

Harvard study: Computers don't save hospitals money - edw519
http://www.computerworld.com/s/article/print/9141428/Harvard_study_Computers_don_t_save_hospitals_money?taxonomyName=Hardware&taxonomyId=12

======
iamelgringo
This just touched a big nerve with me, so be prepared for a rant.

I've been an ER/Critical Care nurse for 15 years. I've worked/contracted at
over 30 hospital, and I've worked in a number of different specialties. I
recently went back to school for a CS degree, and I'm working 3 days a week as
an ER nurse, and I code the other 3 nights a week on my social news site for
economic and financial news, <http://Newsley.com>.

I get asked all the time by people at Hackers and Founders meetups as to why
I'm not going in to Health Care IT. And, the short answer, is that the
computerization of healthcare is wrong. I currently work at a hospital that's
consistently named one of the nation's "Most Wired", and the more I work at a
"Wired" hospital, the more of a luddite I become. As much as I love computers,
I think that their role in Health Care should be limited to a very few places.

Why? Here's the long answer:

\- Culture. When a physician graduates from med school, they take a vow to
"First, do no harm." The culture of safety, is everywhere. Physicians change
their practice slowly based on research that often takes years to vet.
Medications take years to pass FDA approval. This is all because of the very
strong culture of safety in hospitals. Now, try and meld that with an IT
culture where a generation in technology is 18 months, and user's heads
explode. I've seen CardioThoracic surgeons who makes $750 thousand a year
cutting into beating hearts struggle for an hour trying to put orders into a
new computer system . A lot of physicians trained in the last 40 years never
learned to type, and really don't use computers much. It's simply not cost
effective to force physicians to make the huge adjustments in their practice
to fit the needs of the IT department.

-Disasters. If any organization has to run in a disaster, it has to be a hospital. There aren't many disasters that can prevent me from writing a note on a paper chart in a disaster. But, every computer system that I've worked on in hospitals crashes. When that happens the whole hospital is crippled. Fault tolerant, reliable systems are essential for hospitals, and frankly, they just don't have the money to spend to build them or buy them. Paper is much more forgiving in a disaster than a huge distributed computer applcation running on 1000 Windows PC's with a datacenter back in New Jersey.

-Time. More often than not, I've seen software systems slow patient care down by a factor of 1-4x. We have to spend a lot more time looking at the computer rather than looking at my patient.

-Money. I've alluded to it above. But, when hospitals actually are running in the black financially, they tend to run a 1-2% profit margin. Software systems to run hospitals usually tend to cost tens or hundreds of millions of dollars, and a large support team to manage them. Hospitals generally don't have the money to pay top notch talent to maintain a really complex IT system.

-Bugs. Bugs are a fact of life for programmers. Bugs happen all the time. But, when a bug happens in a healthcare setting, people die. I've seen in happen, and it sickens me.

-Proprietary data formats. Every application that I've ever worked with in a hospital has been proprietary. That means proprietary data formats. A typical hospital will use dozens of different systems that all have their own proprietary data formats from automated lab systems, EKG machines, vital sign monitors, billing systems, inventory tracking systems, etc... All those systems have to be integrated, and for that data to be available across systems is really hard. (see Bugs and Money above).

After years of thinking about this, and working in this environment, I've come
to the conclusion that paper is simply a much better technology for the
industry. Really. Paper is cheap, portable, fault tolerant and easy to change.
I don't have to wait for months for a work order to go through IT to change a
database schema when I want to adjust the data that I'm gathering at Triage
for instance. I can just have someone print up a copy of the new form. I'll
stop now, but if you want to hear more of this rant, feel free to stop by our
next meetup and buy me a beer. By the time we're done we'll both need it. As
you can see, it's a hot button issue for me. :)

~~~
dsteinweg
I'm curious, could you provide any details around the death caused by a
software bug?

