healthy4u

Our Policy Is To Always Have Unabashed Faith In The Computer ... Except When It Screws Up, And Then It's The Doctor's Fault

Healthcare IT such as electronic medical records (EMR/EHR) and computerized physician order entry (CPOE) systems are a perfected, safe technology, one might think, from the almost hagiographic and entirely uncritical P.R. about HIT, all the way up to the President of the United States. (Not bad for an entirely unregulated industry. Pharma IT should only have it so well.) Paraphrasing Capt. Chesley Sullenberger in a <a href="http://online.wsj.com/article/SB10001424052748703790404574469160016077646.html">recent WSJ article</a>, however, I'm a long term optimist about HIT, but a short term realist. Healthcare cannot be 'transformed' by a technology that itself has major problems and needs transformation. These issues should have been substantially remediated before forced national rollouts, I feel. That's especially true given the inherent dangers in medicine. You can't be a wishful thinker. You have to know what you know, and perhaps more importantly in medicine, what you don't know (this is especially true both for those in IT who lack formal clinical or biomedical backgrounds, and for those in medicine who lack formal biomedical informatics or computer science backgrounds). You also need to know what your tools can and can't do. Sticking one's head in the sand is no way to approach HIT. <a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgIqCS12K1usmZMlxOoFAud0IU-EE_YeYoCGMIjhSRmlO2uIdWpffcisgn5KDlF1pN8ND6cslVzDqpu-OFmMANL6O2NEY5haMuuDLuSR6vpQ9rQ_3qxYv-Fps4KU43lqGEwVflq89aB4abY/s1600-h/headinsand.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5394097962244199106" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgIqCS12K1usmZMlxOoFAud0IU-EE_YeYoCGMIjhSRmlO2uIdWpffcisgn5KDlF1pN8ND6cslVzDqpu-OFmMANL6O2NEY5haMuuDLuSR6vpQ9rQ_3qxYv-Fps4KU43lqGEwVflq89aB4abY/s320/headinsand.jpg" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 171px; height: 150px;" /></a> That said, here are some sample voluntary reports on HIT malfunctions from just one vendor, taken from the FDA Medical Devices database, the <a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/search.CFM">Manufacturer and User Facility Device Experience (MAUDE) database</a>, links included. These are production systems used on real, live patients, not prototypes: <blockquote> MAUDE data represents reports of adverse events involving medical devices. The data consists of voluntary reports since June 1993, user facility reports since 1991, distributor reports since 1993, and manufacturer reports since August 1996. MAUDE may not include reports made according to exemptions, variances, or alternative reporting requirements granted under 21 CFR 803.19.</blockquote> Emphases below are mine. My comments are in [red italic]. Case 1: (note - added to this post 7/2010) <a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/detail.cfm?mdrfoi__id=1656460">http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/detail.cfm?mdrfoi__id=1656460</a> CERNER MILLENIUM POWERCHART CPOE Event Date 11/19/2006 Event Type: Death Patient Outcome: Death The medication review screen of the subject device does not specify the exact dose in milligrams of combination medications. For example, narcotics are combined with tylenol in at least two strengths. Liquid narcotic tylenol-oxycodone combination is reported in ml, not mg. The exact dose of tylenol is not specified and requires knowledge of the combination medication dose in the volume specified. Certain fields of the grid do not specify the volume, but rather state "date/time" requiring another click or pop up screen. The immediate knowledge of tylenol dosage in mg is directly related to understanding and preventing excessive doses. In the subject, 10 ml of acetaminophen-oxycodone is indicated as having been given 3 times over 4 hours. That means that 1950 mg of tylenol was administered in 4 hours while the patient was in a state of starvation and receiving other medication that increase the effects of tylenol. This dose would equate to 11,700 mg of tylenol over 24 hours, nearly 3 times the maximum daily dose in otherwise health people. In the ensuing days, the patient developed acute renal failure, presumably acute tubular necrosis, and died. In the absence of other etiology, the excess tylenol was the culprit. This was not considered as etiology ante-mortem. The counterintuitive screen impaired the professionals. The pharmacist did not recognize and stop the medication, the nurses administered it, and the excessive dose, clinically meaninglessly listed as a volume of 10 ml -given 3 times in 4 hours- of acetaminophen-oxycodone, was missed by the physicians. Adverse events have been ascribed to "user error" by vendors. The device offers a potent propensity to life endangering oversights. There are other screens on this device which present information that interfere with clinically useful visualization of data. [Who designed these screens, I ask? Clinicians, or business IT personnel used to designing inventory systems for widget control? - ed.] The data does not flow to the professionals. It is not represented in a meaningfully useful manner. The professionals need to hunt for it. As such, the user unfriendly screens [see <a href="http://www.tinyurl.com/hostileuserexper">this link</a> on mission hostile HIT - ed.] impair safe medical care consistent with the impediment to expedient professional understanding of what, exactly, is the dose of medication and how much was administered to the patient. This sentinel case of death is directly attributed to user unfriendly screens on this device. Case 2: <a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfRES/res.cfm?id=64345">http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfRES/res.cfm?id=64345</a> Cerner Millennium RadNet Auto Launch Study and Auto Launch Report software functionalities. Defects in the Auto Launch functionality make it possible for a mismatch of patient data. [That is, in radiology reports. The dangers of transpositions is obvious.] Case 3: <a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=722614">http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=722614</a> The issue involves powerchart local access medication administration task, used when certain cerner millennium solutions are not available. At powerchart local access sites that utilize coordinated universal time (utc) functionality, medication administration tasks might be displayed with incorrect times. When a pt download occurs from cerner millennium servers to powerchart local access, and there is no cerner millennium application session active, powerchart local access adds or subtracts the number of hours equal to the time zone difference from greenwich mean time. Scheduled medication administration tasks may show an incorrect administration time and the possibility exists for a pt to receive medications earlier or later than intended. [As just one example of the dangers with this type of defect, an elderly patient with sepsis might get an early dose of <a style="font-weight: bold; font-style: italic;" href="http://www.uptodate.com/patients/content/topic.do?topicKey=%7E33VV7w5pdwZSOF">aminoglycoside</a>, causing peak levels to rise to nephrotoxic and ototoxic levels - ed.] Case 4: <a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=946706">http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=946706</a> Patient care delay. The issue involves functionality in cerner millennium powerchart office and powerchart core and affects users that utilize the powerchart inbox and message center inbox. In results to endorse or sign and review, if the user clicks ok and next multiple times in quick succession [e.g., a busy clinician with sick patients, waiting for the computer to respond - ed.] while attempting to sign a result or a document, the display could lag behind the system's processing of the action [that is to say, the human-programmed and supposedly tested and validated computer "system" -ed.], and multiple results or documents could be signed without the user's review. In message center, when clicking ok and next or accept and next, or when deleting or completing messages and moving to the next task, a document could be signed or a message could be deleted without the user's review. Results could be endorsed or documents could be signed without physician review, which could impact patient care. Cerner received communication that a patient's follow-up care was delayed as a result of this issue. [Luck prevailed that no injury occurred - in this reported case. One wonders if that is true of all the users who experienced this problem. Also, I do not recall such errors happening on paper order forms due to, say, a busy clinician tapping his pen on the paper - ed.] Case 5: <a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=888215">http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=888215</a> The issue involves the pharmacy medmanager functionality. If the user performs a modify action on an order with an existing duration and duration unit, the order's stop date might not be recalculated. Specifically, this occurs when only the duration value is changed prior to entering the original duration unit. Pt care could be adversely affected, as medication therapy could be concluded prematurely or could last longer than intended based on the order details prior to the modification. This issue can be avoided if the user performs a renew action instead of a modify action to change an order's duration. If performing a modify action is required, users can manually set the stop date and time during the modify action. Cerner received communication that a pt's surgery required rescheduling as a result of this issue. [Again, was the lack of patient harm due to careful clinicians who at that moment just happened to not be distracted or cognitively overloaded or overworked or exhausted from on-call, or an act of Providence? Were other non-reported users at other organizations less lucky? - ed.] Case 6: <a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=920819">http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=920819</a> The issue involves the results to endorse (rte) inbox functionality in powerchart, powerchart office and firstnet and affects users that use the rte inbox to view radiology reports that have been created in radnet. Radiology results might fail to be displayed in the ordering provider's results to endorse folder in the inbox. Treatment or diagnosis decisions could be delayed if the clinician is relying on the display of a result in the inbox results to endorse folder to initiate patient follow-up. Note: the final results are posted to the flowsheet and are available on the patient's chart. Cerner received communication that a patient's follow-up care was delayed as a result of this issue. [Were any diagnoses of, say, cancer missed by other organizations affected? -ed.] Case 7: <a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=700117">http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=700117</a> The issue involves the direct charting flowsheet and icu flowsheet, used within the powerchart system. When the result details box is accessed for a negative result value in either the icu flowsheet or the direct charting flowsheet in powerchart, either by right-clicking a negative, unsigned result value and selecting chart details from the context menu, or by right-clicking a negative signed result value and selecting modify, the dialog box displays a blank result value. When the user clicks ok in the result details dialog box, the value is changed to zero in the result cell in the flowsheet. [Of all places, health IT in ICU's should be extensively validated before going into production - ed.] Case 8: <a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=715963">http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=715963</a> The issue involves the careadmin medication administration wizard used within the carenet system. When scanning a medication in careadmin, the system fails to recognize mckesson identifiers or other miscelaneous identifiers and properly identify the scanned product, which could result in the documentation of an incorrect dose in the careadmini window. In such