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.

User Design - Basic Principles

The British National Health Service (NHS) has one one of the largest healthcare IT projects (National Programme for IT NPfIT) in the world rivaling size and complexity in almost any industry. It's no wonder given the size and complexity that there are problems but in some cases these are just plain simple mistakes and getting basic simple things wrongs does nothing to engender the support and confidence with the embattled clinical users

A Recent post from "Phil Hammond 'Medicine Balls' " Confusing for Health highlights the reasons why the NHS Care Record Service (CRS) implementation systems has been "indefinitely postponed". (I've copied the full post below in case this link fails or ceases to work) but it was item 9 that caught my attention.....

Users who select 'died in department' by mistake (which is default outcome if D is used to navigate drop down), do not receive a warning resulting in appropriate letters sent to the GP. For genuinely deceased patients, the code is mapped incorrectly and does not bring up fields to complete, to register patient dead on the spine.

(The spine in this context is the NHS network backbone)

In a cock-up worthy of the Colemenballs moniker the default value for patient outcome is "Died in Department"!! Someone, somewhere is not firing on all cylinders and there there is a chain of people who let this through into a live systems that are diagonally parked in a a parallel universe.

As Phil Hammond states

...you can only succeed by starting as simply as possible and then getting those who have to use the new system to help build it into something fit for purpose

Sage advice!

>>>>> Confusing for Health >>>>>
Original posting should be available here

The NHS Care Records Service (CRS) is a secure service that links patient information from different parts of the NHS electronically, so that authorised NHS staff and patients have the information they need to make care decisions.' So says the Connecting for Health website, but there isn't much sign of it up and running in the West Country. A computer literate consultant tells me that CRS has been 'indefinitely postponed' where he works because 'it cannot migrate data across the system into the correct coding slots which means there is no way for a hospital to record what work it actually carries out and be paid appropriately.'

Our new market driven NHS depends for its survival on the right money following the right patients. And then there's the extra cost not just of installing the new system but paying extra staff to run it properly. A document sent to me for the Royal Free hospital in London shows not just how many bugs still need ironing out in the CRS, but how we all need to learn a whole new language to communicate with each other.

'1. There are problems associated with the use of smart cards to log on, which takes 7 key strokes, resulting in a very long log-in time, as much as 10% of each hour. This discourages use of the system, and encourages staff to leave the card in place, which then prevents the identification of the user when requesting X-rays, bloods etc.

2. The GP letter is very poor quality and requests to change this via the RFC (Referral Facilitation Centre?) have not been implemented. The treatments and investigations form does not support the user in choosing clinically important tests or support HRG 4. The Inbox not emptying automatically leads to significant delays in the system.

3. Clinics must have DNA patients dealt with as DNA, otherwise 18 weeks reporting is a problem. Reporting for the four-hour target is clunky and can only be done in Explorer because of the delay in updating IM200. This still takes up to 2 hours to validate the performance each day, causing 40-50 breaches a day for first few weeks.

4. Data can be entered but may not be visible to other users, and is difficult to find the forms and summaries. Multiple issues raised with LPfIT and BT/Cerner since going live have not been resolved

5. Free text fields on the discharge letter only allow 750 characters, resulting in limited summaries and poor communication with GPs.

6. Excessive time taken for scanning, registering, creating pending admission and GP letter printing. Five extra A & C (administration and coding?) staff have needed to be employed.

7. Discharge time of patient is displayed rather than check-out time (i.e. time patient left department). This makes reviewing 4 hour breaches impossible, since discharge time may be as much as 24 hours after checkout time

8. Manchester Triage does not populate white board. (I've no idea what this means either).

9. Users who select 'died in department' by mistake (which is default outcome if D is used to navigate drop down), do not receive a warning resulting in appropriate letters sent to the GP. For genuinely deceased patients, the code is mapped incorrectly and does not bring up fields to complete, to register patient dead on the spine.

10. The system crashes 2 or 3 times a week.'

I think I only understand number 10 with absolute certainty, but the message is clear enough. Implementing large scale IT projects is unbelievably complex. And you can only succeed by starting as simply as possible and then getting those who have to use the new system to help build it into something fit for purpose (preferably without inventing a whole new geeky language). I'm generally an optimist but I'm not sure about this. How long before we have more coders than doctors? Or are we there already?