The recent Wall Street Journal and Washington Post pieces critical of stimulating adoption of EHRs are a grand example of the slide to the Trough of Disillusionment in the Gartner Hype Cycle. After being overly high on a new concept the press goes negative, focusing on the early failures rather than early successes.
We know of at least four experience- and evidence-laden response letters to the Washington Post that have languished unpublished. These responses point out the selective nature of citations by Groopman and Hartzband. We expect better from the Post than to ignore these credible letters. With permission of some of the authors I am publishing their responses as guest pieces in my blog.
William Hersh, M.D. is Professor and Chair of the Department of Medical Informatics & Clinical Epidemiology in the School of Medicine at Oregon Health & Science University (OHSU) in Portland, Oregon, USA. Bill is a leader in informatics and informatics education. He created the first offering of the AMIA 10×10 program, which aims to educate 10,000 health care professionals and others in medical informatics by the year 2010. I thank him for his permission to include his letter here.
While Drs. Soumerai and Majumdar are reasonable to question whether President Obama’s investment in health information technology (IT) will meet its goals, they could at least present a more complete view of the research and the science behind health IT and its use for computerized physician order entry (CPOE) with decision support.
It is true that the studies they cite by Han et al. (Pediatrics) and Koppel et al. (JAMA) showed poor outcomes and new forms of error introduction respectively. However, when we look at the whole body of research surrounding these studies, different conclusions emerge.
The Han et al. study looked at overall mortality before and after the introduction of CPOE in the Pediatric Intensive Care Unit of Children’s Hospital of Pittsburgh. Aside from the known limitations of before and after study (i.e., you cannot control for confounding variables, such as the decision to centralize the pharmacy that was made concomitantly at this hospital), analysis by other researchers in the similar pediatric intensive care settings of other hospitals did not find increased mortality after introduction of CPOE (DelBeccaro, Jacobs). Furthermore, postmortem analyses raised significant concerns that the implementation at Children’s Hospital of Pittsburgh ignored several known best practices associated with CPOE implementation (Phibbs, Sittig).
Likewise, the study by Koppel et al. from University of Pennsylvania was very important in identifying new potential errors that could be introduced through CPOE. However, as pointed out by another well-known CPOE researcher (Bates), the Koppel et al. study did not quantify these errors, nor compare their frequency to errors resulting in adverse outcomes for patients. Bates (NEJM) and others have shown in several studies that CPOE does reduce adverse events, even if the systems used are “home grown” and not as generalizable to the rest of the world as we might like.
Finally, the writers completely ignored a new study published recently in Archives of Internal Medicine that assessed 41 Texas hospitals and found use of various aspects of health IT, including CPOE, was associated with better patient outcomes and decreased mortality (Amarasingham).
To me, the major conclusion of all these studies is that we need to pay careful attention to the dangers posed by current medical practice as well as IT-based efforts to improve it. [Emphasis added by Rishel.] Part of the latter involves applying best practices and avoiding known errors in its implementation. To this end, we need more professionals trained in the field of biomedical informatics, where expertise in health care and information technology is combined to use health IT optimally to improve the quality and safety of health care (Hersh). Fortunately, the economic stimulus package includes resources devoted to educating more of these individuals. This will increase the availability of such professionals to fill the jobs that will be created by the incentive funding portion of the stimulus package aimed to increase proper use of health IT in physician practices and hospitals.
While this humble blog is not even a David to the Post’s Goliath, and while I am certainly preaching to the choir, this is more than a fruitless gesture. It gets the responses into cyberspace where they may be discovered by search engines.
For more information on the Gartner hype cycle see the Fenn and Raskino book.