaticists became familiar with the organizational and clinician chaos that ill-conceived clinical IT and/or suboptimally managed electronic medical records projects were causing, a "critical mass" of interest and determination appeared to have been reached by early 2006. At my request my assigned research assistant at Drexel sent out the following message to a number of AMIA message boards, the clinical information systems (cis), ethical, legal and social (els), evaluation special interests (eval-sig) and the people and organizational issues (poi) workgroups. <blockquote style="font-family: arial;">From: poi-wg-bounces@mailman.amia.org [mailto:poi-wg-bounces@mailman.amia.org] On Behalf Of Yunan Chen Sent: February 27, 2006 8:46 AM To: cis-wg@mailman.amia.org; els-wg@mailman.amia.org; eval-sig@mailman.amia.org; poi-wg@mailman.amia.org Subject: [poi-wg] Healthcare IT failure cases Hello: My name is Yunan Chen and I am a research assistant for Dr. Scot Sliverstein in the Institute of Healthcare Informatics , College of Information Science & Technology at Drexel University . Currently, we are working on a project regarding Healthcare IT infrastructure failures. The purpose of our project is to investigate why Healthcare IT infrastructure may fail from a social- technologic perspective. We will collect cases published in scientific papers and newspapers, as well as unpublished stories by the Healthcare IT practitioners. Then, we will categorize these cases and build a casebase for future implementation guideline. We have already collected some cases which are listed in: http://home.aol.com/medinformaticsmd/failurecases.htm . The cases listed here were collected from 1998-2001. Now we hope to gather newly happened cases to enrich our collection. If you experienced or heard of any interesting story, please do not hesitate to write it down and send it to me. We hope to hear more from healthcare IT practitioners' hand-on experience. Any story is valuable to us. Any posting of the cases will be keep anonymous and we won't reveal identities of people or organizations . We will move the Healthcare IT failure cases webpage to Drexel University server later, so all your stories will be listed on that site. We will inform you once the new website is ready. If interested, please write back to me at: yunan.chen@ischool.drexel.edu . Comments and suggestions are welcome. I am looking forward to hearing back from you. Thanks very much. Yunan Chen Doctoral student & Research assistant Institute of Healthcare Informatics College of Information Science & Technology Drexel University</blockquote> It soon became apparent that a critical mass had been reached. A torrent of shared experiences of HIT difficulty in the various message boards appeared from all over the country and from other countries as well. Calls for a formal AMIA panel or workshop on this issue arose. This call was energetically supported by a heterogeneous and widespread group of informatics professionals. This momentum prompted the "<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failure_workshop_final_revised.doc">Avoiding The F-Word</a>" workshop to be collaboratively formulated in a wonderful volunteer effort led by former colleague Bonnie Kaplan at the Yale Center for Medical Informatics (where I'd completed my postdoc in medical informatics), and Kim Harris-Salamone, along with the AMIA workgroup members. Ten <a href="http://www.amia.org/mbrcenter/wg">AMIA workgroups</a> and over fifty HIT experts ultimately participated in the workshop. In Sept. 2006, before the workshop occurred, I wrote at "<a href="http://hcrenewal.blogspot.com/2006/09/holes-in-quest-to-enable-electronic_21.html">The holes in the quest to enable the electronic clinical trial ...</a>": <blockquote style="font-family: arial;">... I also think some answers to the question "Where are the holes in the quest to enable the electronic clinical trial?" will be found in an upcoming Nov. 2006 American Medical Informatics Association Annual Conference workshop on healthcare IT failure entitled "<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failure_workshop_final_revised.doc">Avoiding The F-Word: IT Project Morbidity, Mortality, and Immortality</a>", the first of its kind: <o:p></o:p> <blockquote><div class="MsoNormal">SESSION DESCRIPTION Recent studies of health care computer applications and the reported failures of well-known systems surprised the medical informatics community, leading to questions of how to increase the chances of IT systems success and the reduction of errors. Similar problems plague a variety of different systems, whether for institutions as a whole, for ancillary services, or for consumer health, and have done so for many years. Despite an accumulation of best practices research that has identified a series of success factors, some 40% of information technology developments in a variety of sectors are either abandoned or fail, while fewer than 40% of large systems purchased from vendors meet their goals. According to the recent CHAOS Report by The Standish Group, which surveyed failures of IT in general (not just in health care), only 34% of IT projects were considered truly successful. Similar numbers have been estimated for health care, and the number has unfortunately remained approximately the same for at least the last 25 years. While there have been some published reports of failures, removals, sabotage of systems, or how failures became successes or were otherwise redefined, there has been too little opportunity to learn from studies in which technology interventions resulted in null, negative, or disappointing results. The purpose of this session is to examine why this happens and what might be done to improve the situation, and to collaboratively develop a series of frameworks for various types of systems and healthcare settings to aid in implementation and evaluation. The session builds on a lively exchange by numerous members of a number of AMIA Working Groups concerning success and failure in medical informatics. The session will be devoted to better defining or characterizing "success" and "failure." From there, participants will break out into smaller groups to continue the discussion, develop a set of important issues, action items, and recommendations.<o:p></o:p></div></blockquote></blockquote> The report, now published, is filled with pearls such as these: <ul><li>With the US joining other countries in national efforts towards the many benefits health information technology use can bring for health care quality and savings, recent sobering reports recall the complexity and difficulties of implementing even smaller-scale systems. Despite best practice research identifying success factors for health information technology projects, a majority, in some sense, still fail. </li></ul><ul style="font-family: arial;"><li>With the United States Congress appropriating more than $20 billion for health information technology as part of the February, 2009 economic stimulus package, the US joined other countries in national efforts towards the many proven benefits such technology use can bring for health care quality and savings. Moreover, Medicare, along with private and commercial health plans, is implementing a new paradigm for paying for health care services in the US, known as Value-Based Purchasing (VBP), or pay for performance initiatives (P4P). These initiatives rely heavily on using electronic health records to provide clinical documentation that proves the value of their services. Tempering the fervor, though, are recent sobering reports that raise concerns about how the technology is designed and deployed.</li></ul><ul><li>Similar failure rates [to other types of IT] have been reported for health IT.(14, 15) Hospitals are among those organizations where delays and cancellations of software projects are endemic.(16) For years, problems have plagued the implementation of health IT applications, whether for ancillary services, for whole institutions, for regional or national systems, or for consumers. Today's problems are reminiscent of those analyzed since at least the 1970s in classic studies of hospital information and patient record systems.(17-19) In 1990, Dowling estimated that staff interfere or sabotage with "nearly half" of projects(20), while Heeks noted in 2006 that it is his "best estimate...that most HIS [health information systems] fail in some way."(15) Recent studies and newspaper accounts cite difficulties in a variety of health information technology applications. Over the years, in many countries, patterns of severe problems repeatedly have beset a variety of efforts: hospital information systems and electronic records(21-26); ambulance services(27, 28); community, regional, and national health information networks (28-33); public health systems (34, 35); patient education (36); and physician order entry.(18, 19, 37-41) </li></ul><ul style="font-family: arial;"><li>Yet, while there have been some published research reports of health care IT failures, unfortunately, there has been an absence of systematic and thoughtful publication of lessons learned from IT interventions where there have been null, negative, or disappointing outcomes.(27, 53) Despite calls for increased research, there are insufficient numbers of published research reports of health care IT failures, removals, sabotage of systems, or how failures became successes or were otherwise redefined. As in other sectors (69), IT-related failures in health care often are covered up, ignored, or rationalized, so mistakes are repeated.</li></ul><ul style="font-family: arial;"><li>Participants emphasized that communication and workflow issues add to project complexity. Health care requires collaboration, as does system implementation, yet there is difficulty in translating among specialties, stakeholders, clinicians, and implementers, sometimes to the point of a seeming "culture clash."</li></ul><ul style="font-family: arial;"><li>The workshop concluded with reports from break-out groups charged with discussing ideas for how AMIA could address health informatics failure. Break-out groups made suggestions concerning: research and publication, best practices, advocacy, education, certification, and databases and knowledge integration.</li></ul> The workshop findings concluded with these words of wisdom: <blockquote style="font-family: georgia;">Much has been learned about success and failure in IT implementation, but we need to understand more. There are legal issues when a system "fails," including just what constitutes "failure." There are social issues, ranging from how such failures affect various groups and health informatics as a whole (including possible policy and regulatory reactions), to the social aspects of what makes for a "successful" implementation. Finally there are ethical issues involved in evaluating system "success" or not sufficiently attending to previously-identified success factors and best practices.(24) Most "failures" are failures to properly apply managerial wisdom that has been substantiated by research and experience. Perhaps the worst aspect of failure is failure to learn from past experiences so that the same issues and problems are not perpetuated. </blockquote> While the workshop was a culmination of the kindling on this crucial topic I've been involved in since being overruled on <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=clinical%20computing%20problems%20in%20ICU">patient-endangering healthcare IT mismanagement</a>, I believe we as a society, and the HIT sector as a for-profit, entirely unregulated industry lacking accountability (the accountability rests on clinical end users, as in, in the courtroom in malpractice suits), are still very far from solutions to that final observation on failure to learn from history. The observations of this workshop are only made more acutely important by what I believe are ill advised, rushed plans to coerce US healthcare organizations and practitioners to adopt these evolving, arguably still-experimental virtual medical devices by 2014, or face penalties. -- SS</div></div>

