There have been some interesting discussions in the last little while asking ‘what is wrong with e-health’ or ‘why are we not having more success with e-Health implementation’?
Some commentary is here:
August 10, 2011 | Jeff Rowe, HITECH Watch
Like it or not, spending the public’s money on the HIT transition is a Catch-22.
On the one hand, billions of dollars are being spent on a promise. On the other hand, there’s no way of knowing for sure whether the promise will come true until those billions are spent.
There are, of course, many reasons to believe we’re heading in the right direction, but skepticism remains, and skeptics seem to be getting a little help from researchers.
According to this article, “more and more studies are questioning the efficacy of electronic health records, and the U.S. Food and Drug Administration has begun collecting reports involving electronic health and IT errors, some of which have resulted in death.”
Here is the article that was being discussed.
Studies show errors, inefficiencies still occur in medical services
Sunday, August 07, 2011
By Bill Toland, Pittsburgh Post-Gazette
It has become health care industry dogma that electronic records can help improve efficiency. Reduce errors. Save lives. And -- just maybe -- put the brakes on runaway health costs, by allowing better sharing of patient information and eliminating duplicative services.
It's why hospitals and physicians' practices across the country want a piece of the $27 billion in federal stimulus incentive money to help doctors move their systems away from papers and manila file folders and toward computerization.
It's why Highmark and West Penn Allegheny Health System recently announced a partnership with Allscripts and Accenture to provide Pittsburgh's independent physicians with electronic health records.
And it's why, starting in 2015, hospitals and doctors face cuts to their Medicare and Medicaid reimbursements if they haven't adopted "meaningful" health information technology hardware, electronic prescribing systems and other elements of President Barack Obama's Health Information Technology for Economic and Clinical Health act, known as HITECH.
Moving to a fully electronic system, Mr. Obama told Congress in February 2009 -- citing a 2005 Rand Corp. study -- could net $80 billion annual savings for the health system.
But do electronic records systems fully deliver on their promise? It's not uncommon for doctors, especially those from smaller practices, to complain about the computerization process itself -- it takes time and money to overhaul operations. Change is often unwelcome.
But it's also becoming more common to question whether the measures themselves will meet their lofty expectations. More and more studies are questioning the efficacy of electronic health records, and the U.S. Food and Drug Administration has begun collecting reports involving electronic health and IT errors, some of which have resulted in death.
"I don't think that we are getting our money's worth from all this treasury that we are spending," said Jaan Sidorov, Harrisburg-based health care consultant.
"The thing about these systems is that it doesn't really look like they're getting any cheaper," he said. "And the upgrades and the upkeep represents a very significant cost, especially in outpatient clinics."
Most clinics and hospital systems will say the return on investment for big IT projects is minimal in the short and medium terms.
And in some ways they can contribute cost to the medical system -- some software systems, for example, have auditing components that allow practices to uncover billable services that the practice had been missing.
In other words, the "efficiencies" that are realized may benefit the provider but not necessarily the insurer.
But that's just the cost side -- what about quality of care?
The hope is that computerized decision support systems will warn a physician if a drug dosage is too high or too low; digital health records can be transmitted more quickly among practices and specialists; computers can use logarithms to flag patients who are at risk for high-cost conditions.
The proposed benefits are tantalizing.
But lots of experts say we're just not there yet.
"Health information technology can meet the goals that are talked about," said Scot M. Silverstein, a medical IT expert and adjunct professor at Drexel University, College of Information Science and Technology, in Philadelphia. "But only if done well. And the amount of complexity behind that simple phrase -- 'if done well' -- is enormous and largely unrecognized and ignored."
The Journal of the American Medical Informatics Association published a report this summer suggesting electronic health records aren't as error-proof as advertised.
Having analyzed 3,850 computer-generated prescriptions received by a commercial outpatient pharmacy chain, a clinical panel found that 452 of the prescriptions, or about 12 percent, contained errors. (A "computerized" prescription is one that is typed into a computer, rather than a note pad; an "electronic" prescription is one that has been transmitted by email or wireless to a pharmacy.)
Of those, 163 contained mistakes that could have led to "adverse drug events." Most errors were mistakes of omission -- a doctor left out an important piece of data.
Notably, this "is consistent with the literature on manual handwritten prescription error rates," the report said. Also, the number and severity of errors varied by the type of computerized prescribing system, which suggests that some systems may be better designed than others.
Lots more here:
Some local contributors have also had a recent say on the matter.
What makes Healthcare different?
Posted on August 10, 2011 by Grahame Grieve
Tom Beale has picked up on a thread about what makes healthcare different (and kindly cited my earlier post on the subject).
I’m going to pick up on something Tom says, because it’s very much in my mind at the moment:
why can’t the health sector get its act together with ICT?
The implication here is that some other sectors have. Apparently.
Well, I’d like to know what ones have? When I look at the other industries, I see a pattern:
- Businesses develop new services (sometimes based on new technologies)
- As the use of the service coalesces, the variability of the service becomes a tax, not a benefit
- A bunch of industry big wigs decide to make it a commodity instead (sometimes external prompt from government is needed)
- They create a consortium, gather a bunch of engineers, come up with a partially/mostly bespoke solution, and call it a standard
- Then they pass it over to the operational guys who run it to the ground with adoption and conformance etc
A bunch of piecemeal standards. What is healthcare supposed to learn from this?
We also have a recent contribution from Tom Beale.
Every so often, someone asks: why can’t the health sector get its act together with ICT? Tell me why health is ‘different’?