situations, the system does not display overdose or underdose or route/form compatibility warnings as it should. Patients could receive an inappropriate dose of medication. Cerner has not been made aware of any adverse patient care events that resulted from this issue. [Thank god for that - but were any unreported by other organizations? - ed.] Case 9: <a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=753029">http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=753029</a> Microbiology set up a program within the cerner computer system to automate the reporting system for hsv (herpes simplex virus)testing. The system was tested with the assistance of cerner and found to be working appropriately. The new system was operational for approximately 3 weeks when it was determined that the first word of the sentence, "no" was inappropriately dropping off of the following sentence: "no herpes simplex virus type 1 or herpes simplex virus type 2 detected by dna amplification. " as such, two of five patients were incorrectly informed that they had hsv before the error was detected. One had started an antiviral creme treatment. The other three did not have follow-up visits until after the correct results were determined. Cerner has looked at the program and has not provided an answer for the system issue. In the interim, the previous manual review and entry process is being used. [How does the word "no", an essential descriptor in a medical test, simply get "dropped?" Does <a style="font-style: italic; font-weight: bold;" href="http://www.norad.mil/">NORAD's</a> ballistic missile warning system ever do that, i.e., "no ICBM's incoming" reported as "ICBM's incoming"?- ed.] --------------------------------- Additional reported errors can be seen in a file downloadable by clicking <a style="font-weight: bold;" href="http://www.ischool.drexel.edu/faculty/ssilverstein/maude/Adverse_Event_CPOE__MAUDE.pdf">on this link</a> (PDF). Some of these are a bit startling. --------------------------------- Still others can be seen at: <a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=695436"> </a><a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=695436" target="_blank">http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=695436</a> <a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=688925" target="_blank">http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=688925</a> <a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=996685"> </a><a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=996685" target="_blank">http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=996685</a> <a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=1075747" target="_blank">http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=1075747</a> <a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=574578" target="_blank">http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=574578</a> <a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=1288623"> </a><a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=1288623" target="_blank">http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=1288623</a> <a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=1370640" target="_blank">http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=1370640</a> <a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=834678" target="_blank">http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=834678</a> Again, these are reports about just one HIT vendor but this piece is not just about them. Other HIT vendor products have similar issues. Health IT remains an experimental technology. The MAUDE reports are voluntary, however, so the absence of a report does not mean an absence of a problem. (I note MAUDE queries on a number of major HIT vendors produce no results, or results limited to HIT that is closely associated with physical "medical devices" -- as opposed to virtual ones -- such as radiology systems.) For example, while a query on mfg. "Cerner" brings up hits, a query on another vendor shows this result: <blockquote>No records were found with Manufacturer: Allscripts Report Date From: 10/01/1998 Report Date To: 09/30/2009 </blockquote> ... and this: <blockquote>No records were found with Manufacturer: Nextgen Report Date From: 10/01/1997 Report Date To: 09/30/2009 </blockquote> ... while a <a href="http://google2.fda.gov/search?q=nextgen&x=0&y=0&client=FDAgov&site=FDAgov&lr=&proxystylesheet=FDAgov&output=xml_no_dtd&getfields=*">broader FDA search on "Nextgen"</a> brings up exactly <a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=1055515">one relevant hit</a> on "Nextgen EMR - Medical Device" -- without specifics as to the "malfunction" noted under product code "<a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPCD/classification.cfm?ID=3355">HGM</a>" - which on lookup is a perinatal monitoring system. A <a href="http://google2.fda.gov/search?q=allscripts&x=0&y=0&client=FDAgov&site=FDAgov&lr=&proxystylesheet=FDAgov&output=xml_no_dtd&getfields=*">broader search on Allscripts</a> only brings up drug related issues such as this curious 2002 <a href="http://www.fda.gov/ICECI/EnforcementActions/WarningLetters/2002/ucm145211.htm">warning letter</a> about the marketing of guaifenesin, a cough medicine, from FDA's Center for Drug Evaluation and Research. Either these vendors are not reporting HIT problems, or are listed under another name. Rather unlikely is that they have <a href="http://www.healthcareitnews.com/news/allscripts-shareholders-file-class-action-suit">no problems</a> to <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/DUCOM_EMR_Complaint.pdf">report</a> (latter hyperlink is PDF). As another example, a search on brand name "Centricity" brings up "hits" mostly on specialized GE products such as PACS. So, is HIT safe, or can "glitches" affect patient care? Should this industry be entirely unregulated, or its products "certified" by groups with conflicts of interest such as those affiliated with industry trade groups? Should vendors be <a href="http://jama.ama-assn.org/cgi/content/extract/301/12/1276">held harmless</a> for HIT defects that harm patients? I report, you decide. -- SS

