I note the use of the term "
user error" and lack of the term
"use error" with significant disdain. As I wrote
here regarding the views of a HIT industry exexcutive holding the mystical "American Medical Informatics Certification for Health Information Technology", NIST
itself now defines "use error" (as opposed to "user error
") as follows:“Use error” is a term used very specifically by NIST to refer to user interface designs that will engender users to make errors of commission or omission. It is true that users do make errors, but many errors are due not to user error per se but due to designs that are flawed, e.g., poorly written messaging, misuse of color-coding conventions, omission of information, etc. From "NISTIR 7804: Technical Evaluation, Testing and Validation of the Usability of Electronic Health Records." It is available at http://www.nist.gov/healthcare/usability/upload/Draft_EUP_09_28_11.pdf (PDF).
In the article, in
definites were exchanged with what should have been stronger, declarative statements, and vice versa:
User error ... may also represent a potential health IT-related error yet to happen.
I most decidedly wish they'd stop this "may" verbiage in policy papers like this.
... Anecdotal reports suggest that these application differences [where clinicians use more than one commercial EHR system] result in an increased training burden for EHR users.
"Anecdotal"? How about
"obvious to a third grader?" "Anecdotal" in academic p
apers often is a term of derision for inconvenient truths such as reports of health IT problems. Its use often reflects a need for authors using the term (per a senior clinician from Victoria, Australia on the 'anecdotes' issue, link) "to attend revision courses in research methodology and risk management."
... Some suggest that the expected gains sought with the adoption of EHR are not yet realized.
"Some"? How about "credible experts?" "Suggest?" They merely hint at it? How about "opine?"
... The design of software applications requires both technical expertise and the ability to completely understand the user’s goal, the user’s workflow, and the socio-technical context of the intent
In the meantime, AMIA has been promoting national rollout of a technology where, most often, the latter does not apply.
To ... transform our healthcare delivery system ... clinicians need to use usable, efficient health IT that enhances patient safety and the quality of care.
This is the typical hyperenthusiast mantra. Where's the proof? And, transform into what, exactly? Vague rhetoric like this in allegedly scientific papers is most unwelcome.
Some experts suggest that improving the usability of EHR may be critical to the continued successful diffusion of the technology.
More weak talk. Why not come right out and say "Credible experts opine that ...."?
... While some EHR vendors have adopted user-centered design when developing health information technologies, the practice is not universal and may be difficult to apply to legacy systems.
From the patient advocacy perspective, that's their problem...it's a risk of being in this business. Patients should not be expected to be used as experimental subjects while IT sellers figure out what other industry sectors have long mastered. Further, they should be held accountable for failures that result in harm. Another risk of doing business in this sector that clinicians have long learned to live with...
... Some believe it is difficult or impossible to reliably compare one product with another on the basis of usability given the challenges in assessment of products as implemented.
Nothing is "impossible" and again, if it's "difficult", that's the industry's problem. There is risk of being in the business of medicine or medical facilitation; nobody promised a rose garden, and a rose garden should not be expected.
... Many effects of health IT can be considered to be ‘emergent’ or only discovered after monitoring a system in use
One might ask, where's the industry and AMIA been regading postmarket surveillance (common in other health sectors) for the past several decades?
... AMIA believes it is now critical to coordinate and accelerate the numerous efforts underway focusing on the issue of EHR usability.
Only "now?"
... Establish an adverse event reporting system for health IT and voluntary health IT event reporting
No, no
, no ...voluntary reporting doesn't work. Even mandatory reporting is flawed
, but it's better than voluntary.
I
am invariably disappointed by recommendations like this. I've
observed repeatedly, for example, that "volunat
ary reporting" of EHR problems already exists - in the form of the FDA MAUDE database - and most HIT sellers' reports are absent. See my posts on MAUDE here, here and here. (Also, the only one that seems to report may have ulterior motives, i.e., restraint of trade.)
... A voluntary reporting process could leverage the AHRQ patient safety organizations (PSO) ... This work should be sponsored by the AHRQ.
These folks clearly don't want any teeth in this. AHRQ is a research-oriented government branch, not a regulator, nor does it have regulatory expertise.
