Myth 32. Information technology will improve efficiency and safety.

A large part of the savings projected from “healthcare reform” is supposed to come from wider use of information technology. The federal government is expected to “invest” some $45 billion in encouraging (or compelling) doctors and hospitals to use electronic records systems.

“Information is the lifeblood of modern medicine. Health information technology (HIT) is destined to be its circulatory system,” writes David Blumenthal, M.D., M.P.P., of the Office of that National Coordinator for Health Information Technology (New England Journal of Medicine 12/30/09). “Physicians and institutions trying to practice highest-quality medicine without HIT are like Olympians trying to perform with a failing heart,” he states. (Note that Blumenthal’s numerous financial disclosures are in a separate document.)

In the real world, there are many problems in implementation. The University of California San Francisco Medical Center is one institution that is quietly writing off about a third of the $50 million it has poured into electronic medical records over the past 5 years. The system is still not fully up and running. UCSF terminated its contractor and is prepared to start part of the project from scratch (Huffington Post 11/23/09).

According to one study, between 50% and 80% of electronic health records systems fail. The larger the EHR project, the higher the risk of failure (IEEE Spectrum 1/1/10).

Instructional materials from real institutions include such eye-openers as a complicated 90-page guide for simply entering orders and a 30-page House-Wide Discharge (Depart Process) Training Manual. It is no longer possible to discharge a patient by writing prescriptions and a “discharge today” order in the record. “It’s a wonder clinicians can get any clinical work done at all any more,” writes Scot Silverstein, M.D. (Health Care Renewal 1/3/10).

For more than a decade, Silverstein has been making the case that “health IT is very, very much harder than it looks, especially to those in IT lacking healthcare expertise.” Health IT is still largely a social experiment, and hospitals are a highly risky environment for implementing it.

Paper is far from being technologically obsolete, he notes, citing a December 2009 article in the Milbank Quarterly, “Tensions and Paradoxes in Electronic Patient Record Research: a Systemic Literature Review Using the Meta-narrative Method,” by Greenbaugh et al. of the University College London.

“Paper records, being flexible, portable and tolerant of ambiguity, support the complex work of clinical practice remarkably well…. [H]igh-tech healthcare environments such as intensive care units often make extensive use of paper charts, white boards, sticky notes, and oral communication” (Health Care Renewal 12/15/09).

HIT has become intensely political, note Greenbaugh et al. Publishers need to “invite studies that ‘tell it like it is,’ perhaps using the critical fiction technique to ensure anonymity.”

Silverstein calls the idea that “investment of tens of billions of dollars on a frenetic timeframe” will create massive quality improvements and cost savings “the height of magical thinking and political hubris.”

Specializing in medical informatics, Silverstein is not opposed to HIT, he in fact supports it and dedicated his career to informatics. He is only opposed to HIT that is badly done. He observes that local projects built by experts are far more likely to provide major benefits than extant “shrink-wrapped” and massively expensive HIT.

Numerous serious problems have been reported with HIT in operation. Some prompted an Oct 16, 2009, letter from Senator Charles Grassley (R-IA) to Cerner Chief Executive Officer Neal Patterson.

Sen Grassley wrote: “Over the past year, I have received numerous complaints from patients, medical practitioners and technologies engineers regarding difficulties…with HIT and CPOE devices…. These complaints include faulty software that miscalculated intracranial pressures and interchanged kilograms and pounds, resulting in incorrect medication dosages.”

Sen Grassley also referred to “gag orders” that prohibit disclosure of defects, and lack of a system to monitor performance of these devices.

Experienced systems professionals are increasingly raising concerns about the poor design of electronic medical records (EMRs), which frequently require workarounds and patches. The process is “unsustainable” and could lead to “data breakdowns” (Design Dialogues 11/12/09).

Some physicians like their EMR system, but one senior internist at a major hospital, who feared losing his job if he spoke on the record, reported on one 2006 system that crashed soon after it went online. He struggled to keep patients alive while vendor employees “ran around with no idea how to work their own equipment” (Washington Post 10/25/09).

