by Bob Wachter, MD
In 2001, when my colleagues and I ranked nearly 100 patient safety practices on the strength of their supporting evidence (for an AHRQ report), healthcare IT didn’t make the top 25. We took a lot of heat for, as one prominent patient safety advocate chided me, “slowing down the momentum.” Some called us Luddites.
Although we hated to be skunks at the IT party, we felt that the facts spoke for themselves. While decent computerized provider order entry (CPOE) systems did catch significant numbers of prescribing errors, we found no studies documenting improved hard outcomes (death, morbidity). More concerning, virtually all the research touting the benefits of HIT was conducted on a handful of home-grown systems (most notably, by David Bates’s superb group at Brigham and Women’s Hospital), leaving us concerned about the paucity of evidence that a vendor-developed system airlifted into a hospital would make the world a better place.
Since that time, there have been lots of studies regarding the impact of HIT on safety and, while many of them are positive, many others are not. In fact, beginning about 5 years ago a literature documenting new classes of errors caused by clunky IT systems began to emerge. A study from Pittsburgh Children’s Hospital found a significant increase in mortality after implementation of the Cerner system – a study that was criticized by IT advocates on methodologic grounds, and because “they didn’t implement the system properly.” Studies by Ross Koppel of Penn and Joan Ash of Oregon (such as here and here) chronicled the unintended consequences of IT systems, and urged caution before plunging headfirst into the HIT pool. I raised similar concerns in a 2006 JAMA article, and also recounted the iconic story of Cedars-Sinai’s 2003 IT implementation disaster, where a poorly designed interface, combined with physician resistance to overly intrusive decision support, led the plug to be pulled on the $50 million CPOE system only a few weeks after it was turned on.
A new story line was emerging, and its theme was that implementing an effective HIT system is harder than it looks. And yet one could not deny the political attractiveness of computerization – during the last presidential campaign, the need for HIT was the only thing that McCain and Obama seemed to agree on, and a prominent proponent of a Manhattan Project-like push for HIT has been none other than Newt Gingrich, not exactly a freewheeling spender.
These politics led to $19 billion being included in February’s stimulus package to support HIT implementation in American hospitals and clinics. Once federal HIT Czar David Blumenthal figures out how to divvy up the money (it hinges on coming up with a workable definition of “meaningful use” of HIT, which would unlock the door to the federal vault), HIT will have its big Coming Out Party. Cue the balloons and streamers!
It’s all pretty exciting… if the systems work.
Fast forward to today’s Washington Post, where an article describes a new crusade by Iowa Senator Charles Grassley to confront HIT vendors who sell defective products. Grassley, who has taken on the role of keeping professions honest (including scrutinizing physician relationships with pharma and device companies, attention that is long-past due), has raised a number of concerns about the safety of store-bought IT systems, and has sent a letter of inquiry to one of the companies (Cerner) that looks a lot like a prelude to a Senate subpoena.
Interestingly, many of the issues raised in the Grassley letter mirror an argument advanced by Penn sociologist Ross Koppel in JAMA earlier this year (for which he was vilified by the IT community – both implementers and vendors). Ross (who is a friend) noted that most of today’s IT implementation contracts insist on gag clauses for clinicians who identify errors caused by faulty software, and virtually all contain hold-harmless clauses for the vendors in the event that an IT-related error leads to patient harm. The vendors’ case seems like a version of the “guns don’t kill people…” argument: there is nothing wrong with the software, the errors reflect poor implementation practices or screw-ups by users, yada yada. This is certainly true at times, but Ross and others have documented scores of errors that are absolutely inevitable given clunky software and poor user interfaces. It seems right that the vendors would at least share responsibility if patients were harmed in such circumstances.
This is all acutely interesting to me right now, since my own hospital (UCSF Medical Center) recently entered the not-very-proud fraternity of hospitals who aborted their implementation after an IT system failed to live up to expectations. In our case, nearly a decade ago, we put our IT nickel (actually, more than a billion of them) down on a system built by a vendor named IDX. A few years later, when IDX became wobbly as a company, we were reassured when technology titan General Electric gobbled them up. “They’re GE,” we thought, “they’ll get this right.” We eagerly signed on to be development partners with GE and found ourselves in a world of missed deadlines and inadequate support; in short, neither product nor vendor seemed ready for prime time. After years of negotiations, hair-pulling, and prayer, we recently pulled the plug on our GE relationship. (I’ve been on the committee overseeing our transition, and won’t divulge any confidences, but all of this has now been reported in the media.) Just last week, our CEO Mark Laret publicly announced our intention to pursue an implementation with Epic, the Wisconsin company that appears to be emerging as the best of the breed. I’m hoping that this is the system we’ve been waiting for (the reviews from colleagues who are using Epic elsewhere are generally reassuring), and not, as my friend Jim Reinertsen sometimes quips, simply “The Cream of the Crap.”
