Medical Informatics, Pharma, Health IT, and Golden Advice That Sits Sadly Unused

In recent correspondences with colleagues I was reminded of a letter I wrote seven years ago that was published in Bio-IT World, a journal about biomedicine focusing mainly on pharma, bioinformatics and related fields.<br /><br />As the sole formally-trained Medical Informatics specialist at Merck, I wrote:<br /><br /><blockquote><span style="font-size:85%;"><a href="http://www.bio-itworld.com/archive/081302/letters.html">Medical Informatics MIA</a> <span style="font-style: italic;"> [Missing in Action - ed.]</span><br />Bio-IT World<br />August 13, 2002<br /><br />Dear Bio-IT World:<br /><br />I enjoyed reading the article "Informatics Moves to the Head of the Class" (June Bio·IT World). Thank you for spotlighting the National Library of Medicine (NLM) training programs in medical informatics and bioinformatics, of which I am a graduate (Yale, 1994).<br /><br />Bioinformatics appears to receive more media attention and offer more status, career opportunities, and compensation than the less-prestigious medical informatics.<br /><br />This disparity, however, may impede the development of next-generation medicines. Bioinformatics discoveries may be more likely to result in new medicines, for example via pharmacogenomics, when they are coupled with large-scale, concurrent, ongoing clinical data collection. At the same time, applied medical informatics, as a distinct specialty, is essential to the success of extensive clinical data collection efforts, especially at the point of care.<br /><br />Hospital and provider MIS personnel are best equipped for implementing business-oriented IT, not clinical IT. Implementing clinical IT in patient-care settings constitutes one of the core competencies of applied medical informaticists.<br /><br />Informatics specialists with a bioinformatics focus — even those coming from the new joint programs — usually are not proficient in hospital business and management issues that impede adoption of clinical IT in patient care settings. Such organizational and territorial issues are in no small way responsible for the low utilization of clinical IT in patient care settings.<br /><br />It will be important for medical informaticists focused in the clinical domain and bioinformaticists specializing in the molecular domain to collaborate with other specialists in order to best integrate clinical and genomic data.<br /><br />Further information on these issues can be found in the book Organizational Aspects of Health Informatics: Managing Technological Change, by Nancy M. Lorenzi and Robert T. Riley (Springer-Verlag, 1995). Various publications from the medical informatics community, such as the American Medical Informatics Association (<a href="https://exchangeweb.drexel.edu/owa/redir.aspx?C=3d51436b9a224f06be16751d1de7e240&URL=http%3a%2f%2fwww.amia.org" target="_blank">www.amia.org</a>) and the International Medical Informatics Association (<a href="https://exchangeweb.drexel.edu/owa/redir.aspx?C=3d51436b9a224f06be16751d1de7e240&URL=http%3a%2f%2fwww.imia.org" target="_blank">www.imia.org</a>), are also useful.<br /><br />Scot Silverstein, MD<br />Director, Published Information Resources & The Merck Index<br />Merck Research Laboratories</span><br /><br /></blockquote>I was also responsible for the entry of the term "Medical Informatics" into the controlled vocabulary pool used for various purposes at Merck.<br /><br />As far as I can tell, the Medical Informatics talent gap still exists in all major pharmas despite writings on the topic from colleagues as well as myself. With the present turmoil including declining pipelines, mergers and mass layoffs pending in many large pharmas, and even despite Medical Informatics on a fast path to being declared a full medical subspecialty, it is likely this gap will persist for years longer. This is a shame. The field offers insights that can help R&D substantially, and I speak from direct experience from my time in that domain.<br /><br />I am reminded via all this of another industry that seems to hurt itself via ignoring the advice of Medical Informatics professionals, the health IT industry. Healthcare IT is actually the core competence of Medical Informatics professionals, but those people are under-represented in the higher ranks of the health IT industry as well. Many job postings seek such people, but for lower level roles (as I've posted here in the past), and/or conflate formal training with informal experience and with those who qualify for the title of Medical Informaticist like I qualify (being an amateur radio licensee, extra class) as a professional RF engineer.<br /><br />The irony is this: the wisdom of the Medical Informatics field on health IT goes back not years, but <span style="font-style: italic; font-weight: bold;">decades.</span> It is advice that could have made the vendors much higher margins, allowed them to produce better products, avoid the government regulation that is now nearly inevitable (in some EU countries, clinical IT has already been determined to be a medical device requiring regulation), and in many cases, enabled corporate longevity.<br /><br />Yet the teachings and accumulated wisdom of the field were, and largely still are, ignored, making books such as the new "<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=hitormiss">H.I.T. or Miss: Lessons Learned from Health Information Technology Implementations</a>" necessary even in 2009.