~~~
cakeface
<http://en.wikipedia.org/wiki/Therac-25>

~~~
derefr
The parent said "I've seen in happen, and it sickens me," implying that he
wasn't referring to a famous event that happened more than 20 years ago, but
rather something that occurred in medicine today, even after this generation
of software engineers had all been told the story of the Therac in their first
year of school. That makes this much more interesting.

------
jordanb
I have a friend who manages a hospital IT department.

He said that problem is that American private hospitals already are highly
computerized, it's just that the computer systems are focused entirely billing
and not at all on medical records management.

When they decide to get an EMRS, hospitals turn to their billing software
vendor to provide them with something integrated with their billing systems.
The vendors tack something on to the billing software without adequate
requirements gathering amongst the actual nurses who will use it, so the
result is a system that simply does not have the proper workflow for managing
patient medical records.

While EMRSes like the Veterans Administration's VistA program exist and are
well-liked by nurses and doctors, they provide no functionality to ensure that
you get billed $20 for each tongue depressor used. That functionality is, of
course, of primary importance to private hospital administrators. So effective
EMR software gets passed over unless it integrates with hospitals' existing
billing infrastructure, and the hospital billing system vendors build terrible
EMR software.

~~~
jhancock
great summary. I've noticed the VA system is quite good as well and have been
trying to see why other institutions don't use it. I assume the taxpayer
already paid to create it, so why not open source the product and let people
integrate?

~~~
jberryman
I can't find a link right now, but a month or two ago there was an interview
on NPR with the author of (I believe) this book:

[http://www.amazon.com/Best-Care-Anywhere-Health-
Better/dp/09...](http://www.amazon.com/Best-Care-Anywhere-Health-
Better/dp/0977825302)

In the interview he talked about how some doctors at the VA hacked together a
computerized medical records system in the 70s, and how having these
computerized records actually allowed the VA doctors to discover links between
some dangerous drugs and disease. That's in addition to the benefits of a
doctors being able to pull up 30 years of your medical history on a screen.

Wish I could remember details about the interview, but the book is probably
good.

------
xiaoma
_"For 45 years or so, people have been claiming computers are going to save
vast amounts of money and that the payoff was just around the corner," he
said. "So the first thing we need to do is stop claiming things there's no
evidence for. It's based on vaporware and [hasn't been] shown to exist or
shown to be true."_

Oh, but it has. Outside the US, a number of countries have used computers very
effectively in health care. In Taiwan, my medical records are linked to my
national ID number and follow me wherever I seek care. Furthermore, doctors
can regularly do pull up my chart from a laptop when I meet them in their
office. It's also easy to make appointments online, and they go straight to
the doctor in question, without any need to go through human administrators at
the hospital. It's been a huge time saver for the patients, and the doctors
achieve a turn-over that would be unheard of in N. America.

I can only speculate about the money savings, but it's overwhelmingly likely
they are large. Most visits have a co-pay of about 3-10 US dollars, my one
emergency room visit was about 40 and the highest tax bracket is only 20
percent. Most people are only taxed at about 7-8 percent, so it isn't simply a
case of a health care system flooded with public money.

US hospitals just need good computer-based systems, or if it's a national one
then a single good system.

~~~
anamax
> In Taiwan, my medical records are linked to my national ID number and follow
> me wherever I seek care. Furthermore, doctors can regularly do pull up my
> chart from a laptop when I meet them in their office. It's also easy to make
> appointments online, and they go straight to the doctor in question, without
> any need to go through human administrators at the hospital. It's been a
> huge time saver for the patients, and the doctors achieve a turn-over that
> would be unheard of in N. America.

Apart from the "national ID" part, that's exactly how Kaiser works, and has
for some time.

I don't know how widespread Kaiser is, but it's certainly common in
California.

~~~
allenp
I just wanted to emphasize that the best part about Kaiser is their interface
- it is super simple to schedule and receive care and it rarely felt "slugish"
to go through their processes.

------
maryrosecook
Computers rarely save money. They usually allow people to do more in the same
amount of time for the same money. In the case of hospitals, they provide a
better level of care for the same money and in the same time. e.g. I was in an
appointment with my cardiac consultant yesterday. He was able to pull up the
results of my recent exercise test during the consultation, rather than having
me wait to receive a letter with the results and his thoughts.

~~~
trapper
If this were true we would see a reduction in visit times, costs per visit,
patients per doctor, patients per nurse, medical errors etc. Instead we see
the opposite.

