Health IT is a Good Thing – But It Has to be Done Right!

It is very easy to form a view that this blog is an unalloyed and one-eyed supporter of rapid adoption of e-Health all over our Health System. Given the prospect for that view to be formed it seems important that I point out that while keen to see sensible and planned deployments of proven technologies I am not blind to the possible downsides if it is not done well!

The following appeared in a blog written by Scot Silverstein MD.

http://hcrenewal.blogspot.com/2009/05/machinery-behind-healthcare-reform-how.html

The Machinery Behind Healthcare Reform: How the HIT Lobby is Pushing Experimental and Unsafe Technology on Unconsented Patients and Clinicians

In many past posts on Healthcare Renewal I have commented on a bewildering healthcare and IT industry blindness to a growing body of literature and experiences of those "in the trenches" that throw doubts upon Utopian views of health IT as a panacea for healthcare's problems. Those responsible for this literature advise caution and the highest levels of scientific rigor in the large scale adoption of clinical information technology if that technology is to actually improve healthcare, myself included. We know the difficulties and risks. Bad healthcare informatics wastes money and distracts clinicians. Bad healthcare informatics can kill. "Primum non nocerum" is a critical ideology in health IT.

I first wrote about these observations a decade ago and was merely standing on the shoulders of those who preceded me with their own critical thoughts and observations regarding cybernetic miracles in medicine.

I've also been puzzled about the sudden lurch by the current administration to commit tens of billions of dollars to national HIT, along with eventual penalties for resistance, within the ridiculously short time frame of 2014 and with little public discussion. The provisions seemed to simply "appear" in H.R. 1 EH, a.k.a. the Economic Recovery Act of 2009. I wrote about this here.

Finally, I was curious about the timing of a remarkable set of reports from highly respected U.S. organizations on HIT issues, such as a Dec. 2008 Sentinel Events Alert from the Joint Commission and a Jan. 2009 report from the U.S. National Research Council. What motivated their release?

The answers to these questions have become bit clearer via a remarkable article from the Washington Post. It reveals an administration heavily influenced by - no surprise - powerful industry lobbyists. (I thought this administration had pledged a different mode of government conduct, but as has been said, campaigning is done with poetry, and governing is done with prose.)

Here is an interesting explanation of how medicine has been cross-occupationally invaded by the IT industry, probably ten or more years before that industry really has the depth of understanding, depth of talent and capabilities to make useful, usable, safe, and cost effective national health IT a reality:

The Machinery Behind Health-Care Reform

How an Industry Lobby Scored a Swift, Unexpected Victory by Channeling Billions to Electronic Records

By Robert O'Harrow Jr.

Washington Post Staff Writer

Saturday, May 16, 2009

The full article is found here:

http://www.washingtonpost.com/wp-dyn/content/article/2009/05/15/AR2009051503667.html

The point being made is that there was a planned and very successful lobbying program – supported by the large Health IT providers – to have the Obama Administration release a lot of money to fund the implementation of systems provided by these very same people.

Careful reading of the blog is recommended for the details of both the Washington Post article and Scot’s comments on it.

The key assertion from the blog is that we are uncertain that Health IT is as safe as it should be and that until we can be sure no harm significant harm will flow from deployment and use the precautionary principle should apply.

Example of where things can and have gone wrong are provided here:

Bad Health Informatics Can Kill

ICT can have positive impact on health care, but there are also examples on negative impact of ICT on efficiency and even outcome quality of patient care. Medical informaticians should feel responsble for the effects of ICT on patients and public. Systematic analysis of ICT errors and failures is the precondition to be able to learn from negative examples and to design better health information systems.

This document contains summaries of a number of reported incidents in healthcare where ICT was the cause or a significant factor. For each incident or problem at least one link to a source will be provided. With the following list, we want to rise awareness on this important issue, and provide information for further reading.

This summary was inspired by a citation of Prof. Chris Taylor found in the report "Pathways to Professionalism in Health Informatics" of the UK Council for Health Informatics Professions: "Bad Health Informatics can kill". We would like to acknowledge the contribution of Dr. G.M. Hayes (President, UK Council for Health Informatics Professions; Chairman, Health Informatics Committee of the British Computer Society; President, Primary Health Care Group of the BCS) in collecting those examples.

Table of all sorts of issues found here:

http://iig.umit.at/efmi/badinformatics.htm

I should also note there are others, including Professor Enrico Coiera at UNSW, who have expressed and written on related topics and expressed similar concerns.

What do I make of all this?

First I believe there is strong evidence from all around the world that Health IT has provided demonstrable benefits in many situations.

Examples of where this is true have appeared weekly here on the blog essentially since it was established.

Second I so not in any way diminish or ignore the possibility and real risk of implementations which are not carefully planned and implemented have negative unintended consequences.

Third I do believe that there are important modes of Healthcare Delivery Reform which are simply not possible without better support from information management and communications technologies

Fourth I find issues of vested interest influence to be troubling if not clearly disclosed.

How to proceed. I think there are a few key things that can be done.

First expand clinical involvement dramatically in the planning, procurement and implementation of Health IT.

Second ensure we have an adequate number of properly trained and skilled health informatics professionals who understand both the ethical and technical issues associated with the use of technology in the sector.

Third we ensure there is adequate local control of implementations to ensure possible adverse outcomes are identified and addressed before significant harm occurs.

Fourth that properly designed evaluations are properly sponsored and funded to ensure problematic outcomes are detected and addressed promptly.

Fifth the experiences gained in the implementation of time and safety critical systems in other industry sectors are fully studied and absorbed – software quality, usability, reliability, exception handling etc. (The potential for harm exists and must be addressed proactively).

Sixth we recognise that human nature and psycho-social factors are important in Health Service delivery and we be proactive in ensuring such factors are identified and addressed.

Lastly that we proceed at a pragmatic and sensible pace watching the effects as we go.

If all this is done Health IT can do enormous good with negligible harm. (Who wants to go back to the days of handwritten prescriptions, no CT or MRI scanners and so on!)

David.