healthy4u

Medscape re: Class Action suit: "Doctors Who Sued EHR Company Win First Round"

Interesting article about a Class-Action lawsuit against a health IT seller, Allscripts, see Medscape link below (the story is copyrighted so I cannot repost it here). Relevant excerpts: <blockquote class="tr_bq">On Monday, March 4, a group of doctors who are suing their electronic health record (EHR) manufacturer for selling them a "buggy" product and then discontinuing it learned that the defendant's motion to block the lawsuit and compel them to accept binding arbitration was overruled by a judge in Miami, the first step in getting a court date in what is believed to be a first-of-its-kind case. ... In December 2012, 4 physician practices -- 2 pain clinics in Florida, 1 in Missouri, and a family medicine practice in Alabama -- became plaintiffs in a class-action suit filed against Allscripts, "an action arising from an expensive, but defective electronic health records software product," according to the complaint. The bottom line: The EHR was "buggy." Says one of the doctors plaintiffs: Anesthesiologist Robert J. Joseph, MD, of the Pain Clinic of Northwest Florida in Panama City, a plaintiff in the suit, makes no bones about it. "Our EHR is a piece of crap," he states.</blockquote> ----- Link to full article: <a href="http://www.medscape.com/viewarticle/779721" target="_blank">http://www.medscape.com/viewarticle/779721</a> (It seems to come up fulltext without Medscape login, but I cannot guarantee this will persist.) -- SS

Medscape re: Class Action suit: "Doctors Who Sued EHR Company Win First Round"

Interesting article about a Class-Action lawsuit against a health IT seller, Allscripts, see Medscape link below (the story is copyrighted ...

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On EHR's: See No Evil, Hear No Evil, Speak No Evil: Part 1

This is the first of a series of posts I plan on the issue of "See No Evil, Hear No Evil, Speak No Evil" regarding EHR's.  Frequent reminders are needed by all stakeholders, I believe, to think critically about, and take with a big grain of salt, effusive praise by key opinion leaders, politicians, etc. about health IT, and accompanying attempts to deride those critical of the technology, to counterbalance ongoing HIT hyperenthusiasm (e.g., <a href="http://www.youtube.com/watch?v=ZQIzdBg5gXw" target="_blank">link</a>). In face of growing evidence of risk and adverse outcomes of bad health IT from multiple sources and organizations (such as <a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html" target="_blank">this</a>, as just one example), growing advice on risk remediation from government (such as <a href="http://www.nist.gov/healthcare/usability/upload/NIST-IR-7865.pdf" target="_blank">here</a>), and mass privacy violations (see the multiple posts under <a href="http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy" target="_blank">this query link</a>), it might also be entitled a series on what health IT <a href="http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html" target="_blank">hyper-enthusiasts</a> "knew, should have known, or should have made it their business to know." Let's start out with an extract from a post I wrote on June 29, 2003 entitled "<a href="http://hcrenewal.blogspot.com/2009/06/mark-leavitt-head-of-cchit-behind-times.html" target="_blank">Mark Leavitt, Head of CCHIT: Behind the Times and Uninformed on Health IT Realities?</a>". At the time Leavitt was head of <a href="http://www.cchit.org/" target="_blank">CCHIT</a>, a tester and MU compliance/safety certifier of electronic health records systems:  <blockquote class="tr_bq">... The head of CCHIT, Mark Leavitt, has penned the following at iHealthBeat:  <a href="http://www.ihealthbeat.org/perspectives/2009/health-it-under-arra-its-not-the-money-its-the-message.aspx">June 19, 2009 - Perspectives</a>  Health IT Under ARRA: It's Not the Money, It's the Message by Mark Leavit   ... Before ARRA, most surveys concluded that cost was the No. 1 barrier to EHR adoption. But as soon as it appeared that the cost barrier might finally be overcome, individuals with a deeper-seated "anti-EHR" bent emerged. Their numbers are small, but their shocking claims -- that EHRs kill people, that massive privacy violations are taking place, that shady conspiracies are operating -- make stimulating copy for the media. Those experienced with EHRs might laugh these stories off, but risk-averse newcomers to health IT, both health care providers and policymakers are easily affected by fear mongering. </blockquote> "Laugh these stories off?"  That was, and is, simply perverse. Ironically, this statement was written less than a year before my own mother was seriously and fatally harmed as a result of a health IT-related error.   <table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhMLAOY-zSe3l0ImSmaQsj6EX7UtY9yNRp6gka3ZuuCaH9i3Rdu3NYYL1b0ybojlliYFz96WUIKGEutgtICnhM9O1lk7TPB9a8hwgzlVaia499PLd_nvDohorpZqIeYoEp8M5eKdQZTrUnv/s1600/Cute-Chimpanzees.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhMLAOY-zSe3l0ImSmaQsj6EX7UtY9yNRp6gka3ZuuCaH9i3Rdu3NYYL1b0ybojlliYFz96WUIKGEutgtICnhM9O1lk7TPB9a8hwgzlVaia499PLd_nvDohorpZqIeYoEp8M5eKdQZTrUnv/s200/Cute-Chimpanzees.jpg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">On EHR's:  See No Evil, Hear No Evil, Speak No Evil</td></tr></tbody></table> While I don't proffer claims of "shady conspiracies" (international health IT expert Dr. Richard Cook explains that in a recent guest post "<a href="http://hcrenewal.blogspot.com/2013/03/dr-richard-cook-on-health-it-sectors.html" target="_blank">Dr. Richard Cook on the Health IT Sector's Ills</a>"), I do proffer alternate explanations including arrogance, <a href="http://hcrenewal.blogspot.com/2013/03/solutionism-are-all-healthcare-issues.html" target="_blank">Radical Solutionism</a>, and <a href="http://www.amazon.com/Assholes-A-Theory-Aaron-James/dp/0385535651" target="_blank">this</a>. More to come in this series. There are many more statements like this one already on this blog, and elsewhere. -- SS Note:  Part 2 is <a href="http://hcrenewal.blogspot.com/2013/03/on-ehrs-see-no-evil-hear-no-evil-speak_8.html" target="_blank">here</a>.

