Vladimir Putin and Common Sense on IT

Vladimir Putin may be known for showing off his pectorals riding horses bare chested, but he also seems to have a substantial amount of gray matter between the ears.

Our country, including the healthcare IT sector, could probably learn something from him:

A Walled Wide Web for Nervous Autocrats
Wall Street Journal
Jan. 8, 2011

By EVGENY MOROZOV

At the end of 2010, the "open-source" software movement, whose activists tend to be fringe academics and ponytailed computer geeks, found an unusual ally: the Russian government. Vladimir Putin signed a 20-page executive order requiring all public institutions in Russia to replace proprietary software, developed by companies like Microsoft and Adobe, with free open-source alternatives by 2015.

The move will save billions of dollars in licensing fees, but Mr. Putin's motives are not strictly economic. In all likelihood, his real fear is that Russia's growing dependence on proprietary software, especially programs sold by foreign vendors, has immense implications for the country's national security. Free open-source software, by its nature, is unlikely to feature secret back doors that lead directly to Langley, Va.

It's also less likely to feature a backdoor to a hacker's basement, or a lot of bugs ("glitches") that some health IT vendors and customer organizations allow to accumulate into the thousands before lifting a finger.

This brings to mind the adage that "if you want something done right, do it yourself."

... For ordinary Internet users, there is one silver lining: The embrace of open-source technology by governments may result in more intuitive software applications, written by a more diverse set of developers.

[Read the whole article at the link above - ed.]

More intuitive IT applications could solve a lot of the current health IT problems, such as the mission hostile user experience of many closed-source products from major vendors.

Afrer major IT debacles including the £13 billion abyss of the National Programme for IT in the NHS (NPfIT), the UK also seems to be learning:

New approach urged for government IT
E-Health Insider

2 March 2011
Lyn Whitfield

A new report into government IT failures has warned that previous inquiries may have embedded problems by focusing on inappropriate ‘best practice’ instead of looking for alternative approaches.

The report, from the Institute for Government, says “existing ‘best practice’ project models do not deal with the fundamental issues at the heart of government IT.”

[As I've stated here, one has to consider the "worst practices" as well, the "thou shall not's." Typical Milquetoast, touchy-feely "best practices" models and their "sanitized accounts of successful projects" (cf. Greenhalgh et al.) avoid such inconvenient realities like the plague - ed.]

It also argues that: “By implementing these same, flawed project techniques in an increasingly rigid fashion, these traditional solutions can act to exacerbate the problems further.”

[This sounds familiar, typical of the inflexible, dogmatic business IT culture, descended from the punched-card programmable tabulator culture of the 1920's - see this link - ed.]

Instead, it calls for a new that focuses on using government’s huge buying power to get better deals for what it calls ‘platform' technologies – such as server capacity and PCs – while encouraging departments to adopt ‘agile’ methodologies to deliver systems to meet the particular challenges they face.

... Andrew Adonis, Director of the Institute for Government said: “The billions spent on cancelled IT projects, such as ID cards and National Programme for IT in the NHS, demonstrate precisely why we need a much more flexible approach to government IT.

... The report cites the national programme as one ‘symptom of failure’ in government IT; the tendency for projects to run late and for departments to struggle to keep suppliers on board or hold them to their original delivery requirements as a result.

Agile software development methodologies have traditionally been anathema to the culture of IS departments involved in mercantile, manufacturing and management varieties of business computing. As I've written many times, however, those methodologies are essential in healthcare IT, such as here and here. At the latter link I observed:

... In fact, in my observations IT personnel are the true Luddites [as opposed to clinicians who are often accused of that reactionary characteristic- ed.], clinging to inappropriate, rigid business-IT views on the healthcare IT development and implementation process (vs. more appropriate and modern agile methodologies), holding unshakable, stereotypical views about physicians, and remaining unreasonably obstinate on clinician complaints about "clunky" health IT user experiences.

Perhaps Mr. Putin and Mr. Adonis deserve a copy of the book "Medical Informatics 20/20: Quality And Electronic Health Records Through Collaboration, Open Solutions, And Innovation", Jan. 2007, by the VistA (open-source EMR) pioneers.

The "Open Solutions" part of that title says it all.

-- SS

Vladimir Putin and Common Sense on IT

Vladimir Putin may be known for showing off his pectorals riding horses bare chested, but he also seems to have a substantial amount of gray matter between the ears.

Our country, including the healthcare IT sector, could probably learn something from him:

A Walled Wide Web for Nervous Autocrats
Wall Street Journal
Jan. 8, 2011

By EVGENY MOROZOV

At the end of 2010, the "open-source" software movement, whose activists tend to be fringe academics and ponytailed computer geeks, found an unusual ally: the Russian government. Vladimir Putin signed a 20-page executive order requiring all public institutions in Russia to replace proprietary software, developed by companies like Microsoft and Adobe, with free open-source alternatives by 2015.

The move will save billions of dollars in licensing fees, but Mr. Putin's motives are not strictly economic. In all likelihood, his real fear is that Russia's growing dependence on proprietary software, especially programs sold by foreign vendors, has immense implications for the country's national security. Free open-source software, by its nature, is unlikely to feature secret back doors that lead directly to Langley, Va.

It's also less likely to feature a backdoor to a hacker's basement, or a lot of bugs ("glitches") that some health IT vendors and customer organizations allow to accumulate into the thousands before lifting a finger.

This brings to mind the adage that "if you want something done right, do it yourself."

... For ordinary Internet users, there is one silver lining: The embrace of open-source technology by governments may result in more intuitive software applications, written by a more diverse set of developers.

[Read the whole article at the link above - ed.]

More intuitive IT applications could solve a lot of the current health IT problems, such as the mission hostile user experience of many closed-source products from major vendors.

Afrer major IT debacles including the £13 billion abyss of the National Programme for IT in the NHS (NPfIT), the UK also seems to be learning:

New approach urged for government IT
E-Health Insider

2 March 2011
Lyn Whitfield

A new report into government IT failures has warned that previous inquiries may have embedded problems by focusing on inappropriate ‘best practice’ instead of looking for alternative approaches.

The report, from the Institute for Government, says “existing ‘best practice’ project models do not deal with the fundamental issues at the heart of government IT.”

[As I've stated here, one has to consider the "worst practices" as well, the "thou shall not's." Typical Milquetoast, touchy-feely "best practices" models and their "sanitized accounts of successful projects" (cf. Greenhalgh et al.) avoid such inconvenient realities like the plague - ed.]

It also argues that: “By implementing these same, flawed project techniques in an increasingly rigid fashion, these traditional solutions can act to exacerbate the problems further.”

[This sounds familiar, typical of the inflexible, dogmatic business IT culture, descended from the punched-card programmable tabulator culture of the 1920's - see this link - ed.]

Instead, it calls for a new that focuses on using government’s huge buying power to get better deals for what it calls ‘platform' technologies – such as server capacity and PCs – while encouraging departments to adopt ‘agile’ methodologies to deliver systems to meet the particular challenges they face.

... Andrew Adonis, Director of the Institute for Government said: “The billions spent on cancelled IT projects, such as ID cards and National Programme for IT in the NHS, demonstrate precisely why we need a much more flexible approach to government IT.

... The report cites the national programme as one ‘symptom of failure’ in government IT; the tendency for projects to run late and for departments to struggle to keep suppliers on board or hold them to their original delivery requirements as a result.

