Princess Health and Back to Paper After U.S. Coast Guard EHR Debacle: Proof of Hegel's Adage "We Learn From History That We Do Not Learn From History"?. Princessiccia

Princess Health and Back to Paper After U.S. Coast Guard EHR Debacle: Proof of Hegel's Adage "We Learn From History That We Do Not Learn From History"?. Princessiccia

Coast Guard EPIC Healthcare IT failure Leidos Lockheed Martin Politico

Gusty 11:55 Add Comment

I have become blue in the face writing about healthcare information technology mismanagement over the years.  In fact, the original focus of my 1998 website on health IT (its descendant now at http://cci.drexel.edu/faculty/ssilverstein/cases) was on HIT project mismanagement.

If this industry actually had learned anything from history, I would not be reading nor writing about brutally mismanaged HIT endeavors in 2016.  Sadly, that is not the case.

The Coast Guard, founded by Alexander Hamilton, has this as its motto and mission:

http://www.gocoastguard.com/about-the-coast-guard
Semper Paratus - Always Ready.

The Coast Guard is one of our nation's five military services. We exist to defend and preserve the United States. We protect the personal safety and security of our people; the marine transportation system and infrastructure; our natural and economic resources; and the territorial integrity of our nation�from both internal and external threats, natural and man-made. We protect these interests in U.S. ports and inland waterways, along the coasts, on international waters.

We are a military, multi-mission, maritime force offering a unique blend of military, law enforcement, humanitarian, regulatory, and diplomatic capabilities. These capabilities underpin our three broad roles: maritime safety, maritime security, and maritime stewardship. There are 11 missions that are interwoven within these roles.

It seems the Coast Guard personnel need personal protection from the HIT industry, for the motto of that industry, sadly appears to be something like "Stupra Acetabulus" (Screw the Suckers).

From Politico, one of only a few publications that in recent years has taken a critical approach to this industry and pulls no punches:

http://www.politico.com/story/2016/04/ehr-debacle-leads-to-paper-based-care-for-coast-guard-servicemembers-222412

EHR debacle leads to paper-based care for Coast Guard servicemembers
By Darius Tahir
04/25/16

The botched implementation of an electronic health records system sent Coast Guard doctors scurrying to copy digital records onto paper last fall and has disrupted health care for 50,000 active troops and civilian members and their families.

Five years after signing a $14 million contract with industry leader Epic Systems, the Coast Guard ended its relationship with the Wisconsin vendor, while recovering just more than $2.2 million from the company. But it couldn�t revert back to its old system, leaving its doctors reliant on paper.

This state of affairs is simple inexcusable.  It represents gross negligence and severe multi-axial incompetence at best - but likely primarily not by the Coast Guard, whose core competency does not include HIT.

There�s no clear evidence the EHR disaster has harmed patients, and a Coast Guard spokesman said the use of paper records hasn�t affected �the quality of health care provided to our people.�

Proof by lack of evidence is not reassuring in a debacle of this kind.  However, the Coast Guard admits that paper records aren't the clear and present danger the IT pundits make them out to be.

Politico is skeptical of the claim:

That seems unlikely. Without digital records, if a patient goes outside a Coast Guard clinic, it can take weeks for the paper record to follow him or her back to the Coast Guard, says Michael Little of the Association of the United States Navy. And since the Coast Guard primarily provides outpatient, rather than hospital, services, many of its patients seek outside care.

�It�s one thing if you�re doing paper-based [care] in Ohio, but what about if you�re on paper records in [an] icebreaker or cutter in Alaska, and you need your gall bladder removed?� said Little, the organization�s director of legislative affairs.

In this case, I disagree that the lack of records is so dangerous.  There's the telephone, FAX machines, the patient himself or herself, and the hand-carried note.  Used with care, those serve care reasonably well. 

With the Department of Veterans Affairs weighing whether to buy a top-of-the-line commercial electronic health record and the Pentagon beginning a multibillion-dollar EHR implementation, the Coast Guard case displays how poorly the process can go for the government, even when the biggest names in health IT are involved.

Not just the government.  I'd also argue that this shows that the "biggest names" are, at best, overextended, and at worst, badly needing external investigation as to their software development, customization, implementation and support practices, as well as hiring practices (e.g., see my August 15, 2010 post "EPIC's outrageous recommendations on healthcare IT project staffing"
at http://hcrenewal.blogspot.com/2010/08/epics-outrageous-recommendations-on.html) and contracting.

