Fueled by the economic stimulus passed by Congress in 2008, the federal government has embarked on a controversial $30 billion program to induce doctors throughout the country to adopt electronic health records (EHRs) by 2014. The purpose is to create an interconnected system of electronic health records to improve safety and reduce medical costs.
But the United Kingdom has spent the last 6 years working on the same idea, and it's proven to be a colossal failure -- so much so that the government is drastically cutting its program. What happened to their plan? Should we be paying attention before rushing ahead with our own?
In 2005 the United Kingdom embarked on the largest investment ($18 billion) in health information technology in the world. Yet despite expectations that the system would increase efficiency and reduce medical errors, their efforts neither improved health nor saved money -- in fact in some cases, they may have led to patient harm.
Britain's government-run medical system is obviously different from our complex public-private insurance system. However, its electronic health record project bears an uncanny resemblance to the program President Obama is starting. Here are the mistakes the British committed that we are now repeating:
Too large and ambitious: The UK project tried to accomplish too much, too fast, attempting to digitize health records for the whole population in a period of four years. This massive undertaking is years behind schedule and has delivered only a fraction of what it promised. Despite all the money poured into the system, the vast majority of hospitals in the UK still don't have integrated electronic health records. Because non-clinicians developed the system, the electronic forms they designed have little to do with how doctors treat patients -- making it unworkable for many physicians. As the Chair of the British House of Commons Public Accounts Committee recently stated, "This is the biggest IT [Information Technology] project in the world and it is turning into the biggest disaster."
Too dependent on commercial, proprietary companies: Rather than create one system and beta-test it, the UK government depended on four companies to build the system, two of which quit or were fired for missing deadlines. So the health records were never developed in the south of England. The computer software was secret and proprietary. There was no accountability to the public, and the vendors did not provide enough technical support to clinicians having trouble using the records.
The resulting software errors and crashes caused missing or incorrect clinical information and sometimes threatened patient safety, for example by causing surgical delays and the cancellation of hundreds of operations.
If a country like Britain -- which already has a national health system and is a fraction of the size of the US -- had so many problems with electronic health records, imagine the problems America would face. Here, instead of four companies competing for contracts, we have dozens of vendors -- most with proprietary software -- vying for billions in stimulus funds. It will be virtually impossible to make their products compatible, therefore not allowing all doctors in different offices to see the same patient's health information.
Even our partial adaption of electronic health records is causing problems. Over the last couple of years, doctors and hospitals have reported to the FDA dozens of medical injuries -- including six deaths and preventable heart attacks -- caused by problems related to computerized health records such as software errors and unreadable computer screens. Some errors resulted in drug doses that were 10 times higher than intended. FDA officials called this the "tip of the iceberg".
More than 50 medical organizations, including the AMA, have called on the Secretary of Health and Human Services to delay the program. In response, the administration delayed some of the required health IT functions, but kept the same 2014 deadline.
How do we avoid the UK's failure? The administration or Congress should slow down the program and delete those parts of the legislation that fine doctors for not using this technology. There's no need to have this system in place by 2014. Instead, we should conduct rigorous studies of the cost-effectiveness of electronic health records systems before mandating their use. Rather than force doctors to choose from dozens of commercial software products developed in secret, we should take a hint from the non-commercial sector, such as the Veterans Administration, which uses "open-source" coding so people can work collaboratively to continuously improve the system.
The Obama administration wants government programs to be based on evidence of effectiveness. Simply following the lead of "IT believers" and salesmen without the requisite evidence will repeat the UK's failures. Now is the time to proceed carefully, consider existing research and the British experience, and chart a more rational course into the digital age of medicine.
Stephen B. Soumerai is Professor of Population Medicine at Harvard Medical School. Anthony Avery is Professor of Primary Care at the University of Nottingham Medical School, UK.
Janet Dillione: Electronic Medical Records: How They Affect Patient Care
Electronic medical records could be a tool for improvement, but what the companies are selling to doctors are systems they hype as increasing income (because of the ease of up-coding) and electronically sending prescriptions to pharmacies. Neither of these outcomes will benefit patients.
These devices are indeed dangerous as noted above. HIT devices made the top ten list for tech hazards in the US. I remain shocked that doctors put up with this crap and have not reported the adversity to the FDA and other authorities.
Way to spin it, Doctor.