Agile software development methodologies have traditionally been anathema to the culture of IS departments involved in mercantile, manufacturing and management varieties of business computing. As I've written many times, however, those methodologies are essential in healthcare IT, such as here and here. At the latter link I observed:

... In fact, in my observations IT personnel are the true Luddites [as opposed to clinicians who are often accused of that reactionary characteristic- ed.], clinging to inappropriate, rigid business-IT views on the healthcare IT development and implementation process (vs. more appropriate and modern agile methodologies), holding unshakable, stereotypical views about physicians, and remaining unreasonably obstinate on clinician complaints about "clunky" health IT user experiences.

Perhaps Mr. Putin and Mr. Adonis deserve a copy of the book "Medical Informatics 20/20: Quality And Electronic Health Records Through Collaboration, Open Solutions, And Innovation", Jan. 2007, by the VistA (open-source EMR) pioneers.

The "Open Solutions" part of that title says it all.

-- SS

Professors at Harvard and Nottingham Medical School (UK): Are we repeating the UK's clinical IT failures in the US?

In the opinion piece "Don't Repeat the UK's Electronic Health Records Failure" (Huffington Post, Dec. 5, 2010), Dr. Stephen B. Soumerai, Professor of Population Medicine at Harvard Medical School and Dr. Anthony Avery, Professor of Primary Care at the University of Nottingham Medical School, UK share familiar themes on health IT.

These themes will be especially familiar to HC Renewal readers and to my students and other readers of my Medical Informatics teaching website.

The professors wrote:

Fueled by the economic stimulus passed by Congress in 2008 [The ARRA a.k.a. "American Recovery and Reinvestment Act" and the HITECH legislation it contained - ed.], the federal government has embarked on a controversial $30 billion program to induce doctors throughout the country to adopt electronic health records (EHRs) by 2014. The purpose is to create an interconnected system of electronic health records to improve safety and reduce medical costs.

But the United Kingdom has spent the last 6 years working on the same idea, and it's proven to be a colossal failure -- so much so that the government is drastically cutting its program. What happened to their plan? Should we be paying attention before rushing ahead with our own?

My response to that question is clear, such as at my Nov. 2008 post "Should The U.S. Call A Moratorium On Ambitious National Electronic Health Records Plans?" and the followup Jan. 2009 post "I Ask Again: Should The U.S. Call A Moratorium On Ambitious National Electronic Health Records Plans?" where I wrote:

$50 billion a year is big money that might be better spent elsewhere - such as providing care for the poor and for disadvantaged children - until we know how to get HIT right.

I suggest it may be best not to go all-out for HIT under the current paradigm. It is my belief, in fact, based on the above issues [UK and US issues - ed.] plus a chronic influx of HIT difficulty and mismanagement stories I hear from colleagues, ex-colleagues, recruiters, etc., that healthcare organizations not contractually obligated should consider a postponement of plans to purchase clinical IT (i.e., systems for direct use by clinicians such as EHR's).

This postponement should last at least until the issues that lead to ineffective and counterproductive HIT can be better understood and corrections initiated in the industry.

The professors further write:

In 2005 the United Kingdom embarked on the largest investment ($18 billion) in health information technology in the world. Yet despite expectations that the system would increase efficiency and reduce medical errors, their efforts neither improved health nor saved money -- in fact in some cases, they may have led to patient harm.

Britain's government-run medical system is obviously different from our complex public-private insurance system. [I had written that a smaller, socialized healthcare system should be far easier to automate than our own in the US - ed.] However, its electronic health record project bears an uncanny resemblance to the program President Obama is starting.

They then delineated a number of problems:

Too large and ambitious: The UK project tried to accomplish too much, too fast, attempting to digitize health records for the whole population in a period of four years. This massive undertaking is years behind schedule and has delivered only a fraction of what it promised. Despite all the money poured into the system, the vast majority of hospitals in the UK still don't have integrated electronic health records.

Why? The reasons sound familiar:

... Because non-clinicians developed the system, the electronic forms they designed have little to do with how doctors treat patients -- making it unworkable for many physicians. As the Chair of the British House of Commons Public Accounts Committee recently stated, "This is the biggest IT [Information Technology] project in the world and it is turning into the biggest disaster."

The "biggest IT disaster in the world" is not an honor I wish to see repeated in the U.S.

On another familiar problem:

Too dependent on commercial, proprietary companies: Rather than create one system and beta-test it, the UK government depended on four companies to build the system, two of which quit or were fired for missing deadlines. So the health records were never developed in the south of England. The computer software was secret and proprietary. There was no accountability to the public, and the vendors did not provide enough technical support to clinicians having trouble using the records.

The resulting software errors and crashes caused missing or incorrect clinical information and sometimes threatened patient safety, for example by causing surgical delays and the cancellation of hundreds of operations.

The inquiring mind would want to know about actual patient injuries and deaths that likely resulted from such problems...

The professors observe:

If a country like Britain -- which already has a national health system and is a fraction of the size of the US -- had so many problems with electronic health records, imagine the problems America would face.

This sounds like my comments in a public comment letter of March 9, 2010 to HHS/ONC (Re: RIN 0991-AB59, "Proposed Establishment of Certification Programs for Health Information Technology") where I wrote, among many other things:

... We ignore the UK experience at our peril, an experience in a medical environment smaller and far more government-controlled than our own.

... I believe that a rushed National Program for HIT in the United States will suffer the same fate as the aforementioned National Programme for IT in the UK, and perhaps even a worse fate as the UK’s socialized medicine system is certainly a smaller, more homogeneous and more controllable testbed environment for experimenting with HIT.

The professors relate:

Even our partial adaption of electronic health records is causing problems. Over the last couple of years, doctors and hospitals have reported to the FDA dozens of medical injuries -- including six deaths and preventable heart attacks -- caused by problems related to computerized health records such as software errors and unreadable computer screens. Some errors resulted in drug doses that were 10 times higher than intended. FDA officials called this the "tip of the iceberg."

I wrote about the FDA's findings here, and conducted a "thought experiment" regarding what those numbers might extrapolate out to in my April 2010 post "If The Benefits Of Healthcare IT Can Be Guesstimated, So Can And Should The Dangers."

They continue:

... More than 50 medical organizations, including the AMA, have called on the Secretary of Health and Human Services to delay the program. In response, the administration delayed some of the required health IT functions, but kept the same 2014 deadline.

Indeed. They are courting disaster in my opinion, both clinically and financially, as I wrote in a Feb. 2009 Wall Street Journal letter to the editor entitled “Digitizing Medical Records May Help, but It's Complex”:

Dear WSJ,

You observe that the true political goal is socialized medicine facilitated by health care information technology. You note that the public is being deceived, as the rules behind this takeover were stealthily inserted in the stimulus bill.

I have a different view on who is deceiving whom. In fact, it is the government that has been deceived by the HIT industry and its pundits. Stated directly, the administration is deluded about the true difficulty of making large-scale health IT work. The beneficiaries will largely be the IT industry and IT management consultants.

For £12.7 billion the U.K., which already has socialized medicine, still does not have a working national HIT system, but instead has a major IT quagmire, some of it caused by U.S. HIT vendors.

HIT (with a few exceptions) is largely a disaster. I'm far more concerned about a mega-expensive IT misadventure than an IT-empowered takeover of medicine.

The stimulus bill, to its credit, recognizes the need for research on improving HIT. However this is a tool to facilitate clinical care, not a cybernetic miracle to revolutionize medicine. The government has bought the IT magic bullet exuberance hook, line and sinker.

I can only hope patients get something worthwhile for the $20 billion.