<br /><br />Here is just a small sampling of that wisdom:<br /><br /><span style="font-weight: bold;font-family:Arial;" ></span><span style="font-weight: bold;font-family:times new roman;" ></span><blockquote style="font-family:arial;"><span style="font-size:100%;"><span style="font-weight: bold;">Dr. Donald A. B. Lindberg (now Director of the U.S. National Library of Medicine at NIH), 1969:</span><br />"Computer engineering experts per se have virtually no idea of the real problems of medical or even hospital practice, and furthermore have consistently underestimated the complexity of the problems…in no cases can [building appropriate clinical information systems] be done, simply because they have not been defined with the physician as the continuing major contributor and user of the information."<br /><br /></span><span style="font-size:100%;"><br /></span><span style="font-weight: bold;font-size:100%;" >Dr. Octo Barnett's [Harvard] health IT <span style="font-style: italic;">Ten Commandments</span>, 1970: </span><span style="font-size:100%;"><br />1. Thou shall know what you want to do<br />2. Thou shall construct modular systems - given chaotic nature of hospitals<br />3. Thou shall build a computer system that can evolve in a graceful fashion<br />4. Thou shall build a system that allows easy and rapid programming development and modification<br />5. Thou shall build a system that has consistently rapid response time and is easy for the non-computernik to use<br />6. Thou shall have duplicate hardware systems<br />7. Thou shall build and implement your system in a joint effort with real users in a real situation with real problems<br />8. Thou shall be concerned with realities of the cost and projected benefit of the computer system<br />9. Innovation in computer technology is not enough; there must be a commitment to the potentials of radical change in other aspects of healthcare delivery, particularly those having to do with organization and manpower utilization<br />10. Be optimistic about the future, supportive of good work that is being done, passionate in your commitment, but always guided by a fundamental skepticism.<br /><br /><span style="font-style: italic; color: rgb(255, 0, 0);">[Dr. Barnett played a key role in the 2009 National Research Council report about current approaches to health IT being inadequate,</span> <span style="font-style: italic; color: rgb(255, 0, 0);">Press Release at </span><a href="http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572" style="font-style: italic;">http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572</a><span style="font-style: italic;">, </span><span style="font-style: italic; color: rgb(255, 0, 0);">and full report</span> <span style="font-style: italic;">"</span></span><span style="font-style: italic;font-size:100%;" ><span style="color:black;"><a href="http://www.nap.edu/catalog.php?record_id=12572">COMPUTATIONAL TECHNOLOGY FOR EFFECTIVE HEALTH CARE: IMMEDIATE STEPS AND STRATEGIC DIRECTIONS</a></span></span><span style="font-size:100%;"><span style=""><span style="font-style: italic;">.</span> <span style="font-style: italic; color: rgb(255, 0, 0);">- ed.</span>]<br /><br /><br /></span><span style="font-weight: bold;">Dr. Morris Collen's Five Rules, 1972</span><span style=""><br />Most common causes of health IT failure:<br /></span></span><ul><li><span style="font-size:100%;"><span style="">Suboptimal mix of medical and computer specialists … resulting in communications difficulties and in the computer staff underestimating the vast medical needs</span></span></li><li><span style="font-size:100%;">Gross underestimation of the large amounts of money needed</span></li><li><span style="font-size:100%;">Suboptimal systems approach with serious incompatibilities between modules</span></li><li><span style="font-size:100%;">Unacceptable terminals</span></li><li><span style="font-size:100%;">Inadequate management organization and poor judgment<br /></span></li></ul><span style="font-size:100%;"><span style=""><br /><br /></span></span><span style="font-size:100%;"><span style="font-weight: bold;">Dr. R. Friedman, </span></span><span style="font-size:100%;"><span style="font-weight: bold;">Reasons for slow spread of EMR, 1977:</span><span style=""><br /></span></span><ul><li><span style="font-size:100%;"><span style="">Poor engineering and unreliability</span></span></li><li><span style="font-size:100%;">Physicians not provided with computer-based applications that exceeded their own capability!</span></li><li><span style="font-size:100%;">Inability to prove a positive effect on patient care</span></li><li><span style="font-size:100%;"><span style="">Difficulty transferring one application from one institution to another</span><br /></span></li></ul></blockquote><span><span style="font-size:85%;"><span style=";font-family:arial;font-size:100%;" ><br />(All taken from Collen's "<a href="http://www.amazon.com/History-Medical-Informatics-United-States/dp/0964774305">A history of Medical Informatics in the United States, 1950-1990</a>".</span>)</span></span><br /><br />I might add that the PC did not even exist in 1977, unless you consider the Altair and Heathkit H8 "personal computers."<br /><br />Four-decades-old wisdom like this, and much more, sits out there in the ether and in the Medical Informatics field's professionals like a pot of gold, but is apparently considered as valuable as lead by the HIT - and pharma - industries. I find this amazing - and a pity.<br /><br />-- SS

