On EHR's: See No Evil, Hear No Evil, Speak No Evil: Part 1

This is the first of a series of posts I plan on the issue of "See No Evil, Hear No Evil, Speak No Evil" regarding EHR's.  Frequent reminders are needed by all stakeholders, I believe, to think critically about, and take with a big grain of salt, effusive praise by key opinion leaders, politicians, etc. about health IT, and accompanying attempts to deride those critical of the technology, to counterbalance ongoing HIT hyperenthusiasm (e.g., link).

In face of growing evidence of risk and adverse outcomes of bad health IT from multiple sources and organizations (such as this, as just one example), growing advice on risk remediation from government (such as here), and mass privacy violations (see the multiple posts under this query link), it might also be entitled a series on what health IT hyper-enthusiasts "knew, should have known, or should have made it their business to know."

Let's start out with an extract from a post I wrote on June 29, 2003 entitled "Mark Leavitt, Head of CCHIT: Behind the Times and Uninformed on Health IT Realities?". At the time Leavitt was head of CCHIT, a tester and MU compliance/safety certifier of electronic health records systems: 

... The head of CCHIT, Mark Leavitt, has penned the following at iHealthBeat: 

June 19, 2009 - Perspectives 

Health IT Under ARRA: It's Not the Money, It's the Message

by Mark Leavit  

... Before ARRA, most surveys concluded that cost was the No. 1 barrier to EHR adoption. But as soon as it appeared that the cost barrier might finally be overcome, individuals with a deeper-seated "anti-EHR" bent emerged. Their numbers are small, but their shocking claims -- that EHRs kill people, that massive privacy violations are taking place, that shady conspiracies are operating -- make stimulating copy for the media. Those experienced with EHRs might laugh these stories off, but risk-averse newcomers to health IT, both health care providers and policymakers are easily affected by fear mongering.

"Laugh these stories off?"  That was, and is, simply perverse.

Ironically, this statement was written less than a year before my own mother was seriously and fatally harmed as a result of a health IT-related error.
 

On EHR's:  See No Evil, Hear No Evil, Speak No Evil

While I don't proffer claims of "shady conspiracies" (international health IT expert Dr. Richard Cook explains that in a recent guest post "Dr. Richard Cook on the Health IT Sector's Ills"), I do proffer alternate explanations including arrogance, Radical Solutionism, and this.

More to come in this series.

There are many more statements like this one already on this blog, and elsewhere.

-- SS

Note:  Part 2 is here.

Solutionism: are all healthcare issues transparent and self-evident processes that can be easily optimized, if only the right algorithms are in place?

I've ordered this book:  "To Save Everything, Click Here: The Folly of Technological Solutionism" by Evgeny Morozov.

I've read some excerpts prior to its delivery and find them fascinating.  Emphases mine:

... Alas, all too often, this never-ending quest to ameliorate—or what the Canadian anthropologist Tania Murray Li, writing in a very different context, has called “the will to improve”—is shortsighted and only perfunctorily interested in the activity for which improvement is sought. Recasting all complex social situations either as neatly defined problems with definite, computable solutions or as transparent and self-evident processes that can be easily optimized—if only the right algorithms are in place!—this quest is likely to have unexpected consequences that could eventually cause more damage than the problems they seek to address.

I call the ideology that legitimizes and sanctions such aspirations “solutionism.” I borrow this unabashedly pejorative term from the world of architecture and urban planning, where it has come to refer to an unhealthy preoccupation with sexy, monumental, and narrow-minded solutions—the kind of stuff that wows audiences at TED Conferences—to problems that are extremely complex, fluid, and contentious. These are the kinds of problems that, on careful examination, do not have to be defined in the singular and all-encompassing ways that “solutionists” have defined them; what’s contentious, then, is not their proposed solution but their very definition of the problem itself. Design theorist Michael Dobbins has it right: solutionism presumes rather than investigates the problems that it is trying to solve, reaching “for the answer before the questions have been fully asked.” [Such as, how risk-prone are paper records, exactly, and how might the risks be ameloriated without spending hundreds of billions of dollars on healthcare IT? - ed.] How problems are composed matters every bit as much as how problems are resolved.

Solutionism, thus, is not just a fancy way of saying that for someone with a hammer, everything looks like a nail; it’s not just another riff on the inapplicability of “technological fixes” to “wicked problems” (a subject I address at length in The Net Delusion). It’s not only that many problems are not suited to the quick-and-easy solutionist tool kit. It’s also that what many solutionists presume to be “problems” in need of solving are not problems at all; a deeper investigation into the very nature of these “problems” would reveal that the inefficiency, ambiguity, and opacity—whether in politics or everyday life—that the newly empowered geeks and solutionists are rallying against are not in any sense problematic. Quite the opposite: these vices are often virtues in disguise. [Such as - paper charts that are rapid to produce and browse, redundancies in healthcare processes that can help prevent errors of omission, ambiguities in decision making that take into account that not everyone fits a guideline, etc.? - ed.] That, thanks to innovative technologies, the modern-day solutionist has an easy way to eliminate them does not make them any less virtuous.

It occurs to me that what I've been calling "the syndrome of inappropriate overconfidence in computing" or "healthcare IT hyper-enthusiasm that ignores the downsides" -- or that which authors such as Nemeth/Cook might call a blindness to complexity that is "hiding in plain sight" and "HIT techno-fantasies" -- and similar ideas, may all be the same thing.

"Solutionism" may be a good umbrella label for these ideas.   Thus, those who challenge these ideas in healthcare and call for caution and restraint are not anti-health IT, not anti-technology, but anti-Solutionism, or maybe 'temperate solutionists' as opposed to 'extremist solutionists' or 'radical solutionists.'

And the reason the pushback is so vicious at times may be that we are attacking not just an industry but a broad philosophy or ideology - "a systematic body of concepts especially about human life or culture."

The current culture promotes solutionism - the belief that there's a technocratic (technological & bureaucratic, i.e., management of society by technical 'experts') solution to every problem as "solutionism" is defined elsewhere.  I think a vast majority of people, including the 'intellectuals', have bought into it.  

It doesn't help that "radical solutionism" is exceptionally profitable for its proponents....

Solutionism may be applicable to, say, domains where numbers or logistical matters predominate (e.g., banking and FedEx), but not to "messy" domains such as medicine.  Or at least not to all of medicine's component parts, such as the parts that clinicians perform using hard-earned expertise, judgement and ethics.

Finally, I ask:

Why can't be cure mental illness, or ensure perfect outcomes in cardiac surgery, or prevent wars, with the appropriate computer apps?

After all, with the appropriate tools, why can't we easily perform nuclear fission on our kitchen tables?

More after I read the book.

-- SS