Thursday, April 30, 2009

Digital Medicine Not Fulfilling Promises

The electronic medical record and the digitization of the health care system is entering more main stream media and coverage as evidenced by the article in Business week - "The Dubious Promise of Digital Medicine". As they put it the companies are:
in a stimulus-fueled frenzy, are piling into the business
Neal Patterson from Cerner is quoted likening this to the
19th century land rush that opened his native Oklahoma to homesteaders
If that analogy is correct then much of the activity is individuals and companies tuned to their favorite radio station WIFM...What's in it For Me? There are some interesting quotes including the suggestion from GE that they will "Leapfrog the competition" by not only replacing paper but "guiding doctors to the best, least-costly treatment". Now this is an interesting concept tied to Evidence Based Medicine (EBM) that has been around for centuries dating back even to Greece but has more recently attracted attention given the greater availability of data and the tools to process it. But as the piece highlights this rare consensus in Washington conceals the
checkered history of computerized medical files and (is) drowning out legitimate questions about their effectiveness. Cerner, based in Kansas City, Mo., and other industry leaders are pushing expensive systems with serious shortcomings, some doctors say. The high cost and questionable quality of products currently on the market are important reasons why barely 1 in 50 hospitals has a comprehensive electronic records system, according to a study published in March in the New England Journal of Medicine. Only 17% of physicians use any type of electronic records
In fact the 17% probably over states the actual usage as other reports suggest that while 17% of clinicians have purchased these systems there is a further gap in actual use bringing this down to a lower 7-9% in actual use.

In fact as David Kibbe points out
"Most big health IT projects have been clear disasters. This [digital push] is a microcosm for health-care reform....Will the narrow special interests win out over the public good?"
And nowhere has the challenge and in particular the failures been more apparent than in the UK's National Health Service (NHS) that has spent billions on the NPfIT program but has little to show for it.

But the attraction of large sums of money are hard to avoid, especially in the current economic climate and Allscripts CEO Glen Tullman like many, but perhaps with better access given his established relationship with President Obama, are vying for their share of the cash. McKesson have a slew of lobbyists to push their agenda and "building on existing technologies". Epic inevitably promotes the one system from one vendor with the corresponding price tag.

But implementation of these systems remains a challenge and the paper from 2005 in the Journal of the American Medical Association: Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors (abstract here - full article requires subscription) linked errors not to fatigue but to the order entry system. Many subsequent studies support this and even suggest that once the error is introduced these systems have a tremendous effect on perpetuating and proliferating these errors into more health records. The most recent article from the New England Journal of Medicine hammers home the point on the adoption of these systems - "Use of Electronic Records in US Hospitals" (it's available here in full as a pdf) and reports that 1.5% of hospitals have a comprehensive EMR!

So where is this all going - uphill but with multiple interested and vested parties pushing. Part of the push has to come from the users and making these systems intuitive and easy to navigate should be a basic requirement. Requiring days or weeks of training suggests design problems in my mind. Creating interfaces that engineers like does not necessarily translate into a busy clinical setting. Usability, data capture methods and tools and above all workflow optimization that fits into our current future clinical practice will be critical. Just implementing the technology never delivered the value and it has been this historical method that we must recover from and show a smarter more user friendly system.

Anyone should be able to navigate and use an EHR, clinical knowledge resources and these healthcare systems but using them for greatest effect will require more understanding on the part of our current clinicians and support from the plethora of ancillary services and staff who contribute to the functioning healthcare delivery system. To borrow from one of my favorite innovative and error free industries - the airline industry: It is the whole team from design, construction, build, maintenance and ongoing support of airlines that makes the captain do a fantastic job. Take Capt Sully Sullenberger - his actions were truly awe inspiring but without everything around him doing what it was supposed to do and all the hours of training and support he received the outcome might have been very different. As a true hero and consummate professional while accepting praise he has been quick to credit others.

Healthcare is similar and in the old adage - "there is no I in team". We must all do our part in enabling the delivery of high quality healthcare - EMR's and Healthcare IT is one part of that which we do need to get right.

1 comment:

andy press said...

Very interesting and educative article, I completely agree with it, thanks.

Andy Press