Medical Informatics, Pharma, Health IT, and Golden Advice That Sits Sadly Unused

In recent correspondences with colleagues I was reminded of a letter I wrote seven years ago that was published in Bio-IT World, a journal a...

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Art meets engineering with Google Chrome Artist Themes

A couple of weeks ago we <a href="http://googleblog.blogspot.com/2009/10/fast-simple-and-now-stylish-google.html">introduced</a> Artist Themes for Google Chrome. We asked leading designers, artists, illustrators and musicians to use the browser as their personal canvas for designing interesting themes.<br /><br />Since then, we've enjoyed hearing <a href="http://twitter.com/#search?q=google%20chrome%20themes">your thoughts</a> on these designs and how you've used them to personalize your browser. We've also been intrigued by the ways in which these themes have had <a href="http://chrome.blogspot.com/2009/10/from-anime-to-animation-google-chrome.html">interesting and unusual</a> cultural resonance with people around the world.<br /><br />To continue celebrating this collaboration of engineering and art, we've joined forces with our friends at YouTube to launch a new video (with a surprise ending) that we hope showcases the full beauty of these themes. Check it out at <a href="http://youtube.com/googlechromethemes">youtube.com/googlechromethemes</a> or by clicking on the image below.<br /><br /><a href="http://www.youtube.com/googlechromethemes" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5395441379586553090" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj0A5KE5nhkG3IaGHk3UTXwpiqN8VlXI_g3Y0kycM3B9sddPEET-8HbJm6JMoMguFWvqjN4Nvo8wzKKonxQwVk_jPD48kyio7m7zkyDAiE6FOdX6jtQZOhl_idzN6Y3lug7ys0vSnZFVx-m/s400/GoogleChromeThemes-YouTube.png" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 400px; height: 206px;" /></a><br /><span class="byline-author">Posted by Jeff Gillette, Google Creative Lab</span>

Art meets engineering with Google Chrome Artist Themes

A couple of weeks ago we introduced Artist Themes for Google Chrome. We asked leading designers, artists, illustrators and musicians to use...

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NSW Nightmare and Overuse of Computers: Do We Really Need Full EHR's in ED's?