Reversion to a purely paper-based system is a rare event in the recent annals of electronic records, said Thomas Payne, a health IT expert at the University of Washington. �I can think of examples where that has happened, but in the last decade that is much less common.�

I believe that is because of the general invisibility of, and immunity from, the risks and harms that occur from "making do" with bad health IT due to financial pressures.  Hence one sees hair-raising examples like I wrote of at my Nov. 17, 2013 post "Another 'Survey' on EHRs - Affinity Medical Center (Ohio) Nurses Warn That Serious Patient Complications 'Only a Matter of Time' in Open Letter"at http://hcrenewal.blogspot.com/2013/11/another-survey-on-ehrs-affinity-medical.html where going back to paper to allow a complete rethinking of the EHR implementation would likely have been the safe response.

See also, for example, my July 2013 post "RNs Say Sutter�s New Electronic System Causing Serious Disruptions to Safe Patient Care at East Bay Hospitals" at http://hcrenewal.blogspot.com/2013/07/rns-say-sutters-new-electronic-system.html (there are links there to still more examples).

The Coast Guard is tight-lipped about the causes, timeline and responsibility for the debacle. �Various irregularities were uncovered, which are currently being reviewed,� a spokesman said.

The causes are all covered at http://cci.drexel.edu/faculty/ssilverstein/cases/, and have been since the late 1990s.  In the alternative, the book "Managing Technological Change: Organizational Aspects of Health Informatics" (http://www.amazon.com/Managing-Technological-Change-Organizational-Informatics/dp/0387985484) by Lorenzi & Riley does likewise for an even longer period, since the mid 1990s - for those willing or able to learn from history and from the pioneers

There�s no shortage of candidates: the service relied on five separate vendors to build the new system, and its own planning seems to have been at fault.

Lawmakers are looking into the matter, said a spokesman for the Senate Appropriations Committee, which is �monitoring the situation."

This is symptomatic, in my view, of the fact that there are a lot of "Beltway Bandit" IT consultant companies doing business, few of them very good.

Bungled implementation, followed by chaos

In September 2010, the Coast Guard bid out the contract to Epic Systems, then added an array of other contracts to software vendors and consultants to help implement it. Since 2010, the agency spent, on net, just more than $34 million on health IT.

In a January 2011 speech, Coast Guard Chief Medical Officer Mark Tedesco cited the success of Epic installations at Kaiser Permanente and Cleveland Clinic. He predicted that the Epic implementation would improve the health of its population and save money.

�Overall it�s a cheaper system for us to run than to upgrade to [the next generation military EHR], because of what that would�ve meant to us infrastructure-wise and support-personnel wise,� he said.

It's stunning to think what this says about the next-generation military EHR.  The previous one was not very good, either (see my June 4, 2009 post "If The Military Can't Get Electronic Health Records Right, Why Would We Think Conflicted EHR Companies And IT-Backwater Hospitals Can?" at http://hcrenewal.blogspot.com/2009/06/if-military-cant-get-electronic-health.html). 

Trouble, apparently, struck quickly. The solicitation for the EHR contract envisioned rolling out the software within six months at two to three pilot sites, before deploying it to a total of 43 clinics and the sickbays aboard the Coast Guard�s fleet.

That didn�t occur; the system never deployed to any clinic or cutter, said Eric Helsher, an executive with Epic. The next missed deadline was March 2012, which Trent Janda � the Coast Guard doctor serving as project leader � announced in a summer 2011 newsletter of the Uniformed Services Academy of Family Physicians.

One can only wonder what penalties the contract called for if the goals and timelines were not met.  That software was not deployed even to any pilot sites is nearly unimaginable to me.

As Janda set the new goal, he acknowledged there had been �multiple hurdles and delays,� and explained that the service had expanded its ambitions.

�Immediately upon award of the contract, we began a comprehensive analysis of the clinical workflows and existing information systems,� Janda wrote. �Many of the weaknesses became apparent as we compared ourselves to industry standards and best practices. Frequently, a weakness would lead to others, ultimately leading to the need for an additional system. The work-flow analysis quickly grew into a system wide re-engineering project like a snowball rolling down the mountainside.�

This sounds like a groundbreaking level of project mayhem and chaos, even for HIT.

The comment reveals that the agency failed to do necessary advance planning, says Theresa Cullen, an informatics executive with the Regenstrief Institute who formerly worked with Veterans Health Affairs and the Indian Health Service.

�They should have done a full needs assessment,� she said. �One would have normally done the workflow evaluation prior to the release of the RFP.�

If true, I believe it was an obligation of EPIC and the multiple contractors to have pointed that out to their future customer, and adjusted their bids accordingly, taking into account the time and resources needed for this type of work - or not placed a bid at all.  Such deficiencies and what they mean towards project progress and failure are obvious - to anyone who's learned from history.

