Main menu:

Site search

Categories

September 2010
M T W T F S S
« May    
 12345
6789101112
13141516171819
20212223242526
27282930  

Archive

Assume at your own risk

Dr. Nosey reports that his hospital’s computer physician order entry (CPOE) is now online, three years late and more than $50M over budget. Apparently there are a few problems. One physician noted that the order entry system rounds up fractional morphine doses — a dose of one-half milligram can be entered but the computer renders this internally as a full milligram. When doses are in the tens of milligrams such imprecision might be acceptable but when the provider actually writes for a half-milligram and the nurse sees an order for one milligram you really do have to wonder. Dr. Nosey was told that a fix for this problem is going to be put in place “very soon”.  That’s good, he says, but what does this say about the development of the system itself?

The same people that assumed a fractional milligram should be a full one have surely made a lot of other assumptions.  The physician who discovered this one was astonished; he did not imagine that any system would behave this way. And this is an important problem with clinical healthcare information technology. <i>It can easily be configured to do things no one would anticipate. Because they are not anticipated, no one looks for them & they are discovered only by accident.</i>

U.K. NHS computer system on verge of collapse & implications for the U.S investment in CHIT

News from yesterday indicates that the project to build an integrated healthcare information system for the U.K. is close to collapse. Reaction to a report from the Public Accounts Committee of the House of Commons indicate that key elements of the £13 billion system are not working now, unlikely to work by the projected end of project in 2015, and may never work.

The system, which was supposed to make medical care in the UK “better, safer and faster”, is an end-to-end integrated healthcare information system similar to that currently sought by U.S. healthcare leaders. The U.S. system is one of the projects being targeted for a US$60 billion investment by the Congress and the Obama administration. Read more »

Techno-fantasies & electronic medical/health records (EMR/EHR)

A colleague sent me a pointer to an article on drbicuspid.com (Electronic health records: Part I — Boon or boondoggle?) and asked for my view.  The article reports — generally positively — on how a a proponent of EMR/EHR is trying to influence the Obama administration to make faster progress on a combined medical/dental EMR/EHR.

The proponent, Valerie Powell, PhD, is reported to have said “Our nation needs excellent chronic care, and to make this happen means ensuring that the dentists and physicians can communicate. People are dying. This is urgent now.”

There is, of course, nothing new in this extreme sort of rhetorical flourish. But the exchanges between real practitioners and the proponent that follow the article are, well, testy. Dentists in practice — at least those who left comments — are not especially in favor of EMR/EHRs. They do not believe that IT will necessarily lead to safer care and find the arguments of the proponent — someone with only a peripheral connection to dentistry — unconvincing (an excerpt is included below).

One thing is clear, though: the proponents of IT see a grand opportunity to advance their cause. The Obama administration has embraced the idea of healthcare IT as a key element in its goal to get safer, better, cheaper healthcare. The healthcare IT program has been stalled in the U.S. and the U.K. for some time — for a variety of reasons — and the commercial and academic interest groups are eager to get what they consider to be their share of the Federal spending pie.

The claims made for EMR/EHR are in the realm of technofantasies, about which more later. But here are some of the comments I made to my colleague regarding the DrBicuspid articles.

Read more »

St. Elsewhere’s new computer system to cost 3x the initial estimate

My friend, Ralph, works at St. Elsewhere, which is a pretty big, private hospital in another State. He’s a Doc, not a Suit, so his information is probably a little bit stale as far as information systems is concerned. Here is what Ralph told me last week.

They had a meeting at which the (new) administration of the hospital described the progress on getting the electronic medical record up and running. The hospital bought software from a vendor called Mythic. That software was supposed to be easy to tailor for use by just filling in a few fields and building some templates so the development was pretty much already done.

The project is now about 3 to 5 yrs delayed so there was a bit of explaining to do. The whole thing was to be on-line by 2006 — including the really snazzy pieces that were supposed to streamline access to protocols, provide automated reminders, rationalize antibiotic selection, keep track of allergies, etc. So far there is nothing really useful available yet.

HeadSuit was at the meeting, which is always, according to Ralph, a bad sign. InfoTechExec explained that the system would be up and running in a year or two, things were going well with the development of the software, a new vendor had been added to “help” the internal programmers get the Mythic system configured, and there were going to be rollouts of parts of the system over the next 12 mos.

The clinical staff at St. Elsewhere is pretty docile (according to Ralph) and the meeting was coming to a close when one of the ENT Surgeons, Dr. Nosey, pointed out that there were no financials included in the presentation and asked how much the system was going to cost. Ralph recalls that the original price was US$35 million for the whole thing. There was a good deal of hemming and hawing between HeadSuit and InfoTechExec but they finally admitted that the cost was likely to be somewhat more than originally budgeted. How much?

Turns out that the new estimate was $US100 million! Even Ralph, who is pretty cynical about hospital administrations, was taken aback. That’s 3x the cost that was budgeted. How far along in spending had they gotten, Dr. Nosey wanted to know. Well, neither HeadSuit nor InfoTechExecc could say. Dr. Nosey then asked why the medical staff should have any confidence in the new estimate when the management couldn’t even say how much had been spent to date. There was some back and forth on this but it became clear that the project had already spent US$30 million.

