Being an information technology worker, I read with interest this post by Joe Bugajski titled, The Data Model That Nearly Killed Me. Bugajski has decades of experience in engineering with particular expertise in data and application design. He has patents, peer-reviewed publications, and technical book authorship under his belt. When it comes to IT, Bugajski knows what he is talking about. When it comes to medicine he is no expert, but he has a story to tell.
Bugajski’s article details his horrific experience with getting inadequate treatment for a severe asthma attack he suffered earlier this year. He ended up in a large teaching hospital that reportedly has great care. But he describes how the staff fought continuously with the computer system that was supposedly designed to improve the quality of medical care.
The upshot is that the critical medication Bugajski needed was not administered until 34 hours after his arrival at the hospital and 14 hours after his admittance to intensive care. He says that this was significantly due to a poorly designed computer system. The problem was then repeated when a second dose of the medication was due.
While Bugajski’s article is informative, I found the extensive comments at the end of the article even more informative. Some comments focus on IT issues. Many comments coming from health care professionals expose serious flaws in the medical system that are not directly related to the industry’s use (or lack of use) of information technologies.
IT doesn’t always work well with medicine
Some posters suggest that health care IT systems are inadequate because they attempt to address competing requirements. Getting all of a person’s health data in one place is a worthy goal, but privacy concerns (and policies) often limit the ability of different practitioners (and different levels of practitioners) to access all of the pertinent data. Some systems restrict entry of certain types of data in order to limit liability.
Once an error makes it into the system, it is nearly impossible to correct. Too much data can also produce information overload for practitioners interfacing with the system. Systems are not designed to function well with the way practitioners actually think and work. Databases are poor systems for storing some types of medical knowledge and information.
Some posters suggest that these technical issues are only peripheral to the main problems in health care. Ian, a self-identified physician writes, “Sad truth: doctors are not paid for treating your pain: they are paid for documenting its location, duration, frequency, timing, quality, modifying factors, and associated symptoms.”
A frequently repeated complaint is that there is fragmented care due to the lack of a patient advocate with adequate knowledge and power to bring the various specialist treatments together to achieve a positive result. Numerous highly trained professionals are each only operating with a small piece of the puzzle. They are not empowered or incentivized to see the big picture. There is no ownership of the patient’s general welfare, so nobody in the system really cares about it.
To counter this lack of incentive, an EMT writes, “There is absolutely no substitute for an active sense of skepticism and a very irritated advocate in any healthcare setting. None.”
Another related matter is explained by a poster name Gerry. “… the physician of today has scant training looking at the patient, but lots of training at looking for a molecular cause for any illness. Thus, they tend to believe the lab more than they believe the patient.”
Charlie, a health systems integrator, feels that the problem lies in medical traditions. He writes, “Today, the culture of American medical professionals seems to be unfortunately similar to that of medieval priests - doctors are trained (through fairly brutal treatment involving sleep deprivation and rigorous indoctrination) to have a certain “hero” mindset and to disregard and distrust outside views that conflict with hierarchically dispensed dogmas.” Practitioners are trained not to ignore outside information but to treat it with disdain. That’s why the pleas of Bugajski and his wife for a known treatment were cast aside by multiple practitioners.
An alarming situation
Several posters alluded to the lack of response to audible (and perhaps visual) alarms on various medical devices. One doctor says that these are often ignored because practitioners already know about and have considered the condition causing the alarm. Even if this is true, it points out a glaring lack of concern for the psychological wellbeing of the patient and his family. To them it looks like the patient’s peril is being ignored. Hasn’t anyone considered how to alert care professionals without freaking out patients and their loved ones?
This brings to light another problem. Every medical device is being developed as a standalone thing. Patients are hooked up to numerous devices that don’t know about and don’t talk to each other, and that don’t provide concerted feedback to practitioners. Why is this the case? Why is there no incentive for developing patient friendly devices that provide useful and concerted feedback to practitioners?
Perverse incentives and myths
Another concern voiced is that creating a government based electronic health care record will produce perverse incentives for officially sanctioned misuse of the data. This will create an incentive for people to be less than forthcoming, perhaps creating dangerous situations. Gattaca anyone?
As I wrote in this post last year, GMU economist Robin Hanson argues that our culture has an unhealthy superstition about the heroic capabilities of modern medical treatment. Our cultural conditioning causes us to develop incentives for spending our health care dollars on things that have little impact rather than on more significant factors, “such as exercise, diet, sleep, smoking, pollution, climate, and social status.”
Hanson’s research reveals that much of our heroic based medicine produces as much in negative effects as it does in positive effects. In this article, Hanson argues that we could cut current medical expenses in half without seeing any real decline in health outcomes. Our culture militates against this and we have a massive medical industry that is heavily invested in the practice of heroic medicine. Despite evidence that this is a poor use of resources, people continually demand more of the same.
It seems clear that health care IT systems are a mixed bag, at best. Perhaps the attempt to develop rational IT models to support an irrational health care system is destined to produce an ill fitting outcome. Possibly we need more discussions about how to achieve better health outcomes than about how to pay for heroic medicine.