Tuesday, January 27, 2009

L:imits of technology, Limits of intervention, EMRs, EHRs -Mr. President, Beware of Blind Belief in Information Technologies to Transform Medicine

The $825 billion stimulus plan presented this month by House Democrats called for $37billion in spending in three high-tech areas: $20 billion to computerize medical records, $11 billion to create smarter electrical grids and $6 billion to expand high-speed Internet access in rural and underserved communities.
The computerized records, when used properly, are an indispensable tool for measuring, tracking and improving patient care — yet only about 17 percent of the nation’s doctors are using them. They are commonplace at large medical groups, but 75percent of doctors practice in small offices of 10 physicians or fewer.

Steve Lohr, “Technology Gets A Piece of the Stimulus,” New York Times, January 25, 2008

Mr. President.

Yes, I know your advisors. like Dr. Robert Blumenthal of Partners Health, your unpaid health care advisor during your brilliant campaign, staunchly believes in the power of electronic health records to transform medicine.

Yes, I know your campaign succeeded in large part to your adroit use of the Internet to raise funds and mobilize support.

Yes, I know this is the Internet age, and you have been called the first Internet president.
But don’t let you and your advisors love affair with the Internet blinds you to these realities.

One, beware that too much unedited and undifferentiated information can be a bad thing. What doctors need is the right information. I was reading Malcolm Gladwell’s book Blink. He cites the ER Cook County Hospital in Chicago, where many go to the ER with chest pain. Doctors there who had too much information made the right diagnosis of a heart attack only 75% of the time, while those focusing on the presence of three symptoms – history of unstable angina, chest rales, and systolic pressure under 100 - - made the right diagnosis 95% of the time. Using less information to zero in on the odds of a heart attack is better than 40 ro 50 pieces of information.

Two, beware of information coming out of large institutions like Partners Health in Boston, a huge health system made up of many hospitals and thousands of employed doctors, as the sole guideline to the future of EHRs. These institutions have the money, technical infrastructure, and sophisticated personnel, to use EHRs, but they are not representative of health care as a whole, where 75% of care is delivered by private doctors in small practices. Small practices are a different breed of cat than institutional practices. For big institutions, IT can be useful in judging and managing population health of a subset of people with a given problem, like obesity and diabetes. But small practices may not have enough on any given disorder to judge performance.

Three , beware of the encroachment of information technologies on the privacy of patients and doctors, the use of IT to judge doctor performance, and its misuse in excluding doctors from large networks. The psychological and personal element in medicine, i.e, whether a patient likes and trusts a doctor are underestimated ; the “gray’ areas in diagnosis and treatment are often individualistic; and the Art of Medicine is often more important than the Science of Medicine. One cannot use compute to categorize all patient encounters, because these encounters do not fall neatly into diagnostic bins.

Four, beware of those who say computerized records are ready for prime time. As a means of communicating with patients or hospitals or other doctors, most EHRs are cumbersome, time-consuming, and worthless. Furthermore, they hinder productivity, cost too much, and have a mixed record in improving quality and preventing mistakes. As things now stand, EHRs are more of a giant invoice rather than a patient and doctor flexible device for improving care. Most doctors find implementing them is an overwhelming and unrewarding task, distracting from the important job of taking care of patients. Finally, most of these EHRs don’t even talk to one another, and writing software to overcome this illiteracy is an expensive and daunting proposition, with not enough programmers around to do the job. I’m sure standardization and certification may overcome these obstacles.

In implementing a vast national electronic network , keep in mind that a rifle is sometimes preferable to to a shotgun, that some things do not lend themselves to computerization, and that seeking help from physicians themselves would help make the computer systems workable, useful, and usable. I am keenly aware implementing EHRs may generate more knowledge workers’ jobs, but beware of unintended consequences.

On the other hand, Mr. President,

Beware of the vibes of this health IT skeptic,

Who is wary of IT as a health system antiseptic,

You may prefer to listen to your advisor CEO Eric Schmidt of Google,

When he tells you IT is one answer to the jobs creation struggle,

Or when he and others say health IT the final quality metric.

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