The Ultimate Workaround To Mission Hostile Health IT: Humans (a.k.a. "Scribes")

"Gentlemen, we can rebuild him. We have the technology. We have the capability to build the world's first bionic doctor. Dr. Data will be that doctor; better worse than he was before. Better, stronger, faster Worse, weaker, slower." -- parody of Oscar Goldman from the 1970's scifi series The Six Million Dollar Man.

"Gentlemen, we can rebuild him."

The EMR is a technology that was supposed to improve clinical medicine (revolutionize it, some say). It was supposed to facilitate clinical medicine. It was not supposed to slow physicians and others down to the point of impairing their ability to practice medicine.

However, the rosy predictions are not proving to be the case. Instead, we have the ultimate workaround to the health IT mission hostile user experience:

Los Angeles Times
September 6, 2010

Harris Meyer

Scribes are doctors' tech support

Melissa Genove has dreamed of becoming a physician since childhood. To help her prepare, she spends as many as 35 hours each week shadowing emergency room doctors at Loma Linda University Medical Center. The 23-year-old listens intently as they examine patients, records their treatment plans in a laptop computer, and follows up on prescriptions, lab tests, consultations with specialists and anything else the doctors order.

Genove is not an intern, or even a medical student. She is the chief medical scribe in the hospital's emergency department — and one of several thousand young people pioneering a new healthcare field.

Scribes are filling a necessary niche as doctors make the wrenching transition from old-fashioned paper charts to 21st century electronic medical records. The computerized system is supposed to make doctors more efficient and ensure better care for patients. Congress has such faith in the value of electronic medical records that it provided as much as $27 billion over 10 years to encourage doctors to use them, and the Centers for Medicare and Medicaid Services will penalize those who don't by cutting their reimbursement rates as much as 5%.

But while the conversion is underway, doctors estimate that their productivity plummets by about 30% as they learn to cope with a complicated new system. [And what clinical IT in 2010 isn't complicated, I ask? - ed.] That's where scribes come in.

This brings real meaning to the observation that "you should not have to work around something that is not in the way."

Just one screen from a Cerner product (from a presentation touting recent addition of a simple database "search" feature that should/could have been present eons ago). Each menu item leads to even more screens, subscreens, menus and pick lists, in labyrinthine fashion. Click to enlarge.

In a domain as complex as medicine, ever-increasing demands for fine grained data on clinical encounters now outstrip the 2010-style human-computer interface's abilities to allow capture of the data without massive interference in the process of medicine itself.

This mismatch is due largely to the limitations of the GUI as the primary user interface (UI) metaphor, especially the widget-centric UI currently in vogue, characterized by massive numbers of screens and GUI widgets, labyrinthine navigation, and forced data entry of artificially and needlessly "atomized" data through interaction with multiple widgets.

CPOE as an example has become a Rube Goldberg contraption (def: "deliberately over-engineered machine that performs a very simple task in a very complex fashion"), the furthest thing from a straightforward "typewriter for orders" as can be.

For instance, a simple order requires interaction with search boxes, multiple drop down lists, scroll bars, check boxes, and other widgets to capture each micro-component of the order, wasting much time compared to writing "Sotalol hydrochloride 120 mg PO BID, first dose now." There are alternatives to "data atomization" and "widget-centricity" in the health IT user interface, apart from simply cleaning up the current interaction disorganization and other weaknesses, but the health IT industry seems largely oblivious to alternatives.

Professor Butts and the Self-Operating Napkin: EMR's have become machines that perform simple tasks in a very complex fashion

Unfortunately, it's difficult to show this complexity using actual EMR images, as most health IT vendors avoid posting screen images and user manuals online, and forbid customers from doing so. They are excessively secretive about their products. Try a Google image search on 'Cerner Millenium' as an example (click here), then compare to an image search on, say, Microsoft Word (click here).

The inappropriate-for-medicine, management information systems (MIS)-derived business model of the healthcare IT vendors and HIT ecosystem also contributes to the, at best, stuck-in-the-1980's health IT user interface. (As an example of these issues, the industry wouldn't even listen to aforementioned UI alternatives even if I served them up on a silver platter, because using the advice would require significant investments on their part to incorporate alternative UI approaches into their products, meaning lower short and medium term profits. Unlike pharma and tangible medical devices, interest in advanced R&D in the health IT industry seems nil. Instead, complacency rules.)

An important question to ponder is whether the dream of the health IT pioneers back in the 1950's and 1960's was too idealistic and indeed unrealistic to begin with. Was it based on "2001, A Space Odyssey"-style overoptimism, and the lack of foreknowledge of how little true progress would be made in the commercial IT market in human computer interaction, artificial intelligence, natural language processing, voice recognition, and other innovations by the 21st century?

Doctors have embraced the scribes as well. "The physicians were spending too much time documenting and not enough time with the patient," said Dr. Robert Steele, chief of Loma Linda's emergency department, which began using scribes in November. "The solution was to take the doctors off the computer, put them at the bedside, and let the scribe do the transcription. It's been a huge success. The physicians love it.

It is not hard to understand why physicians, with their years of training and expertise, would welcome relief from extremely tedious clerical tasks.

Leaders of the three biggest companies providing scribes estimate that about 200 emergency departments in community hospitals and academic medical centers currently use them. More scribes are on the way. Ronald Reagan UCLA Medical Center, Emory University Hospital in Atlanta and Beth Israel Medical Center in New York City said they are exploring the idea. Physicians in other specialties, including urology and family practice, also are starting to adopt scribes.

Still, some physicians question whether college students are equipped to handle the complicated task of charting patients after only two to four months of training. Others wonder why it's necessary to hire additional staff to fill out computerized records that were supposed to be simpler and more efficient than paper.

The key phrase is "were supposed to be simpler and more efficient" than paper. I'd likely be hard-pressed to find robust research supporting that assertion in the scientific literature. I'd be more likely find the origins of this meme in vendor marketing materials.

"It will be interesting to watch whether the need for scribes goes away as the next generation of physicians who grew up with computers and electronic medical records comes in," said Dr. Ann O'Malley, a senior researcher at the Center for Studying Health System Change in Washington, D.C.

This passage implies the bottleneck is those physicians who need to "get used to the IT", whereas a major component of the problem is the health IT user interface itself. Scribes might "go away" if the health IT user experience was vastly improved. The IT needs to become more physician and medicine-friendly.

At Loma Linda [Hospital], Steele said doctors used to spend two minutes with a patient, then take four minutes typing the information into a computer. Now the doctor talks to the patient with the scribe present and summarizes the encounter to the scribe in 30 seconds. While the scribe spends three minutes entering the information into an ever-present laptop, the doctor can spend extra time with the patient.

Afterward, the doctor checks the accuracy of the scribe's chart, makes any necessary additions or corrections, and signs off. Although novice scribes sometimes need the doctor's help in understanding terminology, those with several months' experience usually are spot-on, Steele said.

Again, clerical work is a very poor use of a physician's time. Scribes are a good idea considering 2010's EMR technology, at least from the time/skills perspective.

... [Dr. Michael] Murphy of ScribeAmerica estimates that doctors can see eight additional patients over a 10-hour shift, hiking Medicare revenues alone by $91 an hour.

The companies that develop and sell electronic medical records systems are "in total denial" about how complicated they are for doctors to use, [Dr. David] Strumpf said. "They know these systems need scribes," he said. "They work with us to train our scribes on their systems, but they don't want to be public about it."