On EHR's: See No Evil, Hear No Evil, Speak No Evil: Part 1

This is the first of a series of posts I plan on the issue of "See No Evil, Hear No Evil, Speak No Evil" regarding EHR's. Fr...

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More Cause for Hope - After Novartis Chairman's Rescinded Golden Parachute, Swiss Voters Give Control of Hired Executives' Salaries Back to Owners

Recently, we <a href="http://hcrenewal.blogspot.com/2013/02/reason-for-hope-novartis-rescinds.html">discussed</a> the latest stupefyingly big <a href="http://hcrenewal.blogspot.com/search/label/golden%20parachutes">golden parachute</a> given to a departing pharmaceutical executive.  Former Novartis CEO and outgoing chairman Daniel Vasella was to be given more than $75 million, after making multiple millions previously, ostensibly so he would not go to work for a competitor.  After a public outcry, the company cancelled the plan, and Vasella admitted a "mistake."  This was the only instance in recent memory in which a big health care organization pulled back some huge executive pay package due to public protest. Swiss Voters Give Control of Pay of Hired Executives Back to Company Owners Now Swiss voters have approved a referendum which would actually let the owners of public companies, the stockholders, decide how much to pay hired executives.  As <a href="http://www.nytimes.com/2013/03/04/business/global/swiss-voters-tighten-countrys-limits-on-executive-pay.html">summarized</a> by the New York Times, <blockquote class="tr_bq"> Swiss citizens voted Sunday to impose some of the world’s most severe restrictions on executive compensation<a class="meta-classifier" href="http://topics.nytimes.com/top/reference/timestopics/subjects/e/executive_pay/index.html?inline=nyt-classifier" title="More articles about executive pay."></a>, ignoring a warning from the business lobby that such curbs would undermine the country’s investor-friendly image. <div itemprop="articleBody"> The vote gives shareholders of companies listed in Switzerland<a class="meta-loc" href="http://topics.nytimes.com/top/news/international/countriesandterritories/switzerland/index.html?inline=nyt-geo" title="More news and information about Switzerland."></a> a binding say on the overall pay packages for executives and directors. Pension funds holding shares in a company would be obligated to take part in votes on compensation packages. </div><div itemprop="articleBody"> </div><div itemprop="articleBody">In addition, companies would no longer be allowed to give bonuses to executives joining or leaving the business, or to executives when their company was taken over. Violations could result in fines equal to up to six years of salary and a prison sentence of up to three years. </div></blockquote><div itemprop="articleBody"> </div><div itemprop="articleBody">The new rules in Switzerland would be unprecedented in the current era.  </div><div itemprop="articleBody"> </div><div itemprop="articleBody">Those who are Ostensibly Pro-Business Defend Hired Executives, not Owners </div><div itemprop="articleBody"> </div><div itemprop="articleBody">Despite the fact that the new rules would give control over one type of hired employees, hired executives, back to the shareholders, the owners of companies, spokespeople for big companies, but presumably really for their top executives, claimed that the rule would be bad for shareholders.</div><div itemprop="articleBody"> </div><div itemprop="articleBody"> </div><blockquote class="tr_bq"><div itemprop="articleBody">Ahead of the vote, [the Swiss business federation] EconomieSuisse and Mr. Minder’s other opponents warned of dire consequences if the referendum passed, notably in terms of keeping Switzerland attractive to foreign companies and investors. </div><div itemprop="articleBody"> </div>But [chief proponent of the new rules] Mr. Minder argued that Switzerland would benefit if it gave shareholders control over the companies in which they invested.</blockquote> Furthermore, the Guardian <a href="http://www.guardian.co.uk/world/2013/mar/03/swiss-referendum-executive-pay">reported</a>,  <blockquote class="tr_bq">Minder says the massive sums demonstrate that company boards have lost control of pay and prefer to fork out 'astronomical' salaries rather than pay dividends to shareholders. Minder told the Swiss daily Le Temps that the only solution was to give shareholders the power to set pay.</blockquote>  A Bloomberg <a href="http://www.bloomberg.com/news/2013-03-04/angry-swiss-aren-t-done-slimming-the-fat-cats.html">article</a> suggested that driving the vote were how the Swiss are <blockquote class="tr_bq"> worried about how long they can fend off the crisis that has engulfed the rest of Europe, and dissatisfied with a feeling of being ripped off by their elites. 'It is scandalous. No one deserves to be paid such monstrously high salaries, especially when their employees get paid not much in comparison,' Marianne Lecoultre, a pensioner who lives in a modest flat on the outskirts of Geneva, told me.  </blockquote> The Germans are Thinking of Making Hired Executives More Accountable The German media outlet Deutsche Welle <a href="http://www.dw.de/swiss-referendum-fans-executive-pay-debate-in-germany/a-16643835">reported</a> that there is now more interest in returning control of hired executive pay to company owners there as well. <blockquote class="tr_bq"> After Swiss citizens voted Sunday to impose controls on executive pay, a similar debate has started in Germany. </blockquote> Furthermore, <blockquote class="tr_bq">Joachim Poß, the parliamentary leader of the opposition Social Democratic Party, told the daily Neue Osnabrücker Zeitung that the outcome of the referendum was an important step towards restricting the money-grabbing prevalent in corporate management, He noted that the referendum was encouragement for an initiative at the EU level, and added that 'people do no longer accept perverted bonus systems, neither in banks nor in the real economy.'</blockquote> Summary: Ripped Off by Health Care Elites I can start to imagine how supposedly pro-business people in the US will dismiss actions taken by European countries as anti-business and probably "job killing," even though these actions actually gave more control of publicly held business to their owners, not to government, which would seem to be fully in support of capitalism.  Again, maybe some people making the loudest pro-business noises are really sympathetic to, if not paid by, the hired managers of businesses who have put their enrichment ahead of the interests of other employees, customers, clients or patients, the business owners (stockholders, that is), and the public at large.  Enormous compensation of hired health care executives, out of all proportion, if related at all to whether their work had any positive effect on patients' or the public's health, has long been a <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">concern</a> on <a href="http://hcrenewal.blogspot.com/">Health Care Renewal</a>.  For example, back in 2006, we posted repeatedly (look <a href="http://hcrenewal.blogspot.com/2006/10/another-really-big-one-bites-dust-ceo.html">here</a> for links) about the billion dollar plus fortune amassed by the then CEO of UnitedHealthcare which vividly contrasted with the company's avowal to "make health care more affordable."  That seemed to be an example back then of a rip off by a member of the health care elite.  Now the notion that our top elites have been generally ripping us off is becoming more widespread. In my humble opinion, the perverse incentives generated by a system that allows top executives to make almost unlimited amounts, regardless of all other considerations, has been a major reason for US and global health care dysfunction.  Making executive compensation less perverse, and ultimately making health care leaders accountable for the effects of what they do on patients' and the public's health may be an absolutely necessary step to make our health care system more functional.  Now at least there is some precedent, admittedly from Europe, for making top hired managers more accountable.  As Pierre Briancon<a href="http://blogs.reuters.com/breakingviews/2013/03/04/swiss-may-show-the-way-on-pay/"> wrote</a> in Reuters, <blockquote class="tr_bq"> Corporate boards had better take notice: public outrage at what looks like persistent and unapologetic greed in the most severe economic slump in decades is forcing governments to step in. Throughout Europe, indignation at private excess has become a policy problem for administrations trying to explain the need to cut public spending.</blockquote> In addition, <blockquote class="tr_bq">Self-moderation doesn’t work and self-interest continues to prevail. Throughout the Western world, corporate boards have paid lip service to the need to take into account public opinion, and nothing much has changed either in the banking industry – the symbol of immoderation – or in the wider corporate world. In desperation, governments are taking more forceful action – sometimes reluctantly: the Swiss referendum followed a failure by the country’s parliament to heed to public indignation. Government intervention can often be clumsy, and it is fraught with the risk of unintended consequences. But it is the right of governments to legislate on social ills – and excessive and provocative private-sector pay has become one. Meanwhile the lobbies promising economic apocalypse have failed to make their case – and to scare anyone with warnings that 'talent' – as they call it – may relocate to friendlier countries. It would be in the interest of all if they stopped turning a deaf ear to calls for decency emanating even from countries like Switzerland, which is hardly a hotbed of Soviet-style command economics.</blockquote> Even though the final impetus for the overwhelming majority vote on the Swiss referendum came from a ridiculous golden parachute from a pharmaceutical company, the discussion so far has not centered on health care.  So I get to close with something I have repeated on and on, now with a little hope that it may not be considered so extreme....  Health care organizations need leaders that uphold the core values of health care, and focus on and are accountable for the mission, not on secondary responsibilities that conflict with these values and their mission, and not on self-enrichment. Leaders ought to be rewarded reasonably, but not lavishly, for doing what ultimately improves patient care, or when applicable, good education and good research. On the other hand, those who authorize, direct and implement bad behavior ought to suffer negative consequences sufficient to deter future bad behavior. If we do not fix the severe problems affecting the leadership and governance of health care, and do not increase accountability, integrity and transparency of health care leadership and governance, we will be as much to blame as the leaders when the system collapses.