One study showed that more than one in five hospital medication errors were caused at least in part by computers (ibid.).

Emergency physicians in 200 hospitals in Australia were affected by a system credited with decreasing by 50% the number of patients seen within 20 minutes of arrival. Descriptors included “user hostile,” “dangerous,” and “slow at any task I tried.” Vendors offered “more support.” Clinicians said that was like “giving us a defective car and then sending out someone to show us how to drive it” (Health Care Renewal 10/20/09).

HIT raises serious liability concerns, note Sharona Hoffman and Andy Podgurski of Case Western Reserve University. “EHR [electronic health records] systems cannot remain unregulated and largely unscrutinized. It is only with appropriate interventions that they will become a much-hoped for blessing rather than a curse for health care professionals and patients.”

In an earlier report, these authors concluded that “the advantages of EHR systems will outweigh their risks only if these systems are developed and maintained with rigorous adherence to best software engineering.” Unlike other life-critical medical devices subjected to FDA oversight, EHR systems have not been comprehensively assessed.

The Veterans Administration system of EHRs has been in use since the mid-1990s. While reportedly very successful, a software problem that led to major treatment errors in 2008 is still under review. Though no evidence of harm to any patient was found, “the potential for serious injury was staggering” (Ann Intern Med 2009;151:293-296).

After a harrowing hospital experience featuring many staff members pushing around “laptops on wheeled sticks,” his life having been saved by a heroic ICU nurse who worked around the system, and his wife who sneaked his inhaler into his room, a very intelligent patient concluded that “electronic health information systems are mostly broken.”

“The national health information network envisioned by President Barack Obama is a pipedream,” he writes (Joe Bugajski, “The Data Model That Nearly Killed Me,” Syleum.com 3/17/09).

So why did Congress authorize $20 billion for HIT in the stimulus package? Proponents relied on a 2005 RAND estimate of $77 billion in savings—based on the assumption of an error-free system that would be rapidly implemented by 90% of all facilities. Even if achieved, $77 billion would be only 4.5% of total costs, placed at $1.7 trillion by RAND, writes Greg Scandlen (Heartland Institute 2/20/09).

Most likely, “every penny of the $20 billion will be wasted on systems that don’t work and can never be implemented. That was the outcome of federal attempts to upgrade technology at the IRS, the FBI, and the air traffic control system.”

Additional information:

23 thoughts on “Myth 32. Information technology will improve efficiency and safety.

  1. Technology has enormous importance to the lives of men, provided it is produced privately, controlled by private interests, and guided by minds in an agreement freely chosen.

    This means: the government has no place in such transactions other than to protect the rights of patient and physician. It is not the government’s proper role to mandate certain technologies or to fund them.

    All proper creative technologies are private and should be respected as such.

  2. The letter from Sen. Grassley went out to a number of companies.

    Letter was to a number of companies.

    From http://grassley.senate.gov/news/Article.cfm?customel_dataPageID_1502=23839 :

    Click here to view the Grassley letter of inquiry to health information technology companies, including the Cerner Corporation, 3M Company, Allscripts, Cognizant Technology Solutions, Computer Sciences Corporation, Eclipsys, Epic Systems Corporation, McKesson Corporation, Perot Systems Corporation, and Philips Healtcare.

  3. We all understand that the point of EHR is NOT quallity or efficiency, but rather the ability for government to gain access and achieve CONTROL. In fact EHR, in practice, seems to increase errors, delay care, and decrease quality. Scrolling and clicking is much more error prone than thinking and writing (Just today, a neurologist, consulting on one of my hospitalized patients, ordered a chest CT instead of a head CT and hence the patient received the wrong study!) Standardized orders eliminate “thinking” (and hence one of by post MVR patients with chronic C deficile colities received the “standard” colace order.) Finally, we all do not process information in the same way. Computerized medical records box all practioners into the same “size and design,” whether the shoe fits or not. Indeed it stifles creativity, diminishes productivity and reduces efficiency. It may work for packing tuna or building cars, but it doesn’t work for treating patients.

