Monday, January 09, 2006

Is the genie all powerful?

George Anstadt, in a comment on Blake's post on the etiology of crisis, draws attention to the potential benefits of new forms of information technology in health care, which he calls the "digital Genie." This seemingly very wonkish field is one that we should all try to learn something about, as health care consumers and as citizens.

Health Affairs recently published a theme issue on this subject. (Unfortunately, non-subscribers have access only to abstracts of most articles.) The more conventional term is Health Information Technology, which incorporates Electronic Medical Records (EMR) and Computerized Physician Order Entry (CPOE). These are linked, in that the physician's orders automatically enter the medical record, and information in the medical record can theoretically alert the physician if it affects the appropriateness of an order (e.g., a drug allergy or other counterindication).

People hold out great promise for HIT. If all, or at least most provider institutions used the same data format, medical records could be easily exchanged between doctors and hospitals. Consumers could, in principle, truly own their own records because all the records from all providers could be aggregated on a single server. (Did you know that legally, you already own your own records? You can ask to see them, and get copies. But hardly anyone does.) The record system could be programmed with "process of care standards," so that if someone was due a vaccination, or a screening test, the physician would be automatically alerted. They would also provide comprehensive databases of patient medical and treatment histories so that statistical analyses could be readily done establishing the compliance with quality standards of individual practitioners, hospitals, and health networks. CPOEs could be programmed to reduce prescribing errors and adverse events. The systems could automatically send reminders to people with chronic conditions about self-care. And so on.

This all sounds good although as Dr. Anstadt points out, it won't do anything directly about financial and other barriers to access. But as excited as many people are by the promise of such systems, there is a long road to travel before reality can be even close to the vision, and many potential pitfalls. Famous curmudgeonly critics David Himmelstein and Steffi Woolhandler, in the Health Affairs issue, run down the down side.

First, there's been talk of this digital revolution in HIT for decades, but progress has never come close to the hype. Many hospitals have installed computerized systems that they have ultimately abandoned; and while HIT has indeed gradually been installed in more hospitals, the much-touted safety and quality improvement capabilities are often lacking, and don't always work.

A major problem is that electronic systems don't do anything by themselves. They have to be integrated with human work processes and individual human behaviors. This is extremely difficult to achieve. It is also far from straightforward to determine what really constitutes quality of care. While numerous so-called "process indicators" have been developed -- e.g., what tests should be performed under what circumstances, what drugs should be prescribed, etc. -- there is little evidence linking any of these to better outcomes, and many physicians resist them on the grounds that all cases are individual and their judgment may override the one-size-fits-all recommendation. There is also no particular reason to think that patients will generally comply with the reminders and recommendations the systems generate for them.

Economics are also a problem. These may be good investments for large hospitals, but probably won't repay the investment for small and mid-size physician practices and community clinics. (They might repay the investment from a social perspective, but that won't motivate, or even enable, the individual practices to invest.) There would have to be a substantial government subsidy. They also require technical expertise to install, operate and maintain which doesn't currently exist. And inter-operability -- the single standard so that records will really be portable and exchangeable -- is a huge task that will require a major government investment and mandate, which will be accompanied by massive controversy. There is little discussion in Health Affairs of the privacy issues but they are obviously huge.

So HIT is a tool. Like any tool, it has to be wielded by a skilled user, or in this case, millions of skilled users, all working in concert, within systems of work that function effectively with the technology. A hammer and saw won't build a house, that takes a carpenter. We may be able to use HIT to make health care better, but the basic issues diagnosed by Blake will only be solved by people.


Anonymous Blake said...

Cervantes - your post today on HIT was on the mark!Thanks so much!And thanks for alerting our readers to the theme issue on HIT in Health Affairs. Absolutely, these are only tools-albiet powerful. Like other powerful technologies HIT holds great promise only if people with skill,competency and, much more importantly values, own and manage these tools.Also my colleague from Penn Sociolgy Dept-Prof. Ross Koppel-has written on potential downsides of HIT of which there are many. I invite him to post here. One common error I see with many IT (HIT or otherwise) programs is the failure of the technology developers/ vendors to carefully consider the culture in which they are attempting to embedd their IT? Cervantes- You are absolutely correct-we have a long way to go and ,in my opinion, we should "proceed with caution" but we should indeed proceed-The Genie is undoubtedly out of the bottle? :)

12:56 PM  
Anonymous C. Corax said...

My first reaction was to assume that the gov't would invite themselves to browse through the info at will--only the records belonging to terrorists, of course!

As Cervantes may remember, I have a friend who now has type 2 diabetes after being on Zyprexa and nearly doubling in weight in about a year and a half. Do you think that under a system such as this, the "Dear Doctor" letter would go directly to the patients, or would info like that still be filtered through the docs?

5:40 PM  
Blogger Blake said...

c.corax- as Cervantes said the confidentiality issue is huge with e-health records.I'm sure you have heard of HIPAA which is a half-assed beurocratic attempt to control access to private medical information. As far as doctors ever ceding the power to consumers to prescribe their own drugs, I don't think so? Recent trends however are tilting toward consumers. More prescription meds are going otc and of course our friends in Big Pharma directly market prescribed and OTCs to consumers daily- excuse me-hourly!I think you said a while back you don't watch TV-If you did you would also observe many law firms seeking your business for a multitude of unsafe meds. Sorry about your friend :(

6:01 PM  
Anonymous Ross Koppel said...

I've been invited to comment, and I know I'm seen as a sort of CPOE iconoclast. But, uncharacteristically, I have little to add the (excellent) original post -- which touches on many of the points I and others have sought to present.

I would, however, encourage readers to consider additional reasons WHY HIT has not lived up to its promises, why doctors live with systems they find so problematic, and what could be done to make them better? (And remember that HIT has many addition to its frustrating inadequacies.) Just to start the discussion, let me suggest a few of the many following possible causes: lousy understanding of the organizational structures into which the systems are placed, lousy understanding of the workflow processes onto which the systems are placed, a blind faith in technology (i.e., more technology = more efficient and safer), and poorly designed contracts that hospitals negotiate with vendors.

6:09 PM  
Blogger Blake said...

Thanks Ross- Your input is invaluable because you were/are an early leader in looking at HIT broadly.Let's try to keep this discussion going since the internet revolution is so central as a tool to do good or evil in addressing the US Health Care Crises we are attemting to address on this Blog. (Blogs being yet another example of the awesome power of the microchip)- Thanks again :)

5:02 AM  
Anonymous Blue Cross of California said...

Great blog I hope we can work to build a better health care system as we are in a major crisis and health insurance is a major aspect to many.

12:23 AM  
Blogger Blake said...

Thanks blue cross of california- we need your help- Be Well :)

6:20 AM  

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