(One wonders how much in "denial" the companies are and just who is truly in denial; after all, purchase of these systems just became a governmental priority.)

Here, of course, is the major drawback to scribes: money. Scribes "typically cost $20 to $26 an hour" today, and that number is likely to rise. While the article's contributors maintain that physicians can boost their revenues by "$50 to $60 an hour" using scribes, I wonder if the overall economic impact of the generalized use of tens or hundreds of thousands of EMR scribes would be in the "wrong" direction (i.e., from the payor and government perspective). The billions spent on EMR's were supposed to reduce the costs of healthcare, not increase the expenses associated with it.

I also wonder what could happen when a scribe is not available.

At the University of Virginia Medical Center in Charlottesville, Va., emergency room physicians can complete electronic charts just as fast as scribes, most of whom are pre-med students at UVA. But doctors would rebel if the scribes disappeared, said Dr. Robert Reiser, medical director of the scribe program, which the university runs itself.

Sept. 10 Addendum:

See an interesting financial analysis by Doug Perednia here.

-- SS

The Ultimate Workaround To Mission Hostile Health IT: Humans (a.k.a. "Scribes")

"Gentlemen, we can rebuild him. We have the technology. We have the capability to build the world's first bionic doctor. Dr. Data will be that doctor; better worse than he was before. Better, stronger, faster Worse, weaker, slower." -- parody of Oscar Goldman from the 1970's scifi series The Six Million Dollar Man.

"Gentlemen, we can rebuild him."

The EMR is a technology that was supposed to improve clinical medicine (revolutionize it, some say). It was supposed to facilitate clinical medicine. It was not supposed to slow physicians and others down to the point of impairing their ability to practice medicine.

However, the rosy predictions are not proving to be the case. Instead, we have the ultimate workaround to the health IT mission hostile user experience:

Los Angeles Times
September 6, 2010

Harris Meyer

Scribes are doctors' tech support

Melissa Genove has dreamed of becoming a physician since childhood. To help her prepare, she spends as many as 35 hours each week shadowing emergency room doctors at Loma Linda University Medical Center. The 23-year-old listens intently as they examine patients, records their treatment plans in a laptop computer, and follows up on prescriptions, lab tests, consultations with specialists and anything else the doctors order.

Genove is not an intern, or even a medical student. She is the chief medical scribe in the hospital's emergency department — and one of several thousand young people pioneering a new healthcare field.

Scribes are filling a necessary niche as doctors make the wrenching transition from old-fashioned paper charts to 21st century electronic medical records. The computerized system is supposed to make doctors more efficient and ensure better care for patients. Congress has such faith in the value of electronic medical records that it provided as much as $27 billion over 10 years to encourage doctors to use them, and the Centers for Medicare and Medicaid Services will penalize those who don't by cutting their reimbursement rates as much as 5%.

But while the conversion is underway, doctors estimate that their productivity plummets by about 30% as they learn to cope with a complicated new system. [And what clinical IT in 2010 isn't complicated, I ask? - ed.] That's where scribes come in.

This brings real meaning to the observation that "you should not have to work around something that is not in the way."

Just one screen from a Cerner product (from a presentation touting recent addition of a simple database "search" feature that should/could have been present eons ago). Each menu item leads to even more screens, subscreens, menus and pick lists, in labyrinthine fashion. Click to enlarge.

In a domain as complex as medicine, ever-increasing demands for fine grained data on clinical encounters now outstrip the 2010-style human-computer interface's abilities to allow capture of the data without massive interference in the process of medicine itself.

This mismatch is due largely to the limitations of the GUI as the primary user interface (UI) metaphor, especially the widget-centric UI currently in vogue, characterized by massive numbers of screens and GUI widgets, labyrinthine navigation, and forced data entry of artificially and needlessly "atomized" data through interaction with multiple widgets.

CPOE as an example has become a Rube Goldberg contraption (def: "deliberately over-engineered machine that performs a very simple task in a very complex fashion"), the furthest thing from a straightforward "typewriter for orders" as can be.

For instance, a simple order requires interaction with search boxes, multiple drop down lists, scroll bars, check boxes, and other widgets to capture each micro-component of the order, wasting much time compared to writing "Sotalol hydrochloride 120 mg PO BID, first dose now." There are alternatives to "data atomization" and "widget-centricity" in the health IT user interface, apart from simply cleaning up the current interaction disorganization and other weaknesses, but the health IT industry seems largely oblivious to alternatives.

Professor Butts and the Self-Operating Napkin: EMR's have become machines that perform simple tasks in a very complex fashion

Unfortunately, it's difficult to show this complexity using actual EMR images, as most health IT vendors avoid posting screen images and user manuals online, and forbid customers from doing so. They are excessively secretive about their products. Try a Google image search on 'Cerner Millenium' as an example (click here), then compare to an image search on, say, Microsoft Word (click here).

The inappropriate-for-medicine, management information systems (MIS)-derived business model of the healthcare IT vendors and HIT ecosystem also contributes to the, at best, stuck-in-the-1980's health IT user interface. (As an example of these issues, the industry wouldn't even listen to aforementioned UI alternatives even if I served them up on a silver platter, because using the advice would require significant investments on their part to incorporate alternative UI approaches into their products, meaning lower short and medium term profits. Unlike pharma and tangible medical devices, interest in advanced R&D in the health IT industry seems nil. Instead, complacency rules.)

An important question to ponder is whether the dream of the health IT pioneers back in the 1950's and 1960's was too idealistic and indeed unrealistic to begin with. Was it based on "2001, A Space Odyssey"-style overoptimism, and the lack of foreknowledge of how little true progress would be made in the commercial IT market in human computer interaction, artificial intelligence, natural language processing, voice recognition, and other innovations by the 21st century?

Doctors have embraced the scribes as well. "The physicians were spending too much time documenting and not enough time with the patient," said Dr. Robert Steele, chief of Loma Linda's emergency department, which began using scribes in November. "The solution was to take the doctors off the computer, put them at the bedside, and let the scribe do the transcription. It's been a huge success. The physicians love it.

It is not hard to understand why physicians, with their years of training and expertise, would welcome relief from extremely tedious clerical tasks.

Leaders of the three biggest companies providing scribes estimate that about 200 emergency departments in community hospitals and academic medical centers currently use them. More scribes are on the way. Ronald Reagan UCLA Medical Center, Emory University Hospital in Atlanta and Beth Israel Medical Center in New York City said they are exploring the idea. Physicians in other specialties, including urology and family practice, also are starting to adopt scribes.

Still, some physicians question whether college students are equipped to handle the complicated task of charting patients after only two to four months of training. Others wonder why it's necessary to hire additional staff to fill out computerized records that were supposed to be simpler and more efficient than paper.

The key phrase is "were supposed to be simpler and more efficient" than paper. I'd likely be hard-pressed to find robust research supporting that assertion in the scientific literature. I'd be more likely find the origins of this meme in vendor marketing materials.

"It will be interesting to watch whether the need for scribes goes away as the next generation of physicians who grew up with computers and electronic medical records comes in," said Dr. Ann O'Malley, a senior researcher at the Center for Studying Health System Change in Washington, D.C.

This passage implies the bottleneck is those physicians who need to "get used to the IT", whereas a major component of the problem is the health IT user interface itself. Scribes might "go away" if the health IT user experience was vastly improved. The IT needs to become more physician and medicine-friendly.

At Loma Linda [Hospital], Steele said doctors used to spend two minutes with a patient, then take four minutes typing the information into a computer. Now the doctor talks to the patient with the scribe present and summarizes the encounter to the scribe in 30 seconds. While the scribe spends three minutes entering the information into an ever-present laptop, the doctor can spend extra time with the patient.