A health IT complication could be a doctor ignoring a warning on an EMR system or a nurse failing to properly document something, or any number of human errors completely unrelated to the safety or reliability of the EMR itself. The same mistakes are made on paper constantly and in the electronic world are usually related to improper or inadequate training of staff by the facilities that purchase these software products, not the products themselves. My company's software has an average 99.975% uptime, with the lowest value around 99.7% (and that's extremely rare - for the last year of data I have available offhand, only 9 customers out of over 200 had rates below 99.89, with 3 at 99.88, and only 3 below 99.8 - not to mention that downtime is usually due to failures with the customer's hardware, not the software). Now that's certainly something that needs to be spoken to, but it can't be an outright indictment of EHR in and of itself. Much of that sort of thing can be prevented with better onsite IT maintenance.
The doctors don't report any adversity because EMRs are still far and away better and safer than paper. I'd rather have a fuzzy screen one in a million times than illegible chicken scratch every day.
Truth Be Told!!!
As for intrinsic safety of these devices to manage complex illness in complex hospital systems, well, it has been flat out ignore, to the detriment of the patients.
Your excuse and truth is vapid. If the devices were any good, the doctors would not have rebelled.
Complexity is only a problem when using a database-centric model. By using a document-centric model complexity is not an issue, after all human knowledge is captured in document form, so it's just a question of creating structured documents so they can be programmed.
The only organization that has the resources, authority and correct business model (budgetary) is the HHS in America. Although it would even be better if all countries of the world pooled their resources.
The problem is that health care is a process not a turn-key system therefore the IT system must also be a never ending learning process. And as I outlined earlier the technologies already exist it's just a matter designing the public-private process.
http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=2009
Some of this literature, namely the US Joint Commission Sentinel Events Alert and the National Research Council study, come from the most reputable sources. In fact the National Research Council's the highest scientific body in the US, and the study was led by two world renowned pioneers in health IT (Drs. Octo Barnett of Harvard, and Dr. Bill Stead of Vanderbilt).
The National Research Council report concluded: "Current efforts aimed at the nationwide deployment of health care information technology (IT) will not be sufficient to achieve medical leaders' vision of health care in the 21st century and may even set back the cause."
But I agree with you about the Windows-style menuing system and the database which are both based on transactional systems. Where as health care is a series of events. Which is why I feel the structured document and workbooks are a better design. Seems to me anything that mimics the paper folder has the best chance to succeed.
The DITA-based workbooks guide never compel and can never be entirely validated, only some or all the steps can, this allows it to also be a data collection system. Combined with the use of registered steps the workbook could easily integrate with any hospital sub-system through an ESB.
EHR - Secure Audited XML-based Personal Health Record, that is both the medical history as well as the current medical chart.
MediStep - A validated step like a medicinal treatment regiment.
MediBook – Is a collection object that contains all links to current and historical treatments.
MediAlbum – Is a collection object that contains links to all the MediBooks for all members of the immediate family.
MediTree – Is a collection object that contains links to all individual MediBooks in your family tree.
MediForest – Is a collection object that contains links to all individual MediBooks in a geographical area.
MediGroup – Is a collection object that contains link to all individual MediBooks based on a particular race, genealogical or at risk pool.
MediCountry - Is a collection based on cultural habits of a particular group and whether they are in country or not.
MediEnvironment - A collection based on environmental factors that may affect health care decisions or recommendations.
Of course participation in all the workbooks/books is entirely voluntary.
To answer your question, it must be understood that these EMR and CPOE instruments are medical devices that have not been approved by the FDA.
They are experimental devices, and the patients being cared for with these devices are guinea pigs for the vendors.
The experiment in the UK has been a costly failure, using HIT devices manufactured, in part, by American companies.
For starters, there is not ANY evidence that CPOE devices improve overall outcomes or reduce costs.
Thus, there needs to be methodological study to determine if these devices meet standards for safety, efficacy, and usability before being deployed on patients, just like what is done with devices such as artificial knee joints.
There must be after market surveillance whereby all users report near misses, injuries, deaths, device flaws and defects, misidentifications, and user bewilderment.
Yes, deaths have been directly and indirectly caused by these devices, and no one is recording them. Certain CPOE devices out there should be removed from the market.
Stop this experiment now.
Ever seen a system crash? Hard? I have. Not pretty.
