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HCIT Failure

HCIT (Healthcare Information Technology) Failure page brings together the growing evidence of the challenges of HCIT deployment, especially those of a mass scale like the UK's National Health Service (abandoned in 2011) but also the small scale deployments in small medical practices.  There are of course success stories like the US Veteran Administration healthcare information system.  Now that US healthcare organizations must implement HCIT by 2015 or face increasing penalties, the promises of HCIT will need to come to fruition.  McKinsey estimates that HCIT investment of $80,000 to $100,000 per bed is required with the federal government reimbursing upwards of 15% to 20%.  The difference has to be made up primarily by "standardizing best medical practice".  Higher levels of decision support are associated with decreased complications in Texas hospitals (Amarasingham et al, 2009).  But a dubious proposition since most EHR systems don't have the necessary decision support capabilities or organizational commitment to using such tools.  Even e-prescribing systems with much less complexity and organizational integration don't do so.  Some evidence suggests that in coronary heart disease, "... feedback,disease prevalence, and reminders do not have any statistically significant overall effects on physicians’ diagnostic certainty or decisions about the process of care" (Ketcham et al, 2009). 

Michael Krigsman has a ZDNet blog on IT Project failures and comments on a healthcare failure published by the Cutter Consortium in a report titled "How Not to Run an IT Project: A Case Study".  The Cutter report is currently free for download. The reasons for failure (from the report): "a dysfunctional culture, indifferent and naive executives, a lack of accountability, and poor data all contributed to the project’s failure."  What would have happened if it was clinical applications - not just financials, material management, human resources, and payroll?

44 Reported Injuries and 6 Deaths, Probably Just 'Tip of Iceberg' is the headline of Dr. Silverstein's post about the Patient Safety hearing of the HIT Policy Committee, Adoption/Certification Workgroup of the The Office of the National Coordinator for Health IT in late February 2010.  His post gives examples of HIT-related adverse consequences resulting from errors of commission, errors of omission or transmission, errors in data analysis, and incompatibility between multi-vendor software Applications.  One of the notable quotes from Dr. Ross Koppel was "I think we have to get better EHRs, simply not more EHRs, and that‘s my plea."

The Guardian UK newspaper reports that the NHS £12.7billion program for patient administration with the showpiece Lorenzo EHR software is about to implode (their words not mine).  Lorenzo was supposed to have been installed in 2/3 of sites by end of 2006.
 
Around 20% of Arizona physician practices are de-installing EHRs that were mandated by the state due to affordability or adaptation issues. (link)

An Open Letter to Dr. David Blumenthal by Dr. Rick Weinhaus in the Healthcare Blog wrote "The CCHIT model for EHR software certification is fatally flawed because it mandates hundreds of required features and functions, which take precedence over good software design.  This flawed CCHIT model takes valuable physician time and effort away from patient care and leads to increased potential for errors, omissions, and mistakes."

After considering tender offers for over half a year, the Australian Department of Health canceled its e-prescribing tender in January 2010. Reported here and here.

The Milbank Quarterly has a January 2010 article by Greenhalgh, Potts, Wong, Bark and Swinglehurst at University College London titled "Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Method".  At the moment (of this posting) the article is free to download at this link

The commentary on this article by Scot Silverstein found on the Health Care Renewal blog (see posting) is worth reading.  Scot Silverstein has been posting on his website many example of Healthcare IT failures dating back to the 1990s.  See also his HC Renewal blog.

Max Pemberton is a physician going through medical school but moonlights as an investigative reporter (or other way around).  His latest article in the UK Telegraph is called "The chaos of the NHS's electronic records".  A view from the electronic records trenches ...

Atul Gawande, a New Yorker staff writer, wrote in the 26Jan09 issue "Getting There From Here" and says "This is the trouble with the lure of the ideal" after giving the example of the chaos of kicking off Medicare Part D on January 1, 2006 where elderly went for months without medications because of system and implementation issues.

Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions (2009) (link)  From the recommendations: "it is fair to say that the integration of health care IT into operational work processes has proven both more essential and more difficult than was first expected, at least in part because many attempts to deploy health care IT have not taken into account the systems engineering issues inherent in viewing health care as a complex, adaptive system."

The former head of NHS Information Technology, Frank Burns, critiqued the program in a report published by the House of Commons' Health Committee.  The article containing the link comes from Computer Weekly.  One of his quotes "... grotesquely over simplistic view of the transition from paper records to electronic records in the Health Sector"

... and of course when information systems are viewed simplistically, the likelihood for e-iatrogenesis errors increase.  If you can find a way to get your physicians through the first six months, then it appears there are productivity gains (16% increase in billing) (Cheriff et al, 2010).