Our Policy Is To Always Have Unabashed Faith In The Computer ... Except When It Screws Up, And Then It's The Doctor's Fault

Healthcare IT such as electronic medical records (EMR/EHR) and computerized physician order entry (CPOE) systems are a perfected, safe techn...

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This week in search 10/16/09

This is part of a regular series of posts on search experience updates that runs on Fridays. Look for the label "<a href="http://googleblog.blogspot.com/search/label/This%20Week%20in%20Search">This week in search</a>" and subscribe to the series. - Ed. This week, we made a few improvements to help webmasters better understand how their pages interact with Google search. Here's an overview: Fetch as Googlebot As a webmaster, have you ever wondered what Google "sees" when we visit your site? Our understanding of your web page affects which searches your page is returned for and its relevance rank. New this week, we're providing a tool as part of our Webmaster Tools Lab that lets you to <a href="http://googlewebmastercentral.blogspot.com/2009/10/fetch-as-googlebot-and-malware-details.html">see what Googlebot sees</a> in the hope that this will help site owners better understand why we think your pages are relevant, and to what. We think this can help webmasters design pages that are easier for Googlebot to understand, and more importantly, easier for users to understand. Malware details You may occasionally see on Google a notice that says "This site may harm your computer." We place this warning in search result snippets when we see signals that a particular web page may be spreading malware. Webmasters occasionally will see this warning on one of their pages that wasn't intended to be malicious. This is because sometimes your site could be distributing malware — and you might not even know it or be able to easily find it. <a href="http://googlewebmastercentral.blogspot.com/2009/10/fetch-as-googlebot-and-malware-details.html">Malware details</a> is designed to help webmasters track down what on their site is triggering this label and clear the problem — thus, making their page (and the web) safer for users. Hope you enjoyed this week's features. Stay tuned for what's next! Posted by Marissa Mayer, VP, Search Products & User Experience

This week in search 10/16/09

This is part of a regular series of posts on search experience updates that runs on Fridays. Look for the label " This week in search ...

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A new home for accessibility at Google

Information access is at the core of <a href="http://www.google.com/corporate/facts.html">Google’s mission</a>, which is why we work to make the world's content available to people with disabilities, such as blindness, visual impairment, color deficiency, deafness, hearing loss and limited dexterity. Building accessible products isn't only the right thing to do, it also opens up Google services to very significant populations of people. According to the United Nations, <a href="http://www.un.org/disabilities/default.asp?id=18">650 million people</a> live with a disability, which makes them the world's largest minority. We regularly develop and release accessibility features and improvements. Sometimes these are snazzy new applications like the a new <a href="http://google-opensource.blogspot.com/2009/09/talking-rss-reader-for-android.html">talking RSS reader</a> for Android devices. Other times the changes aren't flashy, but they're still important, such as our recent incremental improvements to <a href="http://dev.chromium.org/developers/design-documents/accessibility#TOC-WAI-ARIA-Support">WAI-ARIA support in Google Chrome</a> (adding support for ARIA roles and labels). We also work on more foundational research to improve customization and access for our users, such as <a href="http://code.google.com/p/google-axsjax/">AxsJax</a> (an Open Source framework for injecting usability enhancements into Web 2.0 applications). We've <a href="http://googleblog.blogspot.com/search/label/accessibility">written frequently</a> about accessibility on our various blogs and help forums, but this information has never been easily accessible (pun intended) in one central place. This week we've launched a handy new website for Accessibility at Google to pull all our existing resources together: <a href="http://www.google.com/accessibility/">www.google.com/accessibility</a>. Here you can follow the latest accessibility updates from our blogs, find resources from our help center, participate in a discussion group, or send us your feedback and feature requests. Around here, we often say, "launch early and iterate" — meaning, get something out the door, get feedback, and then improve it. In that tradition, our accessibility website is pretty simple, and we expect this site to be the first of many iterations. We're excited about the possibilities. The thing we're most excited about is getting <a href="https://services.google.com/fb/forms/accessibility/">your feedback</a> about Google products and services so we can make them better for the future. Take a look and let us know what you think. Posted by Jonas Klink, Accessibility Product Manager

A new home for accessibility at Google

Information access is at the core of Google’s mission , which is why we work to make the world's content available to people with disabi...