... Cullen also found it odd that the Coast Guard didn�t hire consultants to implement the new system until September 2012. The service ended up hiring Leidos, which also maintained its old EHR.

The Coast Guard further complicated the process by deciding to team up with the State Department. Its original request was complicated enough, with installations spanning six time zones. The partnership with State meant implementing across 170 countries. (A spokeswoman for State said the agency was investigating its options, but refused additional comment).

The sheer number of sites led Cullen to question whether Coast Guard and State had devoted enough resources to the project. Between Epic and Leidos, the project was budgeted for roughly $31 million. That was �an inadequate amount of funding for what you�re asking to do,� she said. Consultants receive roughly $100 an hour, and Epic�s work with clinicians is time-consuming.

Again, those hired knew, should have known, or should have made it their business to know that under such conditions, if true, project failure was the predictable outcome.  They are supposed to be the HIT experts, after all, not the Coast Guard.

While a very efficient health care system could implement the EHR, she said, the Coast Guard lacks that reputation. She speculated that Epic intentionally underbid the contract. (Epic�s Helsher said that �the contract was viable and we were fully motivated to lead a successful install.�)

Someone is right, and someone is wrong.  I leave it to the reader to decide who was correct and who wasn't.

Anecdotes of further delays pepper various newsletters and reports from 2012 through 2015. Server failures scuttled a pilot rollout in 2014, then developed into deeper problems, and last July the systems started failing on a more regular basis.

Perhaps the "anecdotes" need to be turned into "teachable moments" through legal discovery by federal law enforcement.

The Coast Guard advised retirees and dependents that month that, due to incompatibility between its EHR and the Department of Defense�s new medication reconciliation system, they couldn�t get their prescriptions filled at Coast Guard clinics.

Around Labor Day, Coast Guard health care personnel were directed to copy information from electronic files onto paper, for fear of losing their data.

That is just about the most pathetic sentence I've ever had to read in my 24 years in Medical Informatics.

... doctors are frustrated. One complained in the Uniformed Services Academy of Family Physicians newsletter of �unique challenges which seemed to revolve around many electronic record keeping changes.� �The question we pose is, how is this affecting shipboard life?� Little said. �This is the most important thing that�s happening right now in the Coast Guard.�

My advice to the Coast Guard is to treat the IT invaders and consultants as it would a invading maritime fleet from a hostile nation.

The vendors who worked with the Coast Guard either don�t know what went wrong, or aren�t telling. Leidos � also the lead company implementing the Pentagon�s EHR project � declined comment, as did Lockheed Martin, which was contracted to implement access to the EHR through mobile devices, and Apprio, which was to provide credentialing services.

I believe they have a very good idea of "what went wrong", and aren't telling (per the Fifth Amendment)?  If they have "no idea" what went wrong, what, I ask, are they doing in the IT consulting business?

... The EHR giant [EPIC] says it�s not entirely clear why the Coast Guard pulled the plug. But the situation wasn�t Epic�s fault, company executive Eric Helsher said.

They pulled the plug out of fear for their members' well-being, hopefully.

It seems everyone seeks to escape culpability, with the blame placed on the customer.

The Coast Guard spokesman said the decision was �driven by concerns about the project's ability to deliver a viable product in a reasonable period of time and at a reasonable cost.�

It seems there's still some who don't continue down the sunk-cost fallacy road (https://www.logicallyfallacious.com/tools/lp/Bo/LogicalFallacies/173/Sunk_Cost_Fallacy) and are willing to walk away from bad HIT.

... In general, software contracts deserve more scrutiny, said Kingston, who served on the House Appropriations Committee. �These things don�t get the scrutiny a weapons system does.�

Considering the reputation of military costs, that's saying quite a lot.  The lesson that should have been learned from history is that HIT is both exploratory, and a relative free-for-all.

Caveat emptor.

One last piece of (free!) advice for the Coast Guard leadership.

Read this paper:

Pessimism, Computer Failure, and Information Systems Development in the Public Sector.  (Public Administration Review 67;5:917-929, Sept/Oct. 2007, Shaun Goldfinch, University of Otago, New Zealand).  Cautionary article on IT that should be read by every healthcare executive documenting the widespread nature of IT difficulties and failure, the lack of attention to the issues responsible, and recommending much more critical attitudes towards IT.  linkto pdf

That may be the most valuable learning experience of all for their next attempt to implement EHRs.