Many of the long-term unemployed no longer have the resources to land or keep a private-sector job it's time for the government to step in and make them employable again. Anyone that knows how to work an Excel spreadsheet can do this.
Now if we would just help the unemployed by fixing the infrastructure but not in the way that comes to mind. The movement of government documents from unstructured to structured and the creation of EHR for all medical records are highly labor intensive jobs that require XML but can be learned quickly by the unemployed, the creation of these would provide on the job training, could be done on second or third shift using the computers at our schools and since XML is the next large productivity tool for small and medium size businesses over the next decade the experience is needed by private industry.
Under the current $42,000 for Doctor's offices to convert to electronic records most of the work would be done in India depriving America of a much needed middle-class skill set because categorizing information, XML and information is a growing industry.
1) EHR is the patient's health record - This is the patient's medical history and active chart which is a completely separate entity and complete unto itself.
2) Workflow\treatments\diagnostic - This changes every five years or less and therefore needs to be highly adaptable. It is not dependent on the setting or the tools used but rather evidenced-based "Best Medical Practices" multi-threaded workflow.
3) Administration - This has nothing to do with health care, just payments, resupply, etc. the administration needs of the particular setting.
4) Medical devices, MRI, eg.- Are the tools a medical provider uses as aides in treatment or diagnosis, it is loosely-couple but subservient to the other items.
So the EHR and the workflow are securely accessed through a smartphone and stored at a telecom which has a document\content\record management system. This allows it to be layered over whatever medical setting the medical provider is in, the ability to adapt and to be updated across the country in minutes.
The Administration item is stored in a database at a particular setting because it's specific to the site.
The medical devices are integrated using SOA architecture through an ESB to the other items.
Done.
Now the government has predicted the future, because of that, investors can invest and innovators can innovate. Now the home medical office is a reality.
References
EHR http://en.wikipedia.org/wiki/Electronic_health_record
XML http://en.wikipedia.org/wiki/XML
XML schema http://en.wikipedia.org/wiki/XML_schema
XForms http://en.wikipedia.org/wiki/Xforms
web-services http://en.wikipedia.org/wiki/Web_service
IETM Class V http://en.wikipedia.org/wiki/IETM
DITA http://en.wikipedia.org/wiki/Darwin_Information_Typing_Architecture
A presentation by IBM using DITA
IBM http://dita.xml.org/sites/dita.xml.org/files/IDCMSBlue.pdf
Cloud Computing http://en.wikipedia.org/wiki/Cloud_computing
SaaS http://en.wikipedia.org/wiki/Software_as_a_service
An excellent article from a Brookings Institute Study from a medical standpoint http://www.brookings.edu/reports/2009/0901_btc.aspx
Much of the data we have is utterly useless now.
Get this done. Start with the VA and Military as the Obama administration has done and when that is working, scale it out.
EHR systems really can improve the practice of medicine, but some are better than others. An advantage of the 2009 HITECH Stimulus approach is that Medicare providers can shop around for the system that best meets their needs. The danger is that such freedom will lead to poor choices due to slick marketing and lack of consideration, not to mention quasi-imposition of inferior EHRs via hospitals subsidizing particular systems.
What helps is to learn from the experience of others. The American Association of Family Physicians (AAFP) surveys their members every two years, which generates enough data to be statistically meaningful. (Only 10-20% of all doctors currently use an EHR, and getting enough responses from this already small group is daunting when you consider that there are hundreds of EHR systems on the market.)
Here are links to their latest surveys:
2009: http://www.nxtbook.com/nxtbooks/aafp/fpm_20091112/#/12
2007: http://www.aafp.org/fpm/2008/0200/p25.pdf
(click your 'reload' button if it seems to take a while)
PHYSICIAN ATTITUDES & ADOPTION OF HEALTH INFORMATION TECHNOLOGY (PDF)
http://aapsonline.org/surveys/hitsurveyresults.pdf
I commented on this at http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html
Had the UK government developed it's own in-house open source system it could have been developed for a fraction of the cost in a fraction of the time.
I thought that most issues in the UK occurred because the chosen vendors had expertise with hospital EHR's but were not tuned in to what it takes to have a functional out-patient EHR.
There is more to this story - an investigative reporter from outside the political spectrum needs to take a look. This article does not seem to give a thorough look at the issues.