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Fuzzy Math Indeed: Rising Costs in Government's Digital Health Stimulus

Seen in the blog of the Huffington Post Investigative Fund: <blockquote><a href="http://huffpostfund.org/stories/2009/10/fuzzy-math-rising-costs-governments-digital-health-stimulus">Fuzzy Math? Rising Costs in Government's Digital Health Stimulus</a>  <div id="node-880" class="node odd full-node node-type-article"> <div class="subtitle">Spending Could Be Double The Obama Administration's Public Estimate of $19 Billion </div></div> <div class="author">By <a href="http://huffpostfund.org/users/fred-schulte" title="View user profile.">Fred Schulte</a> Huffington Post Investigative Fund </div> <div class="post-date">15 Oct 2009</div> Creating digital medical records for every American within the next five years – a key provision of President Obama’s stimulus package -- could cost more than twice the $19.5 billion figure that has been cited by federal officials. Federal budget documents show that actual spending for the plan, which will use stimulus money to help doctors and hospitals defray the cost of installing high-tech records systems, could hit nearly $47 billion. The discrepancy between the Obama administration’s <a href="http://huffpostfund.org/stories/2009/10/fuzzy-math-rising-costs-governments-digital-health-stimulus#cost">$19.5 billion public estimate</a> and the entry in the budget of the U.S. Department of Health and Human Services mostly arises from the government’s calculation that it will recoup some of the cost of subsidizing digital systems through billions of dollars in reduced federal health spending. But many health analysts are highly skeptical that such savings can be accurately predicted.</blockquote><div id="TixyyLink" style="border: medium none ; overflow: hidden; color: rgb(0, 0, 0); background-color: transparent; text-align: left; text-decoration: none;"> </div>It's worse. Far worse. I believe the government is underestimating EHR costs by a factor of 5 to 10, due to implementation failure and remediation costs. I'm a long term optimist on health IT, but a short term realist. I believe we will be having an avalanche of failed/stalled projects such as this one in years to come: "<a href="http://hcrenewal.blogspot.com/2009/10/another-major-hit-project-setback.html">Another Major HIT Project Setback at UCSF</a>". The incompetence in this industry is worse than I imagined when I started writing about HIT dysfunction a decade ago. Worse are the coverups of problems that occur in implementation and in use. At least in the U.S. military, there is transparency about health IT problems (e.g., see <a href="http://hcrenewal.blogspot.com/2009/06/if-military-cant-get-electronic-health.html">here</a>). In the private sector, forget about publicity of what actually goes on in the U.S. (The U.K. has increased its own transparency to <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=UK">some extent</a>.) <blockquote>A spokesman for the department [U.S. Department of Health and Human Services], Nicholas Papas, said that the $47 billion figure is “undergoing revision and we anticipate it will decrease.” He said the agency expects to generate a “firmer figure” by the end of the year, but declined to say how much it would be. Papas said there was no attempt to lowball the number for public consumption. Calculating both cost and benefits in the government’s estimate is a sound way to explain the price of the plan, he said.</blockquote> Unfortunately, these calculations do not factor in the cost of dyscompetence, incompetence and failures created by lack of essential cross disciplinary expertise and talent in the HIT industry. <blockquote>Many health policy experts agree that electronic health records can cut costs by reducing harmful medical errors and wasteful spending.</blockquote> I would bet these "policy experts" have never tried to implement clinical IT. <blockquote>The $19 billion figure has appeared in numerous news articles and been widely picked up and repeated by many bloggers covering the fast-growing health information technology industry. Earlier this month President Obama’s chief technology officer, Aneesh Chopra, mentioned the $19 billion figure twice in a live video cast from the White House. But it’s “totally hypothetical,” said Sharona Hoffman, a professor of law and ethic at Case Western Reserve University School of Law. She said it counts on savings “with no concrete evidence they will occur.”</blockquote><div id="TixyyLink" style="border: medium none ; overflow: hidden; color: rgb(0, 0, 0); background-color: transparent; text-align: left; text-decoration: none;"> </div>It's worse than "totally hypothetical." A major confounding variable is simply missing - the cost of HIT failures, false starts, delays, and remediation. More can be read about those risks <a href="http://www.tinyurl.com/hit-misadventure">here</a>. That site has been online for a decade now, and ironically is nearly the only relevant "hit" on a search engine query on "<a href="http://www.google.com/search?client=firefox-a&rls=org.mozilla%3Aen-US%3Aofficial&channel=s&hl=en&source=hp&q=healthcare+IT+failure&btnG=Google+Search">healthcare IT failure</a>" or similar concept. Has anyone in government been paying attention? A slide deck I recently presented entitled "Health IT Promises and Threats" provides a dose of reality on supposed cybernetic miracles. It is at <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/EHR_benefit_peril_final.ppt">this link</a> (PPT). -- SS

Fuzzy Math Indeed: Rising Costs in Government's Digital Health Stimulus

Seen in the blog of the Huffington Post Investigative Fund: Fuzzy Math? Rising Costs in Government's Digital Health Stimulus ...