More Cause for Hope - After Novartis Chairman's Rescinded Golden Parachute, Swiss Voters Give Control of Hired Executives' Salaries Back to Owners

Recently, we discussed the latest stupefyingly big golden parachute given to a departing pharmaceutical executive. Former Novartis CEO an...

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Solutionism: are all healthcare issues transparent and self-evident processes that can be easily optimized, if only the right algorithms are in place?

I've ordered this book:  "<a href="http://www.amazon.com/Save-Everything-Click-Here-Technological/dp/1610391381" target="_blank">To Save Everything, Click Here: The Folly of Technological Solutionism</a>" by <a href="http://www.amazon.com/s/ref=ntt_athr_dp_sr_1?_encoding=UTF8&field-author=Evgeny%20Morozov&search-alias=books&sort=relevancerank">Evgeny Morozov</a>. I've read some excerpts prior to its delivery and find them fascinating.  Emphases mine: <blockquote>... Alas, all too often, this never-ending quest to ameliorate—or what the Canadian anthropologist Tania Murray Li, writing in a very different context, has called “the will to improve”—is shortsighted and only perfunctorily interested in the activity for which improvement is sought. Recasting all complex social situations either as neatly defined problems with definite, computable solutions or as transparent and self-evident processes that can be easily optimized—if only the right algorithms are in place!—this quest is likely to have unexpected consequences that could eventually cause more damage than the problems they seek to address. I call the ideology that legitimizes and sanctions such aspirations “solutionism.” I borrow this unabashedly pejorative term from the world of architecture and urban planning, where it has come to refer to an unhealthy preoccupation with sexy, monumental, and narrow-minded solutions—the kind of stuff that wows audiences at <a href="http://www.ted.com/pages/registration" target="_blank">TED Conferences</a>—to problems that are extremely complex, fluid, and contentious. These are the kinds of problems that, on careful examination, do not have to be defined in the singular and all-encompassing ways that “solutionists” have defined them; what’s contentious, then, is not their proposed solution but their very definition of the problem itself. Design theorist Michael Dobbins has it right: solutionism presumes rather than investigates the problems that it is trying to solve, reaching “for the answer before the questions have been fully asked.” [Such as, how risk-prone are paper records, exactly, and how might the risks be ameloriated without spending hundreds of billions of dollars on healthcare IT? - ed.] How problems are composed matters every bit as much as how problems are resolved. Solutionism, thus, is not just a fancy way of saying that for someone with a hammer, everything looks like a nail; it’s not just another riff on the inapplicability of “technological fixes” to “wicked problems” (a subject I address at length in The Net Delusion). It’s not only that many problems are not suited to the quick-and-easy solutionist tool kit. It’s also that what many solutionists presume to be “problems” in need of solving are not problems at all; a deeper investigation into the very nature of these “problems” would reveal that the inefficiency, ambiguity, and opacity—whether in politics or everyday life—that the newly empowered geeks and solutionists are rallying against are not in any sense problematic. Quite the opposite: these vices are often virtues in disguise. [Such as - paper charts that are rapid to produce and browse, redundancies in healthcare processes that can help prevent errors of omission, ambiguities in decision making that take into account that not everyone fits a guideline, etc.? - ed.] That, thanks to innovative technologies, the modern-day solutionist has an easy way to eliminate them does not make them any less virtuous.</blockquote> It occurs to me that what I've been calling "<a href="http://www.jpands.org/vol14no2/silverstein.pdf" target="_blank">the syndrome of inappropriate overconfidence in computing</a>" or <a href="http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html" target="_blank">"healthcare IT hyper-enthusiasm that ignores the downsides</a>" -- or that which authors such as Nemeth/Cook might call a blindness to complexity that is "<a href="http://www.ctlab.org/documents/Hiding%20in%20plain%20sight.pdf" target="_blank">hiding in plain sight</a>" and "<a href="http://hcrenewal.blogspot.com/2013/03/dr-richard-cook-on-health-it-sectors.html" target="_blank">HIT techno-fantasies</a>" -- and similar ideas, may all be the same thing. "Solutionism" may be a good umbrella label for these ideas.   Thus, those who challenge these ideas in healthcare and call for caution and restraint are not anti-health IT, not anti-technology, but anti-Solutionism, or maybe 'temperate solutionists' as opposed to 'extremist solutionists' or 'radical solutionists.' And the reason the pushback is so vicious at times may be that we are attacking not just an industry but a broad philosophy or ideology - "a systematic body of concepts especially about human life or culture." The current culture promotes solutionism - the belief that there's a technocratic (technological & bureaucratic, i.e., management of society by technical 'experts') solution to every problem as "solutionism" is defined elsewhere.  I think a vast majority of people, including the 'intellectuals', have bought into it.   It doesn't help that "radical solutionism" is exceptionally profitable for its proponents.... Solutionism may be applicable to, say, domains where numbers or logistical matters predominate (e.g., banking and FedEx), but not to "messy" domains such as medicine.  Or at least not to all of medicine's component parts, such as the parts that clinicians perform using hard-earned expertise, judgement and ethics. Finally, I ask: Why can't be cure mental illness, or ensure perfect outcomes in cardiac surgery, or prevent wars, with the appropriate computer apps? After all, with the appropriate tools, why can't we easily perform nuclear fission on our kitchen tables? More after I read the book. -- SS

Solutionism: are all healthcare issues transparent and self-evident processes that can be easily optimized, if only the right algorithms are in place?