The professors then note:

How do we avoid the UK's failure? The administration or Congress should slow down the program and delete those parts of the legislation that fine doctors for not using this technology. There's no need to have this system in place by 2014. Instead, we should conduct rigorous studies of the cost-effectiveness of electronic health records systems before mandating their use. Rather than force doctors to choose from dozens of commercial software products developed in secret, we should take a hint from the non-commercial sector, such as the Veterans Administration, which uses "open-source" coding so people can work collaboratively to continuously improve the system.

Slowing down the program and performing rigorous studies of HIT before wide scale rollout are themes I raised, among other places, in my Dec. 2009 post "Tensions and Paradoxes in Electronic Patient Record Research: Critical Thinking on Health IT" where I wrote:

In conclusion, I believe this literature review supports the notion expressed in other studies and opinion pieces here and elsewhere that we really need to SLOW DOWN the current HIT stampede, largely promoted by the HIT industry lobby. We need to take the appropriate time to better understand how to "do HIT well" before plunging in as if we actually know what we're doing

as well as at my Oct. 2009 post "Washington Post Article: Electronic medical records not seen as a cure-all" where I wrote:

... The literature is indeed conflicting, and the need for rigorous scientific study has never been more essential considering the commitment of tens of billions of dollars towards health IT. The time for story telling, marketing based on opinion, name calling, leap-of-faith extrapolations of light year dimensions, and other forms of pseudoscience and non-science are over. The time for objective study is now.

The professors conclude:

The Obama administration wants government programs to be based on evidence of effectiveness. Simply following the lead of "IT believers" and salesmen without the requisite evidence will repeat the UK's failures. Now is the time to proceed carefully, consider existing research and the British experience, and chart a more rational course into the digital age of medicine.

I do not know if these two professors were familiar with my writings, but I am happy to see these themes (once treated as verboten and as grounds for marginalization by the HIT industry) increasingly going mainstream.

Patient well being - which includes you, dear readers - depends on that.

-- SS

Professors at Harvard and Nottingham Medical School (UK): Are we repeating the UK's clinical IT failures in the US?

In the opinion piece "Don't Repeat the UK's Electronic Health Records Failure" (Huffington Post, Dec. 5, 2010), Dr. Stephen B. Soumerai, Professor of Population Medicine at Harvard Medical School and Dr. Anthony Avery, Professor of Primary Care at the University of Nottingham Medical School, UK share familiar themes on health IT.

These themes will be especially familiar to HC Renewal readers and to my students and other readers of my Medical Informatics teaching website.

The professors wrote:

Fueled by the economic stimulus passed by Congress in 2008 [The ARRA a.k.a. "American Recovery and Reinvestment Act" and the HITECH legislation it contained - ed.], the federal government has embarked on a controversial $30 billion program to induce doctors throughout the country to adopt electronic health records (EHRs) by 2014. The purpose is to create an interconnected system of electronic health records to improve safety and reduce medical costs.

But the United Kingdom has spent the last 6 years working on the same idea, and it's proven to be a colossal failure -- so much so that the government is drastically cutting its program. What happened to their plan? Should we be paying attention before rushing ahead with our own?

My response to that question is clear, such as at my Nov. 2008 post "Should The U.S. Call A Moratorium On Ambitious National Electronic Health Records Plans?" and the followup Jan. 2009 post "I Ask Again: Should The U.S. Call A Moratorium On Ambitious National Electronic Health Records Plans?" where I wrote:

$50 billion a year is big money that might be better spent elsewhere - such as providing care for the poor and for disadvantaged children - until we know how to get HIT right.

I suggest it may be best not to go all-out for HIT under the current paradigm. It is my belief, in fact, based on the above issues [UK and US issues - ed.] plus a chronic influx of HIT difficulty and mismanagement stories I hear from colleagues, ex-colleagues, recruiters, etc., that healthcare organizations not contractually obligated should consider a postponement of plans to purchase clinical IT (i.e., systems for direct use by clinicians such as EHR's).

This postponement should last at least until the issues that lead to ineffective and counterproductive HIT can be better understood and corrections initiated in the industry.

The professors further write:

In 2005 the United Kingdom embarked on the largest investment ($18 billion) in health information technology in the world. Yet despite expectations that the system would increase efficiency and reduce medical errors, their efforts neither improved health nor saved money -- in fact in some cases, they may have led to patient harm.

Britain's government-run medical system is obviously different from our complex public-private insurance system. [I had written that a smaller, socialized healthcare system should be far easier to automate than our own in the US - ed.] However, its electronic health record project bears an uncanny resemblance to the program President Obama is starting.

They then delineated a number of problems:

Too large and ambitious: The UK project tried to accomplish too much, too fast, attempting to digitize health records for the whole population in a period of four years. This massive undertaking is years behind schedule and has delivered only a fraction of what it promised. Despite all the money poured into the system, the vast majority of hospitals in the UK still don't have integrated electronic health records.

Why? The reasons sound familiar:

... Because non-clinicians developed the system, the electronic forms they designed have little to do with how doctors treat patients -- making it unworkable for many physicians. As the Chair of the British House of Commons Public Accounts Committee recently stated, "This is the biggest IT [Information Technology] project in the world and it is turning into the biggest disaster."

The "biggest IT disaster in the world" is not an honor I wish to see repeated in the U.S.

On another familiar problem:

Too dependent on commercial, proprietary companies: Rather than create one system and beta-test it, the UK government depended on four companies to build the system, two of which quit or were fired for missing deadlines. So the health records were never developed in the south of England. The computer software was secret and proprietary. There was no accountability to the public, and the vendors did not provide enough technical support to clinicians having trouble using the records.

The resulting software errors and crashes caused missing or incorrect clinical information and sometimes threatened patient safety, for example by causing surgical delays and the cancellation of hundreds of operations.

The inquiring mind would want to know about actual patient injuries and deaths that likely resulted from such problems...

The professors observe:

If a country like Britain -- which already has a national health system and is a fraction of the size of the US -- had so many problems with electronic health records, imagine the problems America would face.

This sounds like my comments in a public comment letter of March 9, 2010 to HHS/ONC (Re: RIN 0991-AB59, "Proposed Establishment of Certification Programs for Health Information Technology") where I wrote, among many other things:

... We ignore the UK experience at our peril, an experience in a medical environment smaller and far more government-controlled than our own.

... I believe that a rushed National Program for HIT in the United States will suffer the same fate as the aforementioned National Programme for IT in the UK, and perhaps even a worse fate as the UK’s socialized medicine system is certainly a smaller, more homogeneous and more controllable testbed environment for experimenting with HIT.

The professors relate:

Even our partial adaption of electronic health records is causing problems. Over the last couple of years, doctors and hospitals have reported to the FDA dozens of medical injuries -- including six deaths and preventable heart attacks -- caused by problems related to computerized health records such as software errors and unreadable computer screens. Some errors resulted in drug doses that were 10 times higher than intended. FDA officials called this the "tip of the iceberg."

I wrote about the FDA's findings here, and conducted a "thought experiment" regarding what those numbers might extrapolate out to in my April 2010 post "If The Benefits Of Healthcare IT Can Be Guesstimated, So Can And Should The Dangers."

They continue:

... More than 50 medical organizations, including the AMA, have called on the Secretary of Health and Human Services to delay the program. In response, the administration delayed some of the required health IT functions, but kept the same 2014 deadline.