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Data Malpractice on T-Mobile Sidekick: But Don't Worry, Your Medical Data is Safe

One of the promises made about healthcare IT is that your medical data is "safer" in electronic form than in paper form. The Hurricane Katrina example of paper records being destroyed is often used as a poster example of the dangers of paper records. However, the risk of electronic storage of information, especially the talk of national EMR's stored on the "cloud" (an amorphous term meaning distributed storage "out there" whose physical sites and boundaries are supposedly irrelevant from the user's perspective) has also been under-reported. Excluding frequent reports of data confidentiality breaches, we also have this: <blockquote>Wall Street Journal, Oct. 15, 2009 <a href="http://online.wsj.com/article/SB10001424052748704107204574475032328975504.html">Microsoft Recovers Lost Sidekick Data</a> By ROGER CHENG Microsoft Corp. said Thursday that it has been able to recover the personal customer data lost from many of T-Mobile USA's Sidekick devices. The Redmond, Wash., software giant said that most, if not all, customer data was recovered, and that the company would begin restoring data as soon as it has validated it. The company said it will start with personal contacts, and move on to the lost calendar, notes, tasks and pictures as quickly as possible. The fix comes as Microsoft suffers through a public backlash after mishandling the information found on the Sidekick line of messaging phones, which are popular with teenagers ... Over the weekend, T-Mobile and Microsoft initially warned that the recovery of data would be unlikely, but upgraded their prospects on Tuesday.</blockquote> They got lucky. <blockquote> Microsoft blamed a system failure [i.e., an IT system - ed.] for the data loss in the core database and backup system. Microsoft said it had taken steps to strengthen the stability of the Sidekick service and started a more resilient backup process. [More resilient compared to ... what? - ed.]</blockquote> In IT it's always an apersonal "system failure", not "data malpractice." When medical malpractice occurs, it's the doctor's fault, even if that malpractice occurred secondary to the failure or misdesign of an EMR or other clinical IT by dyscompetent software engineers. When data malpractice occurs, the motto is "We always blame the computer." How about some names of those responsible for this debacle? <blockquote>... The Sidekick service, run by Microsoft unit Danger [talk about ironic names - ed.], is supposed to be more secure in storing data because it is kept in the "cloud," which involves storing information on the Internet and not one physically vulnerable location, making the temporary loss of data striking.</blockquote> "Cloud" is a new buzzword du jour to make more appealing a basically bad idea for many fields. Distributing data also distributes risk that some incompetent or careless person or person(s) will cause data corruption or loss (yes, computers are run by people, and either they're in control of their systems, or their systems are in control of them). It also puts organizations storing data on the "internet cloud" at risk of being victims of a network "rainy day" when internet connections might prove unreliable (accidents, sabotage, natural disasters all come to mind). In healthcare, using the "cloud" for data storage seems to be a bad idea, especially in an era of $99 (retail) terabyte hard drive storage, and corresponding economies in mission critical-grade local mass storage, backup, business continuity and disaster recovery capabilities. In summary, is electronic medical data more secure when stored electronically than on paper? Only if the underlying CIO's, information stewards, technicians and system administrators are at least as competent and careful as the trained health information management (HIM) personnel in hospital medical records departments and doctors' offices. Time will tell if that is the case. One mistake, and thousands or millions of records can go *POOF*. Microsoft and T-Mobile were lucky ... this time. -- SS 10/26 addendum: Sometimes, EHR data simply disappears too. At this link is a story of a Canadian clinic that lost two years of electronic health records: <blockquote> <a href="http://www.edmontonjournal.com/health/Clinic+medical+files+vanish/2127101/story.html">Clinic's medical files vanish</a> By Ryan Cormier, Edmonton Journal October 21, 2009During a recent investigation into whether a patient's confidentiality had been breached at the Fairview Medical Clinic, an investigator asked for a log of who had accessed the complainant's file. When the clinic responded that it had automated his records in 2004 but only had files from 2006 on, alarm bells rang."That raised a lot of questions," said Leahann McElveen, an investigator with the office of the information and privacy commissioner.The clinic had permanently lost two years worth of health files that include patient information on visits, prescriptions, lab reports, doctor's notes and other information. The loss happened when the clinic switched from one electronic medical records system to another."They were two similar systems intended to do the same thing," McElveen said. "However, they weren't coded the same way behind the scenes. It's not that the records fall into the wrong hands, they just don't exist anymore."</blockquote> *POOF* again. -- SS

Data Malpractice on T-Mobile Sidekick: But Don't Worry, Your Medical Data is Safe

One of the promises made about healthcare IT is that your medical data is "safer" in electronic form than in paper form. The Hurr...