I've ordered this book: " To Save Everything, Click Here: The Folly of Technological Solutionism " by Evgeny Morozov . I'...

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Comments by Dr. Reed Gelzer on RAND Health IT Report and Op-Ed in Pittsburgh Post Gazette

<div class="ajy">A 2005 RAND Corporation report predicted that health IT could save the U.S. healthcare system $81 billion a year. Since then, however, annual health spending has increased by almost a trillion dollars, and quality and efficiency have not budged much, even with an increase in health IT adoption, according to researchers Arthur L. Kellerman and Spencer S. Jones in a Jan. 2013 <a href="http://content.healthaffairs.org/content/32/1/63.abstract?sid=1667406b-f4db-408e-8226-b472f25c225c">RAND study</a> published in Health Affairs.  Kellermann is chair in policy analysis, and Spencer Jones is an information scientist..</div> A new Op-Ed by Kellerman and Jones entitled "<a href="http://www.post-gazette.com/stories/opinion/perspectives/it-in-health-care-is-mia-677680/" target="_blank">IT in health care is MIA</a>" appeared on Mar. 3, 2013 in the Pittsburgh Post-Gazette. They wrote: <blockquote class="tr_bq">Because information technology has so quickly transformed people's daily lives, we tend to forget how much things have changed from the not-so-distant past. Today, millions of people around the world regularly shop online; download entire movies, books and other media onto wireless devices; bank at ATMs wherever they choose; and self-book travel while checking themselves in at airports electronically. But there is one sector of our lives where adoption of information technology has lagged conspicuously: health care. Some parts of the world are doing better than others in this respect. Researchers from the Commonwealth Fund recently reported that some high-income countries, including the United Kingdom, Australia and New Zealand, have made great strides in the use of electronic medical records among primary-care physicians. Indeed, in those countries, the practice is now nearly universal. Yet some other high-income countries, such as the United States and Canada, are not keeping up.</blockquote> Of course, the U.K. recently suffered a rather severe blow, <a href="http://hcrenewal.blogspot.com/2011/09/npfit-programme-going-pffft.html" target="_blank">on the order of 13 billion Pounds' worth</a>, to its National Programme for Health IT in the NHS (NPfIT).  Australia is not exactly an "Emerald City" in terms of health IT, either, as can be seen from numerous links at the blog of Sydneysider Dr. David More, <a href="http://aushealthit.blogspot.com/" target="_blank">Australian Health Information Technology</a>. The RAND authors throw in some boilerplate grandiose predictions of certainty about health IT, which seems to have become a common phenomenon in newspapers and even scientific publications of late: <blockquote class="tr_bq"> ... The U.S. government is trying to help. In 2009, Congress passed the Health Information Technology for Economic and Clinical Health Act. HITECH has undeniably accelerated IT adoption, yet the problems of usability and interoperability persist. ... The sky is the limit when it comes to potential gains from health IT ... The payoff will be worth it. Indeed, as with the adoption of IT elsewhere, we may soon wonder how health care could have been delivered any other way.</blockquote> Read the whole Op-Ed at the Gazette. (My mother, an unwitting expert with significant experience on health IT adverse effects, is unavailable for comment, as she is dead due to a HIT-related accident.) However, another expert is available: Reed D. Gelzer, MD, MPH is an EHR/HIT systems and policy analyst for private and Federal agency clients, primarily in program integrity and clinical quality support.  In clinical practice for 11 years before transitioning into health IT, he also co-chairs the HL7 Records Management and Evidentiary Support (RMES) Workgroup.  He served US Navy Medicine’s Data Quality Office, various private insurers, as well as three years on CCHIT workgroups.  He was the Prevention Workgroup Chair for the 2007 ONC study on mitigation of EHR mediated waste fraud and abuse. I find his opinions posted at the Gazette comment board of interest.  