I’m well aware that a good fraction of the people in this country – let’s call them Rush fans – spend their lives furious at the New York Times. I am not one of them. I love the Grey Lady; it would be high on my list of things to bring to a desert island. But every now and then, the paper screws up, and it did so in a big way in its recent piece on the federal program to promote healthcare information technology (HIT).
Let’s stipulate that the Federal government’s $20 billion incentive program (called “HITECH”), designed to drive the adoption of electronic health records, is not perfect. Medicare’s “Meaningful Use” rules – the standards that hospitals’ and clinics’ EHRs must meet to qualify for bonus payments – have been criticized as both too soft and too restrictive. (You know the rules are probably about right when the critiques come from both directions.) Interoperability remains a Holy Grail. And everybody appreciates that today’s healthcare information technology (HIT) systems remain clunky and relatively user-unfriendly. Even Epic, the Golden Child among electronic medical record systems, has been characterized as the “Cream of the Crap.”
Moreover, in the last few years we’ve gained a deeper understanding of the hazards of HIT, including new kinds of errors created by the stormy marriage of imperfect computer systems and fallible humans. We’re also becoming familiar with subtler problems, such as the copy and paste phenomenon now plaguing progress notes and the degree to which computers can distance us from our patients (Abraham Verghese’s “iPatient”). These problems are all the more irritating since IT was hyped – overhyped – as the solution to so many of healthcare’s woes.
So it’s natural to be disappointed in the present state of HIT, and even to wonder whether HITECH is on target. But overall, I believe that we are on the right track, that there is no better way to get to an HIT Promised Land than the path we are taking, and that the Federal government should be commended for getting involved in a reasonable way.
The February 19th article in the New York Times – one of the most off-base, unbalanced articles in my recent memory – paints a very different picture. The paper’s lead article – yes, Page 1, Column 1, above the fold – called, “A Digital Shift on Health Data Swells Profits in an Industry,” focuses particularly on the consequences of HITECH. The reporter, Julie Creswell, does raise some new and legitimate concerns, such as the degree to which HIT vendors have jumped into Washington’s toxic swamp of money and politics.
Yet the tone of the article is inordinately conspiratorial about HITECH, and downright dismissive regarding the overall value of HIT. Creswell’s sources are disproportionally slanted to HIT skeptics, including her choice to quote my UCSF colleague Mike Callaham, who pronounced our Epic system “lousy.” (I’d venture to say that most people at UCSF – including me – find the system imperfect but pretty good. Moreover, we switched to Epic, a company that Creswell paints as a Goliath, only after a dismal experience with a different system built by GE, a $240 billion behemoth of a company whose electronic health record product is foundering in the HITECH world.) After reading the Times piece, I found myself in full agreement with Mark Hagland, editor of Healthcare Informatics magazine, who wrote,
The opening one-sentence paragraph says it all. Creswell writes, of a presentation by the Chicago-based Allscripts to physicians in 2009, “It was a tantalizing pitch: come get a piece of a $19 billion government ‘giveaway.’” First of all, characterizing HITECH as a “giveaway,” without in any way mentioning the penalties embedded in the law for providers who haven’t implemented electronic records (EHRs) by the end of 2015, is simply irresponsible journalism….
Ms. Creswell could easily have noted that no other large industry in the United States remains even remotely as paper-based as healthcare… or that study after study has confirmed the benefits to patient safety, care coordination, and cost-effectiveness of the automation of patient records. [The story] will undoubtedly be read by many thousands of laypeople who may or may not have any sense of how misguided and distorted its core thesis is.
The Times article ends as skewed as it begins: with a backhanded reference to the “gold-rush mentality” of today’s HIT players.
Let’s pause to ask a few questions: Does anyone honestly believe that computerizing American healthcare is wrongheaded? Or that the correct strategy was to continue toe-tapping, waiting for “the market” to promote IT adoption when, in 2009, only 16 percent of both US hospitals and doctors’ offices had functioning clinical IT systems? Or that they would like to be a patient, or a clinician, in a paper-and-pencil hospital?
I didn’t think so.