Last year, I wrote about the Technology Hype Cycle, a predictable roller coaster in which new technologies are over-hyped (the “Peak of Inflated Expectations”), fail to live up to their expectations (the “Trough of Disillusionment”), and ultimately (if they’re any good) traverse their “Slope of Enlightenment” before reaching a “Plateau of Productivity.” CPOE, and HIT more generally, are clearly on this roller coaster – somewhere between the “Trough…” and the “Slope…” Since we are about to invest 19 billion tax dollars on nationwide implementation of these systems, let’s collectively hope it is the latter.
Obviously, we simply must computerize American healthcare: in 2009, how can we possibly improve our care and coordination when we document our work by writing in chicken scratch on pieces of dead trees? And there are healthcare organizations that have enjoyed successful implementations and are beginning to reap real benefits, in quality, safety, and efficiency.
But it is not a slam-dunk, and there are some crummy systems out there that have the capacity to cause harm. Having folks like Ross Koppel, and maybe even Senator Grassley, push the IT companies to do better and be accountable for their products is critical if we’re going to get this complex but crucial task right.
Bob Wachter is Professor of Medicine and Chief of the Division of Hospital Medicine at the University of California, San Francisco. Author of 200 articles and 6 books, he coined the term “hospitalist” and is considered one of the nation’s leading experts in health care quality and patient safety. He blogs at Wachter’s World, where this post originally appeared.
Submit a guest post and be heard.
Related posts:
- Data entry in EMRs, and why doctors are slow to adopt information technology
- Working harder won’t reduce medical errors
- How to choose the right electronic health record (EHR) consultant
- Another EMR fear
- Quality and safety are not the same thing
- Implementing electronic records
- The real scoop on EMRs
{ 17 comments… read them below or add one }
Epic is crap. Good luck with the transition. After using it in residency, I won’t work anywhere that has it. It makes CPRS (VA system) look good by comparison.
“because of the inadequacies and medical unfriendliness of Epic, this was a painful chart to review. Review time started 9:00. Review time and dictation completed 1:40.”
This statement was lifted directly from a patient chart in the last week by a world renown specialist (and an excellent clinician in my opinion) consulting on a patient of mine.
I really don’t like that ‘hold harmless’ clause. It’s one thing to have it on a game or payroll system, but where lives are at stake, the common good dictates that this clause is unconscionable. Somebody should test the legality of that type of contract. Seriously! Vendors should be held accountable for significant and costly errors in their systems.
In the disciplines of Information Systems and Computer Science, we now know enough about software engineering, usability testing, and certification/validation of the logic in the processing. In the last 30 years, we’ve learned a lot about user interfaces, electronic data interchange (EDI) and other issues about sharing data across networks, and security. This knowledge has lowered costs, improved efficiency and quality, and improved customer service in business. This knowledge is directly transferable to HIT and EMR systems.
In this profession, we now have a lot of programmers and analysts with professional training in software development and security measures. We now have a lot of managers with professional training in managing large software development teams. We now know a lot about professional project management (including proper estimation for schedules, budgets, testing, and use of slack) and there are excellent certifications to prove qualifications. We know a lot about the factors that affect successful software development and implementation projects (including user involvement and training).
Failure to use that knowledge, choosing to hire less qualified people to lower costs, and hiring people with more current knowledge about specific cutting edge technology but little training in the areas mentioned above (often more cheaply because of H1-B visas) will continue to result in poor software and failed implementation projects and wasted money. Not to mention bad outcomes in terms of health and deaths.
Sorry for the diatribe. I’ll step down from my soapbox now. Bob Wachter’s excellent article just hit a sore spot with me. I just get angry when software development companies adopt a short-term, high-profit orientation and throw what we know about developing quality systems under the bus.
Concerned, educated patient
(with an undergraduate degree in computer science, an MBA, a PhD in information systems, and better than 30 years experience.)
As a former computer programmer, a practicing hospitalist, and the CMIO of a hospital one year into our implementation, I have closely watched this phenomenon across many hospitals.
My own personal take : Of the “user experience” that most docs/nurses/pharmacists describe, only about 20% of it is actual software – The other 80% is support, training, and hospital governance.