Some of the themes are very familiar. His comments are reproduced here with just a few comments of mine interjected: <blockquote class="tr_bq">Good afternoon Mr. Kellerman and Mr. Jones, Thank you for the recitation of the arguments for HIT. I am particularly pleased that you note that a principle block to advancing HIT in the US is the fact that systems are not standardized. One of the reasons many of our Industrialized Nation peers are far ahead of us is that they, in effect, standardized their systems by having one customer, a government entity operating health care. I assume you are not proposing that. If not then what, in the absence of regulation, will achieve your proper objective of standardizing HIT? Well, we could simply let the market decide among the current non-standardized, non-regulated systems by accepting the accompanying burdens of cost, patient harms, and highly variable to unreliable data, and so on, in a nationwide experiment using the citizens of the U.S. as the test subjects [without informed consent or opt-out provisions, I might add - ed.] . A free market though would necessitate an absence of market-corrupting subsidies and transparency on comparing products, so that we can all equally hear when systems don't work as expected or cause problems for users, clinics, hospitals, and patients. No subsidies, no advantage to legacy vendors, and publicly available information about system problems, defects, and harms for a free market in HIT seems as unlikely as a single payer, government run system in the U.S., so what other options do we have? We could say, we as a country want to improve this faulty and expensive industry, and so that is what we will hold providers responsible for. Doctors, hospitals, nurses, clinics, everybody -You have a duty to achieve better.  IT is a means, not the end. Purchase and apply the tools you decide you need to fix the problems you see. If you find you cannot do it, then close your doors and go to work for someone who can. In support of this, as we do with drugs, we do not expect doctors, hospitals, nurses, clinics to independently research what is safe, what is usable in medications, in lab and imaging equipment and medical devices. We make sure that the tools available are safe, reliable, and do what they are intended to do. We do not de-regulate pharmaceuticals to speed innovation [due to the common claim by HIT hyper-enthusiasts that regulation would harm IT innovation, one might surmise they presumably would support pharma deregulation as well - ed.], we regulate minimum requirements of safety and efficacy so that such tools of medicine can be delivered to the bedside without the clinicians having to spend hours worrying about whether they're even fit for use. Improving the safety, value, and effectiveness of patient care is not dependent on HIT.  Fit HIT is an indispensable enabler of KNOWING that we are doing our best and KNOWING where we are falling short and where improvements can best be directed. Meanwhile, there can be no doubt that we will increasingly regulate HIT simply because it is the only way we can ever have non-anecdotal and systematic reporting on what HIT actually does (or doesn't do) for benefiting patients. Otherwise we will continue to be stuck where we are now: between a defective government policy that has bought the vision and promise (and there's a "no return" policy) without evidence, and the accumulating evidence of the difficulty, complexity, costs, and harms rendered by the current national experiment. [This evidence is often ignored or denied by the hyper-enthusiasts - ed.] Again, thank you for reiterating the necessity of standardization. This should progressively elevate the attention to the vast library of HIT standards existent (and still evolving) that remain unused by vendors. Not just vendors, though. Standards also remain unused by doctors, nurses, hospitals, and clinics (and their organizational advocates) who still, amazingly do little, if any due diligence on the fitness of HIT to their use as patient care tools and records thereof.  [This is known as "negligence" and perhaps "gross negligence" - ed.]  Given that Meaningful Use has lowered the Certification bar so much lower than it was in 2009 and since subsidies have made it a Sellers market (and a race to avoid penalties) it is hard to imagine how the geometric progression of risk of non-standardized [systems] untested for safety, usability, or fitness will not assure pain and suffering of many kinds for years to come. I look to you RAND to project your dynamic model for how Standardization will be achieved. In the meantime, of course this means that, among other things, they are not standardized for fitness in use for patient care. RDGelzer, MD, MPH.</blockquote> These are good thoughts. I repeat my warnings that until sanity and caution is restored to the health IT sector (or started, as it may never have  existed) it is not likely that "we may soon wonder how health care could have been delivered any other way." -- SS