Afterward, the doctor checks the accuracy of the scribe's chart, makes any necessary additions or corrections, and signs off. Although novice scribes sometimes need the doctor's help in understanding terminology, those with several months' experience usually are spot-on, Steele said.

Again, clerical work is a very poor use of a physician's time. Scribes are a good idea considering 2010's EMR technology, at least from the time/skills perspective.

... [Dr. Michael] Murphy of ScribeAmerica estimates that doctors can see eight additional patients over a 10-hour shift, hiking Medicare revenues alone by $91 an hour.

The companies that develop and sell electronic medical records systems are "in total denial" about how complicated they are for doctors to use, [Dr. David] Strumpf said. "They know these systems need scribes," he said. "They work with us to train our scribes on their systems, but they don't want to be public about it."

(One wonders how much in "denial" the companies are and just who is truly in denial; after all, purchase of these systems just became a governmental priority.)

Here, of course, is the major drawback to scribes: money. Scribes "typically cost $20 to $26 an hour" today, and that number is likely to rise. While the article's contributors maintain that physicians can boost their revenues by "$50 to $60 an hour" using scribes, I wonder if the overall economic impact of the generalized use of tens or hundreds of thousands of EMR scribes would be in the "wrong" direction (i.e., from the payor and government perspective). The billions spent on EMR's were supposed to reduce the costs of healthcare, not increase the expenses associated with it.

I also wonder what could happen when a scribe is not available.

At the University of Virginia Medical Center in Charlottesville, Va., emergency room physicians can complete electronic charts just as fast as scribes, most of whom are pre-med students at UVA. But doctors would rebel if the scribes disappeared, said Dr. Robert Reiser, medical director of the scribe program, which the university runs itself.

Sept. 10 Addendum:

See an interesting financial analysis by Doug Perednia here.

-- SS

FDA MAUDE Database: Patient Outcome - Death

I present another health IT problem case from the FDA's voluntary MAUDE (Manufacturer and User Facility Device Experience) database below.

From FDA's description of MAUDE:

• MAUDE data represents reports of adverse events involving medical devices. The data consists of voluntary reports since June 1993, user facility reports since 1991, distributor reports since 1993, and manufacturer reports since August 1996. MAUDE may not include reports made according to exemptions, variances, or alternative reporting requirements granted under 21 CFR 803.19.
• The on-line search allows you to search CDRH database information on medical devices which may have malfunctioned or caused a death or serious injury. MAUDE is scheduled to be updated monthly and the search page reflects the date of the most recent update. FDA seeks to include all reports received prior to the update. However, the inclusion of some reports may be delayed by technical or clerical difficulties.
• MAUDE data is not intended to be used either to evaluate rates of adverse events or to compare adverse event occurrence rates across devices. Please be aware that reports regarding device trade names may have been submitted under different manufacturer names. Searches only retrieve records that contain the search term(s) provided by the requester.

I somehow missed the following case when I wrote the Oct. 2009 post 'Our Policy Is To Always Have Unabashed Faith In The Computer ... Except When It Screws Up, And Then It's The Doctor's Fault' but I have added it there as well:

http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/detail.cfm?mdrfoi__id=1656460
CERNER MILLENIUM POWERCHART CPOE
Event Date 11/19/2006
Event Type: Death
Patient Outcome: Death

The medication review screen of the subject device does not specify the exact dose in milligrams of combination medications. For example, narcotics are combined with tylenol in at least two strengths. Liquid narcotic tylenol-oxycodone combination is reported in ml, not mg. The exact dose of tylenol is not specified and requires knowledge of the combination medication dose in the volume specified.

Certain fields of the grid do not specify the volume, but rather state "date/time" requiring another click or pop up screen. The immediate knowledge of tylenol dosage in mg is directly related to understanding and preventing excessive doses. In the subject, 10 ml of acetaminophen-oxycodone is indicated as having been given 3 times over 4 hours. That means that 1950 mg of tylenol was administered in 4 hours while the patient was in a state of starvation and receiving other medication that increase the effects of tylenol.

This dose would equate to 11,700 mg of tylenol over 24 hours, nearly 3 times the maximum daily dose in otherwise health people. In the ensuing days, the patient developed acute renal failure, presumably acute tubular necrosis, and died. In the absence of other etiology, the excess tylenol was the culprit. This was not considered as etiology ante-mortem. The counterintuitive screen impaired the professionals. The pharmacist did not recognize and stop the medication, the nurses administered it, and the excessive dose, clinically meaninglessly listed as a volume of 10 ml -given 3 times in 4 hours- of acetaminophen-oxycodone, was missed by the physicians. Adverse events have been ascribed to "user error" by vendors.

The device offers a potent propensity to life endangering oversights. There are other screens on this device which present information that interfere with clinically useful visualization of data. [Who designed these screens, I ask? Clinicians, or business IT personnel used to designing inventory systems for widget control? - ed.] The data does not flow to the professionals. It is not represented in a meaningfully useful manner.

The professionals need to hunt for it. As such, the user unfriendly screens [see this link on mission hostile HIT - ed.] impair safe medical care consistent with the impediment to expedient professional understanding of what, exactly, is the dose of medication and how much was administered to the patient. This sentinel case of death is directly attributed to user unfriendly screens on this device.

How many cases like this, as well as "near misses" related to health IT go unreported, nationwide and worldwide?

As in my paper "Remediating an Unintended Consequence of Healthcare IT: A Dearth of Data on Unintended Consequences of Healthcare IT", nobody really knows; these devices are unregulated with no requirements for reporting.

However, let's roll it out nationally anyway, because HIT will deterministically "revolutionize" medicine. Just ignore those spoil-the-party, man-behind-the-curtain prattle from writers like these.

We can safely ignore all contrarian research and literature, of course, as we all know HIT will revolutionize medicine from the definitive certainty of HHS in "The 'Meaningful Use' Regulation for Electronic Health Records", NEJM, Blumenthal and Tavenner (10.1056/NEJMp1006114, July 13, 2010):

The widespread use of electronic health records (EHRs) in the United States is inevitable. EHRs will improve caregivers’ decisions and patients’ outcomes. Once patients experience the benefits of this technology, they will demand nothing less from their providers. Hundreds of thousands of physicians have already seen these benefits in their clinical practice.

[Except for those who haven't - ed.]

And our government's called BP Energy Company cavalier?

I offer no additional comments.

-- SS

FDA MAUDE Database: Patient Outcome - Death

I present another health IT problem case from the FDA's voluntary MAUDE (Manufacturer and User Facility Device Experience) database below.

From FDA's description of MAUDE:

• MAUDE data represents reports of adverse events involving medical devices. The data consists of voluntary reports since June 1993, user facility reports since 1991, distributor reports since 1993, and manufacturer reports since August 1996. MAUDE may not include reports made according to exemptions, variances, or alternative reporting requirements granted under 21 CFR 803.19.
• The on-line search allows you to search CDRH database information on medical devices which may have malfunctioned or caused a death or serious injury. MAUDE is scheduled to be updated monthly and the search page reflects the date of the most recent update. FDA seeks to include all reports received prior to the update. However, the inclusion of some reports may be delayed by technical or clerical difficulties.
• MAUDE data is not intended to be used either to evaluate rates of adverse events or to compare adverse event occurrence rates across devices. Please be aware that reports regarding device trade names may have been submitted under different manufacturer names. Searches only retrieve records that contain the search term(s) provided by the requester.

