Sunday, July 17, 2011

Electronic medical records and the muddle of government initiatives

In a recent position, I worked in the health technology sector. A repeated challenge that I tried to impress on the team was that digitizing medical records, medical practices, and healthcare is not as simple as technologizing existing practices. One of the physicians with whom I spoke insisted to me that the best technology for her work was a pen and paper. Actually, I think she might have said a crayon and paper.

The U.S. government recently initiated a program to motivate physicians to start using electronic medical records (EMRs). The government is offering cash back incentives, up to many thousands of dollars, for MDs who meet certain basic criteria in their digitization. As is the wont of the U.S. marketplace, many many business have proliferated to "facilitate" the transition. Unfortunately, while the government provided a list of criteria that have to be met to receive the incentives, they did not really do a very good job at creating a standard format for EMRs. This means that doctors' offices need to evaluate competitors to determine which application will best work for their practice. The transition is daunting and overwhelming for many doctors' offices, which already perceive their workload to be more than they can handle (for the money that they believe they should receive).

This Sunday's Business Section of The New York Times has a cogent article about this problem. [Yes, I know I reference this periodical disproportionately.] I hadn't articulated this point as well as I'd like to have done, but I think the medical records dilemma is a great example of the limitations of innovation. We hurdle ahead to make things fancier, shinier, and purportedly more streamlined. But in the process critical details get lost.

During my last project, I repeatedly reiterated that we needed to really understand workflows and the processes in place. Digitizing practices is great for something that is repetitive and cumbersome, at least early on, as the technology becomes integrated into actors' needs. It also needs to capture tasks with a predictable workflow. This sounds like such a simplistic perspective on technology, missing all the amazing and fantastical things technological innovation might offer. But in industries in which data remain non-digital, you can't simply waltz in and show off the fancy things that might be possible. It's simply far too daunting and impractical.

Thus far, I have yet to see a platform or computerized set of practices that really address the needs of healthcare practices. These still remain too piecemeal and focused on the future to really meet the demands of the people who will use the tools. While one might be tempted to say that the healthcare industry is a particularly complex arena (and it is in some ways) because of the competing users' priorities (healthcare payers, for example, have a very different end goal than the users of the system [patients]), this is an overly simplistic explanation for why the tech industry hasn't gotten it quite right in the healthcare field. I would suggest that many of the people in the tech industry simply haven't done due diligence in understanding the problems.

Wednesday, July 13, 2011

On the "lure of innovation"

Innovation and technology are essential components of medicine and science. There is a constant drive to push our understanding of processes and improve upon existing knowledge further. It is a fairly central tenet of medical culture. Yet, as I've discussed here, it can be difficult to really balance the drive to move forward without trade-offs, sometimes losing the things that work well (though maybe not the most efficient).

This article appeared in The New York Times a couple of weeks ago, and I made a mental note to read it and comment on it. Meier looks at a new technology of hip implants, designed to allow patients to be more active, and the dangers posed by the implants' shedding of metal debris in the patients who received them. It's not just the hip implants, however, there have been an increase of medical technology developments that have posed very significant risks in the pursuit of the latest and greatest. The implants, Meier writes, "show[...] how innovation’s lure led almost everyone to seize on a product promoted as a breakthrough without convincing evidence that it was better or even as good as existing options."

My time as a consultant in oncology biotech/pharma certainly bore this out, as well. The current debates around Avastin for breast cancer struggle with whether incremental benefits (to some) are worth the risks to many. Often new drugs will have a couple of months' improvement over an existing drug, but this potential may be touted as a critical need, even when the trade-offs in quality of life may not be considered by the scientific criteria of risks and benefits.

I would suggest that this is a very American conception of innovation. As one of the physicians interviewed in the article, Dr. Henrik Malchau, notes, "As a non-American, I don’t completely understand it, but there is a phenomenon in the U.S., the latest and the greatest." One of the arguments for the U.S. structure of healthcare and privatization of health (including pharma companies, etc.) has been that the capitalist model generates innovation in a way that government run health simply does not. This position takes American individualism and competition as critical drivers for improvements and innovation in health (and elsewhere). But it's also clear that this model has serious consequences. Even the way in which medical science is funded and regulated reflects this prioritization of privatization as the way to better medicine and knowledge.

What I'm calling for is not a complete abandonment of existing models, but I believe we need to actually take these instances (of which there are many) of failure/serious tradeoffs to be more methodical in how we approach innovation. I realize this is probably highly impractical. People drive technology forward fairly heedless of the individual effects, with the hope that the population-level overall benefit will be worth the costs to the individuals affected. I do believe that one should be circumspect about embracing new products/technologies. And I think that the government could actually make some in-roads into demanding higher standards of proof before approving health-related technologies. Meier writes, at the end of his article, that it is not just a problem with regulation, but also with the attitudes of physicians and patients. This is a cultural problem as much as a structural one.