Health IT Project Success and Failure: Recommendations from Literature and an AMIA Workshop

A preprint article " Health IT Project Success and Failure: Recommendations from Literature and an AMIA Workshop " by Bonnie Kapl...

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Tipping points

Ideas are everywhere, but how do we know which ones actually work? At Google, we put a lot of stock in both the wisdom of crowds — the idea that lots of people responding to a given question can collectively find the best answer — and the value of community. We believe that people working together can help one another through even the most difficult times. As we all navigate today's choppy economic waters, we'd like to put these beliefs into practice. That's why we created <a href="http://www.google.com/tipjar">Tip Jar</a> (www.google.com/tipjar), an experiment powered by <a href="http://googleappengine.blogspot.com/2008/09/introducing-google-moderator-on-app.html">Google Moderator</a> that we hope will help you discover the most effective ways to save money. There are lots of money-saving tips scattered across the web, but even if you found them, it would be hard to know which ones were worth trying. Tip Jar gathers tips in one place and invites people — i.e., you, me and everyone else — to rank them in order of usefulness and even add their own tips to the list. Over time, the best and most useful tips will rise to the top. So go ahead: <a href="http://www.google.com/tipjar">Take a Tip. Share a Tip</a>. We'll all be a little bit richer for it. Posted by Colby Ranger, Software Engineer

Tipping points

Ideas are everywhere, but how do we know which ones actually work? At Google, we put a lot of stock in both the wisdom of crowds — the idea ...

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