  4. Blumenthal ebullient premise: ” Physicians and institutions trying to practice highest-quality medicine without HIT are like Olympians trying to perform with a failing heart,” he states.

    NOT exactly how current versions of HIT work.

    HIT causes the”Olympian’s heart” to fail by serving as a disruptive influence to careful clinical thought and as a facilitator to unintended consequences and mistakes. The HIT I use clogs the “circulatory system” with ravaging atherosclerosis and thrombus. The hospital and its nurses are forever suffering acute coronary syndrome, until the work around bypass mitigates the destructive influence of the HIT systems.

  5. James Fallows, in a recent Atlantic Monthly, writes that, unlike paper in any of its forms–which retains images –computer software, disks, and drives contain only magnetic impulses that can dissipate. Furthermore, anything over 5 years old runs the risk of there being no software or hardware which can read it. In the coding cubicle of a famously “wired” hospital, I recently noted scores of pigeonholes containing packs of forms.
    With the advent of electronic methods to manipulate and store data, business has between 1980 and 2000 quadrupled its production and utilization of paperwork.
    Hence:

    ODE TO THE PAPERLESS SOCIETY
    By Bill Waters, MD

    Write on the beach, the tide will erase;
    Write on the dune, the wind will deface;
    Write on the disk, time will show its hand;
    Remember now—they’re all just sand.*

    But papyrus and parchment are so well made
    The Dead Sea Scrolls will never fade.
    The vaunted electron will soon turn to vapor
    And its principal product is still just—paper.

    ____
    *For those in Washington, we’re talking about
    silicon, get it?

  6. I can think of no other reason, whatsoever, for both sides of the aisle of Congress to spend billions of dollars on insufficient and probably dangerous computerized medical care records and electronic ordering equipment, other than they were deceptively educated by the manufacturers who will take the money.

  7. I have refused to use the services of several specialists due to the inefficiency and inconsistent data coming forth from their EMRs. With pages of nonrelevant “negatives,” that I am sure they in reality never looked at, the “record” becomes unreadable. In many places, the data contradicts, one place in the record with another, making the report of no value. I use a single page template that we designed to allow multiple point computer data entry and access, with a final single page paper note being generated for the patient chart. Keep it simple, and keep the government out of the doctor-patient relationship. If you want medical reform, empower HSAs, and get tort reform.

  8. The recent article in “Emergency Medicine News -Quality Matters: Beyond Scribes: A Better Idea on the Horizon” by Shari J. Welch, M.D. Describes real world implementation of EMR in 2004 at Parkview Medical Center in Pueblo, CO. :

    “Efficiency suffered, patient satisfaction fell, and walkaways rose…”
    “Physician productivity fell to an unsustainable .5 patients per hour!”

    Does everyone see the conflict in mindset that produced this outcome?

    For the bureaucrat, documentation is everything. That is all he produces.

    For the doctor, documentation is a tool to assist other doctors in caring for the patient. Other reporting and recording demands of govt. and insurers alike, steals the doctor’s time to produce data that are used to withhold payment of claims and limit procedures, medications, and tests. This harms patients by denying care, and by putting doctors to work on paperwork instead of medical care.

    Because doctors have sworn to do no harm, and government and insurance reporting harms patients, doctors should not participate in coding or reporting programs.

  9. Sorry, one more note on the EMR experience in Pueblo. The high dollar system was supposed to increase efficiency.

    To manage the problems caused by their EMR, hospital hired 40 “physician assistant liaisons” to chase data and paper so that doctors could actually treat patients!

  10. The government is planning penalties for doctors who do not spend thousands on the EMRs that make caring for patients more time consuming, difficult and risky.

    The best strategy is to take the penalty and do not purchase. Reconciling penalty with initial cost and annual maintenance costs tinctured with aggravation costs, it will be a wash at worst.