Every so often a new and interesting answer to this question pops up…John Halamka just published an excellent list of 7 things that make healthcare (and by extension, health-related computing) hard in this post. Given his day job, this list can be taken as something very close to reality rather than being purely speculative. I mentioned a few of these things peripherally in an old blog post on the e-health standards crisis. Halamka’s comments just make me think that the The Innovator’s Prescription (Clayton M Christensen, Jerome H Grossman, Jason Hwang) really does provide an excellent analysis on how to think about economics and health care.
For a bit of history on the economic analysis of healthcare, including the amoral view on health of right-wing US commentator Rush Limbaugh, see here.
Grahame Grieve recently put up his list of why healthcare is special, which touches on computing, sociology and economics.
In 2005 I wrote a paper for IMIA called ‘Why is the EHR so hard‘, in which I took a biomedical/social complexity viewpoint (more or less ignoring Halamka’s points above), and used EHR requirements as a way of looking at health complexity:
- information and efficient user interface reflecting multiple levels of hierarchical biological and social organisation;
- mobile patients;
- longevity of information (e.g. 100 years);
- data shared and authored by multiple users simultaneously;
- integrated with knowledge bases such as terminology and clinical guidelines;
- wide geographical availability of a given record to multiple carers and applications;
- consent-based, potentially finegrained privacy rules on information use (with exceptions for emergency access);
- multiple sources of constant change to requirements including medical technology, clinical procedures and guidelines, genomic/proteomic medicine;
- reliable medico-legal support for all users.
More from Tom Beale here:
The original post from Grahame Grieve is here:
Healthcare is Special
Posted on May 21, 2011 by Grahame Grieve
Healthcare is special. Things that work in other industries won’t work in healthcare.
If I had a dollar for every time I’ve heard that… well, I could be sitting off a beach somewhere, surfing. Though usually, this statement is immediately followed by its denial, that healthcare is not actually special, that every industry thinks it’s special (and, if every other industry thinks it’s special, doesn’t that make healthcare special all by itself?). But for every person who says that, who wishes to claim it’s not true, there’s ten people who, whether they believe it or not, act like it’s true, behave as if its truth is one of the founding principles of their lives.
But is healthcare so special? In fact, just what is healthcare?
There is a wide scope of IT systems and/or applications that may be included under the banner of “Healthcare”:
- Patient Administration systems
- Clinical Tracking and Reporting software
- Clinical Decision Support Systems
- Financial transactions for payments related to healthcare
- Population statistics and forecasting software
- Specialized variants of standard IT infrastructure
- Patient-centric healthcare data tracking software
- Bioanalytical programs or frameworks, both in research and in diagnostics
Within this wide scope, several different factors combine to make healthcare different, and potentially special.
Note: to get the full flavour of this all the links really need to be followed and each read in full.
Having read all this I am stimulated to have my two cents worth.
For me the issue is one of how we represent clinical information in electronic form and how that actually relates to how clinicians think about clinical information in the processes of delivering care.
I recognise all that the various writers are saying, and there is much truth there. What I think is missing is what I would term the ‘subtlety’ and non-binary way in which clinical information is gathered and processed by a clinician in the process for formulating a diagnosis and then deciding on treatment.
Underpinning most EHRs there is a data and ultimately information model and, like all models, this can only represent one version of ‘truth’ and like all models is only able to handle a part of reality. As they say no model is complete but some are useful. When it comes to modelling an individual expression of illness residing in an individual patient the complexity is really quite daunting.
Most diagnosis and diagnoses are not utterly clear cut and each diagnosis will usually have - in the clinician’s mind - a degree of uncertainty associated with it. This uncertainty is typically not documented well with a diagnosis being described in words which provide only a limited degree of shades of grey. (Probable, Possible, Highly Likely or Unlikely being the most common). Many physicians also have a final section in their letter headed ‘Impression’ which tries to capture the level of uncertainty.
Similarly extra complexity and difficulty arises when you start to realise that most of the patients we think can be most helped by a clinical record have multiple, interacting illnesses which lead to all sorts of issues as treatment is planned.
As I said to one correspondent “Tell me how we can handle a specialist letter - subtle, complex, unique to the patient and reflecting insights from patient and doctor?” Inevitably there is more that could be said, some things are maybe highlighted while others are de-emphasised - on the conscious decision of a clinician trying to communicate what they see as important. Coding and processing this subtle maybe subtext information is really just not possible as far as I can tell.
With SNOMED seemingly having issues, HL7 V3.0 requiring a ‘fresh look’ after 18 years and the complexity issues I have raised above I really think the strategy should be to approach record sharing (where the clinicians don’t know each other etc.) as sharing of the absolute basics - until these more ‘existential’ issues about EHRs can be worked through. (I don’t expect to see that in my life time I have to say!)
We should aim to do the absolute basics well - and use a very constrained information model, recognising all the limitations, - and when, and only when, that is all working reliably with broad coverage then start on Phase 2!
I would love to know what others think. Are there other ways to skin the transfer of complex, subtle health information cat?
After finishing this I came upon even more relevant commentary.
The previously mentioned Grahame Grieve has written up some thoughtful comments on the value and fate of "HL7 Version 3", the latest Health Level 7 Standard from a pro and con perspective.
HL7 V3 has Failed: www.healthintersections.com.au/?p=476
HL7 V3 has Succeeded: www.healthintersections.com.au/?p=482
All this is starting to make my head hurt!