President Barak Obama is presenting healthcare reform as an element of his economic stimulus package and as good medicine for a sick economy. If legislators can be coaxed into swallowing the stimulus pill whole and healthcare reform is allowed to go forward, computerization of the nation’s health records will be a foundation project.
His predecessor was there before him. In 2004 former president George Bush ordered an e-health record system for the nation by 2014, and stakeholders set about building a national health information network. Obama will need to assess the headaches of the first years of the program to determine if the present concept remains the best way forward.
As envisioned, the network will replace paper patient files with a digital record containing his or her complete medical history. That record will be accessible in an instant wherever treatment is sought. It will operate as a large number of independently managed, peer-to-peer, regional networks, not a centralized system. At present, the federal government is only a junior partner.
Listing the potential benefits of an interoperable e-system shortly before he took office, Obama said it will “cut waste, eliminate red tape, and reduce the need to repeat expensive medical tests. It just won’t save billions of dollars and thousands of jobs – it will save lives by reducing the deadly but preventable medical errors that pervade our health care system."
Bush argued for the system in terms like these when he presented it in his State of the Union Address on 27 April 2004. As a sign of the times, he also promoted it as a surveillance tool for pandemics and biological terrorist attacks.
Bush choose David J. Brailer, M.D., Ph.D. to lead the project in 2006. Though Brailer has since resigned as health IT czar and Robert Kolodner has taken his place, he remains one of the network’s most fervent advocates. In a recent CNN Money interview, he conceded the network would be expensive, but pointed out that the potential savings for the health industry amounted to $200-300 billion a year.
The network’s advocates argue that the system will give physicians a cradle-to-grave view of a patient, allowing them to focus on preventive care. They also maintain that the death toll from medical errors – which different studies put at anywhere from 44,000 to 195,000a year in the United States – could be cut dramatically if doctors had better information about each patient. The Institute of Medicine, part of the National Academy of Sciences, maintains that better information could help resolve the drug interaction problem that claims some 7,000 deaths a year in this country.
The advocates’ conviction that an interoperable e-patient record system will inject money-saving efficiency and safety into the US healthcare system remains unshaken, but faith alone won’t expedite this project. The obstacles to progress and false starts represent “rich pickings” for the media, while research findings introduce a note of skepticism about the vaunted benefits.
Robert. N. Charette’s overview of the project in the October 2008 issue of IEEE Spectrum, the journal of the Institute of Electrical and Electronics Engingeers, Inc. (IEEE), laid out some of the most perplexing issues for the experts. If the system is to be realized, he explained, it will mean getting every hospital, every nursing home, every pharmacy, and every one of the hundreds of thousands of physicians who belong to solo or small group practices to participate. “Decades after virtually every significant enterprise in the developed world turned to computers to keep records,” he wrote, “computers still remain astonishingly underutilized in medicine, their use suppressed by financial, sociological, and political issues—and the sheer complexity of the automation challenge.”
Charette reported that only a quarter of the 5,000 or so community hospitals in the United States even have an electronic medical record system in place, and hardly any of them are accessible outside their host institutions. The era of under-equipped emergency rooms and nursing shortages helps to explain the slow uptake, he explained. “Convincing a cash-strapped hospital to invest millions in computers, software, networks, and consultant fees can be a tough sell.”
One formidable challenge is persuading clinicians, in particular, to give up old routines and adopt new ways, Charette added.
Human Factors Hurdles
Luis Castillo, senior vice president of Siemens Healthcare, a company that designs health care technology, said the experts will have the extremely difficult task of designing a system that "thinks like a physician." Doctors cannot spend hours and hours learning a new system," he said in the CNN Money interview. "It needs to be a ubiquitous, ‘anytime, anywhere’ solution that has easily accessible data in a simple-to-use Web-based application." The doctors have to learn how to interact naturally with their patients, even as they are entering data into their PCs.
Experts project that there will be delays in seeing patients while physicians climb the learning curve. Business Week Online reported in October 2005 that the United States Health and Human Services Department will adopt rules that provide greater access to hospital computer systems for outside doctors. The measure is aimed at encouraging more doctors to keep electronic medical records.
Charette points out that figuring out how to integrate the many types of information that could be included in a patient’s record—doctor’s notes, test results, billing data, not to mention the dozens of sources of information—has been an enormous challenge. Still unanswered are how the hundreds of thousands of electronic medical record systems will interconnect, he says; how they will they exchange data; how the privacy and security of hundreds of millions of personal files be maintained; and who will pay. He notes that the biggest question of all is whether the network, once installed, will work.
The effort to build patient privacy into a network that is national in scale presents both human factors challenges and technical headaches. Several articles cite concerns about hackers and system failures. As reported in the Charette article, Britain’s experiences to date offer a foretaste of issues that will have to be confronted on this side of the Atlantic. One hospital in Oxford reported patients’ digital records disappearing from its database. A recent study found security systems that were so poorly constructed medical staff routinely bypassed them when accessing Britain’s National Health Service computer systems. The study documented 70,000 cases in a single month of people at one medical trust gaining inappropriate access. Some doctors have refused to enter any patient data into the system, for fear of making errors or compromising their patients’ privacy. In some surveys, support for the project among doctors has fallen by almost half over the past two years.
Charette asks how it will be possible to ensure that various healthcare workers see only what they need to see. Should a podiatrist be able to see a patient’s psychiatric file, for instance? Who’s responsible for fixing mistakes in a patient’s record, and how can a patient even tell if a mistake has been made? He noted that during a typical hospital stay, an average of 150 people—including nurses, X-ray technicians, and billing clerks—have access to a patient’s medical records. In one incident, a star baseball player who had been treated at a New York City hospital for a shoulder injury had his test results looked at by nearly 7,000 people.