-- SS

Princess Health and The Future Pathways for e-Health in NSW .Princessiccia

Princess Health and The Future Pathways for e-Health in NSW .Princessiccia

Healthcare IT experiment Healthcare IT failure Jon Patrick

Gusty 05:16 Add Comment

Prof. Patrick has now added a new section to his report on health IT in NSW Australia, entitled "The Future Pathways for e-Health in NSW." It is available at this link (PDF).

It inoculates against most of the 'Ten Plagues' that bedevil health IT projects (such as the IT-clinical leadership inversion, lack of transparency, suppression of defects reporting, magical thinking about the technology, and lack of accountability of the bureaucrats).

Emphases mine:

In Short Term ( 0-3 months)

1. Halt further rollouts of Firstnet or other CIS systems. The current roll-out programs use significant efforts in training staff for a system that is counterproductive to patient well being.
2. Complete a full and thorough risk assessment analysis and usability of the software. The CIS report indicates there are a number of risks in the current software that are not likely to have been assessed in the past.
3. Address the current problems before doing anything else. There are a number of problems that appear solvable in the short term that would improve the situation for current users, such as providing needed reports.
4. Create the NSW IT Improvement Panel composed of ED Directors, IT-savvy clinical and quality improvement staff responsible for advising on the preparedness and process of the rollout.
5. Create an effective error and bug reporting mechanism that is viewable by all ED directors and with the display of the priority of each entry and expected completion time.
6. Initiate a high profile campaign to encourage staff to lodge fault records on anything they discover wrong, problematic or inefficient in using the system.

In the longer term (3-12 months)

1. Review the Health Support Services and make it clinically accountable by appointing a clinical head with an IT education.
2. Create a culture change in the HSS. The current operation of the HSS seems to be devoid of influence from the clinical community.
3. All NSW CIS system procurement should be guided by an IT Advisory Board of IT experienced clinical, academic and medical software industry experts.
4. Create pathways for hospitals that wish to be early adopters and take a lead role in the development of new methods for using and deploying IT systems.
5. Support innovation within the Australian medical software communities that contribute to a culture of innovation and continuous quality improvement.
6. Adopt transparency rules in all new healthcare information acquisitions. Secrecy has bedevilled the efforts of staff and management to get improvements in the CIS systems and hold service agents accountable for their failure to comply to service level agreements. All agreements about a signed contract should be available to the ED Directors.
7. Replace the State Based Build policy with a policy of providing a technology to match the technology experience of the individual departments so that leaders are not dragged backwards with inappropriate technology installation

The de facto "National Program for IT in the HHS" here in the United States needs a similar inoculation.

I can only add that our own ONC office (Office of the National Coordinator for Health IT of the Dept. of HHS) had more granular recommendations about expertise levels required for leadership roles in such undertakings. I wrote about them at my Dec. 2009 post "ONC Defines a Taxonomy of Robust Healthcare IT Leadership."

--SS

Princess Health and Physicians, Even Those Educated in IT and Informatics, Are Not "Real" IT People. Princessiccia

Princess Health and Physicians, Even Those Educated in IT and Informatics, Are Not "Real" IT People. Princessiccia

Healthcare IT failure

Gusty 09:23 Add Comment

I've been participating in the comment thread on the HisTALK heath IT industry news/gossip site at http://histalk2.com/2009/09/17/news-91809/ . At this time there are 40 comments - mine start at #4. (I've also archived the thread in Word format here.)

It's been quite interesting, demonstrating that many of the harmful attitudes of IT personnel about healthcare I observed more than a decade ago are still around.

An anonymous commenter under the title "Programmer" has been forthcoming with views I think are actually common in the health IT field about medicine, science, IT flaws and shortcomings, and physician involvement in HIT. I will let you read them for yourself at the above link.

Others have indicated in that comment thread and other threads that "Programmer" is an executive with a large HIT company, but I cannot confirm this.

Among other stunning views, this commenter exhibited:

• Serious errors in logic such as repeatedly and unshakably mistaking well-documented reports about known rates of IT project failure as a condemnation that all IT projects fail, perhaps reflecting a state of denial;
  
• Lack of understanding that in scientific fields such as biomedicine, conclusions generally should be supported by reasonable evidence, not "because I think so";
  
• Lack of understanding and dismissal of the value of the peer reviewed scientific literature on health IT, and further, a seeming inability or unwillingness to peruse the "references" section of scientific articles, a profoundly unscientific approach to the world;
  
• Dismissal of the written views of organizations such as the Joint Commission, US National Research Council, European Federation for Medical Informatics and others on HIT deficiencies;
  
• Perhaps most harmfully, dismissal of faulty conceptual and physical data models, inadequate workflow and cognitive support, and IT of poor user interaction design that presents a mission hostile user experience as a real problem in critical care areas such as Invasive Cardiology (specifically, in this case). Instead, this IT person dismissed physician dismay and rejection of such ill-designed and profoundly unusable IT as a mere "pissing contest" between IT and clinicians, consistent with narrow, territorial, paternalistic, indeed autocratic IT-centric views and a reversal of enabler (clinician) vs. facilitator (IT service provision) roles in patient care.

