Digital panacea is fiscally disastrous, clinically dangerous

While advances in technology—eagerly adopted by doctors and hospitals—are often blamed for high medical costs, there is one type of technology that will supposedly save billions once we “invest” billions in it and force it on supposedly recalcitrant, technophobic doctors and hospitals: health information technology (HIT), including the electronic medical record (EMR) and computerized physician order entry (CPOE).

“Faith-based cost control” is the term used by Dr. Jon Oberlander in a “Perspective Roundtable: Health Care and the Recession,” offered by The New England Journal of Medicine in January, 2009.

The “stimulus” package provides between $44,000 and $64,000 for physicians who acquire an EMR and demonstrate “meaningful use.” However, “the price is dwarfed by the problems [an EMR] causes the office,” stated Evan Steele, CEO of SRS Soft, which provides a less complex alternative. If a specialist who bills $750,000 a year loses 5% of her productivity dealing with the computer system, she loses $162,000 over 5 years (Physicians Practice, April 2009).

Even the vaunted Veterans Administration system has major problems. An 8-year, $167 million project was not able to develop acceptable scheduling software. The military’s AHLTA system is so slow, unreliable, and cumbersome that clinicians spend 40% of their time inputting data, causing a “near mutiny” (CPR #172, 4/3/09).

For ₤12.7 billion the UK still does not have a national health information technology system, but rather an HIT quagmire, some of it caused by U.S. HIT vendors, writes Dr. Scot Silverstein to the Wall Street Journal.

The province of Ontario just created a new agency, eHealth Ontario, to replace Smart Systems for Health Agency, which spent $647 million without showing any noticeable results. The new agency is supposed to provide EMRs for all citizens by 2015. The province has just hired a consultant to examine whether eHealth Ontario is spending too much money on consultants (Canada Free Press 6/9/09).

In the U.S. also, “most big health IT projects have been clear disasters,” says Dr. David Kibbe, senior technology advisor to the American Academy of Family Physicians. And it’s not just the money.

One U.S. pharmaceutical data base found 43,372 medication mistakes, or about 25% of the total reported in 2006, that involved computer technology: flaws in data entry, inadequate software, and confusing screens. In 2006, Children’s National Medical Center in Washington, D.C., found an eightfold increase in dosage errors for high-risk medications (Terhune C, et al., Business Week 4/23/09).

A 2005 study by University of Pennsylvania sociologist Ross Koppel found 22 circumstances in which the software boosted the probability of error. Doctors also suffered from “alert fatigue” from endless false alarms about minor drug interactions.

“If drug companies sold products with this quality level,” states Dr. Scot Silverstein, “it would be a scandal” (Forbes 5/11/09).

HIT vendors shift liability to users and insert contract language that keeps them from learning of serious faults (Koppel R, Kreda D, JAMA 3/25/09).

“There is a dearth of data on the incidence of adverse events directly caused by HIT overall” (Joint Commission. Sentinel Events Alert, Issue 42, 12/11/08). Among many potential problems are “dangerous workarounds” necessitated by counterproductive technology.

Potential benefits have been greatly exaggerated. Large randomized controlled studies in both the U.S. and Britain have found that EMRs with computerized decision support “did not result in a single improvement in any measure of quality of care for patients with chronic conditions including heart disease and asthma” (Washington Post 3/17/09).

As a direct consequence of the EMR and pay for performance (P4P), the veracity of the clinical record is compromised, write David J. Gibson, M.D., and Jennifer Shaw Gibson (“The Case Against the Electronic Medical Record,” MedicalTuesday.net). Reported data may be “dry-labbed,” and, once entered, data are rarely checked for accuracy.

There are good reasons why only 1.5% of U.S. acute-care hospitals have a comprehensive EMR (Jha AK, et al. N Engl J Med 4/16/09).

Obama’s estimate of savings is an $80 billion exaggeration,” write Jerome Groopman and Pamela Hartzband (Wall Street Journal 5/12/09).

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Ministry of Information “held harmless” by contract

If patients die as a result of health information technology (HIT) defects, the clinicians will be liable—not the vendors. Hospital administrators have signed contracts with “hold harmless” clauses that protect their HIT vendors.

At the same time, like a Soviet-style Ministry of Information, the vendors demand secrecy about the defects. Some hospitals maintain lists of HIT defects, which might contain thousands of items, some of which pose considerable risks to patients. But they are contractually bound not to disclose them (Health Care Renewal 3/26/08).

“Enforced nonsharing of software problems is an industry norm,” write Ross Koppel and David Kreda, although anathema to improving patient care or to evidence-based medicine (JAMA 2009;301:1276-1278).

Vendors avoid liability by relying on the doctrine known as “learned intermediaries,” they note. Users are medical professionals with the expertise to recognize the errors and protect the patients from harm.

Though supposedly the panacea for correcting inefficiency and medical error, “implementations of HIT are massively complex and fraught with delays, errors, resistance, work process redesign, frustration, and outright failure,” they observe, citing numerous references.

There has been very little change in the difficulties with HIT over the past 35 years, writes Scot M. Silverstein, M.D., of Drexel University, College of Information Science and Technology. Those responsible for HIT are not held to the same standards of accountability as clinicians are, though both patient wellbeing and institutions’ financial resources are at risk. Dr. Silverstein has developed a website about “what has been shown best not to do.”

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HHS Secretary nominee pushes HIT’s role in data mining even as new report of stolen electronic medical records surfaces

On Tuesday, HHS Secretary nominee, Kansas Gov. Kathleen Sebelius, confirmed her support for the use of electronic medical records as a way of data mining patient information.

During the Senate hearings on her confirmation, Gov. Sebelius said that electronic health records (EHR) data was crucial to conduct “comparative effectiveness research [CER] to provide information on the relative strengths and weaknesses of alternative medical interventions to health providers and consumers.”

The stimulus bill passed with $1.1 billion allocated for CER to compare the clnical outcomes, effectiveness, and appropriateness of medical services. During the hearing, Sen. Pat Roberts from Gov. Sebelius’s own state of Kansas, expressed his concern that CER would be used to justify rationing by comparing costs, rather than effectiveness.

But Gov. Sebelius’s pledge to “provide every American with a safe, secure electronic health record by 2014” came on the same day that another breach of electronic medical records was leaking out.

The Mercury News reported that laptops containing 1,000 patient files were recently stolen at the Palo Alto Medical Foundation’s office in Santa Cruz, CA. (Mercury News, 3/31/09)

Even though the records were stolen in February, patients weren’t told until March 23, when they received a letter from the Medical Foundation. The records included diagnoses, treatment plans, E results and patient medical record numbers.

The laptop was stolen during a break-in when the office was closed. It was attached to a piece of equipment.

The Medical Foundation promises to do better in the future, and the Senate Finance Committee is expected to confirm Gov. Sebelius on Thursday.

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