Everyone Wants IT to Work in Healthcare, It’s Up to You

This is true whether IT refers to information technology or just "it."  What is "it?" It's the "it" in the movie, "Oh, God" with George Burns and John Denver         .

 Jerry: Well, have you read the papers lately? It ain't workin'!

God: That's why I came - to tell everybody I set the world up so it can work. Only it's up to you. You can't look to me to do it for you.

It ain't workin' in healthcare either. Everyone gripes that there is inadequate interoperability. To a doctor, interoperability means being able to find out what happened prior to the time the patient arrives at your door. Doctors can achieve interoperability without fancy systems or mountains of regulations. It only requires telling (writing) a clear, concise, meaningful narrative that tells the patient’s story: Who, what, where, when, how and why and then, either giving it to the patient or sending it when requested.

 To regulators and expert panels, however, interoperability means something else -it means that everyone collects the same pre-defined elements, regardless of whether they are correct, relevant, or meaningful. This sounds nice, but in practice it’s impossible. The universe will reach the end of its life before a task like this is completed, and until it’s complete, people will always be griping about the lack of interoperability because their pet data element hasn’t been addressed yet.

Committees (the way these things are decided) can never arrive at a useful end-point. As interested parties join the committee, the number of opinions grows exponentially. To avoid endless conflict, hardly anyone dares to say what they actually think. So what happens is that someone with an agenda commandeers the group and everyone else ends up just nodding their heads in agreement. When the meeting ends and people get out in the hall, their real opinions come spewing out to no effect.

 It's also not working for the healthcare process. Procedural errors of all sorts abound. Humans can only keep track of about seven things at once, not hundreds. These were detailed by the Institute of Medicine (IOM) in 1999 ("To err is human"). In response, more committees were formed. Quality improvement projects were undertaken. Some produced local, limited improvement, but being resource intensive, none are guaranteed to be permanent. The good ideas don’t automatically become part of the nationwide standard of care. In fact, hardly anyone else even knows about them. In the past 15 years, in spite of having made errors a big deal, very few classes of errors have been structurally and permanently eliminated from the healthcare system.

 Errors of the kind discussed by the IOM in 1999 should be easy to remedy compared to the "diagnostic errors" described in the latest IOM report ("Improving diagnosis in healthcare" 2015). The new report identifies practically every factor that might lead to a diagnostic error. To reduce the errors all that needs to be done is for someone (God?) to change virtually everything - the complexity of the human organism, the kind of uncertainties introduced by the environment, the way medicine is taught and practiced, and the way doctors and patients behave.

These reports have defined problems that are so massive, so complex, and so pervasive that it boggles the mind of someone who contemplates tackling them head-on. However, doing something needn’t be complicated. The things that aren't working can be separated into two broad categories: 1) things that are well understood, inherently predictable and thus, controllable and 2) things that are not understood or are inherently unpredictable.

There is not much that one can do about the second group except to be prepared to be surprised, so there is no point in agonizing about them. To make a dent in the first group, reduce their cognitive overload. Allow time to think, remember, reason, and do everything that they intended to do. Stop requiring them to code and enter data.

Confine computers in the healthcare setting to functioning as assistive devices for physicians, don’t let them act as agents of the CFO or of the government. If patient care matters, patient care should be the focus of Health IT. Billing should be handled in some back room by people and systems specifically devoted to that function. Data to support billing should be derived from what doctors have written in their notes. Patient care systems should not be compromised by being forced to double as a cash register.

To paraphrase what God said: it's up to you. You can't look the government or your EHR vendor to suddenly understand what they have not understood in the past. The government is not going to suddenly replace its senseless mandates with sensible ones. Vendors aren't going to suddenly make their unusable systems usable. God has already told us the he or she is out of the loop and it’s up to us.

My message to physicians: The patient is in your care and should be the focus of your time and attention. If someone thinks that a non-clinical task is essential, that person should take the responsibility for completing it. If they are not willing to supply the time and money and it’s non-clinical, it should be left undone. The world wouldn’t come to an end if meaningful use was dumped.

Physicians must choose between playing the patient-care game or the government-mandated data-collection game. The movie "War Games" suggests the take-home lesson. "The only winning move is not to play…" the data-collection game. There can be no winners there because data are inherently meaningless and therefore, almost worthless.