Comments by Dr. Reed Gelzer on RAND Health IT Report and Op-Ed in Pittsburgh Post Gazette

A 2005 RAND Corporation report predicted that health IT could save the U.S. healthcare system $81 billion a year. Since then, however, ann...

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Wisdom from the Medical Journal of Oz: "Good HIT and bad HIT"

The recognition and partitioning of "good health IT" from "bad health IT" is now a mainstream meme.  I have few comments about this new article; it reflects views frequently expressed here at Healthcare Renewal (indeed, one of its references is to this blog and this author): <blockquote class="tr_bq"><a href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit" target="_blank">Good HIT and bad HIT</a> Jon D Patrick and Susan Ieraci Medical Journal of Australia 2013; 198 (4): 205.</blockquote><div class="ui-tabs-panel ui-widget-content ui-corner-bottom" id="article"><blockquote></blockquote><div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><blockquote><div class="Intro">First and foremost, do no harm. Second, do some good</div><div class="Intro"> </div></blockquote><div class="field field-name-field-provenance field-type-text field-label-above"><blockquote><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_elementId-1140662" name="0_elementId-1140662"></a> <div class="P">O<a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1140078" name="0_pgfId-1140078"></a>ne of the key issues for high-volume, high-risk workplaces like hospital emergency departments (EDs) is the struggle of conflicting aims. While hospital managers need information systems for data collection and storage, clinicians need efficient clinical documentation, data retrieval and order-entry systems that save time rather than steal it from the patient. The work of clinicians is aided by reliable data but impaired by the delays of real-time input, difficult system navigation, suboptimal presentation of information, and other problems in the user experience of health information technology (HIT).<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#1">1</a></div><div class="P"> </div><div class="P"><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1139847" name="0_pgfId-1139847"></a>Mohan and colleagues’ study of the impact of an electronic medical record information system on ED performance had some limitations.<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#2">2</a> It was retrospective and unable to control for all confounders, and therefore could only show a correlation with ED delays, not causation. However, the premise for the study delivers an important message — the work required to use the information system was perceived by the ED staff to directly conflict with time spent with patients.</div><div class="P"> </div><div class="P"><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1139851" name="0_pgfId-1139851"></a>Another study has shown that the same electronic medical record information system is perceived to have had a negative impact on the care of patients, as well as the productivity and morale of staff, in six EDs in New South Wales.<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#3">3</a> The need to be hypervigilant about the accuracy of the information supplied by the electronic health record compounds an already stressful clinical environment, which in turn leads to resentment towards the technology and the people who have imposed it. This makes it “bad” HIT. Unless this is corrected, HIT efforts will overuse precious health care resources, will be unlikely to achieve claimed benefits for many years to come, and may actually cause harm.<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#4">4</a>,<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#5">5</a></div><div class="P"> </div><div class="P"><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1139861" name="0_pgfId-1139861"></a>The large HIT corporations produce a type of technology that is best categorised as enterprise resource planning (ERP), which has its roots in the manufacturing industry. It is based on the idea that all processes within an organisation can be standardised, and that all processes of the same type should have their information modelled and processed in the same manner. If this high degree of standardisation were considered the best way to process and model information derived from clinical activity, then ERP would be a favoured technology to adopt, as has happened in many places.</div><div class="P"> </div><div class="P"><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1139862" name="0_pgfId-1139862"></a>However, there is an alternative, almost contradictory, perspective on the nature of clinical work: that it is non-deterministic and performed by a group of diverse staff working in an ecologically stable network of people that has to respond to diverse medical needs and diseases. The ecology model accommodates staff joining and leaving the process, with differing needs emerging at different times, so that the other individuals in the network have to adapt and modify their behaviour and improvise in an unpredictable manner. Amid all this variability is the ever-demanding imperative to improve the processes of care and attention to the patient, while also increasing staff productivity.<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#6">6</a></div><div class="P"> </div><div class="P"><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1139866" name="0_pgfId-1139866"></a>Where the ERP model has been imposed in the clinical setting, staff may be coerced into an approach to their work that is at odds with established best practices. This could only be considered “good” HIT if it brought greater staff productivity with at least no loss (and, preferably, improvement) of patient safety and services and staff morale.</div><div class="P"> </div><div class="P"><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1139867" name="0_pgfId-1139867"></a>It is not enough just to identify problems: effort must be invested in transforming bad HIT into good HIT. This process must identify and optimise all the operative factors: human behaviour, system design, equipment performance, skills of the IT participants, and the operational policy framework.<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#7">7</a> Good HIT should include clinician control of the interface design for content, dataflow and workflow. It includes the ability to change the system in real time, and it incorporates inbuilt data analytical capability, natural language processing, and native interoperability and clinical coding.<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#8">8</a> Finally, there must be an appropriate opportunity to test systems for useability, effectiveness and suitability before their release.</div><div class="P"> </div><div class="P"><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1139874" name="0_pgfId-1139874"></a>There must be a move away from standardised processing models and towards improving the user experience in the clinical setting. Clinicians should not have to shoehorn their activity into predefined, externally imposed work processes that do not reflect actual activity and will not improve efficiency. A true patient-focused system aligns all its components towards the same aim. Like a good clinician, good HIT does no harm — to patients or staff.</div></blockquote></div><div class="field field-name-field-provenance field-type-text field-label-above"> American medical / HIT journals are perhaps a bit too beholden to industry to directly commit such health IT heresy.  Thank the stars those Down Under are a bit more bold.</div></div></div></div><div class="field field-name-field-provenance field-type-text field-label-above"> </div><div class="field field-name-field-provenance field-type-text field-label-above">-- SS</div></div>

Wisdom from the Medical Journal of Oz: "Good HIT and bad HIT"

The recognition and partitioning of "good health IT" from "bad health IT" is now a mainstream meme. I have few commen...

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Michael Millenson and "the adamant refusal by hospitals and doctors to adopt electronic records no matter what the evidence"