    Spread the word, far and wide. Boycott these systems.

  11. “One study showed that more than one in five hospital medication errors were caused at least in part by computers (ibid.).”

    So who makes the other four?…. I would rather get rid of the 4 other errors and just have to worry about one. Wait reducing medication errors by 80% isn’t that better quality?

    That statistic doesn’t help your argument.

  12. “So who makes the other four?…” says Shaun.

    if it said “one on five plane crashes was due to computer malfunctions, the other four due to pilot error”, one would not want to put the plane on autopilot 100% as a solution.

  13. But Shaun, the other four out of five hospital medication errors presumably occured in the same hospitals using EMR’s. Therefore
    the EMR actually CAUSED 20% of medication errors and FAILED TO
    PREVENT 80% of them. One of the principal arguments for EMR is that
    it will alert physicians and staff to medication entries that are errors, and
    prevent them from occuring. Therefore that statistic DOES help the
    argument.

  14. Shaun asked “Who makes the other four?” Good question. Maybe they are also computer related. Seems that you need to figure it out before we, as you answer implies, simply throw more dollars at technology that is unproven and potentially harmful. I agree that the more problems we can eliminate, the better. Technology will no doubt play a role, but we need to do the research to find those roles. We need good information before acting. You’re familiar with science. History has taught us that ‘shooting from the intellectual hip’ is not good. Look at what the financial wizards did on Wall St with collateralized debt obligations (CDOs) and the like. They said, “Gosh, they work great! Let’s throw money into them!” We all know how that ended…

  15. Next firemen will be required to fill out an electronic data sheet before they put water on the fires?..Lawyers don’t do electronic records..neither should docs..PS I worked at St Louis area Computer hospital a few months, computer kept crashing, we had no idea what the tests showed even on ICU patients!
    Such a JOKE! ABOVER IDEAS Made by snot nosed ACORN or ACLU folks on MS-NBC and C=SPAN who have NEVER run a medical clinic!
    Why are non MD speakers even allowed on TV media? They know nothing about their area! “If you don’t KNOW medicine, then don’t DO medicine!”

  16. The government is pushing EMR based on the theory (unproven, of course) that it will save money and make care safer. (They keep saying this over and over to try and make it true. ) This seems to me to be analogous to making a new drug the standard of care and requiring its use BEFORE it is tested by the FDA for safety and efficacy, simply based on the inventor’s belief that it will be wonderful.
    As is the case with so many “facts” pronounced by government officials and repeated by the news media, the Emperor still has no clothes.

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  18. I see little to no difference between the government being able to ruin us by auditing our charts (if we are Medicare participants) and fining us $10K per “infraction” and having immediate access to the data online to do so. It just makes it a little easier for them to threaten us and control us. We need to phase out government health care (Medicare and Medicaid) altogether. The government has no business telling physicians and patients what to do when it comes to individual health care decisions. As long as they pay, they think they should control all health care decisions. Imagine what will happen if government succeeds in gaining control over 16% of the economy. As long as government plays such a strong role in health care, we’ll have to deal with the thugs, somehow, unless we opt out completely… a major decision that I’m giving careful consideration.

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  20. “In the real world, there are many problems in implementation. The University of California San Francisco Medical Center is one institution that is quietly writing off about a third of the $50 million it has poured into electronic medical records over the past 5 years. The system is still not fully up and running. UCSF terminated its contractor and is prepared to start part of the project from scratch”

    …I bet I know who that contractor was.. lol..

  21. Having spent over 40 years in the information technology field I can assure you that the 45 Billion dollar investment in automating records, bascially record regurgitation, will not reduce costs or improve health care.

    Health care is an individual choice and a partnership between a physician and a patient that should not be taken lightly. The automation of records will not obviate the need for sound patient/practictioner information exchange. Besides who’s will ensure that the quality of what is in the so called automated record is sound.

    Garbage in Garbage out — what’s the incentive.

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