Indeed. They are courting disaster in my opinion, both clinically and financially, as I wrote in a Feb. 2009 Wall Street Journal letter to the editor entitled “Digitizing Medical Records May Help, but It's Complex”:

Dear WSJ,

You observe that the true political goal is socialized medicine facilitated by health care information technology. You note that the public is being deceived, as the rules behind this takeover were stealthily inserted in the stimulus bill.

I have a different view on who is deceiving whom. In fact, it is the government that has been deceived by the HIT industry and its pundits. Stated directly, the administration is deluded about the true difficulty of making large-scale health IT work. The beneficiaries will largely be the IT industry and IT management consultants.

For £12.7 billion the U.K., which already has socialized medicine, still does not have a working national HIT system, but instead has a major IT quagmire, some of it caused by U.S. HIT vendors.

HIT (with a few exceptions) is largely a disaster. I'm far more concerned about a mega-expensive IT misadventure than an IT-empowered takeover of medicine.

The stimulus bill, to its credit, recognizes the need for research on improving HIT. However this is a tool to facilitate clinical care, not a cybernetic miracle to revolutionize medicine. The government has bought the IT magic bullet exuberance hook, line and sinker.

I can only hope patients get something worthwhile for the $20 billion.

The professors then note:

How do we avoid the UK's failure? The administration or Congress should slow down the program and delete those parts of the legislation that fine doctors for not using this technology. There's no need to have this system in place by 2014. Instead, we should conduct rigorous studies of the cost-effectiveness of electronic health records systems before mandating their use. Rather than force doctors to choose from dozens of commercial software products developed in secret, we should take a hint from the non-commercial sector, such as the Veterans Administration, which uses "open-source" coding so people can work collaboratively to continuously improve the system.

Slowing down the program and performing rigorous studies of HIT before wide scale rollout are themes I raised, among other places, in my Dec. 2009 post "Tensions and Paradoxes in Electronic Patient Record Research: Critical Thinking on Health IT" where I wrote:

In conclusion, I believe this literature review supports the notion expressed in other studies and opinion pieces here and elsewhere that we really need to SLOW DOWN the current HIT stampede, largely promoted by the HIT industry lobby. We need to take the appropriate time to better understand how to "do HIT well" before plunging in as if we actually know what we're doing

as well as at my Oct. 2009 post "Washington Post Article: Electronic medical records not seen as a cure-all" where I wrote:

... The literature is indeed conflicting, and the need for rigorous scientific study has never been more essential considering the commitment of tens of billions of dollars towards health IT. The time for story telling, marketing based on opinion, name calling, leap-of-faith extrapolations of light year dimensions, and other forms of pseudoscience and non-science are over. The time for objective study is now.

The professors conclude:

The Obama administration wants government programs to be based on evidence of effectiveness. Simply following the lead of "IT believers" and salesmen without the requisite evidence will repeat the UK's failures. Now is the time to proceed carefully, consider existing research and the British experience, and chart a more rational course into the digital age of medicine.

I do not know if these two professors were familiar with my writings, but I am happy to see these themes (once treated as verboten and as grounds for marginalization by the HIT industry) increasingly going mainstream.

Patient well being - which includes you, dear readers - depends on that.

-- SS

Are computers in medicine narcotic? "Why did the National Programme for IT fail?"

I noted an article Why did the National Programme for IT fail? by an "ex-IT person" at the site Smart Healthcare.com in a series entitled "Patient from Hell."

Aside from the intoxicant qualities of crisp bank notes, I am beginning to suspect that computers exert a narcotic effect, like Kool Aid laced with morphine or alcohol, on many in the population.

Many people who should know better of the challenges, dangers and myths surrounding these tools are drawn in to comparisons and analogies that I would charitably call magical thinking and puerile - and absurdist and stupid when not so charitable.

This article shows the muddled thinking behind the health IT mania. My observation: when you see the word "revolutionary" in the same paragraph as health IT you're dealing with hysterics.

The "patient from hell" asks:

Why is the road to electronic healthcare so much more rocky than computerising other bits of the economy? Other professions, including bankers, accountants and lawyers, have made the jump, some 30 years after the advent of personal computers. Even musicians, poets, journalists, artists, philosophers and MPs have got up to speed.

"Even?"

Yes, and you can train a dog to fetch a stick, therefore you can train a potato to dance.

Why is the road to HIT more rocky than the road to computer poetry or art?

Perhaps because the endeavors of clinicians are not like those of a musician or poet or lawyer or banker, but just a bit more informationally, operationally, cognitively, scientifically, and socially complex?

I was amazed at the time by the irresponsibility, primarily of the consultants [i.e., physicians - ed.], who were effectively opting out of the planning process. They showed no interest in playing a part in designing a new way of working – for themselves, for nurses and all others involved in the revolutionary changes which digitalisation would bring to their working practices.

In fact, they were showing responsibility - to patients - in not being so eager to "change to new ways of working" according to the diktats of computer geeks, government and other bureaucrats and myriad non-clinicians running around like drunks, hysterically screaming "revolution!"

I fear that communication between clinician and IT has now got so contaminated that crazy solutions will come out of the deliberations of the coalition government on the future of IT in the health service. All I ask is that clinicians and IT people talk to each other. Is that so hard?

If you have the right tools on your kitchen table, shouldn't it be easy to generate nuclear fission at home?

Due to factors such as the asymmetry in responsibilities, obligations and liabilities between the two fields, of differences in knowledge and expertise, and in mindset and qualifications to attain privileges to intervene in people's lives (who qualifies IT personnel to be involved in clinical affairs?), yes, idealistic "let's all play nice in the sandbox together" dreams are "so hard."

Unfortunately, these types of comparisons and sentiments are extremely common in the Healthcare-IT-industrial complex.

The reality is:

The NPfIT failed because its purveyors and promoters hadn't a clue about the complexities and wicked problems involved in such an endeavor, problems known and described in the Medical Informatics and Social Informatics literature, among others, for decades.

It also failed because of collective ignorance of these domains among its leaders, and among those who chose the leaders. For instance, as I wrote here:

The Department of Health has announced the two long-awaited senior management appointments for the National Programme for IT ... The Department announced in February that it was recruiting the two positions as part of a revised governance structure for handling informatics in the Department of Health.

Christine Connelly will be the first Chief Information Officer for Health and will focus on developing and delivering the Department's overall information strategy and integrating leadership across the NHS and associated bodies including NHS Connecting for Health and the NHS Information Centre for Health and Social Care.Christine Connelly was previously Chief Information Officer at Cadbury Schweppes with direct control of all IT operations and projects. She also spent over 20 years at BP where her roles included Chief of Staff for Gas, Power and Renewables, and Head of IT for both the upstream and downstream business.

Martin Bellamy will be the Director of Programme and System Delivery. He will lead NHS Connecting for Health and focus on enhancing partnerships with and within the NHS. Martin Bellamy has worked for the Department for Work and Pensions since 2003. His main role has been as CIO of the Pension Service.

Excuse me. Cadbury Schweppes (candy and drink?) The Pension Service? As national leaders for healthcare IT?

Instead of sobriety, attitudes about health IT seem to universally be "sure, the experts think you shouldn’t ride a bicycle into the eye of a hurricane, but we have our own theories." (See here and here.)

The domain of health IT needs a very stiff period of detox and rock-solid sobriety before it can achieve the (non-revolutionary) benefits of which it is capable.

-- SS

Are computers in medicine narcotic? "Why did the National Programme for IT fail?"

I noted an article Why did the National Programme for IT fail? by an "ex-IT person" at the site Smart Healthcare.com in a series entitled "Patient from Hell."