The point of the research is that none of these benefits are supported by the
data we have available. Individual anecdotes are the exact opposite of what we
should be thinking about after reading this paper.

~~~
aplusbi
That assumes that the only thing that has changed is the computerization of
records. In the same time span that we've seen increased computer usage we
have also seen increased red tape from insurance companies, malpractice
lawsuits, etc.

I'm not saying you're wrong, just that we don't have enough information to
make any claims.

------
cakeface
I used to work for a health care information systems company called Meditech.
They are one of the largest providers software and EHR to hospitals. While I
was there I was amazed at how inefficient the whole process was. My daily
coding work did not even involve version control! Also we were programming in
a language developed in house from like 1985 or something. Its certainly easy
for me to believe that a system like that would only cause more problems than
it solved.

~~~
sethg
I have a friend who told similar horror stories about working for Meditech. I
hope she's escaped to a better job by now.

~~~
niels_olson
I used meditech as a medical student on the wards. Very painful experience.
I'm sure it was really slick 20 years ago, but it's painful now.

------
samuel
I work in IT for my country's National Health System. I made the switch only
six months ago so my domain knowledge is still very limited. Anyway, I have
already seen how automation may greatly improve doctors and nurses efficiency.

For example, RIS/PACS(Radiology Information System/Picture archiving and
communication system) systems may (and do) save millions euros a year only in
radiographic film. I've seen figures stimating the ROI and its only 3-4 years.
That without mention the advantages of having radiological data instantly
accesible from anywhere, which opens the door to telediagnostics and
telemedicine.

That's a very clear example. In other cases it may be harder to calculate real
savings(if any), but not the improved care level.

------
sethg
_The problem "is mainly that computer systems are built for the accountants
and managers and not built to help doctors, nurses and patients," the report's
lead author, Dr. David Himmelstein, said..._

So the software works for the only interest group in the hospital that
actually has the power to spend five- and six-figure amounts on
infrastructure. The system works! :-/

------
aik
This article seems overly negative. The tone makes it sound like computers
should not exist in hospitals. I wonder what their agenda is?

"The problem 'is mainly that computer systems are built for the accountants
and managers and not built to help doctors, nurses and patients,'"

There are plenty of products out there specifically to help doctors and
nurses, and an increasing amount are being installed in hospitals. If it is in
fact true that a majority of hospitals only have billing software, I would say
it is the fault of the hospital/institution in that they chose to go that
route.

"Implementing e-health records nationwide would cost between $75 billion and
$100 billion, Brailer said, adding that individual hospitals "will have to
make sizable, potentially multi-hundred-million-dollar budget commitments."
Still, he said a fully functioning national electronic health system could
reduce U.S. health care costs by $200 billion to $300 billion annually by
cutting down on duplicate records, reducing record-keeping errors, avoiding
fraudulent claims and better coordinating health care among providers.
Himmelstein called those claims "unsupported.""

The dollar amounts I don't know where come from, but the advantages of a
universal health care record aren't too difficult to see. Supposedly 50+% of
faulty diagnoses are due to a doctor not having the information they need
(that is available elsewhere).

------
aho
I was surprised to learn how just little computerization there is in the ER.
Each medical device is basically a standalone unit, with its own input and
display. There is no central computer system that automatically alerts doctors
if the devices connected to a patient are configured in a potentially
dangerous way. For example, apparently it is surprisingly common for surgery
teams to use a ventilator, switch to a heart-lung bypass machine, but then
forget to turn the ventilator back on once the heart-lung bypass machine is
off. This can cause permanent brain damage if the patient doesn't get enough
oxygen. There should probably be some system that warns the doctors if both
devices are turned off. Unfortunately there is no standard communication
protocol for these devices, which makes it impossible to build such a system.
Here is a presentation on the state of affairs if anyone is interested:
[http://www.mdpnp.org/uploads/Capitol_Hill_NSF_CPS_MD_PnP_9Ju...](http://www.mdpnp.org/uploads/Capitol_Hill_NSF_CPS_MD_PnP_9July09.pdf)

------
jfoutz
amusingly, the computerworld summary doesn't include the paper's summary:

"Finally, we believe that the computer’s potential to improve efﬁciency is
unrealized because the commercial marketplace does not favor optimal products.
Coding and other reimbursement-driven documentation might take precedence over
efﬁciency and the encouragement of clinical parsimony. The largest computer
success story has occurred at Veterans Administration hospitals where global
budgets obviate the need for most billing and internal cost accounting, and
minimize commercial pressures."

It seems like hospitals hyper-optimize single actions at the expense of
efficiency of pipelined actions. sort of like... An addition takes a single
clock, a multiplication takes a single clock, but a multiplication followed by
an addition takes 100 clocks. Except tongue depressors and temperature taking
instead of arithmetic; money instead of time.

I doubt you could build a more cost effective system to have a doctor walk in,
take your temperature and leave.

------
Alex3917
Paul A. Strassman wrote a book about this in 1997. You can read the executive
summary here:

<http://www.infoeconomics.com/squandered.php>

If organizations aren't following Strassman's recommendations for technology
implementation, then it's not really that much of a surprise that they're
still wasting money. The costs of technology are basically the same today as
they were ten years ago, and it's not like human behavior has magically
changed.

------
va_coder
I have a friend who is a hospital administrator. She recently complained about
an awful Oracle system that tries to do everything and fails.

As I think about my friend with the Oracle system I wonder if the problem is
technology or the companies implementing the technology?

