JAMIA: Health information technology: fallacies and sober realities
An excellent, well-researched, and I believe watershed position paper in JAMIA was published in Oct. 2010. I will briefly cover its major points due to current time limitations (ironically, I have an elderly health IT-injured mother to tend to).
The paper dispels many health IT industry myths, memes and cavalier business practices that I have found highly disappointing.
The article organizes many of the themes around HIT myths, irrational exuberances and marketing memes into one coherent position paper (unfortunately, free fulltext is not as of this writing available online, but if you can obtain the article from JAMIA, it is a must-read):
J Am Med Inform Assoc. 2010 Nov 1;17(6):617-23.
Health information technology: fallacies and sober realities
Karsh BT, Weinger MB, Abbott PA, Wears RL.
Department of Industrial and Systems Engineering and Systems Engineering Initiative for Patient Safety,
Current research suggests that the rate of adoption of health information technology (HIT) is low, and that HIT may not have the touted beneficial effects on quality of care or costs. The twin issues of the failure of HIT adoption and of HIT efficacy stem primarily from a series of fallacies about HIT. [Not discussed are the origins and maintenance vectors of those fallacies, a topic for significant research itself - ed.] We discuss 12 HIT fallacies and their implications for design and implementation. These fallacies must be understood and addressed for HIT to yield better results. Foundational cognitive and human factors engineering research and development are essential to better inform HIT development, deployment, and use.
PMID: 20962121 [PubMed - in process]
The article presents a series of HIT "fallacies" akin to logical fallacies lists including:
THE ‘RISK FREE HIT’ FALLACY
THE ‘HIT IS NOT A DEVICE’ FALLACY
THE ‘LEARNED INTERMEDIARY’ FALLACY
THE ‘BAD APPLE’ FALLACY'
THE ‘USE EQUALS SUCCESS’ FALLACY
THE ‘MESSY DESK’ FALLACY (i.e., the fallacy that medicine is neat and linear)
THE ‘FATHER KNOWS BEST’ FALLACY
THE ‘FIELD OF DREAMS’ FALLACY
THE ‘ONE SIZE FITS ALL’ FALLACY
THE ‘WE COMPUTERIZED THE PAPER, SO WE CAN GO PAPERLESS’ FALLACY
Readers of this website, where I've covered these issues, can probably ascertain the meanings of these fallacies regarding health IT without further explanation.
This is not just a "what is wrong with health IT" paper. The paper points out that insufficient contextual research has been conducted to support effective commercial HIT design and implementation despite decades of exemplary research on these topics, and suggests a path to remediation.
At the most fundamental level, HIT must be focused on transforming care and improving patient outcomes and must be designed to support the needs of clinicians and their patients. For example:
- The needs of users and the complexities of clinical work must be analyzed first, followed by evaluation of the entire scope of potential solutions, rather than examining the current array of available products and characterizing the needs that they might meet.
- Appropriate metrics for HIT success should not be adoption or usage, but rather impact on health.
- The ‘comparative effectiveness’ perspective must also be applied to HIT - what is the return-on-investment of each HIT initiative compared with alternative uses of these funds?
- There must be substantive collaboration with those who can contribute unique and important expertise such as human factors engineers, applied psychologists, medical sociologists, communication scientists, cognitive scientists, and interaction designers.
- During HIT development, vendors and healthcare
organizations must focus on more meaningful measures of design success:
clinician and patient ease of learning, time to find information, time to
solve relevant clinical problems, use errors, accuracy of found
information, changes in task and information flow, workload, situation
awareness, communication and coordination effectiveness, and patient and
- We must also consider the likely undesirable consequences of current policies and regulations on HIT advancement, e.g., hold harmless clauses.
If you have access to JAMIA via a library, I recommend downloading the article and reading it.
be interesting is the healthcare IT industry and government response, and the
response of those with financial interests in pushing for rapid HIT diffusion
along HITECH timelines (the "Bullet
train out of the station with only a quarter mile of track"
For a pro-industry alternate view on the importance and credibility of this article, see the Review posted on the HisTALK site by its owner at Monday Morning Update 11/1/10, approximately at the halfway mark.
My major concern with the review is not just on its internal logic and anti-academic, academics-automatically-hate-business bias (having been employed in academia, the healthcare IT industry and in Big Pharma myself, I see multiple perspectives).
... The authors of this paper are academics. I like their objectivity, but I’m left with the feeling that they are disillusioned about this fact that is distasteful to them: both healthcare and healthcare IT are businesses that, rightly or wrongly, make decisions based on their own self-preservation, not high-minded academic ideals. [Such as the Hippocratic oath - ed.]
My other concern is the review's taking on the JAMIA article in isolation, ignoring the increasing body of other literature up to the National Reseaarch Council (quoted at the beginning of the Karsh article) shedding doubt on HIT beneficence, effectiveness and ROI, and the statements of the Healthcare IT industry itself such as:
HIMSS's former Chairman of the Board Barry Chaiken admitting the technology remains experimental:
... We’re still learning, in healthcare, about that user interface. We’re still learning about how to put the applications together in a clinical workflow that’s going to be valuable to the patients and to the people who are providing care. Let’s be patient. Let’s give them a chance to figure out the right way to do this. Let’s give the application providers an opportunity to make this better;
and a HIMSS task force itself admitting in this 2009 PDF report that:
"Electronic medical record (EMR)!adoption rates have been slower than expected in the United States, especially in comparison to other industry sectors and other developed countries. A key reason, aside from initial costs and lost productivity during EMR implementation, is lack of efficiency and usability of EMRs currently available";
It seems that from the ethical point of view, when industry leaders themselves express doubts in their own products, the responsible position is to err on the side of caution.