Is Healthcare Information Technology Based on Evidence?

Summary

Is healthcare information technology (HIT) based on evidence of efficacy? Are the trillions of dollars already devoted and in the pipeline for HIT implementations based on systematic evaluations? If evaluated, would those evaluations focus on patient safety, return on investment, clinical efficiency, improved clinician satisfaction, and/or workflow integration? Do we have reliable evidence of usable interfaces, of successful implementations, of data standards allowing interoperability, of continuous improvement, of responsiveness to clinician feedback?

While measurement of HIT's efficacy is extraordinarily difficult—complicated by a myriad of other factors involved in providing healthcare and in organizational dynamics—it is not impossible. But is such evidence required before most implementations? Any implementation? Or are the goals of patient safety and efficiency so self-evident, profoundly desired, and laudable that HIT's beneficence is accepted without rigorous data? Note that lack of systematic evidence does not mean HIT is ineffective. HIT may provide untold benefits even if there is no hard proof of those benefits.

We find that HIT is seldom objectively measured, and that evidence of its efficacy is at best spotty, and often influenced by self-promotion. Most measures, especially those associated with cost-benefit analyses, are aspirational or hubris transubstantiated into numbers.

Keywords

Healthcare IT - EHR - EMR - evidence-based - ROI - CPOE - HIT

• References

• 1 Karsh B-T, Matthew B, Weinger MB, Abbott PA, Wears RL. et al. Health Information Technology: Fallacies and Sober Realities. J Am Med Inform Assoc 2010; 17: 617-23.
• 2 Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E. et al. A Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care. Ann Intern Med 2006; 144 (10) 742-52.
• 3 Koppel R, Localio AR, Cohen A, Strom BL. Neither panacea nor black box: responding to three Journal of Biomedical Informatics papers on computerized physician order entry systems. J Biomed Inform Aug 2005; 38 (4) 267-9.
• 4 Garg A, Adhikari N, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J. et al. Effects of computerized clinical decisio support systems on practitioner performance and patient outcomes: a systematic review. JAMA 2005; 293 (10) 1223-38.
• 5 Wears R, Berg M. Computer technology and clinical work: still waiting for Godot. JAMA 2005; 293 (10) 1261-3.
• 6 Nebeker JR, Hoffman JM, Weir CR, Bennett CL, Hurdle JF. High Rates of Adverse Drug Events in a Highly Computerized Hospital. Arch Intern Med 2005; 165: 1111-6.
• 7 Shulman R, Singer M, Goldstone J, Bellingan G. Medication Errors: A Prospective Cohort Study of Hand-Written and Computerised Physician Order Entry in the Intensive Care Unit. Crit Care 2005; 9 (5) R516-R521.
• 8 Ash JS, Sittig DF, Poon EG, Guappone K, Campbell E, Dykstra RH. The Extent and Importance of Unintended Consequences of Computerized Physician Order Entry. J Am Med Inform Assoc 2007; 14: 415-23.
• 9 Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of Unintended Consequences Related to Computerized Provider Order Entry. J Am Med Inform Assoc 2006; 13 (5) 547-56.
• 10 Aarts J, Ash J, Berg M. Extending the Understanding of Computerized Physician Order Entry: Implications for Professional Collaboration, Workflow nd Quality of Care. Int J Med Inf 2007; 76: S4-13.
• 11 Han Y, Carcillo J, Venkataraman S, Clark R, Watson S, Nguyen T. et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics 2005; 116: 1506-12.
• 12 Harrison M, Koppel R, Bar-Lev S. Unintended consequences of information technologies in health care: an interactive socio-technical analysis. J Am Med Inform Assoc 2007; 14: 542-9.
• 13 Spencer J, Koppel R, Ridgely MS. AHRQ Guide to reducing unintended consequences of HIT Implementation and Use. 2011 www.ucguide.org (accessed May 13, 2011).
• 14 Kellermann AL, Jones SS. What It Will Take To Achieve The As-Yet-Unfulfilled Promises Of Health Information Technology. Health Aff 2013; 32 (1) 63-8.
• 15 Madara JL. Open Letter to Office of the National Coordinator of HIT Chair, Dr. Farzad Mostashari on the American Medical Association's position on “Meaningful Use” regulations. http://www.ama-assn.org/resources/doc/washington/stage-3-meaningful-use-electronic-health-records-comment-letter-14jan2013.pdf (accessed January 21, 2013).