Ouch!

about virtualgryphon

History: Between 1984 and 1998 I was writing occasional essays on technology — especially computers — and accidents. These were quick-and-dirty pieces, not the polished stuff that was suitable for publication, and circulated just among a few colleagues on the earliest versions of the internet. E-mail was primitive and the process was pretty awkward but I got a fair amount of encouragement from the half dozen recipients. An example is Scenarios for Bedside Medical Communication. There were also some fun pieces, for example Learning Theories Implicit in Medical School Lectures.

The Gang of Four: In 1994 I moved to Chicago and found, in my new position, four people who were interested in these little bits. The e-mail software was beginning to improve, making it possible to assemble sets of e-mail addresses to make distribution easier. In my mailer I collected the e-mail addresses of this internal group under a heading “The Gang of Four” (Gof4).

Fellow Travelers Society: The readers from outside my place of employment became “The Fellow Travelers Society” (FTS). The FTS was an eclectic group and we passed around comments on journal papers and current events — using email and the “reply-to-all” button to generate a primitive sort of blog.

Gof4? FTS?: There are probably only a few people who will recognize these names. “Gang of Four” was the name given to the wife of Mao Tse Tung and her three co-conspirators who were, after Mao’s death, blamed for the Chinese Cultural Revolution. After a show trial, two of these were condemned to death and the others to life imprisonment. No one was executed; all have since died. “Fellow traveler” was a term applied during the witch hunts of the early 1950’s to people believed to have Communist sympathies. Those identified as Fellow Travelers were ostracized. The FTs were not usually members of the Communist Party or even activists working towards the Party’s ends. They were attacked because of having Communist friends or family members or for acknowledging that some of the goals or positions of the communists were reasonable or desirable.

About what? Initially, the FTS and Gof4 e-mails were brief items taken from news services about accidents or technology snafus or some research result or citation that I found interesting and wanted to pass along. I would add a line or two of my own comments — often disparaging or ironic. Because the circle of people interested (or willing!) to be included in a group called The Fellow Travelers Society was small and I knew each person, the comments could be short, cryptic, and even nasty. The result was a sort of micro-listserver, with a difference: there was no privacy for FTS members; every e-mail had all the members’ e-mail addresses in the header. But these were the PS (Pre-Spam) years and no one minded. The small size of the FTS made it a pleasure to collect and send the materials. I was, after all, writing to people I knew and there was no pressure to produce; every posting was opportunistic.

The RISKS listserver was a prime source of events. Some of the Gof4/FTS pieces drew on event reports from Peter Neumann’s RISKS. Peter is at the Stanford Research Institute (SRI) and the many back-issues of RISKS are cataloged at a site in the U.K. You can subscribe to RISKS yourself.

The growth of the FTS: My comments became more extensive, more discursive, and more explanatory. This was partly due to the growth of the FTS. By the late 1990’s it included about 30 people, some of whom I did not know well. I didn’t intend to write essays, really. But the larger the FTS became, the more it seemed that the implications of events needed to be stated explicitly and the greater was the potential for misunderstanding. The postings were still impromtu and written quickly in response to current events or recent research.

Death of the FTS: After 2000 the FTS postings died out. There was no single reason for this. There were technical problems. I was busy and trying to start up a research lab to address issues no one in healthcare was considering. There seemed to be a chance to have a direct impact on patient safety rather than the indirect and long-term effects that the FTS materials might someday yield. And too, the work of preparing the essays was becoming more of a chore than a pleasure.

I’m baaaaaaack: I think that it is time to revive the FTS. There is no single reason for this either. Partly it is because the technology is so much better than it was. Software like WordPress is truly amazing. Website hosting is now a trivial technical matter and a minor expense and easily done using a browser. No command lines needed! Golly. It’s heaven.

It’s also time to do this because there is more stuff to write about. There are technological disasters looming, critical choices to make, opportunities to get right — or wrong. Some disasters-in-the-making are easy to see. I’ll start writing about one in the next post. This blog is a little different than the original Fellow Travelers Society of course. It’s set up around a ‘pull’ rather than ‘push’ structure. It has a more persistent — notice that I wrote persistent and not permanent — quality than the e-mail version of the FTS. It’s also much less private than the e-mail version. Ah, well, that might be a problem. We’ll see. The original FTS grew out of a small sense of a community with a disparate background but common interest. If we’re lucky, perhaps the virtualgryphon blog will lead to the revitalization of that community.

 

Joining the Fellow Travelers Society: Feel free to enter a comment when you have something to add. I’m going to ask that you use your real name for your posts. (If you hesitate to write under your own name, well, maybe you should send me an e-mail first!) I’ll try to moderate regularly to see that new posts get in quickly. Suggestions are always welcome. Original members of the FTS are especially encouraged!

Best wishes, Gryph