With perhaps billions of records accessible, an interoperable e-health record system is seen as an irresistible target for hackers interested in probing the secret lives of celebrities and politicians. It could also be the mother lode of consumer information for data brokers and pharmaceutical and insurance companies.
More Headaches In Need of Remedies
Computerized provider order entry issues and unintended adverse consequences are so common in e-health system research that they have earned their own acronyms—CPOE and UACs, respectively. The sheer number of research papers on the problems suggests an almost bottomless demand for ergonomics and human factors solutions.
After a near miss involving a diabetic patient and bar coding, researcher Clement J. McDonald, MD, concluded in the 4 April 2006 issue of Annals of Internal Medicine that “computer systems may have the pernicious effect of weakening human vigilance, removing an important safety protection.”
In 2005 Emily M. Campbell, RN, MS, et al, set out to identify types of UACs resulting from CPOE implementation. In the June 23, 2006, issue of AMIA, the journal of the American Medical Informatics Association, they concluded that the UACs “led to more and new work for clinicians; unfavorable workflow issues; never-ending system demands; problems related to paper persistence; untoward changes in communication patterns and practices; negative emotions; generation of new kinds of errors; unexpected changes in the power structure; and overdependence on the technology.
In a 2005 issue of JAMA, the American Medical Association publication, Ross Koppel, Ph.D., and colleagues worked to identify and quantify the role of CPOE in facilitating prescription error risks. Published studies report that CPOE reduces medication errors up to 81 percent, they noted, but few researchers have focused on the existence or types of medication errors facilitated by CPOE.
One widely-used CPOE system facilitated 22 types of medication error risks, the researchers found. Examples include fragmented CPOE displays that prevent a coherent view of patients’ medications, pharmacy inventory displays mistaken for dosage guidelines, ignored antibiotic renewal notices placed on paper charts rather than in the CPOE system, separation of functions that facilitate double dosing and incompatible orders, and inflexible ordering formats generating wrong orders. Three quarters of the house staff reported observing each of these error risks, indicating that they occur weekly or more often. As CPOE systems are implemented, they wrote, “clinicians and hospitals must attend to errors that these systems cause in addition to errors they prevent.”
In the journal Pediatrics in December 2005, Yong Y. Han, MD and colleagues tested the hypothesis that the implementation of a commercially-sold CPOE results in reduced mortality among children who are transported for specialized care. They found just the opposite: Mortality increased from 2.80 percent before CPOE implementation to 6.57 percent afterwards. Robert G. Berger, MD and J.P. Kichak, BA, looked at whether CPOE systems are helpful or harmful in a November 2004 paper in AMIA. “Although the literature suggests that such systems have the potential to improve patient outcomes through decrease of adverse drug events, actual improvements in medical outcomes have not been documented. Installation of such systems could actually increase the number of adverse drug events and result in higher overall medical costs, particularly in the first few years of their adoption.”
At the moment nobody can say exactly what the US system will look like. But everyone agrees that as a first step, developers need an accepted set of data standards that will allow e-records to be easily and securely exchanged among disparate systems—assembled from software and components supplied by vendors. “We’ve been talking about medical standards harmonization and cooperation for 20 years,” notes William Hammond, professor emeritus of community and family medicine at Duke University in North Carolina. “Yet no one has defined all the standards needed to support a national health information network, and no one has identified what’s missing.”
Since 1987, Hammond has been involved in developing one such set of standards, known as the Health Level 7 data interchange standards. Among other things, HL7 defines how data are captured and formatted so that medical devices and record systems can share that information.
The Next Step
Obama has not yet revealed whether he will replace the network, as envisioned by his predecessor, or build on it. He also hasn’t said how he expects to overcome the myriad problems that bedevil the project.
The network is seen as a partnership of peer groups working towards a common goal. For “peer groups,” read “competing interests.” Generally speaking, the companies, hospitals, and medical institutions that have signed on are business rivals. Some analysts have questioned whether vested interests, proprietary secrets and investors’ demands for profitability have a place in a system that demands sharing. Additionally, no two hospitals or medical institutions are alike, a handicap for a system built on the concept of sharing.
The Bush administration laid much of the groundwork for the program, according to the CNN Money report. It had lead to several pilot programs in a handful of states as well as progress with standardization of medical records. Massachusetts, for example, has developed a plan to fully computerize records at its 14,000 physicians’ offices by 2012 and its 63 hospitals by 2014. The Mayo Clinic in Rochester, Minn., has a well regarded system that is already functioning. Obama’s experts could explore local and regional networks for lessons that can be applied nationally.
If he scraps the peer-group, decentralized concept, he could go in the direction of the United Kingdom’s envisioned system – a single, closed national network, with the central database overseen by one government agency. With a centralized system in mind, he could choose to expand an existing e-record system and network. The US Department of Veterans Affairs, for example, has run a well-regarded medical record system since the mid-1990s.
Perhaps sensing that the network and its developers will be assessed by the new Obama administration, the partners are looking for something to show for the four-plus years and dollars invested to date. In 2009 they plan to exchange “live” data among those organizations that are in a position to participate, using the specifications and standards that have been developed to date.
Sources: IEEE Spectrum, CNN Money; Business Week Online; JAMA; AMIA; Pediatrics; Annals of Internal Medicine
This article originally appeared in The Ergonomics Report™ on 2009-01-21.