In 2004, then-president George W. Bush asked David Brailer – a brilliant MD and PhD in economics – to direct a new federal office of healthcare information technology, whose primary goal was to promote IT adoption. Brailer and his staff realized that a top-down program that had Washington forcing computer purchases on doctors and hospitals would be a disaster. (In fact, such a strategy was adopted by the UK’s National Health Service – a centralized, command-and-control initiative that, in 2011, was deemed a fiasco and junked, at a cost to British taxpayers of $19 billion.)
Instead, Brailer began planning a program consistent with American values, one that would allow physicians and hospital leaders to choose their own vendors, and encourage market competition. The plan that he and subsequent heads of the Office of the National Coordinator for Health Information Technology (ONCHIT) developed was to fashion a set of standards – relatively easy to reach at first and progressively more ambitious over time – and then to find the cash to fuel a national incentive program. They found the booty (about $20 billion worth) in 2009 when Congress and the president were seeking “shovel-ready” projects to include in the $700 billion federal stimulus package.
That, my friends, is the crux of the story. The meaningful use standards were developed and disseminated after extensive public comment. The IT vendors, a sleepy industry of true survivors (many of them barely maintained their pulses for over a decade, just hoping that the day would come when HIT adoption finally tipped to their side), did what all U.S. businesses would do when the feds were considering tossing money in their direction: they hired lobbyists and made campaign contributions. I don’t love this (and there is a risk that the Epics of the world will succeed in thwarting competition by scrappy upstarts), but that is our system, and any responsible business would have done the same thing – in fact, they’d be stupid not to.
It’s not a conspiracy. It’s America.
And trumping everything, the program has worked. The HIT adoption curve, previously stuck on flat, is now extraordinarily brisk: by 2011, 35 percent of US hospitals had functioning electronic health records, more than double the percentage of 2009; a similar surge has been seen in outpatient practices. The literature continues to demonstrate that, overall, these systems do reduce medical errors and harm. The promise of easier data collection to fuel transparency, pay for performance, and quality improvement activities will soon be realized, and we will ultimately enter the long-awaited world of “Big Data” in healthcare – one in which we can aggregate patient-level data on millions of patients, paving the way for more efficient methods of determining best practices and risk factors.
There have been problems. The systems are not great, and the vendors – including Epic – are putting most of their energy into keeping up with the insatiable demand for installations, and relatively little into improvements. Studies have demonstrated that the promised productivity gains have been weak to nonexistent. We have the aforementioned problems with IT-based errors and new challenges to clinician-patient communication. But the history of IT innovation is one in which systems become optimized only after many cycles of user feedback and vendor improvements. That cycle is beginning to play out, and the result is sure to be better, more mature HIT over time. There is no shortcut.
The Times (full disclosure, my wife Katie Hafner, writes about healthcare and technology for the newspaper) has covered HIT, including its glacial pace of adoption, responsibly, up to now. The Creswell piece, by failing to acknowledge the value of healthcare IT, the absolute necessity of wiring our healthcare system, and the fact that a federal program to kick start this process was a perfectly reasonable policy approach, was unbalanced and unfair. While a cautionary note is welcome, one could come out of reading this article clamoring for a Congressional investigation of the HITECH program and of the activities of Epic, Cerner, and Allscripts. If our goal is to find ways to create an improved, and ultimately less expensive, healthcare system, such a response would be unwise, even counterproductive.
The HIT industry, and those who regulate it, don’t need any special favors, and the Fourth Estate should keep a close eye on things, particularly now that there is gold in them thar hills. But as journalists are drawn to the increasingly vibrant world of healthcare information technology, it will be important that they do their homework and strike a balanced tone. The Times piece, I’m afraid, was a HIT job.
Bob, I quote from your article: “And trumping everything, the program has worked. The HIT adoption curve, previously stuck on flat, is now extraordinarily brisk: by 2011, 35 percent of US hospitals had functioning electronic health records, more than double the percentage of 2009; a similar surge has been seen in outpatient practices. The literature continues to demonstrate that, overall, these systems do reduce medical errors and harm.”