In short, the best software, installed at a hospital with clunky organizational structures, will fail.
This is the part that most hospitals struggle with : How much to invest in the ongoing support? How much to invest in the training? How do we reorganize our hospital’s hierarchy to fit the needs of a modern EMR?
(The flip side of this coin : Yes, the VA Vista has 100% CPOE, and is entirely electronic – And yet, I believe that taking Vista to a private hospital will ultimately fail if the hospital doesn’t rearrange its culture.)
There is certainly room to improve these processes.
The alternative, sadly, is not computerizing – Which results in patients showing up in EDs with no med list, who are then subject to extra testing and medication duplications or interactions which further drive up the cost of healthcare and decrease quality.
The solution, I think, is vendors working closely with strong physician leadership to provide a more intuitive clinical experience – And, at the same time, hospitals being aware of the hidden support/maintenance costs, and giving ample resources to hold up this side of the EMR equation.
(Most vendors don’t talk about this hidden side of the equation because, essentially, it makes for a difficult sell.) But I think if hospital administrators are better aware of the ongoing maintenance needs, they will at least have the chance to devote resources to this essential piece of the puzzle.
Besides the choice of EHR, the implementation of the chosen EHR is very important, as “concerned, educated patient” stated. There is a good history of software implementation in various settings. Any implementation, and indeed, choice of an EHR should include a team made up of representatives of potential users led by a respected physician or upper level administrator. The rollout should be well-paced and deliberate. Not all features of the software need be used initially.
I’ve recently written a brief paper on implementation strategies and posted it on my home page, if any are interested.
Even with the best implementers you can’t get a good implementation if the staff doesn’t buy-in. Even with bought-in staff it’s a process, not a one time event.
How many of us have been to the doctor with some problem and been told – take this, if you aren’t better call me back….. Oftentimes the first pass at something isn’t some $4 drug, it’s an expensive pill or procedure that didn’t solve the problem, so back you go.
It’s the same with IT. You start in one place, you change, you never totally end the process.
So yes, to agree with the author – it’s hard.
Face it, EHRs are crap. We have had ours for 3 years. No pt lives have been saved, and my workdays are an hour longer. The front office staff’s days are shorter.
Interestingly, the author’s data, which indicate no or minimal benefit from EHRs, don’t support his conclusion, which is that “we simply must computerize American health care.” Wrong. Follow the evidence to where it leads, Dr. Wachter.
I am an overbusy family doc who precepts med students. They are also not impressed with our EHR. Will that dissuade them from primary care? Now that would be an interesting study.
emr’s are terrible for direct patient care. they may and this is unclear afaik, improve care in the global sense. but they take an enormous amount of the most precious resource-physician time- and convert work other people could do into stuff physician’s do.
i definitely knew my patient’s better when i had to handwrite every medication and past medical problem down myself.
when i had to ask about allergies.
and when i had time to do those things. Now, i can’t concentrate on patients because i get paged incessantly for a million crap things. inpatient or outpatient, can i change it for you? someone somewhere wrote pt smoked. can you enter an order for smoking cessation. pt bmi >x, can you add obesity to list. but i digress. the point was the emr allows other people to scan these charts for all this stuff easily. we should focus on making the emr do what we want as well as what we don’t want.
whose idea was all this anyway?
As someone who has worked in and around healthcare and the health insurance industry for 30 years I have seen a lot of changes…some good, some bad. I think everyone agrees we need a good, simple, effective EHR system that will integrate seamlessly with other related systems. The problem becomes with getting all the players to work together to create such a system. Every company is worried about profit and securing their section of the market rather than what is in the best interst of the patients, practitioners and payers. The systems has to be something that will work globally to be truly effective. We now have dictation and billing being done off shore to save money, so any system has to work for them. We have surgeries being done remotely via robotic or web instruction so these records have to be able to be accessed globally. We also have the need for other service providers to access and add to the records, such as pharmacies or home health providers so information can be available real time for providers to make the best treatment decisions. With a good system that will serve all those that will interface with it care will improve and after the learning curve, the work load of those using it will decrease. I have always found it funny that while medicine is a field of change, we are some of the slowest to want to adopt change, we do so only while complaining and dragging our feet! I do believe our current EHR options are limited and until we can get cooperation instead of competition between the factions we will not have a strong enough, reliable enough system to see its true capabilities and possibilities. I also believe the best system will probably come about from insiders rather than outsiders trying to get on board with the next great money maker. This will have to happen in the near future, so we as users have to work together to point out the flaws and benefits if we hope to see this technology develop into the useful tool we all need.