AMIA recommends:
Research and promote best practices for safe implementation of EHR
In 2013 this is valuable information in the same sense that advice to use sterile technique during neurosurgery is valuable."Promoting best practices" has been done for decades. Not mentioned is avoiding worst practices. I've long written these are not the same thing, as toleration of the inappropriate leadership by health IT amateurs (a term I use in the same sense that I am a Radio Amateur, not a telecommunications professional), politics, empire-building and other dysfunction that goes on in health IT endeavors negates laundry lists of "best practices."
What is required is to research and abolish worst practices, including the culture and dynamics of the 'health IT-industrial complex.' I made this point in my very first website in 1998. It appears the authors don't get it and/or won't admit to the dysfunction that goes on in health IT projects. ... The adoption of useful and usable EHR will lead to safer and higher quality care, and a better return on investment for institutions that adopt them.
"Will?" With respect to my observation above about the paper's prominent misuse of indefinites vs. stronger declarative terms, the word
"may" would have been the appropriate term here
. As I wrote about similar statements from ONC in the NEJM in my 2010 post "Science or Politics? The New England Journal and The 'Meaningful Use' Regulation for Electronic Health Records"
, I'm quite disappointed seeing speculation and PR prese
nted as fact from alleged scientists and scientific organizations.
Finally, I wrote the following email letter to the authors
, to which (except for Ross Koppel) I received no reply. While Dr. Koppel (a PhD) graciously expressed sympathy for my me and mother, the others (many MD's) were silent.
Perhaps the silence is the best indicator of their concern for the rights of computers and HIT merchants relative to the rights of people:
Mon, Jan 28, 2013 at 1:12 PM
Dear authors,
I've reviewed the new paper "Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA" and wanted to express thanks for it.
It's a good start. Late, but a good start at returning the health IT domain to credibility and evidence-based practice.
It's too bad it didn't come out years earlier. Perhaps my mother would not have gone through a year of horrible suffering and death, with me as sad witness, due to the toxic effects of bad health IT.
Perhaps you should hear how horrible it was to hear my mother in an extended agitated delirium; to hear her cry hysterically later on when the rehab people told her that her weight was 95 pounds; to have to make her a "no code" and put her on hospice-care protocols, and then to have watched her aspirate a sleeping pill when she was agitated, and die several days later of aspiration pneumonia and sepsis ... in the living room of my home ... and then watch the Hearse take her away from my driveway...as a result of bad health IT.
I will be writing more thoughts on your article at the Healthcare Renewal blog, of course, but wanted to raise three issues:
1. The use of "may" and "will" is reversed, and conflating the term "anecdote" with risk management-relevant case reports.
- They may also represent a potential health IT-related error yet to happen. ---> They likely represent a potential health IT-related error yet to happen
- Anecdotal reports suggest that these application differences result in an increased training burden for EHR users. ---> Credible reports indicate...
- Some suggest that the expected gains sought with the adoption of EHR are not yet realized. ---> Credible experts opine ....
- Some experts suggest that improving the usability of EHR may be critical to the continued successful diffusion of the technology. ---> "Credible experts opine that ..."
- The adoption of useful and usable EHR will lead to safer and higher quality care, and a better return on investment for institutions that adopt them. ---> The adoption of useful and usable EHR may lead to safer and higher quality care
You really need to show more clarity ... and guts ... in papers like this, and drop the faux academic weasel words.
2. You neglected to speak to the best source for information on EHR-related harms, evidence spoliation, etc... med mal attorneys.
3. You also neglected to speak to, or cite, the writings of a Medical Informaticist on bad health IT now going back 15 years - and whose mother was injured and died as a result of the issues you write about - me. In fact I am rarely cited or mentioned by anyone with industry interests.
An apparent contempt for 'whistleblowers' such as myself makes me wonder ... what kind of people are the leaders of health IT, exactly?
Do they value computer's rights over patients'?
It is not at all clear to me which has been the primary motivator of many of the health IT leaders.
I think the rights which I value are quite clear.
Sincerely,
Scot Silverstein
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