Amazing, pay an incentive to people and they respond. Better yet coerce them by implicit or explicit methods with a penalty and even more respond. I challenge your premise that these systems reduce medical errors and harm. As someone who takes care of patients ” in the trenches” I see a substitution of errors and harm with these systems. Errors used to occur because the ward clerk and consultant could not read the attending physician’s handwriting. Now time pressed clinicians waiting for the slow and clunky systems to function simply find the fastest method to place orders electronically ( or skip an order all together) and hope the pharmacists and other support people will correct the information they input as they simply don’t have time to stumble through the system trying to find the correct electronic order that they want. Redundant copy and paste progress notes full of inaccuracies and reams of useless data embedded among the clinically relevant information that colleagues caring for the patient may never find. And nurses who rarely see the patient as they are too busy point and clicking useless data into assessment forms no one ever looks at except for malpractice attorneys. I agree we have to go electronic but this upgrade in systems is far from bloodless.
Your points are well-taken. Better a carrot first and sticks later. But, as ‘weakanddizzy’ points out, it’s different in the trenches. Most of American medicine is not done in large clinics or hospitals with their own in-house IT staff and the burden on ‘the rest of us’ has been near intolerable. See http://thehealthcareblog.com/blog/2013/02/25/death-of-an-evangelist/ for another loss in the field. These ideas should have been piloted and refined in large institutions with in-house IT. Forcing it (“Let them eat carrots”), on people trying to run and office and see patients is akin to torture.
The Electronic Medical Record/Information Technology boom has separated nurses from patients even more than it has separated doctors from patients. The need to adopt another skill and learning new technology/language has been painful for our profession. Furthermore, since none of these products really speak to each other, it remains the Tower of Babel. This is all the more frustrating because of the obvious potential of a unified system and a mechanism for unlimited data dredging (for both good and bad). A truly functional system would allow us to do outcomes research and improve care on a national level. It might allow reasonable rewards for good practice, once there is general agreement on what that truly means. Whether that occurs remains to be seen.
I hope your optimism is well placed.
Steve
Steven W Harrison M.D.
Sorry to have to point this out, but:
Rush is a band.
“overall, I believe that we are on the right track, that there is no better way to get to an HIT Promised Land than the path we are taking, and that the Federal government should be commended for getting involved in a reasonable way.”
The IOM disagrees with you.
So do most of the hundreds of commenters to the NYT article. Their comments should be read;.
Bob,
Your diatribe suggests that the NY Times front page expose of the HIT industry has gotten under your skin.
Fascinating that for years, the HIT industry and its trade groups have been trumpeting the virtues of HIT, on the front pages and in POTUS’ speeches, yet these devices have totally bypassed the usual regulatory vetting for medical devices. You neglected to say that President Bush, upon announcing D. Brailer, an HIT entrepreneur, as ONC Director, stated that HIT was safe. Where was his data published?
When you honestly and accurately enumerate and publish all of the adverse events, system breakdowns, near misses, and deaths at UCSF, associated first, with the GE product, and now, with the Epic product, you would ascertain more credibility in your criticism.
It appears that you have concluded that seven page progress notes containing meaningfully useless jabberwock are better than a 3 paragraph narrative in script in the evaluation and management of patients.
Did you happen to read the comments on the article? Are you, yourself, entering the orders by CPOE on your patients? Are you, yourself, completing the transition of care documents, on the EHR?
Be honest, Bob, cause it is well known how the trainees are used.
Best regards,
Menoalittle
The NY Times and other news publications (as well as academic journals) have devoted much ink to the examination of HIT costs and benefits, but relatively little attention has been paid to more fundamental questions, i.e., why are these systems so difficult to install and so costly to maintain? Regardless of the industry, the installation of enterprise software in large, complex organizations tends to be extremely labor intensive and the failure rate for deployments is widely perceived to be high. Software vendor gag orders and the reluctance of clients to publicize their failures are among the factors that impede the transfer the knowledge that could help institutions avoid the installation problems that so many other organizations have experienced. For example, much information has been published about the positive results that Kaiser Permanente ultimately achieved through its installation of an EHR after several failed attempts, but very few details have been disclosed about Kaiser’s more than $1 billion software investment write-off following its initial EHR failure a decade or so ago, nor is there much useful information available in the public domain about the lessons in IT governance that Kaiser presumably learned from its mistakes.