Aside from the intoxicant qualities of crisp bank notes, I am beginning to suspect that computers exert a narcotic effect, like Kool Aid laced with morphine or alcohol, on many in the population.

Many people who should know better of the challenges, dangers and myths surrounding these tools are drawn in to comparisons and analogies that I would charitably call magical thinking and puerile - and absurdist and stupid when not so charitable.

This article shows the muddled thinking behind the health IT mania. My observation: when you see the word "revolutionary" in the same paragraph as health IT you're dealing with hysterics.

The "patient from hell" asks:

Why is the road to electronic healthcare so much more rocky than computerising other bits of the economy? Other professions, including bankers, accountants and lawyers, have made the jump, some 30 years after the advent of personal computers. Even musicians, poets, journalists, artists, philosophers and MPs have got up to speed.

"Even?"

Yes, and you can train a dog to fetch a stick, therefore you can train a potato to dance.

Why is the road to HIT more rocky than the road to computer poetry or art?

Perhaps because the endeavors of clinicians are not like those of a musician or poet or lawyer or banker, but just a bit more informationally, operationally, cognitively, scientifically, and socially complex?

I was amazed at the time by the irresponsibility, primarily of the consultants [i.e., physicians - ed.], who were effectively opting out of the planning process. They showed no interest in playing a part in designing a new way of working – for themselves, for nurses and all others involved in the revolutionary changes which digitalisation would bring to their working practices.

In fact, they were showing responsibility - to patients - in not being so eager to "change to new ways of working" according to the diktats of computer geeks, government and other bureaucrats and myriad non-clinicians running around like drunks, hysterically screaming "revolution!"

I fear that communication between clinician and IT has now got so contaminated that crazy solutions will come out of the deliberations of the coalition government on the future of IT in the health service. All I ask is that clinicians and IT people talk to each other. Is that so hard?

If you have the right tools on your kitchen table, shouldn't it be easy to generate nuclear fission at home?

Due to factors such as the asymmetry in responsibilities, obligations and liabilities between the two fields, of differences in knowledge and expertise, and in mindset and qualifications to attain privileges to intervene in people's lives (who qualifies IT personnel to be involved in clinical affairs?), yes, idealistic "let's all play nice in the sandbox together" dreams are "so hard."

Unfortunately, these types of comparisons and sentiments are extremely common in the Healthcare-IT-industrial complex.

The reality is:

The NPfIT failed because its purveyors and promoters hadn't a clue about the complexities and wicked problems involved in such an endeavor, problems known and described in the Medical Informatics and Social Informatics literature, among others, for decades.

It also failed because of collective ignorance of these domains among its leaders, and among those who chose the leaders. For instance, as I wrote here:

The Department of Health has announced the two long-awaited senior management appointments for the National Programme for IT ... The Department announced in February that it was recruiting the two positions as part of a revised governance structure for handling informatics in the Department of Health.

Christine Connelly will be the first Chief Information Officer for Health and will focus on developing and delivering the Department's overall information strategy and integrating leadership across the NHS and associated bodies including NHS Connecting for Health and the NHS Information Centre for Health and Social Care.Christine Connelly was previously Chief Information Officer at Cadbury Schweppes with direct control of all IT operations and projects. She also spent over 20 years at BP where her roles included Chief of Staff for Gas, Power and Renewables, and Head of IT for both the upstream and downstream business.

Martin Bellamy will be the Director of Programme and System Delivery. He will lead NHS Connecting for Health and focus on enhancing partnerships with and within the NHS. Martin Bellamy has worked for the Department for Work and Pensions since 2003. His main role has been as CIO of the Pension Service.

Excuse me. Cadbury Schweppes (candy and drink?) The Pension Service? As national leaders for healthcare IT?

Instead of sobriety, attitudes about health IT seem to universally be "sure, the experts think you shouldn’t ride a bicycle into the eye of a hurricane, but we have our own theories." (See here and here.)

The domain of health IT needs a very stiff period of detox and rock-solid sobriety before it can achieve the (non-revolutionary) benefits of which it is capable.

-- SS

The National Program for Healthcare IT in the United States, 2015

Here is what I predict the the National Program for Healthcare IT in the United States will likely resemble in 2015 - namely, the National Programme for IT in the NHS in 2010:

Delays with £12.7bn NHS software program bring it close to collapse
Sunday 21 March 2010 18.47 GMT
Simon Bowers
guardian.co.uk

The government's ailing £12.7bn IT programme to overhaul paper-based NHS patient records in England is close to imploding, potentially triggering a deluge of legal claims against the taxpayer running into billions of pounds, which could start to emerge weeks before a general election.

The Guardian has discovered that mounting chaos and delays in installing core care records systems across the country is reaching a tipping point, with intense political pressure from Whitehall now falling on Morecambe Bay NHS Trust and a software "go-live" deadline set for the end of this month.

Morecambe Bay is intended to be the first acute trust to take a new patient administration software package called Lorenzo, which has been delayed for four years. After a string of missed deadlines, the Department of Health set a deadline of March 2010 for Lorenzo last April. "If we don't see significant progress... then we will move to a new plan for delivering infomatics in healthcare," Christine Connelly, the Department of Health's director general of IT, said at the time.

Problem #1:

A problem of leadership. As I mentioned here, Christine Connelly knows as much about "informatics" as I know about candy making.

She was previously Chief Information Officer at Cadbury Schweppes with direct control of all IT operations and projects. She also spent over 20 years at BP where her roles included Chief of Staff for Gas, Power and Renewables, and Head of IT for both the upstream and downstream business.

Candy experience? More than Willy Wonka. Experience producing gas? Plentiful. Medical informatics expertise? Not so much. Predecessors also lacked genuine medical informatics expertise. This lack of appropriate expertise is all too common in healthcare leadership, and no exception is made for healthcare IT.

Preparatory testing at Morecambe Bay is believed to have failed some weeks ago, though iSoft, the firm behind Lorenzo, last week insisted testing was "on track" and dismissed as "media speculation" suggestions that the deadline was in jeopardy.

Problem #2:

Claiming everything is going just fine. This initiative has been a debacle from the start, partly due to it being rushed for purposes of governmental grandstanding. Don't take my word for it. Take the word of these people:

• The UK Public Accounts Committee report on problems in the £12.7 billion national EMR program is here.

• Gateway reviews of the UK National Programme for IT from the Office of Government Commerce (OGC) are here (released under the UK’s Freedom of Information Act), and a summary of 16 key points is here.

• ComputerWeekly.com - Blair Rushed NHS IT

• Telegraph.co.UK - more on rushing - Patients' medical records go online without consent

Back to the article:

The BMA (British Medical Association) echoed calls for greater public scrutiny of contracts. "Changes to NHS IT should be driven not by financial or political expedience, but by a commitment to improving clinical care. If any new system is rushed through too quickly, there can be a negative impact on patient care."

Problem #3: The obvious as stated by clinicians is ignored by project leaders and politicians.

Failure at Morecambe Bay could see the largest regional contractor on the 10-year programme, US outsourcing firm Computer Sciences Corporation (CSC), come under renewed pressure to book heavy provisions against the value of three £1bn NHS contracts – a move likely to send the group's share price tumbling.

It would also be bad news for iSoft, the Australian firm formerly called IBA Health, which in 2007 acquired crisis-stricken iSoft plc, the British firm behind Lorenzo, and took its name. It has told investors: "iSoft expects the milestone at Morecambe Bay to be met according to the timetable agreed between its partner CSC and the NHS, and expects this achievement to trigger a cash payment to the company."