At "<a href="http://hcrenewal.blogspot.com/2009/10/from-down-under-story-of-deployment-of.html">From Down Under: The Story of the Deployment of an ED Clinical Information System ‐ Systemic Failure or Bad Luck</a>" I posted excerpts from a paper of the same name by an Australian medical informatics specialist, Professor Jon Patrick from the <span>Health Information Technologies Research Laboratory (HITRL)</span>, <span>University of Sydney</span>, about what appears to be an Emergency Department (ED) nightmare. The paper is <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/ed3.pdf">here</a>. <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">[10/24 note: not available at present at this link or from its author in Australia; I pulled it from the Drexel U. server in the U.S. at the author's request while his right to post it on his department's server in Australia is being discussed Down Under - ed.]</span><br /><br /><span style="font-size:100%;"><blockquote>[2010 update: the paper is now at the following link (PDF):<span style="font-weight: bold;"><a href="http://www.it.usyd.edu.au/%7Ehitru/essays/The%20Story%20of%20the%20Deployment%20of%20an%20ED%20Clinical%20Information%20System6.0.pdf"> A Critical Essay on the Deployment of an ED Clinical Information System - Systemic Failure or Bad Luck</a>, version 6</span>. Prof. Jon Patrick, Health Information Technologies Research Laboratory, University of Sydney, Australia, Dec. 2009.]</blockquote></span><br />Those excerpts should be frightening to anyone who ever gets ill and might need to visit an ED (meaning, all of us).<br /><br />An ED electronic health record system (EHR) is being installed in an entire Australian state, New South Wales (NSW), with 200+ hospitals that apparently presents a <a href="http://tinyurl.com/hostileuserexper">mission hostile user experience</a> and is causing great opposition by critical care physicians in a setting where death can occur - suddenly and irreversibly - in the flash of an eye.<br /><br />His essay about the problems with complex EHR's (of American design and manufacture, no less) being installed in Australian ED's -- without doubt a highly expensive undertaking -- raises several questions about both the EHR industry and hospitals themselves.<br /><br />When I was a CMIO at a 1400+ bed hospital system a decade ago, a regional center in a state with very few hospitals at all (Medical Center of Delaware, now Christiana Care Health System), I counseled that the best solution in my opinion for the very, very busy ED was document imaging of paper, supplemented by a nurse/intake triage system to rapidly record and/or confirm basics (e.g., meds/major problems/allergies/vitals) that was interfaced to the main EHR system.<br /><br />I based this on the assessment that in the ED, a localized and "closed" environment, the incidence of charts getting lost or writing being illegible <span style="font-weight: bold; font-style: italic;">resulting in adverse outcomes</span> was minimal. ED charts also did not get lost when patients moved to the floors and the information passed along on paper was adequate for quick transfer and acceptance. Therefore we felt images of past ED charts (of paper) would be satisfactory for assisting care in the ED, where time constraints and hectic pace made the type of EHR system and primary data entry described in the Australian paper disadvantageous (and for exactly the reasons described in the above linked essay from Down Under).<br /><br />Document imaging is a proven technology that works well even in high volume settings. For example I managed a pharma departmental budget of $13 million, as did an entire pharma company, using an enterprise document imaging system.<br /><br />I've also been startled by the ED EHR installed at the hospital where I take my mother, who unfortunately has needed far too many admissions in recent years than I care to see. Some of the ED staff were my former medical colleagues and even high school classmates. They've told me, in no uncertain terms, that they felt the system was terrible, again for many of the reasons cited in the Australian essay. My own views of it (albeit brief) showed what appeared to be a <a href="http://tinyurl.com/hostileuserexper">mission hostile user environment</a>, including multiple very tiny pulldowns, cornucopia-like picklists, and screens.<br /><br />Most recently that system did not prevent busy ED docs from almost giving my mother Levaquin after her telling the triage nurse it had caused tendon rupture in the past - and the data being entered. They actually brought in a bag of it to hang, and if I'd not been there as medical advocate for my mother they might have given it. Then when she got to the floor, the next day they almost gave it to her again, except by this time mom was her own medical advocate. I trained in that hospital, and as Admitting Officer for the ED held the record for the most number of admissions, ever, in one night (New Year's Eve 1986), when it was beyond crazy, starting out with one of our own physicians being brought in, shot in the chest, and dying after open heart massage just to set the mood.<br /><br />The surgeons did the cutting. The heart massage was relegated to the physician present who <span style="font-style: italic;">didn't</span> cut - the internal medicine representative - me.<br /><br />We managed to treat hundreds and admit several dozens of sick patients using paper, and despite our gloomy emotional state not a single error occurred, to my knowledge.<br /><br />With all this in mind, I raise these questions:<br /><br /><ul><li>Can the EHR industry actually produce a competent ED EHR that can be used by ED physicians to enter detailed data in real time?</li></ul><ul><li>Do we really need full EHR's in the ED?</li></ul><ul><li>A related question: is the extent of ED adverse events related to lost or illegible ED charts (that could not be remediated with non-technology-based solutions far less expensive and troublesome than EHR's) known to a significant degree of confidence?</li></ul><ul><li>Is there <span style="font-weight: bold; font-style: italic;">trustworthy</span> literature that shows that the time, expense, and resources for a full ED EHR are worth it in terms of clinical outcomes, ROI etc.? (By trustworthy, I mean scientific peer reviewed literature without author conflict of interest - common in biomedicine as readers of this and other healthcare blogs know, e.g., see <a href="http://hcrenewal.blogspot.com/search?q=ghostwriting">this link</a> - not glossy pseudo-P.R. health IT throwaway journals.)</li></ul><ul><li>Considering that the literature on benefits of EHR's in general is equivocal, I should also ask, is there literature that refutes the value of full ED EHR's, or shows it as possibly having a negative return?<br /></li></ul>Or:<br /><br /><ul><li>Are we over-computerizing healthcare, even specialties and subspecialties where doing so might actually be deleterious due to the nature of their specific medical environments, just because "we can" (and because there is money to be made by some)?</li></ul><ul><li>Are we doing so based on irrational exuberance, leap of faith, hope, and/or an uncritical belief that if health IT provides benefits to medical domain "A0", it therefore must benefit medical domains and subdomains B1 to B99 through Z1 to Z99 as well?<br /></li></ul><br />I am concerned about the probability that the latter is the case.<br /><br />I think it not unreasonable to ask these questions before we in the United States spend billions of dollars on our own ED's.<br /><br />-- SS