I somehow missed the following case when I wrote the Oct. 2009 post 'Our Policy Is To Always Have Unabashed Faith In The Computer ... Except When It Screws Up, And Then It's The Doctor's Fault' but I have added it there as well:

http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/detail.cfm?mdrfoi__id=1656460
CERNER MILLENIUM POWERCHART CPOE
Event Date 11/19/2006
Event Type: Death
Patient Outcome: Death

The medication review screen of the subject device does not specify the exact dose in milligrams of combination medications. For example, narcotics are combined with tylenol in at least two strengths. Liquid narcotic tylenol-oxycodone combination is reported in ml, not mg. The exact dose of tylenol is not specified and requires knowledge of the combination medication dose in the volume specified.

Certain fields of the grid do not specify the volume, but rather state "date/time" requiring another click or pop up screen. The immediate knowledge of tylenol dosage in mg is directly related to understanding and preventing excessive doses. In the subject, 10 ml of acetaminophen-oxycodone is indicated as having been given 3 times over 4 hours. That means that 1950 mg of tylenol was administered in 4 hours while the patient was in a state of starvation and receiving other medication that increase the effects of tylenol.

This dose would equate to 11,700 mg of tylenol over 24 hours, nearly 3 times the maximum daily dose in otherwise health people. In the ensuing days, the patient developed acute renal failure, presumably acute tubular necrosis, and died. In the absence of other etiology, the excess tylenol was the culprit. This was not considered as etiology ante-mortem. The counterintuitive screen impaired the professionals. The pharmacist did not recognize and stop the medication, the nurses administered it, and the excessive dose, clinically meaninglessly listed as a volume of 10 ml -given 3 times in 4 hours- of acetaminophen-oxycodone, was missed by the physicians. Adverse events have been ascribed to "user error" by vendors.

The device offers a potent propensity to life endangering oversights. There are other screens on this device which present information that interfere with clinically useful visualization of data. [Who designed these screens, I ask? Clinicians, or business IT personnel used to designing inventory systems for widget control? - ed.] The data does not flow to the professionals. It is not represented in a meaningfully useful manner.

The professionals need to hunt for it. As such, the user unfriendly screens [see this link on mission hostile HIT - ed.] impair safe medical care consistent with the impediment to expedient professional understanding of what, exactly, is the dose of medication and how much was administered to the patient. This sentinel case of death is directly attributed to user unfriendly screens on this device.

How many cases like this, as well as "near misses" related to health IT go unreported, nationwide and worldwide?

As in my paper "Remediating an Unintended Consequence of Healthcare IT: A Dearth of Data on Unintended Consequences of Healthcare IT", nobody really knows; these devices are unregulated with no requirements for reporting.

However, let's roll it out nationally anyway, because HIT will deterministically "revolutionize" medicine. Just ignore those spoil-the-party, man-behind-the-curtain prattle from writers like these.

We can safely ignore all contrarian research and literature, of course, as we all know HIT will revolutionize medicine from the definitive certainty of HHS in "The 'Meaningful Use' Regulation for Electronic Health Records", NEJM, Blumenthal and Tavenner (10.1056/NEJMp1006114, July 13, 2010):

The widespread use of electronic health records (EHRs) in the United States is inevitable. EHRs will improve caregivers’ decisions and patients’ outcomes. Once patients experience the benefits of this technology, they will demand nothing less from their providers. Hundreds of thousands of physicians have already seen these benefits in their clinical practice.

[Except for those who haven't - ed.]

And our government's called BP Energy Company cavalier?

I offer no additional comments.

-- SS

Did EPIC CEO Judy Faulkner of Epic declare that ‘healthcare IT usability would be part of certification over her dead body?'

At the HisTALK blog 5/31/10 update, a site with thousands of readers involved in all aspects of health IT, the following anonymous (at this point) report appeared:

From Tabula Rosa: “Re: EMR usability. At one of the ONC Policy Committee meetings, [founder and CEO] Judy Faulkner of Epic supposedly declared that ‘usability would be part of certification over her dead body.’ I wonder if she has similar sentiments about making software accessible to people with disabilities?” Unverified. This inspired my new poll question – keep reading below.

Epic Systems Corporation is one of the largest health IT vendors in the U.S.

If this report is true, it would have very, very serious implications towards the healthcare IT industry's attitudes about the usability - and ultimately the safety - of its products.

The essential nature of usability and the relationship to safety is not an issue for debate - period. It was settled long ago in relation not only to IT, but also to devices and machinery that use IT. For instance, see the mid 1980's wisdom written for the U.S. Air Force on user interfaces at my eight part series on mission hostile health IT user experiences at http://tinyurl.com/hostileuserexper. Microsoft and other responsible IT vendors spend billions on usability research.

I think it incumbent of the U.S. Office of the National Coordinator for Health IT, and its leader Dr. David Blumenthal, to confirm or deny that such a statement was made, on or off-record, at an ONC policy committee meeting, and if it was made, its exact context.

If it was made, it would raise the following questions:

• Would its utterer be saying this out of concern that their products have usability deficiencies that competitors do not, and that are not correctable in a short time frame?
• How much concern would such a statement indicate for the complex jobs of physicians, nurses and other clinicians whose safe conduct of their medical obligations depends on health IT?
• How much concern would such a statement imply towards the injured and dead bodies of patients affected by health IT of deficient usability?
• Since the CEO sets the tone for their company and has the ultimate responsibility for its conduct (and its Board of Directors as well), would such a statement reflect willful negligence and perhaps criminal conduct?

The last question is pertinent, for if, say, the CEO of Boeing were to relate that "usability of the control systems of its aircraft would be an FAA certification requirement over his or her dead body", or the CEO of oil drilling companies said same about their instrumentation that helps avoid underwater blowouts, I believe it would rise to the level of criminally negligent conduct.

This is all the more pertinent to me, as my relative was just seriously injured by a medication error that appears to have started with the med list in an EMR.

I am seriously wondering, in fact, if the average hospital has the gravitas and political and technologic maturity to truly implement health IT so that the technology is uniformly beneficial, instead of spontaneously harmful, to meet the needs of the grandiose plans for national health IT.

The lack of seriousness, petty political fights, and technological dyscompetence and incompetence I have noted in my 20 years in this field do not seem surmountable in any time frame I consider "soon."

Here seems to be the health IT industry and hospital MIS department view of healthcare IT, as some sort of game to be played for profit, power and political advantage:




-- SS

Did EPIC CEO Judy Faulkner of Epic declare that ‘healthcare IT usability would be part of certification over her dead body?'

At the HisTALK blog 5/31/10 update, a site with thousands of readers involved in all aspects of health IT, the following anonymous (at this point) report appeared:

From Tabula Rosa: “Re: EMR usability. At one of the ONC Policy Committee meetings, [founder and CEO] Judy Faulkner of Epic supposedly declared that ‘usability would be part of certification over her dead body.’ I wonder if she has similar sentiments about making software accessible to people with disabilities?” Unverified. This inspired my new poll question – keep reading below.

Epic Systems Corporation is one of the largest health IT vendors in the U.S.

If this report is true, it would have very, very serious implications towards the healthcare IT industry's attitudes about the usability - and ultimately the safety - of its products.

The essential nature of usability and the relationship to safety is not an issue for debate - period. It was settled long ago in relation not only to IT, but also to devices and machinery that use IT. For instance, see the mid 1980's wisdom written for the U.S. Air Force on user interfaces at my eight part series on mission hostile health IT user experiences at http://tinyurl.com/hostileuserexper. Microsoft and other responsible IT vendors spend billions on usability research.