Recent work by Furakawa, Raghu, and Shao so that EMRs increase inefficiency of nurses and may increase patient complications. Now weren't EMRs supposed to decrease costs and increase patient safety?

There was no association of Leapfrog Safe Practices score with either mortality or hospital-associated infections (Glance et al, 2010).

A system might also be considered a failure if the benefit accrues to someone other than those making an investment.  This is problematic in e-prescribing where those who buy the systems (e.g., medical practice) and use the formulary feature help the insurers lower their cost of medications but with little or no benefit to themselves.  A similar example is given on a post about cost effectiveness and ROI on the IT Forum blog.  The EHR allows a hospital to send patient reminders to get their pneumococcal vaccine saving the healthcare system money - but not necessarily the hospital.


Related Websites

Contemporary Issues in Medical Informatics: Common Examples of Healthcare Information Technology Difficulties by Dr. Scot Silverstein  See also his post on the blog Healthcare Renewal for a history of activities leading up to the 2009 AMIA Workshop.


Healthcare IT Failure Articles and Reports

Coiera, E., Aarts, J. & Kulikowski, C. (2012) 'The Dangerous Decade', Journal of the American Medical Informatics Association, Vol. 19, No. 1, pp. 2-5.

Debono, D, Greenfield, D, Travaglia, J, Long, J, Black, D, Johnson, J & Braithwaite, J 2013, 'Nurses' workarounds in acute healthcare settings: a scoping review', BMC Health Services Research C7 - 175, vol. 13, no. 1, pp. 1-16.

Esmaeil Zadeh, P & Tremblay, MC 2015 in press, 'A review of the literature and proposed classification on e-prescribing: Functions, assimilation stages, benefits, concerns, and risks', Research in Social and Administrative Pharmacy

Fontaine, P, Ross, SE, Zink, T & Schilling, LM 2010, 'Systematic Review of Health Information Exchange in Primary Care Practices', J Am Board Fam Med, Vol. 23, no. 5, pp. 655-70.

Furukawa, MF, Raghu, TS & Shao, BBM 2010, 'Electronic Medical Records, Nurse Staffing, and Nurse-Sensitive Patient Outcomes: Evidence from California Hospitals, 1998–2007', Health Services Research, Vol. 45, no. 4, pp. 941-62.

Glance, L.G., Dick, A.W., Osler, T.M., Meredith, J.W., Stone, P.W., Li, Y. & Mukamel, D.B. (2011) 'Relationship between Leapfrog Safe Practices Survey and Outcomes in Trauma', Arch Surg, Vol. 146, No. 10, pp. 1170-1177.

Greenhalgh, T, Potts, HWW, Wong, G, Bark, P & Swinglehurst, D 2009, 'Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-Narrative Method', Milbank Quarterly, Vol. 87, no. 4, pp. 729-88.

Heeks, R 2006, 'Health Information Systems: Failure, Success and Improvisation', International Journal of Medical Informatics, Vol. 75, no. 2, pp. 125-37.

Hsiao, C-J, Beatty, PC, Hing, ES, Woodwell, DA, Rechtsteiner, EA, Sisk, JE & Statistics, DoHC 2009, Electronic Medical Record/Electronic Health Record Use by Office-Based Physicians: United States, 2008 and Preliminary, National Center for Health Statistics.

Johnson, ME & Willey, ND 2011, 'Usability Failures and Healthcare Data Hemorrhages', Security & Privacy, IEEE, vol. 9, no. 2, pp. 35-42.

Kaplan, B & Harris-Salamone, KD 2009, 'Health It Success and Failure: Recommendations from Literature and an AMIA Workshop', Journal of the American Medical Informatics Association, Vol. 16, no. 3, pp. 291-9.

Kellermann, AL & Jones, SS 2013, 'What It Will Take To Achieve The As-Yet-Unfulfilled Promises Of Health Information Technology', Health Affairs, vol. 32, no. 1, pp. 63-8.

Niazkhani, Z, Pirnejad, H, Berg, M & Aarts, J 2009, 'The Impact of Computerized Provider Order Entry Systems on Inpatient Clinical Workflow: A Literature Review', Journal of the American Medical Informatics Association, Vol. 16, no. 4, pp. 539-49.

Simon, P. 2010. "How Not to Run an IT Project: A Case Study", Cutter Consortium report



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