A Morecambe Bay delay could also push mounting tensions between the Department of Health and CSC into the hands of lawyers, as a squabble breaks out over who should foot the bill for seven years of underperformance since the National Programme contracts were signed in 2003. The government is already facing a reported £700m legal dispute with CSC's fellow regional contractor Fujitsu after the Japanese consultancy firm walked away from a £1bn contract to supply and install IT systems at NHS trusts across the South of England and the West Country three years ago.

If CSC, an $11bn (£7.3bn) Virginia-based group listed on the New York stock exchange, were to enter into a parallel legal battle, it would leave 80% of care records IT contracts – the heart of the National Programme – in the hands of lawyers. After the departure of Fujitsu, and Accenture a year earlier, the only remaining regional contractor aside from CSC is BT, responsible for the London area. It was forced last year to wipe between half and 70% from the value of its £1bn contract with NHS London because of delays and software failings.

Problem #4 (if you can follow all that nonproductive but expensive mayhem that does little beyond consuming precious healthcare resources better spent elsewhere):

Too much outsourcing to a musical-chairs confederacy of management consultant firms rather than use of local expertise.

... Disappointing results from the National Programme – once a flagship NHS modernising push for then prime minister Tony Blair – have become an embarrassment for Labour, and the project has lost the confidence of many NHS staff. Up to now, however, ministers have sought to stress that the taxpayer has not lost out. Earlier this month, health minister Mike O'Brien told BBC Radio 4's File on 4: "Yes, there have been delays. These delays have not cost the tax payer. They have cost the companies – they have taken the risk... Some of these companies have been more ambitious than they should have been." [In other words, they promised far more than they could deliver with the talent on hand - ed.]

Problem #5:

Incompetence, talent mismangement and not knowing what they do not know about healthcare IT.

Read the rest of the article at the link above.

Also note the UK's healthcare system is far smaller, far more monolithic, and far more easily controlled by government than that in the U.S.

My belief is that the US program for health IT will likely resemble the UK's in just a few years' time, for the very same reasons. Unless, that is, major changes in the approaches to design and implementation occur, and soon, and the purpose of HIT reigned in to clinician support, not support of massive bureaucracies. I consider the necessary changes unlikely due to the intransigence of the IT culture and of the leadership behind the effort.

Again, don't take it from me, take it from the U.S. National Research Council and other writers at this link.

-- SS

The National Program for Healthcare IT in the United States, 2015

Here is what I predict the the National Program for Healthcare IT in the United States will likely resemble in 2015 - namely, the National Programme for IT in the NHS in 2010:

Delays with £12.7bn NHS software program bring it close to collapse
Sunday 21 March 2010 18.47 GMT
Simon Bowers
guardian.co.uk

The government's ailing £12.7bn IT programme to overhaul paper-based NHS patient records in England is close to imploding, potentially triggering a deluge of legal claims against the taxpayer running into billions of pounds, which could start to emerge weeks before a general election.

The Guardian has discovered that mounting chaos and delays in installing core care records systems across the country is reaching a tipping point, with intense political pressure from Whitehall now falling on Morecambe Bay NHS Trust and a software "go-live" deadline set for the end of this month.

Morecambe Bay is intended to be the first acute trust to take a new patient administration software package called Lorenzo, which has been delayed for four years. After a string of missed deadlines, the Department of Health set a deadline of March 2010 for Lorenzo last April. "If we don't see significant progress... then we will move to a new plan for delivering infomatics in healthcare," Christine Connelly, the Department of Health's director general of IT, said at the time.

Problem #1:

A problem of leadership. As I mentioned here, Christine Connelly knows as much about "informatics" as I know about candy making.

She was previously Chief Information Officer at Cadbury Schweppes with direct control of all IT operations and projects. She also spent over 20 years at BP where her roles included Chief of Staff for Gas, Power and Renewables, and Head of IT for both the upstream and downstream business.

Candy experience? More than Willy Wonka. Experience producing gas? Plentiful. Medical informatics expertise? Not so much. Predecessors also lacked genuine medical informatics expertise. This lack of appropriate expertise is all too common in healthcare leadership, and no exception is made for healthcare IT.

Preparatory testing at Morecambe Bay is believed to have failed some weeks ago, though iSoft, the firm behind Lorenzo, last week insisted testing was "on track" and dismissed as "media speculation" suggestions that the deadline was in jeopardy.

Problem #2:

Claiming everything is going just fine. This initiative has been a debacle from the start, partly due to it being rushed for purposes of governmental grandstanding. Don't take my word for it. Take the word of these people:

• The UK Public Accounts Committee report on problems in the £12.7 billion national EMR program is here.

• Gateway reviews of the UK National Programme for IT from the Office of Government Commerce (OGC) are here (released under the UK’s Freedom of Information Act), and a summary of 16 key points is here.

• ComputerWeekly.com - Blair Rushed NHS IT

• Telegraph.co.UK - more on rushing - Patients' medical records go online without consent

Back to the article:

The BMA (British Medical Association) echoed calls for greater public scrutiny of contracts. "Changes to NHS IT should be driven not by financial or political expedience, but by a commitment to improving clinical care. If any new system is rushed through too quickly, there can be a negative impact on patient care."

Problem #3: The obvious as stated by clinicians is ignored by project leaders and politicians.

Failure at Morecambe Bay could see the largest regional contractor on the 10-year programme, US outsourcing firm Computer Sciences Corporation (CSC), come under renewed pressure to book heavy provisions against the value of three £1bn NHS contracts – a move likely to send the group's share price tumbling.

It would also be bad news for iSoft, the Australian firm formerly called IBA Health, which in 2007 acquired crisis-stricken iSoft plc, the British firm behind Lorenzo, and took its name. It has told investors: "iSoft expects the milestone at Morecambe Bay to be met according to the timetable agreed between its partner CSC and the NHS, and expects this achievement to trigger a cash payment to the company."

A Morecambe Bay delay could also push mounting tensions between the Department of Health and CSC into the hands of lawyers, as a squabble breaks out over who should foot the bill for seven years of underperformance since the National Programme contracts were signed in 2003. The government is already facing a reported £700m legal dispute with CSC's fellow regional contractor Fujitsu after the Japanese consultancy firm walked away from a £1bn contract to supply and install IT systems at NHS trusts across the South of England and the West Country three years ago.

If CSC, an $11bn (£7.3bn) Virginia-based group listed on the New York stock exchange, were to enter into a parallel legal battle, it would leave 80% of care records IT contracts – the heart of the National Programme – in the hands of lawyers. After the departure of Fujitsu, and Accenture a year earlier, the only remaining regional contractor aside from CSC is BT, responsible for the London area. It was forced last year to wipe between half and 70% from the value of its £1bn contract with NHS London because of delays and software failings.

Problem #4 (if you can follow all that nonproductive but expensive mayhem that does little beyond consuming precious healthcare resources better spent elsewhere):

Too much outsourcing to a musical-chairs confederacy of management consultant firms rather than use of local expertise.

... Disappointing results from the National Programme – once a flagship NHS modernising push for then prime minister Tony Blair – have become an embarrassment for Labour, and the project has lost the confidence of many NHS staff. Up to now, however, ministers have sought to stress that the taxpayer has not lost out. Earlier this month, health minister Mike O'Brien told BBC Radio 4's File on 4: "Yes, there have been delays. These delays have not cost the tax payer. They have cost the companies – they have taken the risk... Some of these companies have been more ambitious than they should have been." [In other words, they promised far more than they could deliver with the talent on hand - ed.]

