"Real" Medical Informatics: What Does a Problem List of Typical Health IT Look Like, Part 2

At my Mar. 15, 2011 post "What does a "problem list" of typical health IT look like?" I displayed a chart by Jon Patrick at U. Sydney on the ill-suited nature of an American EHR system for use in Emergency Dept. settings. That system had been mandated for rollout in public ED's in the entire Australian state of New South Wales.

As it turns out, that chart was just preliminary.

A new chart is up entitled "Analysis of Problems Defined by ED Directors", divided into four sections:

1. Workarounds and Abandonments (27 elements)
2. Functions Lost from the Pre-FirstNet System or Desirable Functions (31 elements)
3. Processes with Added Risk to the Integrity of the EMR (11 elements)
4. General Problem List - What is the Potential for Resolution? (60 elements)

The entire chart can be viewed at this link (best with browsers other than MS Internet Explorer): http://sydney.edu.au/engineering/it/~hitru/index.php?option=com_content&task=view&id=120&Itemid=116 .

It is lengthy, detailed and - stunning.

Prof. Patrick concludes (emphases mine):

Reviewing this compendium of difficulties and obstacles created for staff makes it entirely unsurprising that the patient throughput of most EDs dropped by 50% on the day FirstNet was introduced and now some years later throughputs are only just beginning to recover as staff have been able to instigate work practices to minimise the worst aspects of the system.

[A spectacular waste of clinician energy - ed.]

The workarounds and abandonments give an expression of the frustration of staff and their strategy for retaining equilibrium in their work practices despite FirstNet's presence. In a number of cases we have seen the practice guidelines of NSWHealth surrendered by the imperatives of the technology with the imposition of the HSS. It is astounding that practices defined from years of clinical experience can be discarded so whimsically.

[As I have written, the IT industry has invaded the healthcare sector, and this is the absolutely non-whimsical result - ed.]

Fortunately, in the case of one pathology laboratory, patient safety was put ahead of the technological imperative lest it jeopardise the registration of the laboratory. The described function-losses with FirstNet compared to the pre-FirstNet systems, and the functionality needs expressed by the staff indicate that they are acutely aware of the value of good technology and have a strong desire to be equipped with something that works properly without creating unacceptable risks to patients and a draconian reduction in their efficiency. The risks posed by the system to maintaining the integrity of the medical record is something that staff are acutely concerned about as they feel it fails to fulfil their legal obligations.

Emergency Departments are too important to have to endure these stressful and unproductive conditions.

[This is a first principle, as as such is not open to debate - ed.]

It is time that the knowledge and experience of the Directors and their staff were listened to and taken seriously [actually, six decades or so into the "computer revolution", I'd say that time was long ago - ed.] for the sake of improving our hospitals's use of technology. After all we have to ask: What business would commit to an interloping "integrated" system whose services are being necessarily dismembered piecemeal as a matter of survival by the users? This is a system whose pieces are not used by the staff, but rather are shadow mirrored by them, not for redundancy but primacy.

Who would want a system that is progressively de-activated by the staff to overcome the hazards and operational inefficiencies it has introduced?

[My answer: those who profit handsomely, and at no liability to themselves, from this arrangement. I leave it to the reader to decide who might fit in that category - ed.]

As a physician and medical informatics specialist myself, I would not want my ED care or that of my family interfered with by such IT.

Several questions:

  • How did a government for an entire state of a major country come to allow themselves to believe an EHR system such as this would improve conditions in the most mission critical section of their hospitals, the ED's?
  • What testing and validation of the software was done by officials and representatives of said government, and who were they, exactly?
  • What experience and background did the validators possess?
  • How were clinician complaints during implementation, which has apparently been underway for several years now, handled?
  • What other countries are going down the same path?
  • Why is not all health IT subject to the same type of government regulator-led validation as this system was put under by a private academic researcher? (Note that the U.S., pharma IT validation is led by the FDA, but that same agency has essentially shied away from healthcare IT validation.)
  • Would a country buy software as ill suited to purpose for, say, mitigating disaster risk in their nuclear power facilities?

Finally, I ask:

If the purpose of Medical Informatics is the improvement of healthcare (as opposed to career advancement of a small number of academics through publishing obscure articles about HIT benefits while ignoring downsides in rarified, echo-chamber peer reviewed journals), then:

  • Who are the "real" medical informatics specialists, and;
  • Who are the poseurs?

I opine that researchers like Jon Patrick who address real-world issues of great import to patients on HIT risks, and further go public on the web with their work without the full blessings of some dusty journal (and those like Ross Koppel who also directly address the downsides, and others who make available to the public material such as on blogs like this and this, papers like this and sites like this) are the former.

Those who deem only "peer reviewed" articles worthy of daylight, and everything else - especially and particularly reports of downsides - "anecdotal" (the anecdotalists) are the latter.

-- SS