• 16 Silverstein S. Contemporary Issues in Medical Informatics: Common Examples of Healthcare Information Technology Difficulties. http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases (accessed May 13, 2011).
• 17 Koppel R, Gordon S. First Do Less Harm: Confronting The Inconvenient Problems of Patient Safety. Ithaca, NY: Cornell University Press; 2012
• 18 Koppel R, Majumdar SR, Soumerai SB. Electronic Health Records and Quality of Diabetes Care. Editor's Correspondence. N Engl J Med 2011; 365: 2338-9.
• 19 Berger R, Kichak J. Computerized Physician Order Entry: Helpful or Harmful?. J Am Med Inform Assoc 2004; 11: 100-3.
• 20 Hillestad R, Bigelow J, Bower A, Girosi F, Meili R, Scoville R. et al. Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, and Costs. Health Aff 2005; 24 (5) 1103-17.
• 21 Healthcare Information Management and Management Systems Society. http://www.himss.org/ASP/aboutHimssHome.asp (Accessed 12/25/12)
• 22 EHRA of HIMSS (Electronic Healthcare Record Association of HIMSS). http://www.himssehra.org/ASP/index.asp (Accessed 12/25/12).
• 23 McCormick D, Bor D, Woolhandler S, Himmelstein D. The Effect of Physicians' Electronic Assess to Tests: A response to Farzad Mostashari. Health Affairs Blog. March 12 2012 http://healthaf-fairs.org/blog/author/dmdbswdh/ (Accessed 12/25/12).
• 24 Jha AK, Desroches CM, Campbell EG. et al. “Use of Electronic Health Records in U.S. Hospitals,”. N Engl J Med 2009; 360: 1628-38.
• 25 Ridge MS, Greenberg MD. Too many alerts, too much liability: sorting through the malpractice implications of drug-drug interactions clinical decision support. Journal of Health Law and Policy 2012; l5 (2) 257-96.
• 26 Koppel R. The marginal utility ofmargin guidance: commentary on Ridgely and Greenberg. Journal of Health Law and Policy 2012; l5 (2) 311-8.
• 27 Metzger J, Welebob E, Bates DW, Lipsitz S, Classen DC. Mixed results in the safety performance of computerized physician order entry. Health Aff (Millwood) 2010; 29 (4) 655-63.
• 28 Kalra D. “Health Informatics 3.0”. Yearb Med Inform 2011; 8-14.
• 29 Lawler EK, Alan H, Pavlovic-Veselinovic S. Cognitive ergonomics, socio-technical systems, and the impact of healthcare information technologies. Int J Ind Ergon 2011; 41: 336-44.
• 30 Committee on Patient Safety and Health Information Technology. Institute of Medicine of the National Academies Health IT and Patient Safety: Building Safer Systems for Better Care. Washington DC: National Academies Press; 2011
• 31 Kannry J, Kushniruk A, Koppel R. Meaningful usability: Health information for the rest of us. In: Ong K. editor. Medical Informatics: An Executive Primer (2nd Ed). Chicago: Healthcare Information and Management Systems Society (HIMSS); 2011
• 32 Koppel R, Kreda DA. Healthcare IT usability and suitability for clinical needs: challenges of design, workflow, and contractual relations. Stud Health Technol Inform 2010; 157: 7-14.
• 33 Middleton B, Bloomrosen M, Dente MA, Hashmat B, Koppel R, Overhage JM. Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. J Am Med Inform Assoc 2013; Jun 20 (e1) e2-8.
• 34 Spencer J, Koppel R, Ridgely S. AHRQ Guide to reducing unintended consequences of HIT Implementation and Use. 2011 www.ucguide.org (Accessed January 21, 2013).
• 35 Terry K. Doctors' 10 biggest mistakes when using EHRs. WWW.Medscape.com May 1 2013 http://www.medscape.com/viewarticle/803188 (accessed May 11, 2013).
• 36 Duke JD, Li X, Dexter P. Adherence to drug-drug interaction alerts in high-risk patients: a trial of context-enhanced alerting. J Am Med Inform Assoc 2013; 20: 494-8.
• 37 Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE. et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005; 293 (10) 1197-203.
• 38 Koppel R, Wetterneck T, Telles JL, Karsh BT. Workarounds To Barcode Medication Administration Systems: Their Occurrences, Causes, And Threats To Patient Safety. J Am Med Inform Assoc 2008; July/August (4) 408-23.
• 39 Goodman KW, Berner ES, Dente MA, Kaplan B, Koppel R, Rucker D. et al. Challenges in ethics, safety, best practices and oversight regarding HIT vendors, their customers, and patients: a report of an AMIA special task force. J Am Med Inform Assoc 2011; January 18 (1) 77-81.