“I have always found it funny that while medicine is a field of change, we are some of the slowest to want to adopt change, we do so only while complaining and dragging our feet!”
I disagree vehemently with this. Medicine is very quick to change when there is valid evidence to prove that the change is beneficial. Most MDs feel instinctively that EMRs will not improve patient care, and so far, the evidence supports their gut reactions.
Posted on Facebook
A great deal of mischief is being caused by the EMR being forced on doctors and hospitals by outside forces. IT is successful when the players who own it, implement it, and control it are free to do so in a manner and at a time of their choosing and initiation because they become convinced that it is going to help them achieve their goals. The health care industry hasn’t fully implemented it because they shouldn’t. They have only gone as far as they have because they are being coerced. It should be no surprise that under these coercive conditions, it is a failure. Such a process is why the soviet union failed of course.
The idea that doctors are luddites is ridiculous. If they were, we would just be getting around to accepting antibiotics for strep throat.
The idea that hospitals need to spend massive resources on training to implement a system is ridiculous. If the system is well designed with full knowledge of how the hospital and workers do things, little or no training should be necessary. Good software is intuitive. The best IT system that I have ever used was used by me with no formal training. I was given a user id and password and the rest I picked up on my own or brief 30 second “Let me show you” sessions by other users. It was great.
You can’t blame inadequate hardware development–that system was in 1987. Every system that I have used since was cumbersome or unusable in comparison. The difference was the software design. Fitting the shoe to the foot rather than the foot to the shoe.
Hold harmless clauses make since in most industry software implementations. The industry is completely free to not use software at all, is completely free to set the parameters and desired object and functions if the system. The purchaser is in control and knows it’s needs better than the vender and therefore rightfully fully responsible for making sure the product fits those needs. It is the element of coercion that is making the normal “hold harmless” contract seem unfair and it is the force premature implementation that is making the gag clause such a danger, as it prevents working the bugs out of what is a massive beta implementation.
The notion that anything any of those clowns in the Senate or congress is actually going to be helpful is, in the face of observed reality, silly. Can anyone actually still believe that our ruling classes can touch anything without turning it into shit?
Marianne writes that we all agree that we need a good,simple, effective EHR that will integrate seamlessly with other systems. No, Marianne, everyone does not agree with that. In fact, several of us doctors at this thread have stated that we think EHRs are junk technology that should be scrapped. Moreover, evidence for our view is as strong or stronger as the evidence for your view.
I of course don’t believe they will be scrapped and fully expect to see collateral damage to the HC system from their implementation.
Some technology is fine for the primary care doc. PDAs are great, I use mine all the time, especially epocrates . Our digital radiology setup is fabulous. UpToDate, couldn’t live without it. The problem with EHRs is that they force us to deal with irrelevancies and waste our precious time–even the good ones do this, because they turn us into data-entry clerks. Adam Smith addressed this issue in 1776. His example of the pin factory shows how division of labor leads to increased productivity. EHRs go the other direction, lumping physician labor with clerical labor. This leads to decreased productivity. Come on folks, this is a 200 year-old insight, not rocket science. And all the re-engineering in the world won’t change this fact. If doctors have to input data and if physician labor is in short supply, then EHRs will decrease productivity.
Oh, but they’ll improve pt care and save money, they tell us. Balderdash. Show us the data.
And that’s not all. Med students are not beating down the doors to be EHR-jockeys–I mean primary care docs. Who can blame them? Maybe the hope is that midlevels won’t mind.
On average, 30% of patient charts are not available during a patient visit, according to a Gartner Group research study. With EMRs, patient information is immediately accessible, which can save every doctor using an EMR around an hour per week that would have been spent waiting for charts to be delivered. That’s 52 hours a year waiting for charts instead of seeing patients!
Any office that can’t locate 30% of their charts is so poorly run that EMRs won’t make any improvement (and may make things worse).
@ R Watkins: Ditto
@ SpringCharts: my charting/reviewing time per day went up by 2 hours with our EMR. That’s 52 hours a month.
When I ran my own office, my paper charts were available 100% of the time. I have worked in may settings and the probability of charts not being available increased in inverse proportion to the power of the physician to influence the hiring and retention of the person responsible for delivering the chart. Interestingly, the same has held true for the unusability of IT systems. IT does NOT fix poor management . . . rather it magnifies the chaos. A computer is only a calculator that can be instructed to do the same thing over and over again. It is an effort multiplier like a lever. It multiplies misguided efforts as readily as appropriate ones.