Over at Health Beat by Maggie Mahar appears a piece critical of NYT reporter Julie Creswell's Feb. 20, 2013 article "<a href="http://www.nytimes.com/2013/02/20/business/a-digital-shift-on-health-data-swells-profits.html" target="_blank">A Digital Shift on Health Data Swells Profits in an Industry</a>."  (The piece was also cross-posted at The Health Care Blog.)  There have been several responses highly critical of the NYT article recently in various venues. The Health Beat piece "<a href="http://www.healthbeatblog.com/2013/03/the-health-it-scandal-the-ny-times-didnt-cover/" target="_blank">The Health IT Scandal the NY Times Didn’t Cover</a>" is by Michael L. Millenson, president of Health Quality Advisors LLC in Highland Park, IL, and the author of the critically acclaimed book, <a href="http://www.amazon.com/Demanding-Medical-Excellence-Accountability-Information/dp/0226525880" target="_blank">Demanding Medical Excellence: Doctors and Accountability in the Information Age</a> published in 2000. I bought and read that book at the time. The posting at Health Beat contains the following statement: <blockquote class="tr_bq">The actual scandal is more complicated and scary. It has to do with the adamant refusal by hospitals and doctors to adopt electronic records no matter what the evidence.  </blockquote> I am profoundly disappointed by this statement in view of issues (frequently written about here and elsewhere) such as: <ul><li>The <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=readinglist" target="_blank">conflicting literature</a> by credible and responsible parties on health IT's real-world value and risks as it exists today;  </li><li>Fiduciary obligations of hospital executives to maintain safe operating conditions; </li><li>Legal and ethical obligations of physicians to resist technology they find or believe harmful without rigorous proof of its beneficence and efficacy (which includes the absence of major evidence conflicts); </li><li>The evidence of major and frequent <a href="http://hcrenewal.blogspot.com/2011/01/maude-and-hit-risk-mother-mary-what-in.html" target="_blank">flaws, bugs</a> and "<a href="http://hcrenewal.blogspot.com/search/label/glitch" target="_blank">glitches</a>", some of which are alarming; </li></ul>not to mention: <ul><li>The 500+ reader comments in response to Creswell's article, many by clinicians describing why they don't like today's health IT; </li><li>Examples of unintended adverse consequences such as <a href="http://hcrenewal.blogspot.com/2011/06/babys-death-spotlights-safety-risks.html" target="_blank">here</a> (plus at least 5 other IT-related crippling injuries and/or deaths of infants I know of but cannot speak about), and <a href="http://hcrenewal.blogspot.com/2011/09/sweet-death-that-wasnt-very-sweet-how_24.html" target="_blank">here</a>, and <a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html" target="_blank">here</a>; </li><li>Other factors as at this blog and at my teaching site <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/" target="_blank">here</a>.</li></ul> I am trying to find a polite term for the statement, and struggling to do so in view of the author's prior work, which I admired. The statement really is saying: <blockquote class="tr_bq">... It [the "scandal"] has to do with the adamant refusal by hospitals and doctors to adopt electronic records no matter what the evidence ... which is all exceptionally robust and positive, leaving no room whatsoever for reasonable doubt or caution. </blockquote> Regrettably, here is the most polite term I can come up with describing the statement: <a href="http://thesaurus.com/browse/preposterous" target="_blank">Preposterous</a>. If anyone takes offense to that term, please suggest a more precise one. Perhaps a book needs to be written entitled "Demanding Information Technology Excellence: Health IT and Accountability in the Information Age." -- SS Mar. 4, 2013 addendum: In a response to a reader's comment to the cross-posting of this piece at The Health Care Blog (<a href="http://thehealthcareblog.com/blog/2013/03/03/the-health-it-scandal-the-ny-times-didnt-cover/" target="_blank">link</a>), Millenson responds: <blockquote class="tr_bq">"platon20: my point, that EMRs were available in the 1970s but never changed their interface because doctors never cared enough to demand it, is not refuted by your argument, but confirmed."</blockquote> This is bizarre and inconsistent with my experience and that of other Chief Medical Informatics Officers I've mentored or spoken with.  Since my entry into the domain of Medical Informatics 21 years ago I've heard many physicians, myself included [1], demand that health IT sellers and/or hospital IT departments "improve the user interface", among other areas for improvement.  Based on my own observations and that of others (e.g., via reader comments at my teaching site dating to <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/informaticsmd/opinions1.htm" target="_blank">at least 1999</a>), these pleas have often fallen on the deaf - and in some cases ill-informed and/or incompetent - ears of hospital senior and IT executives and industry pundits.  The latter have often responded by accusing the physicians of being "Luddites" or technophobes, and the advocates for change such as myself "anti-health IT." The most stunning example regarding this phenomenon is the industry pushback against Prof. Jon Patrick at U. Sydney, and the ignoring of his work (on both the user experience and the fundamental software engineering quality) sitting on a University server for several years now, regarding a major U.S. ED EHR <a href="http://sydney.edu.au/engineering/it/~hitru/index.php?option=com_content&task=view&id=91&Itemid=146" target="_blank">slated for rollout in an entire state of Australia</a>.   With usability issues now being forced of the industry for reconsideration by HHS via NIST, the industry response has been to claim that "<a href="http://ehrdecisions.com/2011/05/11/from-the-chair-usability-still-in-the-eye-of-the-beholder/" target="_blank">usability is in the eye of the beholder</a>" and other frivolous claims, up to and including <a href="http://hcrenewal.blogspot.com/2012/09/from-what-i-can-tell-epic-was.html" target="_blank">interference in the the public comments period on Meaningful Use via ghostwriting</a>, and possibly <a href="http://hcrenewal.blogspot.com/2010/05/did-epic-ceo-judy-faulkner-of-epic.html" target="_blank">outrageous statements</a> (although that issue became anechoic), to get their way, which is to do little or nothing on that score. I remind Millenson that "improving the user experience" of health IT cuts into the bottom line. [1] e.g.,  in a project initiated 20 years ago <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story" target="_blank">by the clinicians themselves</a> - in a critical care area no less - in which I had to take over through force of will from the hospital's own IT department and COO and  re-engineer not just the commercial user interface but the entire dataset itself.  The project ultimately proved successful after my intervention, but the mid-level executive who facilitated my takeover to do that, and I, were punished by our superiors for our efforts. -- SS

Michael Millenson and "the adamant refusal by hospitals and doctors to adopt electronic records no matter what the evidence"

Over at Health Beat by Maggie Mahar appears a piece critical of NYT reporter Julie Creswell's Feb. 20, 2013 article " A Digital Sh...

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