I think it incumbent of the U.S. Office of the National Coordinator for Health IT, and its leader Dr. David Blumenthal, to confirm or deny that such a statement was made, on or off-record, at an ONC policy committee meeting, and if it was made, its exact context.

If it was made, it would raise the following questions:

• Would its utterer be saying this out of concern that their products have usability deficiencies that competitors do not, and that are not correctable in a short time frame?
• How much concern would such a statement indicate for the complex jobs of physicians, nurses and other clinicians whose safe conduct of their medical obligations depends on health IT?
• How much concern would such a statement imply towards the injured and dead bodies of patients affected by health IT of deficient usability?
• Since the CEO sets the tone for their company and has the ultimate responsibility for its conduct (and its Board of Directors as well), would such a statement reflect willful negligence and perhaps criminal conduct?

The last question is pertinent, for if, say, the CEO of Boeing were to relate that "usability of the control systems of its aircraft would be an FAA certification requirement over his or her dead body", or the CEO of oil drilling companies said same about their instrumentation that helps avoid underwater blowouts, I believe it would rise to the level of criminally negligent conduct.

This is all the more pertinent to me, as my relative was just seriously injured by a medication error that appears to have started with the med list in an EMR.

I am seriously wondering, in fact, if the average hospital has the gravitas and political and technologic maturity to truly implement health IT so that the technology is uniformly beneficial, instead of spontaneously harmful, to meet the needs of the grandiose plans for national health IT.

The lack of seriousness, petty political fights, and technological dyscompetence and incompetence I have noted in my 20 years in this field do not seem surmountable in any time frame I consider "soon."

Here seems to be the health IT industry and hospital MIS department view of healthcare IT, as some sort of game to be played for profit, power and political advantage:




-- SS

Why The Apple iPad Will Not Revolutionize, Change the Game, Transform or Create New Paradigms in Medicine Anytime Soon

The announcement of the Apple iPad has been accompanied by the usual irrationally exuberant, buzzword-laden statements and bellicose grandiosity from the IT punditry about how it will "revolutionize" or "transform" medicine.

However, this will not occur anytime soon, for in medicine, the device may help solve a portability and visibility problem (compared to PDA's), but it will not solve this problem: the mission hostile user experience.

The solution to that problem will require significant human magic.

-- SS

Why The Apple iPad Will Not Revolutionize, Change the Game, Transform or Create New Paradigms in Medicine Anytime Soon

The announcement of the Apple iPad has been accompanied by the usual irrationally exuberant, buzzword-laden statements and bellicose grandiosity from the IT punditry about how it will "revolutionize" or "transform" medicine.

However, this will not occur anytime soon, for in medicine, the device may help solve a portability and visibility problem (compared to PDA's), but it will not solve this problem: the mission hostile user experience.

The solution to that problem will require significant human magic.

-- SS

Finnish EHR's Clumsy, Mission Hostile, Consume Doctors' Precious Time

It seems common wisdom in the U.S. that the "Europeans are way ahead of us" in computerized medicine.

Perhaps the common wisdom is not so wise. This from Finland:

HELSINGIN SANOMAT
INTERNATIONAL EDITION - HOME

Clumsy computer systems consume doctors’ time

When Arto Virtanen, a doctor at a public health clinic, wants to access the information of a young patient, 12 windows of different sizes open up on different parts of his computer screen. Virtanen has to deal with each of them every time a patient visits him for routine postnatal care.

“It used to be that a municipal doctor would see six or seven patients in an hour, when documentation was not at its present level”, Virtanen says. “Then there came more paperwork, and four patients were seen in an hour. Now if a doctor wants to read all the information about a patient in the information system, there would only be time for consultations with, say, two patients in an hour.”

Clumsy computer systems are already seen as a danger to patient security, says Tiina Lääveri, a member of the board of the Finnish Medical Association, who has acquainted herself with the various systems.

Clumsy retrieval of data is one source of danger. Important information can disappear into the nooks and crannies of the software.

“There can be 100 pages of text without any summary, out of which a doctor should find information in a couple of minutes."

In hospitals, the systems do not separately tell nurses about changed dosages of medicines.

“The information is there, mixed in the mass of all of the rest of it, where it gets lost.”

In addition to causing outright dangers, computer systems waste precious working hours. In addition to actual medical data, the computer requires the recording of various items of statistical information.

Patients can see the problem as well. Up to 43 per cent of time reserved for a patient with an appointment to see a public health doctor can be spent dealing with a computer, according to a study published earlier this year in Lääkärilehti, the publication of the Finnish Medical Assotiation.

A national health archive now under development would not help things, as data would still be handled with existing software.

“Software companies have started to become interested in listening to users only in recent years”, Lääveri says.

Virtanen in Rajamäki would like to see more compatibility between systems. “There could be a common database, which should be easily accessible by a network browser”, Virtanen says.

“It might also be constructed according to what this working process really is.” [You don't say? - ed.]

Can health IT be any more mission hostile than this? (Unfortunately, the answer to what started as a rhetorical question is probably "yes." See this post on the US military's EHR AHLTA, and see my eight part series "Are Health IT Designers, Testers and Purchasers Trying to Harm Patients?" on mission hostile commercial HIT starting here.)

Reports of difficulty in EHR Utopia have leaked out of other European countries such as the Netherlands and Germany, not to mention the UK.

The most startling observation is that “software companies have started to become interested in listening to users only in recent years."

What manner of cavalier simpletons and opportunists populate such health IT companies?

-- SS

Addendum:

It appears AHLTA may be a bad as it is due in part to "politics as usual" a.k.a. corruption. See "Company won earmarked funds for work on military health records." If such conduct has been commonplace during AHLTA'a tortured history, it could explain just how AHLTA became as terrible as the senior military officials describe it in the linked article above.

Finnish EHR's Clumsy, Mission Hostile, Consume Doctors' Precious Time

It seems common wisdom in the U.S. that the "Europeans are way ahead of us" in computerized medicine.

Perhaps the common wisdom is not so wise. This from Finland:

HELSINGIN SANOMAT
INTERNATIONAL EDITION - HOME

Clumsy computer systems consume doctors’ time

When Arto Virtanen, a doctor at a public health clinic, wants to access the information of a young patient, 12 windows of different sizes open up on different parts of his computer screen. Virtanen has to deal with each of them every time a patient visits him for routine postnatal care.

“It used to be that a municipal doctor would see six or seven patients in an hour, when documentation was not at its present level”, Virtanen says. “Then there came more paperwork, and four patients were seen in an hour. Now if a doctor wants to read all the information about a patient in the information system, there would only be time for consultations with, say, two patients in an hour.”

Clumsy computer systems are already seen as a danger to patient security, says Tiina Lääveri, a member of the board of the Finnish Medical Association, who has acquainted herself with the various systems.

Clumsy retrieval of data is one source of danger. Important information can disappear into the nooks and crannies of the software.

“There can be 100 pages of text without any summary, out of which a doctor should find information in a couple of minutes."

In hospitals, the systems do not separately tell nurses about changed dosages of medicines.

“The information is there, mixed in the mass of all of the rest of it, where it gets lost.”

In addition to causing outright dangers, computer systems waste precious working hours. In addition to actual medical data, the computer requires the recording of various items of statistical information.

