Sunday, March 13, 2005

Should doctors be using computers?
The New York Times often goes out of its way to make it clear that everything bad that happens, or that might be happening, is about Bush and his administration. One example is this article entitled, "Under Bush, a New Age of Prepackaged Television News". In paragraph 12 they tell us that this practice "also occurred in the Clinton administration". I guess that was the Previous Age.

But what especially upsets me now is that the Times administration has decided that in order to aid their Bush-bashing, they have to come out against the computerization of medical records. At least for now. As I've mentioned before, I have a long standing interest in this subject. I think it is absurd that computers are not used more to keep track of patients' medical records and of the decisions of their physicians. Obviously this should be computerized, and obviously it should be done well and not badly.

The article begins with a really damning attack against Bush: "The Bush administration and many health experts have declared that the nation's health care system needs to move quickly from paper records and prescriptions into the computer age." We are not told just when the administration declared this, nor what they might mean by "quickly". We are told that Dr. David Brailer, the administration's national coordinator for health information technology, took issue with "the suggestion that the Bush administration is encouraging a headlong rush to invest in health information technology". We are not told who made this "suggestion", nor are we given any evidence for it. Brailer says that "for the next year, ... his policy efforts will be to try to encourage the health industry to agree on common computer standards, product certification and other measures that could become the foundation for digital patient records and health computer systems." That certainly sounds like a headlong rush to me.

Just why is the New York Times so afraid of doctors using computers? The excuse is three articles that appeared Wednesday in the Journal of the American Medical Association; all of the abstracts, and the text of one of them, can be read for free. These papers apparently "cast doubt on the wisdom of betting heavily that information technology can transform health care anytime soon".

[The paper by Koppel et. al.] found 22 ways that a computer system for physicians could increase the risk of medication errors. Most of these problems, the authors said, were created by poorly designed software that too often ignored how doctors and nurses actually work in a hospital setting.

The likelihood of errors was increased, the paper stated, because information on patients' medications was scattered in different places in the computer system. To find a single patient's medications, the researchers found, a doctor might have to browse through up to 20 screens of information.

Among the potential causes of errors they listed were patient names' being grouped together confusingly in tiny print, drug dosages that seem arbitrary and computer crashes.

... The study did not try to assess whether the risks of computer systems outweigh the benefits, like the elimination of errors that had been caused by paper records and prescriptions.
In fact, the paper tells us (although the Times does not) that, "Published studies report that CPOE reduces medication errors up to 81%." This is the benefit we apparently get even from a program that is horribly designed and atrociously implemented. The program in question has been in use since 1997, presumably as part of Bush's headlong rush.

Dr. Koppel tells the Times that he is "skeptical of the belief that broad adoption of information technology could deliver big improvements in health care". I guess he wasn't present when my sister took our father to the hospital and had to describe (over and over again) his medical history of cancer, diabetes, high blood pressure, Parkinson's, and Alzheimer's, and the medication he was taking for each of these. I guess Dr. Koppel was never present in an emergency room where patients similar to my father come in -- often by themselves -- all the time.

The JAMA issue also has an editorial that propounds at great length the remarkable insight that people designing computer systems should be very familiar with the needs and the practices of the intended users. It also asserts that, "health care ... is from an organizational standpoint probably the most complex enterprise in modern society." This is highly questionable.

Another paper examines more generally computer support systems used by doctors. Or rather, it examines a whole lot of studies that examined these systems. It concludes: "Many CDSSs improve practitioner performance. To date, the effects on patient outcomes remain understudied and, when studied, inconsistent." The Times article didn't have room for this conclusion, but they did say:
[The editorial] found that most of the glowing assessments of those clinical decision support systems came from technologists who often had a hand in designing the systems.

"In fact, 'grading oneself' was the only factor that was consistently associated with good evaluations," observed the journal's editorial ...".
This last statement from the editorial isn't true. Other factors given involve whether or not practitioners used the system, the usability and integration of the system into practitioner workflow, practitioner acceptance of computer recommendations, and the presence of automatic prompting. And the authors point out that there are reasons beside (obvious) bias why people who are involved in both evaluating and designing a system might produce a system that evaluates better.

Of course, the Times provides token balance by experts. But it makes sure to tell us that "even those experts conceded that the articles raised some good points."

It would be nice if the Times would tell us what, exactly, should be done. How much longer should we expect it to take to develop these computer systems, or should we just give up on the absurd idea of doctors using computers? Perhaps we should take away those dangerous, flawed computer systems from nuclear reactors and air traffic control. Perhaps New York Times writers should go back to using typewriters pencil and paper to record their work.

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