NSW Nightmare and Overuse of Computers: Do We Really Need Full EHR's in ED's?

At " From Down Under: The Story of the Deployment of an ED Clinical Information System ‐ Systemic Failure or Bad Luck " I posted e...

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RT @google: Tweets and updates and search, oh my!

At Google, our goal is to create the most comprehensive, relevant and fast search in the world. In the past few years, an entirely new type of data has emerged — real-time updates like those on Twitter have appeared not only as a way for people to communicate their thoughts and feelings, but also as an interesting source of data about what is happening right now in regard to a particular topic.<br /><br />Given this new type of information and its value to search, we are very excited to announce that we have reached an agreement with Twitter to include their updates in our search results. We believe that our search results and user experience will greatly benefit from the inclusion of this up-to-the-minute data, and we look forward to having a product that showcases how tweets can make search better in the coming months. That way, the next time you search for something that can be aided by a real-time observation, say, snow conditions at your favorite ski resort, you'll find tweets from other users who are there and sharing the latest and greatest information.<br /><br /><span class="byline-author">Posted by Marissa Mayer, Vice President of Search Products and User Experience</span>

RT @google: Tweets and updates and search, oh my!

At Google, our goal is to create the most comprehensive, relevant and fast search in the world. In the past few years, an entirely new type ...

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Private medical records offered for sale