Then there are the the peculiar practices that are vendor-specific. Soon after our hospital began installing Epic 2 years ago, I was handed a plane ticket and sent to Epic’s headquarters in Wisconsin to attend 4 training courses. Among the things I found odd was sitting in a classroom in which database administrators and systems analysts were lumped together with admitting clerks and medical records coders—the EHR skills and knowledge that these kinds of positions require differ significantly, yet Epic forced everybody to sit through hours and hours of extremely tedious presentations that were largely irrelevant to half the people in the room. Multiply the cost of airfare, hotels, etc. by more than a hundred hospital staffers and you can begin to get an idea of why it costs so much to install an EHR.
The role of legacy systems is also critical to understanding why so many hospital EHR installations are problematic. A large investment in middleware is often required to integrate the new software with existing applications that hospitals feel compelled to maintain, either because cost of the replacing the old applications is thought to be too high and/or because they believe the old applications have functionality that is superior to the new, new thing. In other words, the lack of interoperability is not only a problem across health care institutions, it is also a problem within these institutions.
Re: ” nor is there much useful information available in the public domain about the lessons in IT governance that Kaiser presumably learned from its mistakes.”
That was why, in 1998, I started a website on health IT difficulties and failures, now at Drexel Univ.
I recognized there was little if any knowledge sharing, especially at the “ground floor” level.
The costs of wiring hospitals and maintenance of same are formidable. Outcomes have not improved. Costs have not decreased. Deaths of patients that are unexpected are being reported. The profits of HIT sellers are at record levels. The same HIT sellers are wreaking financial havoc in the UK. Professional time is being wasted as clerks. Professionals are being distracted with meaningfully useless decision support. Meaningful use has no scientific basis.
I do not see any innovation.
Outcomes would be better if you used merely one fourth of these $ billions to care for the indigent, reduce the costs of medications, pay for better nurse to patient ratios, and pay for surveilance of HIT devices many of which should be pulled from the market place.
Those making and enforcing the policies have ignored the skeptic truth tellers and used the patients as guinea pigs in the HIT infrastructure experiments. Kudos to the NY Times and Ms. Creswell for exposing the abuses.
Thanks for all the thoughtful comments on my post – this is understandably an issue that people are passionate about. While I appreciate the concerns about the existing HIT systems and federal policies, I believe that we need a strategy that will get us to a new place in our healthcare system in the next 5-7 years: interoperable electronic health records, accessible to both clinicians and patients, that can serve as a scaffolding for levels of decision support, advanced analytics, patient engagement, trainee education, and quality improvement that we can only dream about today.
If you accept that as a goal, then the question is not whether Epic is perfect (it’s not) or HITECH is flawless (it’s not), but rather: What is the set of policies that are most likely to get us to that place, with the least pain and cost? I believe that the present strategy is about right. (Of course, like any policy, it’ll have to be tweaked over time as we get smarter, as will the HIT systems themselves, but that would be true of any path that we might choose).
Living in the Bay Area as I do, one always hopes that there is some brilliant teenager in a garage in Menlo Park right now, working on a new and perfect EHR. But I don’t think so — the systems required are too big and complicated, they require too much expert (not IT, but clinical domain) knowledge, and there are too many regulatory barriers and business imperatives (HIPAA, legal, billing…). I continue to believe that our best hope is to get these systems implemented and then create and promote a market that drives improvement and competition. I agree that there is a risk here that the legacy providers will figure out a way of locking in their position and locking out competitors – and this does need to be guarded against.
But I stand behind my post, and my general support for HITECH and what it’s accomplishing. For those who disagree, I’m looking forward to hearing alternatives that aren’t a blend of status quo and wishful thinking. Remember what they say about insanity and doing the same thing… We’ve tried the same thing in healthcare for 20 years – while every other industry computerized, to great effect – and we see where it has gotten us: low quality, insufficient safety, poor reliability, confused patients, massive waste, and backbreaking cost. I, for one, am ready to try something new.
“What is the set of policies that are most likely to get us to that place, with the least pain and cost?”
Least pain to whom, exactly?
Also, why should anyone assume there is a set of easy policies to “get us to that place” in 5-7 years different than that of other health sectors, where formal testing and regulation have proven essential to end or lessen abuses?