Problem #5:

Incompetence, talent mismangement and not knowing what they do not know about healthcare IT.

Read the rest of the article at the link above.

Also note the UK's healthcare system is far smaller, far more monolithic, and far more easily controlled by government than that in the U.S.

My belief is that the US program for health IT will likely resemble the UK's in just a few years' time, for the very same reasons. Unless, that is, major changes in the approaches to design and implementation occur, and soon, and the purpose of HIT reigned in to clinician support, not support of massive bureaucracies. I consider the necessary changes unlikely due to the intransigence of the IT culture and of the leadership behind the effort.

Again, don't take it from me, take it from the U.S. National Research Council and other writers at this link.

-- SS

Troubled £12bn NHS IT System to be Scaled Back: UK MP's Come to Their Senses on Health IT. Will the U.S. Follow?

The UK National Programme for Health IT in the NHS, by the findings of the House of Commons Public Account audit committee, has been a £12bn debacle. Started as a starry-eyed utopian fantasy about experimental computerized clinical tools by former Prime Minister Tony Blair, nearly every possible mistake outlined at my ten year old website on HIT failure has been made, and made in abundance, the coup de grâce being dependence on an American health IT company.

It seems people's ability to detect rigor and seriousness in industrialists has become seriously impaired, the recent spectacular Ponzi schemes fallen for by quite prominent people and foundations being one example. Now the UK is at the point where hospitals are "unable to share documents" relating to problematic EHR's as their contract with that vendor includes a confidentiality clause. (Not that such clauses are limited to one company.

The health IT industry has generally profited from a sweetheart relationship of stunning proportions with healthcare regulatory agencies (it is entirely unregulated); with government (in the U.S., hundreds of billions of dollars are being thrown their way on similar starry-eyed dreams about reduced costs and improved quality per the economic "stimulus" bill); and with healthcare organizations (who accept HIT marketing puffery hook, line and sinker, do not perform due diligence properly for such critical clinical tools, who manage IT and informatics talent poorly, and who willingly sign defects nondisclosure and hold harmless clauses that violate the fiduciary responsibilities of their governance bodies as in my JAMA letter here and longer essay here).

At least for the £12bn down the drain, the U.K. is coming to their senses:

Troubled £12bn NHS IT system to be scaled back
BBC News
6 December 2009

The government is to scale back its £12bn NHS IT system in what the Tories are calling a "massive U-turn".

Chancellor Alistair Darling said he would be delaying parts of the scheme in Wednesday's pre-Budget Report as it was "not essential to the front line".

The move may save hundreds of millions but Mr Darling admitted it was only a fraction of total spending cuts needed.

The Tories and Lib Dems have been calling for the IT system, which has been hit by costly delays, to be axed.

... “It has held back the development of IT at a local level, cost billions and is running years behind schedule” - Norman Lamb, MP Liberal Democrats.

... [Chancellor Darling] said the full picture of cuts would not emerge until "the first half of next year at some point" - a reference to the comprehensive spending review, which the government has delayed until after an election.

The comprehensive spending review should be interesting, to say the least. I humbly suggest the NHS look at the contracting practices of the vendors, especially the gag clauses, the multiply-layered subcontracting deals with dyscompetent consulting companies common in IT, and conflicts of interest of local and national program leaders with IT and consulting suppliers.

I also suggest the reviewers borrow from the U.S. Senate Committee on Finance letter here from Senator Grassley to HIT vendors and consultants.

'Procurement disaster'

Treasury officials have stressed that only part of the NHS IT programme is facing the axe, and the whole project will not be scrapped.

But the Conservatives said Mr Darling's words represented a "massive U-turn".

Shadow Health Secretary Andrew Lansley said it was "another government IT procurement disaster".

"After seven years Labour have finally acknowledged what we've said for years, that the procurement for NHS IT was costing billions and not delivering," he said.

Why did it take years to acknowledge the obvious? The driving force behind blindness to IT failure goes way beyond wishful thinking. Lack of knowledge by the leadership of the complexities of "doing health IT right" and the ease of getting it wrong are a factor, especially when employing management talent in top positions inappropriate to the job such as these:

Two senior management appointments for NHS National Programme for IT announced
12 August 2008

The Department of Health has announced the two long-awaited senior management appointments for the National Programme for IT ... The Department announced in February that it was recruiting the two positions as part of a revised governance structure for handling informatics in the Department of Health.

Christine Connelly will be the first Chief Information Officer for Health and will focus on developing and delivering the Department's overall information strategy and integrating leadership across the NHS and associated bodies including NHS Connecting for Health and the NHS Information Centre for Health and Social Care.Christine Connelly was previously Chief Information Officer at Cadbury Schweppes with direct control of all IT operations and projects. She also spent over 20 years at BP where her roles included Chief of Staff for Gas, Power and Renewables, and Head of IT for both the upstream and downstream business.

Martin Bellamy will be the Director of Programme and System Delivery. He will lead NHS Connecting for Health and focus on enhancing partnerships with and within the NHS. Martin Bellamy has worked for the Department for Work and Pensions since 2003. His main role has been as CIO of the Pension Service.

"Informatics leadership" in healthcare with these backgrounds? Where's Winston Churchill when you need him?

Large sums of money in one's pocket also creates the most rabid enthusiasm in face of the obvious.

The electronic patient record system, which is thought to have cost about £12bn so far, was commissioned in 2002 by then prime minister Tony Blair, and was meant to be completed by 2010.

This sounds eerily familiar to the U.S., which set an equally unrealistic ten year timeline for a major social re-engineering project -- entirely dependent on experimental IT -- of immense proportions.

Mr Lansley told BBC One's Politics Show the Tories would scrap the "enormous centralised IT system" and instead give hospitals "the opportunity to buy IT systems" that could transfer images, patient records and prescriptions electronically.

A focus on easy wins - providing local hospitals leeway to buy or build systems to transfer images, basic records useful to clinicians in the real world (as opposed to every data point in the known universe possible about a patient) and prescriptions, with incremental refinement and slow spread as IT and human capabilities warrant, should have been the focus at the start, not an idealistic project to create a centralized national Medi-net.

It comes as the Conservatives called for a moratorium on all government computer projects, ahead of the publication of the government's five-year IT strategy later this week. They say Labour has spent £100bn on IT since 1997 and contracts worth another £70bn are due to be renewed or commissioned in the next two years.

That's a lot of money. What's the ROI, exactly?

The Liberal Democrats said the NHS programme had been "flawed from the start".

The party's health spokesman, Norman Lamb, said: "It has held back the development of IT at a local level, cost billions and is running years behind schedule."

That is subtantiated by the above linked House of Commons report.

But Dr Grant Ingrams, from the British Medical Association, said the system currently scheduled to come into effect would result in the NHS saving money.

"It's an essential tool for clinicians, for doctors and other staff to be able to treat patients," he said.

"The NHS pays out a third of a billion pounds a year on mistakes; a lot of that could be put right if the IT was in place."

That type of statement about medical mistakes is at the crux of the idealists' and zealots' dream. Unfortunately, they do not ask these simple minded questions:

• Are those mistakes due to informational issues, e.g., lack of immediate availability of patient information, or due to other personal, local and/or systemic factors?

• What percentage of the mistakes meet the criterion of being amenable to "prevention by IT"?

• Could computerized systems create new mistakes of their own?

• Where is the robust evidence that supports such a statement about error prevention?

• Has such evidence been rigorously reconciled with an accumulating evidence base to the contrary?
  

