Digital records no panacea,
docs' journal says
9, 2005, 7:34 AM PST
The Bush administration and many
health experts have declared that the nation's health care system
needs to move quickly from paper records and prescriptions into the
But research papers and an editorial
published Wednesday in the Journal of the American Medical
Association cast doubt on the wisdom of betting heavily that
information technology can transform health care anytime soon.
One paper, based on a lengthy study at a large teaching hospital,
found 22 ways that a computer system for physicians could increase
the risk of medication errors. Most of these problems, the authors
said, were created by poorly designed software that too often
ignored how doctors and nurses actually work in a hospital setting.
The likelihood of errors was increased, the paper stated, because
information on patients' medications was scattered in different
places in the computer system. To find a single patient's
medications, the researchers found, a doctor might have to browse
through up to 20 screens of information.
Among the potential causes of errors
they listed were patient names' being grouped together confusingly
in tiny print, drug dosages that seem arbitrary and computer
"These systems force people to wrap
themselves around the technology like a pretzel instead of making
sure the technology is responsive to the people doing the work,"
said Ross J. Koppel, the principal author of the medical journal's
article on the weaknesses of computerized systems for ordering drugs
and tests. Koppel is a sociologist and researcher at the Center for
Clinical Epidemiology and Biostatistics at the University of
Pennsylvania School of Medicine.
The research focused on ways that
computer systems can unintentionally increase the risk of medical
errors. The study did not try to assess whether the risks of
computer systems outweigh the benefits, like the elimination of
errors that had been caused by paper records and prescriptions.
Yet Koppel said he was skeptical of
the belief that broad adoption of information technology could
deliver big improvements in health care. "These computer systems
hold great promise, but they also introduce a stunning number of
faults," he said. "The emperor isn't naked, but pretty darn
Another article in the journal
looked at 100 trials of computer systems intended to assist
physicians in diagnosing and treating patients. It found that most
of the glowing assessments of those clinical decision support
systems came from technologists who often had a hand in designing
"In fact, 'grading oneself' was the
only factor that was consistently associated with good evaluations,"
observed the journal's editorial on computer technology in clinical
settings, titled "Still Waiting for Godot."
The principal author of the
editorial, Dr. Robert L. Wears, a professor in the department of
emergency medicine at the University of Florida College of Medicine
in Jacksonville, said the message from the research studies was that
computer systems for patient records, the ordering of treatments and
clinical decision support have not yet shown themselves to be mature
enough to be useful in most hospitals and doctors' offices.
"These systems are as much
experiments as they are solutions," said Dr. Wears, who also holds a
master's degree in computer science.
The medical journal's articles,
according to some physicians and technology experts, tend to be too
broad in their criticisms because the technology is still developing
rapidly and some of the computer systems reviewed were old.
Still, even those experts conceded
that the articles raised some good points.
"They are absolutely right that the
people who design these systems need to be in tune with the work,"
said Dr. Andrew M. Wiesenthal, a physician who oversees information
technology projects at Kaiser Permanente, the nation's largest
nonprofit managed care company. "But the newer systems are designed
more that way."
Dr. David J. Brailer, the
administration's national coordinator for health information
technology, termed the articles a "useful wake-up call," though he
said the findings were not surprising. In health care, as in other
industries, he said, technology alone is never a lasting solution.
"The way health information
technology is developed, the way it is implemented and the way it is
used are what matter," Brailer said.
But Brailer did take issue with the
suggestion that the Bush administration is encouraging a headlong
rushBush administration is encouraging a headlong rush to invest in
health information technology.
For the next year, he said, his
policy efforts will be to try to encourage the health industry to
agree on common computer standards, product certification and other
measures that could become the foundation for digital patient
records and health computer systems.
"We're not ready yet to really
accelerate investment and adoption," Brailer said. "We have about a
year's worth of work."
Dr. David W. Bates, medical director
for clinical and quality analysis in information systems at Partners
HealthCare, a nonprofit medical group that includes Massachusetts
General Hospital and Brigham and Women's Hospital, said careful
planning and realistic expectations were essential for technology in
"But the danger is if people take
the view that computerized physician order entry and other systems
are a bad idea," said Bates, who is a professor at the Harvard
Medical School. "That would be throwing out the baby with the bath