Patients can see the problem as well. Up to 43 per cent of time reserved for a patient with an appointment to see a public health doctor can be spent dealing with a computer, according to a study published earlier this year in Lääkärilehti, the publication of the Finnish Medical Assotiation.

A national health archive now under development would not help things, as data would still be handled with existing software.

“Software companies have started to become interested in listening to users only in recent years”, Lääveri says.

Virtanen in Rajamäki would like to see more compatibility between systems. “There could be a common database, which should be easily accessible by a network browser”, Virtanen says.

“It might also be constructed according to what this working process really is.” [You don't say? - ed.]

Can health IT be any more mission hostile than this? (Unfortunately, the answer to what started as a rhetorical question is probably "yes." See this post on the US military's EHR AHLTA, and see my eight part series "Are Health IT Designers, Testers and Purchasers Trying to Harm Patients?" on mission hostile commercial HIT starting here.)

Reports of difficulty in EHR Utopia have leaked out of other European countries such as the Netherlands and Germany, not to mention the UK.

The most startling observation is that “software companies have started to become interested in listening to users only in recent years."

What manner of cavalier simpletons and opportunists populate such health IT companies?

-- SS

Addendum:

It appears AHLTA may be a bad as it is due in part to "politics as usual" a.k.a. corruption. See "Company won earmarked funds for work on military health records." If such conduct has been commonplace during AHLTA'a tortured history, it could explain just how AHLTA became as terrible as the senior military officials describe it in the linked article above.

EHR's and Scarcity of Public Reviews of the User Experience

I recently downloaded the public beta (incomplete trial version) of Apple's new web browser Safari 4.

I like its user experience and features, presenting a main page "posterboard" of most visited or user-selected sites, a searchable, flip-panel history of visited pages (using the Macintosh OS X Spotlight and Cover Flow paradigms), top located tabs, and other useful features. (Note: I use both Macs and PC's, and hold no financial stakes in Apple whatsoever.)

What struck me was the vociferous online discussions and debates about every facet of the new browser version, down to the level of minutiae. The following review particularly struck me for its level of detail - Observations, Complaints, Quibbles, and Suggestions Regarding the Safari 4 Public Beta Released One Week Ago, Roughly in Order of Importance by John Gruber. It includes minutiae such as this:

... THE TABS

Safari’s new tab layout, placing the tabs directly in the window title bar, is a radical change. There’s no use addressing the specific details — good and bad — of this new arrangement, without first trying to figure out why Apple did this. Again, the designers are behind Apple’s wall of silence, so we’re left to speculate.

Rule out the notion that Safari’s designers undertook this change lightly. This is a major change to an important feature that many users feel strongly about. My guess is that this is an attempt to bring tabbed browsing to the masses. The biggest and most important change is that the interface for the tabs is now far more prominent. In fact, previously, the entire interface for tabbed browsing was not visible in Safari by default — in a window with just one tab, Safari’s default settings were such that the tab bar was not shown.

In Safari 4, there’s a prominent and unique “+” button that is always visible in the top right corner of every window, where the standard tic-tac button for toggling the display of the toolbar usually resides.1 Because the interface to create new tabs is now obvious, I can only assume that the point of this redesign is to encourage more people to use, or at least try, tabbed browsing.

But the problems with this new tab layout are significant.

Conceptually, the basic idea is sound. Browser tabs are, effectively, a collection of separate browser windows grouped together in a single parent window. Safari’s new tab layout makes this a tab is like a sub-window metaphor more explicit. The anchor, the conceptual root, of a standard Mac OS window is the title bar, and in Safari 4, the tabs aren’t just in the title bar, they are the title bar ...

Etcetera and so forth, on and on, as in other reviews easily found online.

In Electronic Health Records and other clinical IT, by way of contrast, reviews at this level of detail are ... nearly nonexistent (I use the term "nearly" because I authored such a review, in general terms, starting here). One reason EHR and other clinical IT user experience and performance debates are so rare is because customers are contractually forbidden to engage in them publicly. Koppel's and Kreda's JAMA paper makes that clear:

Health Care Information Technology Vendors' "Hold Harmless" Clause - Implications for Patients and Clinicians, Ross Koppel and David Kreda, Journal of the American Medical Association, 2009; 301(12):1276-1278

Vendors claim they are protecting their "intellectual property." I'm not exactly sure what IP they are holding as closely as the crown jewels.

Is it their:

• Earth shaking, 22nd century user interfaces?
• Secretive and ingenious widgets that revolutionize user selection from choice lists?
• Hyper-efficient, never before seen data structures and algorithms?
• Artificial intelligence routines that would make Captain Picard and his android sidekick Mr. Data envious?

In other words, what, exactly, is being protected by shielding commercial EHR's from external scrutiny and debate?

Is this the Secret Sauce the commercial EHR vendors seek to conceal?

The loss engendered by such policies is the reduced feedback from, and reduced interaction among endusers. This interaction occurs commonly on the Internet in 2009 on a great number of topics, but EHR user experiences are not one of them.

Companies like Apple and Microsoft, strongly user centric, encourage such debates through release of their beta's, both of enduser tools and of operating systems e.g., Windows 7 Beta. I should note that with these pieces of software, lives are not at stake, unlike with electronic health records systems.

The Veterans Health Administration makes a full working copy of VistA Computerized Patient Record System (CPRS) available as a free public download to anyone in the world here. I use it in my teaching (and am forced to do so, as commercial EHR demos are as available as, say, demos of the National Security Agency's spy and decryption software).

What, exactly, is the commercial EHR vendors' real excuse for the levels of product secrecy they maintain?

Could it be embarrassment and fear of exposure of defects, ill conceived design features and a mission hostile user experience?

-- SS

IT Vulnerabilities Highlighted by Errors, Malfunctions at Veterans Medical Centers

Bill Gates's company, Microsoft, touts the User Experience as the Sine Qua Non of computing. Billions of dollars have been spent tweaking every little nuance of Windows, with version 7.0 soon to appear. Apple has done likewise with Mac OS X. (The various X-windows managers for Linux, less so). I respect these efforts and use both mainstream OS's in my daily work.

In HIT, however, the "user experience" as I outlined in my eight part series starting here is deemed an issue to solve once the sale is made and physicians are scrambling to avoid harming or killing patients. After all, the HIT industry is unregulated, shielded from liability based on the "learned intermediary" doctrine (a.k.a., clinicians are the bank and insurance company for IT vendors, in that they are the creative implementors of workarounds to IT mismanagement and misdesign), and contractual gag clauses against public disclosure of product defects.

This arrangement makes the pharmaceutical industry look like kids in a sandbox.

In the article "IT Vulnerabilities Highlighted by Errors, Malfunctions at Veterans' Medical Centers", Journal of the American Medical Association 2009;301(9):919-920, author Bridget M. Kuehn illustrates the risk of improperly implemented or managed HIT, even in the VA.

The VA is probably the finest environment in the world for HIT, its development of clinical IT over the past few decades being largely driven by experts from within, and being dedicated to patients and not profits. Yet its HIT is subject to the same issues as HIT in the for-profit HIT sector.

Kuehn writes in JAMA:

Medical errors and software malfunctions that were linked to changes in the electronic medical records system used at Veterans Affairs (VA) medical centers across the country are drawing attention to the potential vulnerabilities of such systems.

Although many advocates of electronic medical records systems promote them as a means to reduce mistakes affecting patient care, the recent problems in the VA system and other evidence suggest that malfunctions of these systems or problems with the way they are implemented have the potential to lead to medical errors.