Private medical records have been offered for sale in the U.K.<br /><br />And quite cheaply, too...<br /><div><br /></div> <p></p><blockquote><p>e-Health Insider (Europe)<br /><a href="http://www.e-health-insider.com/news/5311/private_medical_records_offered_for_sale">Private Medical Records Offered for Sale</a><br />Oct. 20, 2009</p><p>Medical records of patients treated at a private British hospital, The London Clinic, have been illegally sold to undercover investigators.</p> <p>The revelations were made in ITV’s Tonight Programme report, Health Records For Sale, broadcast last night.</p> <p>The programme reported that hundreds of files containing details of patients’ conditions, home addresses and dates of birth were offered to undercover reporters for just £4 each by sales executives from India, contacted online. </p></blockquote><p><br /></p><p>That's about $6.56 U.S. each. A genuine bargain for those intrepid medical identity thieves, and pesky government death panels ...<br /></p><p><br /></p><p></p><blockquote><p>The records offered for sale appear to have been medical records that consultants working at the London Clinic, the hospital processes its own records internally, who contracted with a firm called DGL (DGL) Information Technologies UK to digitise their records.</p> <p>DGL is then claimed to have sub-contracted to another firm, Scanning and Data Solutions (SDS), which scanned them into computers in the UK. SDS in turn is said to have sub-contracted further work on the files to a company in Pune, India, which had signed tight confidentiality agreements.</p></blockquote><p></p> <p><br /></p><p>With all this contracting and subcontracting - four layers? - adding potential security breach possibilities, and if this is not an uncommon practice, perhaps paper is safer than electronic health records?</p><p><br /></p> <p></p><blockquote><p>... The reporters bought more than 100 records belonging to UK patients but were told they could obtain up to 30,000 more on demand. Confidential records were offered by condition such as particular cancers.</p> <p>Of 116 files bought by ITV, 100 of which were confirmed as genuine, were for patients who had been treated in private hospitals. Although not NHS records they did contain some NHS data, including referral letters from GPs.</p></blockquote><p></p> <p><br /></p><p>The potential abuses resulting from such sales are of great concern. If it happened in the UK, it can happen in the U.S.<br /></p><p><br /></p> <p></p><blockquote>One patient whose record was affected by the security breach said in the documentary that the data breach was ‘one step up from grave-robbing’.</blockquote><p></p><br />I agree with that assessment.<br /><br />These practices call for the most severe penalties, and if the authorities lack the will, confidence in EMR privacy, confidentiality and security will suffer, along with the physician-patient relationship.<br /><br />The old ST:TOS line "Sometimes a man will tell his bartender things he'll never tell his doctor" could become too applicable for comfort.<br /><br /><br /><div><div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjJp41WBDQ76VdB-mxikHGGecfpdKHyB-zpaa3i2Lp_ZkzMjCDey9Qr3xTH5pku0zE99lZ3xjDU7Llu6lt9svT3eweuxseDlGh_9EE9gcqXXiFPeWzn118de6q0xAidCuN5U-Ngev95-U7r/s1600-h/Cage_05.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5394858019287916098" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjJp41WBDQ76VdB-mxikHGGecfpdKHyB-zpaa3i2Lp_ZkzMjCDey9Qr3xTH5pku0zE99lZ3xjDU7Llu6lt9svT3eweuxseDlGh_9EE9gcqXXiFPeWzn118de6q0xAidCuN5U-Ngev95-U7r/s320/Cage_05.jpg" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 262px; height: 196px;" /></a><span style="font-size:85%;">Sometimes a man will tell his bartender things he'll never tell his doctor ... especially if they suspect their data is for sale to the <a href="http://en.wikipedia.org/wiki/Talosians">Talosians</a>, Captain ...<br /></span></div><br /></div><div>-- SS</div>

Private medical records offered for sale

Private medical records have been offered for sale in the U.K. And quite cheaply, too... e-Health Insider (Europe) Private Medi...

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From Down Under: The Story of the Deployment of an ED Clinical Information System ‐ Systemic Failure or Bad Luck?