~~~
gaius
I'm always fascinated by the thinking behind these ERP behemoths. Like, does
anyone at Oracle or SAP ever take a vacation, or get promoted? How? Do they
use their own software to do it?

------
mildweed
Its not just about the money. Its about increased quality of healthcare.

I think one of the important things to note is that the true benefits of
healthcare reform are going to come with IT in the form of
payment/reimbursement reform legislation and a restructuring of Health
Insurance. As this article also notes, greater public benefit of IT comes from
the data exchange pieces which are being put in place, big news this week with
Kaiser sharing data with the VHA, I expect this to be a trend that snowballs
more information into the NHIN.

Other pieces of Healthcare IT that will benefit outcomes and burden on the
system that this article doesn’t mention is Telemedicine for greater
collaboration around providers, that is a sample among other emerging
technologies that it will take government funding to really skyrocket.

Taking a massive IT project inside the four walls of a Hospital can be tricky
since you have to account for some soft metrics like time saved, reduced
LOS’s, and other non direct financial rewards. The other piece that does not
have widespread adoption is the analytics piece, mining the data and being
able to use for process and efficiency improvement is HUGE, doubt that was
taken into account either.

------
aneesh
There are positive externalities from the use of EHRs, though. The whole
health ecosystem benefits (including patients, other providers, insurers,
etc), not just hospitals, so it's misleading to consider the hospital's bottom
line as the overall impact of EHRs.

~~~
jhancock
There is no "ecosystem" that I can see since the data cannot be shared. Have
you seen some examples where its providing value? I truly would like to know
if I'm missing out on some great software.

I've helped a mid size doctor's office for over 10 years with their IT system.
The only value it has for them is managing billing with insurers and
scheduling patients. Everything else the system does (tracking lab reports,
patient history) is either not practical for the doctors to use or they don't
need it. The part about helping with insurers is a business they'd rather not
be in but have no choice. The scheduling could be replaced with Google
Calendar if not for the tie-in to the data already mandatory for the insurers.
Overall the system is something they consider they have to use but a bit of a
pain and provides no other value.

~~~
aneesh
I can access my dental records online. But you're right, that's probably not a
common scenario.

Since you have some experience in this field, could you imagine this situation
changing in the next several years, so that there is a meaningful ecosystem?

~~~
jhancock
I'm highly skeptical of the current program to subsidize purchasing EHR
systems. I only see it leading to multiple vendors providing proprietary
systems and frankly all the systems we've evaluated don't wow the doctors into
finally believing they have a solution to the backlog of patient records they
have to maintain. Sure, there's supposed to be an interoperable data format,
but when I try to find how any of these vendors have made it accessible, I
come up short. I don't think its in their best interest to do this. When I try
to find out how to become an approved solution which qualifies for the subsidy
(maybe to take an open source solution and run with it), I don't find out how
you break into this magic government approved list of vendors.

If we do find a solution to the data sharing/privacy issues, its useless
without a common core platform that all doctors/hospitals/insurers use. I
think we need a core open source platform and have vendors provide value on
top of this. I've heard good things about the VA program. Maybe this could be
the start of the FOSS platform.

------
raheemm
I would attribute this failure to the vendors/developers/IT experts in the
healthcare sector. IT works extremely well in many sectors that need speed,
accuracy and reliability such as finance, transportation, manufacturing, etc.
So why can't IT provide the same level of service in healthcare?

------
teyc
Toyota's kanban was done with cards and physical cues. Computers aren't as
flexible.

------
ecq
Harvard study: Computers don't save hospitals money

They save lives..