The answers to these simple questions are not hard to obtain to anyone who cares to look, and who will take off their global warming "Hide the Decline" blinders (warning: YouTube link to a most apropos satire and mockery).

Lacking the miracle of our own government officials sprouting new brain cells in cortical centers responsible for critical thinking and ethics, I regrettably predict the U.S. will be at this same point in approximately three to five years.

-- SS

Troubled £12bn NHS IT System to be Scaled Back: UK MP's Come to Their Senses on Health IT. Will the U.S. Follow?

The UK National Programme for Health IT in the NHS, by the findings of the House of Commons Public Account audit committee, has been a £12bn debacle. Started as a starry-eyed utopian fantasy about experimental computerized clinical tools by former Prime Minister Tony Blair, nearly every possible mistake outlined at my ten year old website on HIT failure has been made, and made in abundance, the coup de grâce being dependence on an American health IT company.

It seems people's ability to detect rigor and seriousness in industrialists has become seriously impaired, the recent spectacular Ponzi schemes fallen for by quite prominent people and foundations being one example. Now the UK is at the point where hospitals are "unable to share documents" relating to problematic EHR's as their contract with that vendor includes a confidentiality clause. (Not that such clauses are limited to one company.

The health IT industry has generally profited from a sweetheart relationship of stunning proportions with healthcare regulatory agencies (it is entirely unregulated); with government (in the U.S., hundreds of billions of dollars are being thrown their way on similar starry-eyed dreams about reduced costs and improved quality per the economic "stimulus" bill); and with healthcare organizations (who accept HIT marketing puffery hook, line and sinker, do not perform due diligence properly for such critical clinical tools, who manage IT and informatics talent poorly, and who willingly sign defects nondisclosure and hold harmless clauses that violate the fiduciary responsibilities of their governance bodies as in my JAMA letter here and longer essay here).

At least for the £12bn down the drain, the U.K. is coming to their senses:

Troubled £12bn NHS IT system to be scaled back
BBC News
6 December 2009

The government is to scale back its £12bn NHS IT system in what the Tories are calling a "massive U-turn".

Chancellor Alistair Darling said he would be delaying parts of the scheme in Wednesday's pre-Budget Report as it was "not essential to the front line".

The move may save hundreds of millions but Mr Darling admitted it was only a fraction of total spending cuts needed.

The Tories and Lib Dems have been calling for the IT system, which has been hit by costly delays, to be axed.

... “It has held back the development of IT at a local level, cost billions and is running years behind schedule” - Norman Lamb, MP Liberal Democrats.

... [Chancellor Darling] said the full picture of cuts would not emerge until "the first half of next year at some point" - a reference to the comprehensive spending review, which the government has delayed until after an election.

The comprehensive spending review should be interesting, to say the least. I humbly suggest the NHS look at the contracting practices of the vendors, especially the gag clauses, the multiply-layered subcontracting deals with dyscompetent consulting companies common in IT, and conflicts of interest of local and national program leaders with IT and consulting suppliers.

I also suggest the reviewers borrow from the U.S. Senate Committee on Finance letter here from Senator Grassley to HIT vendors and consultants.

'Procurement disaster'

Treasury officials have stressed that only part of the NHS IT programme is facing the axe, and the whole project will not be scrapped.

But the Conservatives said Mr Darling's words represented a "massive U-turn".

Shadow Health Secretary Andrew Lansley said it was "another government IT procurement disaster".

"After seven years Labour have finally acknowledged what we've said for years, that the procurement for NHS IT was costing billions and not delivering," he said.

Why did it take years to acknowledge the obvious? The driving force behind blindness to IT failure goes way beyond wishful thinking. Lack of knowledge by the leadership of the complexities of "doing health IT right" and the ease of getting it wrong are a factor, especially when employing management talent in top positions inappropriate to the job such as these:

Two senior management appointments for NHS National Programme for IT announced
12 August 2008

The Department of Health has announced the two long-awaited senior management appointments for the National Programme for IT ... The Department announced in February that it was recruiting the two positions as part of a revised governance structure for handling informatics in the Department of Health.

Christine Connelly will be the first Chief Information Officer for Health and will focus on developing and delivering the Department's overall information strategy and integrating leadership across the NHS and associated bodies including NHS Connecting for Health and the NHS Information Centre for Health and Social Care.Christine Connelly was previously Chief Information Officer at Cadbury Schweppes with direct control of all IT operations and projects. She also spent over 20 years at BP where her roles included Chief of Staff for Gas, Power and Renewables, and Head of IT for both the upstream and downstream business.

Martin Bellamy will be the Director of Programme and System Delivery. He will lead NHS Connecting for Health and focus on enhancing partnerships with and within the NHS. Martin Bellamy has worked for the Department for Work and Pensions since 2003. His main role has been as CIO of the Pension Service.

"Informatics leadership" in healthcare with these backgrounds? Where's Winston Churchill when you need him?

Large sums of money in one's pocket also creates the most rabid enthusiasm in face of the obvious.

The electronic patient record system, which is thought to have cost about £12bn so far, was commissioned in 2002 by then prime minister Tony Blair, and was meant to be completed by 2010.

This sounds eerily familiar to the U.S., which set an equally unrealistic ten year timeline for a major social re-engineering project -- entirely dependent on experimental IT -- of immense proportions.

Mr Lansley told BBC One's Politics Show the Tories would scrap the "enormous centralised IT system" and instead give hospitals "the opportunity to buy IT systems" that could transfer images, patient records and prescriptions electronically.

A focus on easy wins - providing local hospitals leeway to buy or build systems to transfer images, basic records useful to clinicians in the real world (as opposed to every data point in the known universe possible about a patient) and prescriptions, with incremental refinement and slow spread as IT and human capabilities warrant, should have been the focus at the start, not an idealistic project to create a centralized national Medi-net.

It comes as the Conservatives called for a moratorium on all government computer projects, ahead of the publication of the government's five-year IT strategy later this week. They say Labour has spent £100bn on IT since 1997 and contracts worth another £70bn are due to be renewed or commissioned in the next two years.

That's a lot of money. What's the ROI, exactly?

The Liberal Democrats said the NHS programme had been "flawed from the start".

The party's health spokesman, Norman Lamb, said: "It has held back the development of IT at a local level, cost billions and is running years behind schedule."

That is subtantiated by the above linked House of Commons report.

But Dr Grant Ingrams, from the British Medical Association, said the system currently scheduled to come into effect would result in the NHS saving money.

"It's an essential tool for clinicians, for doctors and other staff to be able to treat patients," he said.

"The NHS pays out a third of a billion pounds a year on mistakes; a lot of that could be put right if the IT was in place."

That type of statement about medical mistakes is at the crux of the idealists' and zealots' dream. Unfortunately, they do not ask these simple minded questions:

• Are those mistakes due to informational issues, e.g., lack of immediate availability of patient information, or due to other personal, local and/or systemic factors?

• What percentage of the mistakes meet the criterion of being amenable to "prevention by IT"?

• Could computerized systems create new mistakes of their own?

• Where is the robust evidence that supports such a statement about error prevention?

• Has such evidence been rigorously reconciled with an accumulating evidence base to the contrary?
  

The answers to these simple questions are not hard to obtain to anyone who cares to look, and who will take off their global warming "Hide the Decline" blinders (warning: YouTube link to a most apropos satire and mockery).

Lacking the miracle of our own government officials sprouting new brain cells in cortical centers responsible for critical thinking and ethics, I regrettably predict the U.S. will be at this same point in approximately three to five years.

-- SS