I'd opine that bad luck had little to do with it.<div><br /></div><div>A paper by an Australian professor of informatics about travails with a new ED EHR, manufactured by a large American HIT vendor, appeared recently (it is currently unavailable.) I remind that the issues affect a most critical area, the ED's in over <span style="font-weight: bold;">200 hospitals </span><span>in Australia's</span><span style="font-weight: bold;"> </span><em></em>most populous state, New South Wales (NSW). The paper is <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/ed3.pdf">here</a>.<br /><br /><span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">[10/24 note: not available at present at this link or from its author in Australia; I pulled it from the Drexel U. server in the U.S. at the author's request while his right to post it on his department's server in Australia is being discussed Down Under - ed.]</span><br /><br /><span style="font-style: italic; font-weight: bold;">[Jan. 2010 followup: an attempted censorship situation was resolved. See </span><a href="http://hcrenewal.blogspot.com/2009/11/academic-freedom-and-ed-ehrs-down-under_10.html" style="font-style: italic; font-weight: bold;">this update</a><span style="font-style: italic; font-weight: bold;">. Current paper in ver. 6 is </span><a href="http://www.it.usyd.edu.au/%7Ehitru/essays/The%20Story%20of%20the%20Deployment%20of%20an%20ED%20Clinical%20Information%20System6.0.pdf" style="font-style: italic; font-weight: bold;">here</a> <span style="font-style: italic;"><span style="font-weight: bold;">- </span></span><span style="font-style: italic; font-weight: bold;">PDF.]</span><br /><br />Highlights:</div><div><br /></div><div><div></div><blockquote><div>... One criticism of [new ED EHR] is that the clinical documentation is built on the American model which doesn't fit the Australian workflow. In the same vein another commentator said it was a "system designed by administrators for administrators with no understanding whatsoever of clinical workflow and need".</div><div><br /></div><div>... At the operational level in EDs staff dislike the software for various reasons such as: too many keystrokes to load data, hence, too complicated search pathways to find data, plus they are unable to get extraction of reports.</div><div><br /></div><div>Their dislike has reached very intense levels with many staff dismissive of its usefulness. In more than one hospital the system was credited with causing a 50% decrease in the number of patients seen by a doctor in the first 20 minutes of arrival at the ED. In at least one hospital the direct data entry of clinical notes as done with [old ED EHR] <b><i><span class="Apple-style-span" style="color: rgb(255, 0, 0);">[an earlier system - ed.]</span></i></b> has been abandoned and transferred to paper as the [new ED EHR] process was seen as too cumbersome and time costly.</div><div><br /></div><div>... Other comments about [new ED EHR] were: "I prefer looking at a paper result than the counter-intuitive waste of my time trolling through the system.</div><div><br /></div><div>... I keep forgetting how the damn thing is supposed to work and find it more a time waster than a help."</div><div><br /></div><div>... Similarly, "every single user *hates* it with a passion ... ENTERING the data is a pure nightmare"</div><div><br /></div><div>And another: </div><div><br /></div><div>... "it is exclusively used by the nurses and entirely ignored by the doctors"</div><div><br /></div><div>And another:</div><div><br /></div><div>... "Clumsy, complicated (not complex), user hostile, and above all slow at any task I tried".</div><div><br /></div><div>... “We stated the system was dangerous (multiple reasons) and that we would not use it in its current state. We also got agreement that the nurse practitioner not use it for clinical details."</div><div><br />... “We in X and Y had a major confrontation with the NSW ‘gurus’ and refused to use it in ED in its current state. A clinician produced a well researched document to support our claims of its cumbersome stupidity. “People present (at the meeting) were local vmos, nurse practitioner who works in ED and the local ceo etc, plus reps from [new ED EHR vendor] , NSW health etc. One clinician was present by videoconference. Nurses presented a long document detailing multiple concerns. </div><div><br /></div><div>“The meeting was quite emotional and heated as they tried over and over again to pull the wool over our eyes. For example, they started out offering “more support”. One clinician replied that this was like giving us a defective car then sending out someone to show us how to drive it. </div><div><br /></div><div>I asked was the support available at 3 A.M.? Blank faces.</div><div><br />They dissimulated info that “other doctors” in small country hospitals were trialing the system and had “no problems”. When asked which hospitals and which doctors again blank faces. They finally came up with a name who one of our partners rang that night and found him to be furious his name was used and that they were about to dump the system too...</div></blockquote><div><br /><br />The conclusion probably sounds familiar to HC Renewal readers:<br /><br /><blockquote>... I wish to make a salient point about the nature of the delivered software with respect to the whole process of change management in the introduction of new IT infrastructure. In these situations there is always a great deal of noise and attention given to the processes of systems review, workflow redesign, and staff training.<br /><br />In many ways this is paying attention to the smoke rather than the fire. The actual design and operation of the software is fundamental to the successful introduction of information technology. It is a necessary condition that the software works in a fashion that optimally fits the activities and workflow of the recipient organisation, and this fit is the single largest determinant of a successful system wide implementation. Like any foundation if it is not properly designed and constructed the edifice above it will collapse no matter what amount of attention and details you put into it. The delivered software is the foundation of any clinical information system. It would seem that in this case this understanding has not been grasped by authorities in NSW.<br /><br />... Without optimal design and implementation there will be <span style="font-weight: bold;">no cost efficiencies and productivity gains delivered by IT, but rather, it will contribute to the spiralling expense</span>. We can only hope that Government will understand that a modest investment in R&D for clinical information systems is needed to create the desired improvements in productivity, cost reduction and patient safety.</blockquote><br />I believe our own government here could learn from this.<br /></div><div><br /></div><div style="font-weight: bold;">Read the whole thing, <span style="font-weight: normal;">including the series of ethical issues the author raises.</span> <span style="font-weight: normal;">I believe the lessons apply not just to the one vendor mentioned, but to most HIT vendors, especially the large ones.</span><br /><br /><span style="font-weight: normal;">Also note the observations from another Australian, Dr David G More MB, PhD, FACHI in an essay entitled "The Blight on the Landscape Health IT Awards" <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=australia">at this link</a>.</span><i style=""><span style="font-family:Arial;"></span></i> </div><div><br /></div><div>-- SS</div></div>