Drawing attention after how many years of physicians observing such problems in the commercial HIT sector and being muted by HIT companies on such issues, I ask?

How many times will we need to see such articles in print before physicians and patient advocates wake up? How many times would we need to see in print "chiropractors performing neurosurgery is harming patients" before we put a stop to that practice?

How many medical centers have lists and databases of known HIT defects, waiting to be fixed, that their patients and the public do not know of? How many physicians have been threatened with litigation for airing the dirty laundry?

Understanding how such problems occur as well as how they might be prevented is particularly critical as the Obama administration considers health care reforms that include more widespread adoption of electronic records systems in health care.

Indeed, although I would add "... as the Obama administration also moves from a suggested timeline of 2014 to a coercive 'do this or else' timeline."

As I've written, such a change is cavalier and suffers from the misinformation fed the administration by both the HIT ecosystem industrialists and opportunists, and those suffering from the utopian Syndrome of Inappropriate Overconfidence in Computing.

After a software update of the electronic medical records system at VA hospitals in August, health care workers at these facilities began to report that as they moved from the records of one patient to those of a second patient, they would sometimes see the first patient's information displayed under the second patient's name.

If not for the diligence of the users, that type of error could lead to dead patients.

This records-scrambling problem was reported at 41 of the 153 VA medical centers, said Gail Graham, deputy chief officer of Health Information Management at Veterans Health Administration Headquarters in Washington, DC. Graham explained that the jumbling of records was an uncommon occurrence that only occurred after a particular sequence of events.

As I mentioned above, the VA is an example of the finest environment, probably in the world, for HIT, being dedicated to patients and not profits (see the book "Medical Informatics 20/20" by Goldstein et al., and my linked quote, on that culture).

Imagine what goes on in commercial products where vendors' first priority is to profit margin.

Health care workers at the VA medical centers were notified about this potential problem in October, and on December 20, the centers received a software "patch" to fix the problem.

Nine VA medical centers reported another type of problem related to their electronic records system: physician orders to stop medication were missed, causing some patients to receive intravenous medications longer than necessary. The problem occurred because after the software upgrade, physician orders to discontinue such medications, which had previously appeared at the top of the screen, were not displayed.

In 3 cases, patients received infusions of drugs such as heparin for up to 11 hours after their physician had ordered the drug to be discontinued. Graham said the affected patients were not notified because they had not been harmed by the oversights. This software problem was corrected on December 8.

Again, this type of error occurs once too often, your patient's dead.

There are hundreds of types of problems that can occur as a result of such technology, and those experienced by the VA medical centers are not uncommon, according to Ross Koppel, PhD, professor of sociology at the School of Medicine at the University of Pennsylvania in Philadelphia.

For example, the scrambling of two different electronic records is a common problem that is not limited to systems used in health care settings, he said. Additionally, research indicates that poor layout of information in electronic medical records and related health information technology systems is the most common type of flaw (Koppel R et al. JAMA. 2005;293[10]:1197-1203). He explained that when health care workers have to look at several different screens or scroll through pages to access the information needed to make medical decisions, mistakes can occur.

My eight part series came to the same conclusions. In fact, I reached those conclusions and started writing publicly about them, in 1998. Was anyone listening? How many patients have been harmed, or died, in those past ten years due to industry inattention to these issues and leadership of HIT projects by unqualified personnel?

Additionally, medical errors also may arise from poor communication between electronic medical records and related technologies (such as computerized physician order entry systems) or between software applications created by different companies.

Other types of errors are caused not by flawed software but by how workers use that software in real medical settings. For example, an electronic medical record system may require a physician to enter a weight for a patient before prescribing a drug, even if a precise weight is not needed for that particular drug. A physician in a rush may enter an estimate of the patient's weight, but another physician who subsequently views the record might use that estimated weight to prescribe a medication that does require an accurate weight, potentially causing a dosage error. Detecting such problems requires careful observation of how systems are being used in real clinical settings and interviewing clinical staff about their experience, noted Koppel.

I claim these types of errors are due to flawed software. The flaw is in the ill-conceived, management information systems (MIS) inventory-system-mentality, mission hostile user experience the software presents to clinicians.

Although makers of electronic medical records software test it to detect problems that may lead to errors, federal oversight of such testing is lacking. The Certification Commission for Healthcare Information Technology, which is composed of health information technology industry organizations, has a certification program, but critics argue that such oversight is not sufficient and that the US Food and Drug Administration, the Centers for Medicare & Medicaid Services, or a new governmental agency should be given the authority to oversee these systems (Hoffman S and Podgurski A. Harv J Law Tech. 2008;22[1]:104-165).

"The bar on certification has to be raised to a level that ensures real safety, not just minimal compliance," Koppel said.

The CCHIT process is merely a specifications check or qualification of features, and is nearly useless by their own admission regarding most of the issues discussed in these articles. Worse, CCHIT has significant conflicts of interest with the HIT industry, having senior people who also hold senior industry positions and thus have fiduciary responsibilities to their employers (whether that is acceptable for a "certifying" organizations is open to debate, but the conflicts exist as fact). On a more minor point, this organization can't even manage its books properly, failing to file its required reports and temporarily being dissolved, involuntarily.

In fact, let me state that the lack of oversight of this industry amounts to, at best, governmental negligence, and at worst a complete dereliction of obligation to protect the public.

Imagine this type of arrangement in pharma or the (physical) medical device industry. Almost ten years ago I wrote HIT is a clinical tool for unforgiving medical environments that happens to involve computers, not a management information system that happens to involve doctors.

In other words, HIT systems are virtual medical devices that affect every aspect of care, and can cause the "learned intermediaries" to commit error as the JAMA article illustrates.

Koppel also urged caution as electronic records are rolled out. Although these technologies offer great promise in providing data for research and quality-improvement initiatives, he said more work is needed to make these systems work effectively in the context of health care.

"We should encourage [the technologies' development, but we should not force doctors to use them until they are shown to be more responsive to the needs of physicians and other clinicians," he said.

As to the "they", I believe Ross Koppel was referring to the computer artifacts themselves.

I would extend the "they" to mean the healthcare IT vendor industry itself, to most of whose leaders I've probably give an "F" regarding these issues and knowledge of Biomedical Informatics.

Excluding NextGen, whose AVP for Government Relations holds the vaunted and much coveted "American Medical Informatics Certification for Health Information Technology."

Finally, the VA is going to embark on upgrades to its laboratory components not by relying on its internal expertise, but by engaging the services of a private HIT company, Cerner, a company with a troubled record regarding the national IT initiatives in the UK (see here, here).

Considering that company's issues, and the internal complexities, dependencies, intra-component messaging, and other idiosyncracies of a system as complex as VistA, I opine that this is a major error.

Based upon my decades of knowledge about IT, biomedical informatics training, my analytical abilities and my own informed judgment, it is my deep fear that the VA will not "luck out" as in the above JAMA article. Patients will be harmed as a result somewhere down the line, I fear.

-- SS


Addendum 3/5/08:

I am promoting a user comment and my response to the body of this post itself, as I think they exemplify a central issue regarding HIT:

Paul Trossel on March 5, 2009 5:05:00 AM EST said...

Computer software in the Health industry are tools to use. Often the user thinks they are the ‘law’ in what they have to do. As long as people don’t understand the way they have to use their tools (eg surgical scalpel, machines, software etc.) mistakes will be made. Always check the outcome of the computer with your own judgement. As long as supervisors, bosses etc. help their people to understand that the use of the mind of a qualified professional is the outmost important and that the outcomes of the tools are the next, mistakes that lead to the death of a patient, will keep occurring!