"Programmer" also attacks (from the perspective of arrogant ignorance) the "Health IT Project Success and Failure: Recommendations from Literature and an AMIA Workshop" white paper drawing together the thinking at a workshop attended by over fifty informatics experts from all areas of medicine and technology. The role of the medical informatics expert itself, and other issues as well relating to reasons for HIT failure and difficulty are attacked and dismissed.

(If the person is a fake or "sock puppet", they're doing a mighty accurate approximation of my own uncomfortably-common observations in managing health IT and biomedical research IT projects while working with non-biomedical IT personnel, see cases here.)

The crux of the matter came out towards the end where "Programmer" maintains in Comment #28 that I am "just someone who likes to talk about IT� and he is a �real IT person.�

A "real IT person?" I've heard that before: this is the "doctors don't do things with computers" (including medical informaticists) type of comment I've heard face-to-face periodically from healthcare IT personnel since I entered the field in the early 1990's, and commented upon a decade ago here.

I've emailed Tim, the proprietor of the HISTalk site [mr_histalk AT yahoo.com], to inquire if this poster was real or just a provocateur.

Tim's response: "He's real and has been around for awhile, although lately he seems to be enjoying an escalated level of confrontation when he can create one."

I maintain -- based on personal experience and that told me by others -- that this person's views are not all that rare in the HIT vendor and hospital IS communities.

I also opine that thinking such attitudes can be dealt with by logical argument and persuasion is a belief itself lacking in rigor.

IT personnel of views as in the HisTALK comments thread represent an older culture of data processing, dating from the days of card punch tabulators that ran businesses prior to computers. It is a culture that has failed to mature with the times.

As I wrote here, the unimaginative, process over results, tight fisted control, bureaucratic data-processing culture of the business IT (management information systems) world is the lineal descendant of IBM's patchcord plug-panel programmed, card tabulating machines from which IBM made a large portion of their profit in the days before the electronic computer:

Hollerith Type III Tabulator with its control panel exposed. Photo: MNRAS, Vol.92, No.7 (1932). Click to enlarge.

Fortunately, such personnel and their designer-centric, as opposed to user- and work-centric philosophies are starting to become obsolete. This can be observed (as an example) via the mission of the iSchool consortium, of which my organization, the Drexel College of Information Science and Technology, is a member:

The iSchools are interested in the relationship between information, people and technology. This is characterized by a commitment to learning and understanding the role of information in human endeavors. The iSchools take it as given that expertise in all forms of information is required for progress in science, business, education, and culture. This expertise must include understanding of the uses and users of information, as well as information technologies and their applications. [the order of these priorities is pertinent - ed.]

Unfortunately, the data processing culture and its adherents are not becoming obsolete quite fast enough. There are still too many in the upper echelons of management, including health IT vendors, hospitals and pharmaceutical R&D environments.

Finally, IT personnel with such attitudes as displayed in the comments, from the lowliest programmer to the CEO and Board, have no place anywhere near where patient care is conducted, or where information systems serving clinical medicine are designed and built.

In line with other character types one encounters in healthcare that are often discussed on Healthcare Renewal, clinicians should not accommodate such IT personnel and these types of views.

-- SS

Addendum:

The final (at this time) comment, #40, left by the above commenter states:

#40 Programmer: If I decide to become a medical informatproctolicist, I�m going to specialize in sardonicology.

IT personnel of such views bring to life Lecia Barker's paper "Defensive climate in the computer science classroom":

�Defensive climate in the computer science classroom� by Barker et al., Univ. of Denver. Link here (subscription required). May help explain the control-seeking culture of IT personnel. As part of an NSF-funded IT workforce grant, the authors conducted ethnographic research to provide deep understanding of the learning environment of computer science classrooms. Categories emerging from data analysis included 1) impersonal environment and guarded behavior; and 2) the creation and maintenance of informal hierarchy resulting in competitive behaviors. These communication patterns lead to a defensive climate, characterized by competitiveness rather cooperation, judgments about others, superiority, and neutrality rather than empathy.

-- SS