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Street View: We can trike wherever you like

With Street View on <a href="http://maps.google.com/">Google Maps</a>, you can take a virtual drive over the <a href="http://maps.google.com/maps?f=q&source=s_q&hl=en&geocode=&q=Golden+Gate+Bridge&sll=37.81973,-122.479025&sspn=0.001725,0.002733&ie=UTF8&radius=0.07&rq=1&ev=zi&hq=Golden+Gate+Bridge&hnear=&ll=37.81973,-122.479025&spn=0,359.997267&z=19&layer=c&cbll=37.819772,-122.478565&panoid=U9_6P97bDfQmlIINE_R-Vg&cbp=12,350.7,,0,9.59">Golden Gate Bridge</a> or see the bustle of <a href="http://maps.google.com/maps?f=q&source=s_q&hl=en&geocode=&q=Times+Square,+New+York,+NY&sll=37.817717,-122.478247&sspn=0.053497,0.087461&ie=UTF8&hq=&hnear=Theater+District+-+Times+Square,+New+York&ll=40.756242,-73.986263&spn=0.001654,0.002733&z=19&layer=c&cbll=40.756344,-73.98623&panoid=YKzjs_hAkQam2a6nDKtYGw&cbp=12,21.59,,0,3.94">Times Square</a> from the comfort of your own home. But some of the country's most interesting and fun places aren't accessible with our Street View car. What if you want to tour the campuses of prospective universities, scout a new running trial, or plan the most efficient route to your favorite roller coasters in a theme park? I first started thinking about this question around two years ago. My day job is working as a mechanical engineer on the Street View team, but I do a lot of mountain biking in my spare time. One day, while exploring some roads less traveled, I realized that I could combine these two pursuits and build a bicycle-based camera system for Street View. The result? The Street View trike: <object height="340" width="560"><param name="movie" value="http://www.youtube.com/v/Hr-4Aln1Il8&hl=en&fs=1&"><param name="allowFullScreen" value="true"><param name="allowscriptaccess" value="always"><embed src="http://www.youtube.com/v/Hr-4Aln1Il8&hl=en&fs=1&" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" width="560" height="340"></embed></object> I've already had a chance to take the Street View trike out to photograph some hard-to-reach places for Google Maps, like the <a href="http://maps.google.com/maps?f=q&source=s_q&hl=en&geocode=&q=Arastradero+Preserve&sll=37.0625,-95.677068&sspn=65.645551,135.263672&ie=UTF8&t=h&layer=c&cbll=37.388961,-122.17177&panoid=NIRehIo_5KZdObaDCK8QCA&cbp=11,181.98,,0,-0.44&hq=Arastradero+Preserve&hnear=&ll=37.389629,-122.173634&spn=0.00329,0.016512&z=17?utm_campaign=en&utm_medium=et&utm_source=en-et-na-us-gns-svn">Arastradero Open Preserve</a> and <a href="http://maps.google.com/maps?f=q&source=s_q&hl=en&geocode=&q=legoland+california&sll=40.752508,-73.98159&sspn=0.011525,0.021865&ie=UTF8&layer=c&cbll=33.12585,-117.311392&panoid=JXjE_5SG502bLVp6jAzmEQ&hq=Legoland+California&hnear=Legoland+California&ll=33.12585,-117.311392&spn=0,359.997267&z=19&cbp=12,355.67,,0,5.44">LEGOLAND California</a>. When I'm out riding — and once people understand what exactly I'm up to — I'm often asked if we can come to their alma mater, local bike trail or favorite beach boardwalk. Now, we're giving everyone a chance to tell us exactly where in the U.S. they'd like the trike to go next. At <a href="http://maps.google.com/trike">www.google.com/trike</a>, you can suggest interesting and unique spots in six categories: <ul><li>Parks & Trails</li><li>University Campuses</li><li>Pedestrian Malls (e.g., outdoor shopping areas, boardwalks)</li><li>Theme Parks & Zoos</li><li>Landmarks </li><li>Sports Venues (e.g., golf courses, racing tracks, stadium grounds)</li></ul>Nominations will be open until October 28. We'll then comb through all of the suggestions and let all of you cast your final votes on a winner from each category for the Street View trike to visit. For any privately-owned or operated location, like a campus or theme park, we'll work directly with the relevant organization prior to collecting the imagery. When we unveiled the Street View trike in the U.K., we received more than 10,000 nominations and 35,000 votes; <a href="http://www.youtube.com/watch?v=oO8l8hL0cuw">Stonehenge</a> and <a href="http://www.warwick-castle.co.uk/misc/press-view.aspx?id=19">Warwick Castle</a> were two of the top vote-getters. We can't wait to see what you'll come up with in the U.S. — head to <a href="http://maps.google.com/trike">www.google.com/trike</a> to submit your most inspired ideas. <iframe src="http://sketchup.google.com/3dwarehouse/mini?mid=d05847768a494474ae682533f3f1d4dd&etyp=sw&width=400&height=300" frameborder="0" scrolling="no" marginheight="0" marginwidth="0" width="400" height="300"></iframe> Posted by Dan Ratner, Senior Mechanical Engineer

