The EMR rollout dilemma: The necessary evil

EHR's would still be considered "experimental" if not for industry and giovernmental "irrational exuberance." As a medical informaticist who's stayed on top of this issue for a decade, I'm beginning to think a moratorium is needed on these massive EHR rollouts, at a time when the limited healthcare capital could likely be better spent providing actual care.

We need more research on how to make EHR's live up to the expectations of the "irrationally exuberant."

See my website on health IT failure: "Sociotechnologic Issues in Clinical Computing: Common Examples of Healthcare IT Difficulties" at this link.

Also see this recent article:

Pessimism, Computer Failure, and Information Systems Development in the Public Sector. (Public Administration Review 67;5:917-929, Sept/Oct. 2007, Shaun Goldfinch, University of Otago , New Zealand ). Cautionary article on IT that should be read by every healthcare executive documenting the widespread nature of IT difficulties and failure, the lack of attention to the issues responsible, and recommending much more critical attitudes towards IT. link to pdf

I'm not sure if your statement about "most industries, billion-dollar enterprises don't get pressured into buying a product this early in its lifecycle" is true. On the other hand, I am reasonably certain that most industries don't accidentally kill a few hundred thousand people a year because they lack access to critical patient data. The current healthcare delivery system in this country, if you can call it a system, makes the losses suffered in Iraq seems casually annoying. With regard to adoption rates, I'm sympathetic to the vendors who cannot seem to accommodate our archaic payer and provider processes in their workflow systems.

Please reconsider your weekly attacks on the government and the thousands of committee volunteers for their efforts to push the healthcare industry out of the 70s.

An anonymous writer stated: "Please reconsider your weekly attacks on the government and the thousands of committee volunteers for their efforts to push the healthcare industry out of the 70s."

Who is going to push the IT industry out of the 70's that causes healthcare orgs to waste countless dollars on ill-conceived IT boondoggles, and then cover it up? Do a google search on "Bad Health Informatics Can Kill."

Finally, re: Iraq, please spare us the Bush Derangement Syndrome. Thanks.

Anne,

"Lack of information" is not a primary cause of medical errors. You are correct about the process/system issues. On the other hand, cognitive overload from ill-designed information systems *is* a cause of error.

Example:

A 2003 press release about research at OHSU (one of numerous NIH-funded centers for Medical Informatics research and training) entitled "Most hospitals don't use latest ordering technology" is illuminating:

• Computers programmed to screen out errors and standardize physicians' orders for prescriptions, tests and other care have been a source of hope in reducing medical errors and improving patient safety. The problem is that most hospitals aren't using this technology, known as computerized physician order entry (CPOE) ... Patient care information systems like CPOE can create unintended or "silent" errors, according to a separate study conducted by the same author in the Netherlands and Australia.

  "Many information systems simply don't reflect the health care professional's hectic work environment with its all too frequent interruptions from phone calls, pages, colleagues and patients. Instead these are designed for people who work in calm and solitary environments. This design disconnect is the source of both types of silent errors … Some patient care information systems require data entry that is so elaborate that time spent recording patient data is significantly greater than it was with its paper predecessors," the authors wrote. "What is worse, on several occasions during our studies, overly structured data entry led to a loss of cognitive focus by the clinician."

Good clinicians can usually work around an "information vacuum" through improvisation. In the article “Hiding in Plain Sight: What Koppel et al. tell us about Healthcare IT” (Nemeth & Cook, Journal of Biomedical Informatics 2005;38:262-263), that issue is described well:

• On the surface, healthcare work seems to flow smoothly. That is because the clinicians who provide healthcare service make it so. Just beneath the apparently smooth-running operations is a complex, poorly bounded, conflicted, highly variable, uncertain, and high-tempo work domain. The technical work that clinicians perform resolves these complex and conflicting elements into a productive work domain. Occasional visitors to this setting see the smooth surface that clinicians have created and remain unaware of the conflicts that lie beneath it. The technical work that clinicians perform is hiding in plain sight. Those who know how to do research in this domain can see through the smooth surface and understand its complex and challenging reality. Occasional visitors cannot fathom this demanding work, much less create IT systems to support it.

If you want EMR to penetrate the market, companies need to stop hiding the value proposition.