From Down Under: The Story of the Deployment of an ED Clinical Information System ‐ Systemic Failure or Bad Luck?

I'd opine that bad luck had little to do with it. A paper by an Australian professor of informatics about travails with a new ED EHR, m...

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More accessibility features in Android 1.6

<span style="font-style: italic;">From time to time, our own T.V. Raman shares his tips on how to use Google from his perspective as a technologist who cannot see — tips that sighted people, among others, may also find useful.</span><br /><br />The most recent release of Android 1.6, a.k.a. Donut, introduces accessibility features designed to make Android apps more widely usable by blind and low-vision users. In brief, Android 1.6 includes a built-in screenreader and <a href="http://android-developers.blogspot.com/search/label/Text-to-Speech">text-to-speech</a> (TTS) engine which make it possible to use most Android applications, as well as all of Android's default UI, when not looking at the screen.<br /><br />Android-powered devices with Android 1.6 and future software versions will include the following accessibility enhancements:<br /><ul><li>Text-to-Speech (TTS) is now bundled with the Android platform. The platform comes with voices for English (U.S. and U.K.), French, Italian, Spanish and German.</li><li>A standardized Text To Speech API is part of the Android SDK, and this enables developers to create high-quality talking applications.</li><li>Starting with Android 1.6, the Android platform includes a set of easy to use accessibility APIs that make it possible to create accessibility aids such as screenreaders for the blind.</li><li>Application authors can easily ensure that their applications remain usable by blind and visually impaired users by ensuring that all parts of the user interface are reachable via the trackball; and all image controls have associated textual metadata.</li><li>Starting with Android 1.6, the Android platform comes with applications that provide spoken, auditory (non-speech sounds) and haptic (vibration) feedback. Named TalkBack, SoundBack and KickBack, these applications are available via the Settings > Accessibility menu.</li><li>In addition, <a href="http://eyes-free.googlecode.com/">project Eyes-Free</a> (which includes accessibility tools such as TalkBack) provides several UI enhancements for using touch-screen input. Many of these <a href="http://www.nytimes.com/2009/01/04/business/04blind.html">innovations</a> are available via Android Market and are already being heavily used. We believe these eyes-free tools will serve our users with special needs as well.</li></ul>You can turn on the accessibility features by going to Settings --> Accessibility and checking the box "Accessibility". While the web browser and browser-based applications do not yet "talk" using these enhancements, we're working on them for upcoming releases. Check out this <a href="http://google-opensource.blogspot.com/2009/10/talkback-open-source-screenreader-for.html">Google Open Source Blog post</a> for more details, and stay tuned to the <a href="http://www.youtube.com/user/eyesfreeandroid">eyes-free channel on YouTube</a> for step-by-step demonstrations on configuring and using accessibility support on Android.<span class="byline-author"><br /></span>

More accessibility features in Android 1.6

From time to time, our own T.V. Raman shares his tips on how to use Google from his perspective as a technologist who cannot see — tips that...

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