Street View: We can trike wherever you like

With Street View on Google Maps , you can take a virtual drive over the Golden Gate Bridge or see the bustle of Times Square from the comf...

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Managing your reputation through search results

<div>(Cross-posted on the <a href="http://googlewebmastercentral.blogspot.com/2009/10/managing-your-reputation-through-search.html">Webmaster Central Blog</a>)</div><div> </div>A few years ago I couldn't wait to get married. Because I was in love, yeah, but more importantly, so that I could take my husband's name and people would stop getting that ridiculous picture from college as a top result when they searched for me on Google. After a few years of working here, though, I've learned that you don't have to change your name just because it brings up some embarrassing search results. Below are some tips for "reputation management": influencing how you're perceived online, and what information is available relating to you. Think twice The first step in reputation management is preemptive: Think twice before putting your personal information online. Remember that although something might be appropriate for the context in which you're publishing it, search engines can make it very easy to find that information later, out of context, including by people who don't normally visit the site where you originally posted it. Translation: don't assume that just because your mom doesn't read your blog, she'll never see that post about the new tattoo you're hiding from her. Tackle it at the source If something you dislike has already been published, the next step is to try to remove it from the site where it's appearing. Rather than immediately contacting Google, it's important to first remove it from the site where it's being published. Google doesn't own the Internet; our search results simply reflect what's already out there on the web. Whether or not the content appears in Google's search results, people are still going to be able to access it — on the original site, through other search engines, through social networking sites, etc. — if you don't remove it from the original site. You need to tackle this at the source. <ul><li>If the content in question is on a site you own, easy — just remove it. It will naturally drop out of search results after we recrawl the page and discover the change. </li><li>It's also often easy to remove content from sites you don't own if you put it there, such as photos you've uploaded, or content on your profile page.</li><li>If you can't remove something yourself, you can <a href="http://www.google.com/support/websearch/bin/answer.py?answer=9109">contact the site's webmaster</a> and ask them to remove the content or the page in question.</li></ul>After you or the site's webmaster has removed or edited the page, you can expedite the removal of that content from Google using <a href="http://www.google.com/support/webmasters/bin/answer.py?answer=92865">our URL removal tool</a>. Proactively publish information Sometimes, however, you may not be able to get in touch with a site's webmaster, or they may refuse to take down the content in question. For example, if someone posts a negative review of your business on a restaurant review or consumer complaint site, that site might not be willing to remove the review. If you can't get the content removed from the original site, you probably won't be able to completely remove it from Google's search results, either. Instead, you can try to reduce its visibility in the search results by proactively publishing useful, positive information about yourself or your business. If you can get stuff that you want people to see to outperform the stuff you don't want them to see, you'll be able to reduce the amount of harm that that negative or embarrassing content can do to your reputation. You can publish or encourage positive content in a variety of ways: <ul><li>Create a <a href="http://www.google.com/profiles">Google profile</a>. When people search for your name, Google can display a link to <a href="http://googleblog.blogspot.com/2009/04/search-for-me-on-google.html">your Google profile in our search results</a> and people can click through to see whatever information you choose to publish in your profile.</li><li>If a customer writes a negative review of your business, you could ask some of your other customers who are happy with your company to give a fuller picture of your business.</li><li>If a blogger is publishing unflattering photos of you, take some pictures you prefer and publish them in a blog post or two.</li><li>If a newspaper wrote an article about a court case that put you in a negative light, but which was subsequently ruled in your favor, you can ask them to update the article or publish a follow-up article about your exoneration. (This last one may seem far-fetched, but believe it or not, we've gotten multiple requests from people in this situation.)</li></ul>Hope these tips have been helpful! Feel free to stop by our Web Search Forum and <a href="http://www.google.com/support/forum/p/Web+Search/thread?tid=31539c32bdd9eebf&hl=en">share your own advice or stories</a> about how you manage your reputation online. Posted by Susan Moskwa, Webmaster Trends Analyst

Managing your reputation through search results

(Cross-posted on the Webmaster Central Blog ) A few years ago I couldn't wait to get married. Because I was in love, yeah, but more impo...

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