My reply:

Mr. Trossel,

Forgive me for saying so, but you sound like an apologist for the Health IT medical device industry, which rightly fears increased scrutiny of its design, development, QC and lifecycle practices.

HIT is a medical device that happens to involve computer automation.

My apologies if I am incorrect, but it appears you're not taken care of a patient in the "fog of war" known as the ED, ICU or busy hospital floor.

Tools that distract, tools that mislead, tools causing cognitive overload are simply dangerous in such an environment. That is a clinical reality.

It is also clear you've not read my post [as above] in its entirety, nor my multi part series on the mission hostile user experience presented by HIT.

It appears even the most highly trained experts, especially when distracted, can be misled by faulty devices.

The recent crash of the Turkish airliner seems a case of just that. See "Altimeter, Crew Cited in Dutch Crash" in the Wall Street Journal.

It is the primary responsibility of the manufacturer of a medical device such as HIT to assure it is the best device possible, accounting for the very well known realities of the clinical workplace.

It is not the responsibility of the end user to be the bank and insurance policy for cavalier software design through tiring improvisation and workarounds to software device mismanagement and design decisions made by incompetents and HIT amateurs.

There is no excuse for ill conceived, designed and implemented HIT devices. None whatsoever, most especially depending on busy human users to compensate for the flaws on a 100% reliability basis.

Resilience engineering, a term I learned when presenting these HIT issues to the IEEE Medical Technology Policy Committee in Dec, 2007 (PPT here), is not about depending on busy people to cover for your device's defects.

Regarding a meta-issue:

It's absolutely a sign of our culture being in great distress when physicians have to answer to IT personnel about why the physicians best not be the "workarounds" and safety valves to ill conceived IT.

-- SS

The Malpractices of the Multitudes: the HIT Mission Hostile User Experience, Part 8

More on the origin of this post's title, penned in 1836, below.

(Note: Part 1 is here, part 2 is here, part 3 is here, part 4 is here, part 5 is here, part 6 is here, and part 7 is here.)

This post is part 8, and the finale, of a series on the stunningly poor human engineering of production healthcare IT from major vendors, in use today at major medical centers. These devices provide a decidedly mission hostile user experience, yet with an almost religious fervor are being touted as cybernetic miracles to cure healthcare's ills.

April 2011 addendum: see what might be considered part 9 at this link.

My college is a member of the iSchool consortium, consisting of schools of information science and technology (notably, not "information technology and science").

The iSchools are interested in the relationship between information, people and technology. This is characterized by a commitment to learning and understanding the role of information in human endeavors. The iSchools take it as given that expertise in all forms of information is required for progress in science, business, education, and culture. This expertise must include understanding of the uses and users of information, as well as information technologies and their applications.

Note the "as well as." Note the primary focus, and that which is secondary. This philosophy parallels that of Medical Informatics well.

This probably sounds like Martian to many in the healthcare and perhaps the broader business IT sector.

One of my colleagues on reviewing this HIT series had this to say:

It's really nice to hear that for once IT professionals have been able to successfully repeat the development lifecycle for healthcare information systems:

• Fail to understand the problem ->

• create a fragmentary and inaccurate requirements definition ->

• design an ambiguous, ignorant and risk-laden user interface ->

• pull all the misguided notions together with baling wire and call it a design->
  

• translate the "design" into an executable form, adding and subtracting design elements at random ->
  

• observe the first output from the system and declare it ready for the healthcare professionals. fini
  

Did I miss anything?

I believe he captured the essense of today's HIT vendor market well.

Here are examples of screen displays of vital patient information, displays that force clinicians to go on wild goose chases and seem designed by true neophytes to the field of information presentation and user interaction design. This is not to single out any one vendor. Many vendor products have deficiencies.

See this display of something as simple (one would think) as blood pressures:

(click to enlarge)

Note the following:

• Diastolic blood pressures in the left column;
• Systolic blood pressures in the roight column;
• An adventure to match them by date;
• No column headers at top.

Which value goes with which? How much energy does it use up to scroll around and connect the two?

This display is so poorly conceived, one wonders why it was included at all in a production system.

There's more. Let's troll for data, shall we?

See the blood oxygen saturation level, circled?

(click to enlarge)

What percentage oxygen was this patient receiving?

It's not there! Where is it?

Scroll down ...

(click to enlarge)

... and down ...

(click to enlarge)

Our answer, at last! Circled. Of course, the corresponding pulse oximetry is now off the screen.

How much attention would it have taken to present the two together?

How much coding would it have taken with today's computers, that execute billions of instructions per second, to dynamically condense the presentation of information, eliminating the absolutely empty cells between the two values?

Similar isses are noted for other biomedically coupled values, such as coumadin dose and blood thinning value (INR).

Screw matching those up, and as my mentor Victor P. Satinsky, MD might have said, your patient's dead.

Speaking about information sparsity, how's this display?

(click to enlarge)

There's one value in the entire screen. What a waste. How much difficulty would it have been to simply present the one row, automatically?

The EHR disperses and fragments vital patient information. How, exactly, is this is supposed to make clinicians more efficient and less error prone?

I am only presenting the easiest to present problems, easiest that is in a static medium such as a blog.

If presented dynamically, we find with some EHR's, for example, that it takes 50 or so mouse clicks across various screens and drop down lists and drop boxes to enter 5 common diagnoses.

It takes selecting from multiple hierarchical lists and buttons across four different screens, multiple times repetitively, to find out how well a patient is eating.

Here is simple advice from J Gen Intern Med 2009; 24(1):21-26.

It is imperative that usability principles are embedded in CPOE design to avoid

• overly complex screens
• poor grouping of like terms
• an inflexible human-computer interface
• mis-use of clinician time

Do the HIT vendors actually read such advice?

I wonder.

Medical Informatics reminds me of dentistry in its early days. B.T. Longbothom, author of the second dentistry book published in the U.S. ("A Treatise on Dentistry", 1802), gave an excellent description in his preface of problems at the time. His observations apply to Medical Informatics in our present age:

The word "dentist" has been so infamously abused by ignorant pretenders, and is in general so indifferently understood, that I cannot forbear giving what I conceive to be its original meaning: viz, the profession of one who undertakes and is capable not only of cleaning, extracting, replacing by transplantation and making artificial teeth, but can also from his knowledge of dentistry, preserve those that remain in good condition, prevent in a very great degree, those that are loose, or those that are in a decayed state, from being further injured, and can guard against the several diseases, to which the teeth, gums and mouth are liable, a knowledge none but those regularly instructed, and who have had a long, and extensive practice, can possibly attain, but which is absolutely necessary, to complete the character of a Surgeon Dentist.

Hardly anyone spoke out.

More than thirty years later, untrained practitioners were as prevalent as ever. One of the leading dentists of the time, Shearjashub Spooner, in his "Guide to Sound Teeth, or, A Popular Treatise on the Teeth" (1836) warned the public of a phenomenon I believe now applies to Medical Informatics and healthcare IT:

One thing is certain, this profession must either rise or sink. If means are not taken to suppress and discountenance the malpractices of the multitude of incompetent persons, who are pressing into it, merely for the sake of its emoluments, it must sink, - for the few competent and well educated men, who are now upholding it, will abandon a disreputable profession, in a country of enterprise like ours, and turn their attention to some other calling more congenial to the feelings of honorable and enlightened men.

I understand that point of view.

And with that, I end this series.

-- SS