I STRONGLY disagree we have been trying “the same thing in healthcare for 20 years”. This may seem true in an academic center but not in the community. Like many others I have seen MASSIVE changes in the way medicine has been practiced, going from a cottage industry which at least had the advantages of continuity of care and a physician who had in depth knowlege of his or her patients, through HMO’s, managed care organizations, and now a system where much care is done by non-MD’s and most of us are hired by large hospitals or clinics. A lot of acute problems are now unfortunately handled in ER’s and urgent care clinics with little interface with the “primary care provider” whereas previously the were handled by the local doc. There were very few hospitalists 20 years ago and doctors followed their own patients through the entire courses of their illnesses. I didn’t see the polypharmacy of marginally beneficial drugs with questionable risk/benefit ratios being used 20 years ago. I do agree that many of these changes have not much benefitted the patient, which makes me very skeptical when I hear statements about how great any new change is going to be. Note that the changes I’ve mentioned have been implemented to make health care delivery more efficient, not necessarily better or safer.
New technology is avidly picked up by users if it makes someone’s job easier or more efficient – witness digital cameras replacing film, or the extent to which physicians use on-line resources such as UpToDate or drug information packages. If you have a product which is easy to use, saves time and makes the job easier and safer it will be embraced. The system I work with is a pretty good system for retrieving data but I spend a lot more time at a computer screen than I should inputting the data and the physician and nurses’ notes in are system are riddled with the templated cut and paste garbage that is like a cancer in the medical record. Yet every time I turn around there is another requirement to add some verbaige into the record that does not help patient outcomes but increases the length of the notes. My role any more is about 50% practicing medicine and the rest being a data entry clerk. It has overall decreased my efficiency rather than increased it. I really like some aspects of it, such as drug interaction warnings and clinical reminders. There’s a lot I don’t like.
No other industry would tolerate the problems present with health care IT – heck, they pay attention to whether a six inch difference in height of an assembly line will make the workers more productive. You want an alternative idea? I think the entire industry should adopt a system similar to that used by the VA, which has been around a long time and allows every VA to communicate with every other VA. We should work to get rid of the billing, medicare and JCAH requirements which have turned the medical notes into piles of chaff in which you have to hunt for the wheat, and free the doctors up to interacting with and thinking about their patients. As pointed out, these systems are geared to satisfy medicare and billing concerns, which are WAY too complex. We need to get systems which allow doctors to focus on patient care with no other distractions, which is the most import aspect of ensuring patient safety. Do I think this will happen? I seriously doubt it.
You love bringing up the aviation industry. In World War 2 the Grumman aircraft company produced the F6F Hellcat which outperformed the Mitsubishi zero in every respect. The Grumman company received three requirements from the Navy in producing this plane – “Make it strong, make it work, and make it simple”. Concepts to live by.
I think that a portion of this reply by Mt Doc makes the most important point;
“Yet every time I turn around there is another requirement to add some verbaige into the record that does not help patient outcomes but increases the length of the notes”
If the EMR vendors were asked to make products to help clinicians provide better, more effiicient care, they MIGHT have a chance. But this is not what they are asked. They are asked to make products to help as maximize coding/billing, check for elements of notes/op reports, associated ICD-9’s to claims and SNOMED’S to quality measure, provide SNOMED/ICD-9 maps, code “never” events, comply with MU, “prove” that education occured, make giving the chart to the lawyer easier, satisfy TJC and CMS, produce metrics that are often only important to regulators. If this all can get done, then with any extra time, they try to make them work for the clinicians.
They are failing miserably, but much of it is due to our miserable regulatory/payment environment that adds so much time and practicly no value to care whether you use a paper and pencil or an EMR. As bad as the EMR’s are, imaging using pure paper and dealing with all the metrics and requirements. Paper would fail as much as the EMR.
Until we have payment and regulatory reform, nothing will help us provide better care. Maybe the government should do this first and then the EMR companies can try to make a more simple, reliable system.
This comment is absolutely right on the money. Data has many species, and the variety EMRs produce has little to do with patient care and everything to do with maximizing payment as well as satisfying both regulators and lawyers. As far as I can see we’ll never get rid of the regulators, but the other two, well, just maybe. And until we do, EMRs will continue to be a large millstone.
Just a tiny example from the operating room: at every single surgery done every day in the country the circulating nurse and anesthesiologist have to confer and agree on what time anesthesia started, what time the patient came in the room, and what time the procedure ended. How many man-hours per day do you think is wasted doing this? And this agreement is necessary for…the lawyers. God forbid they disagree by 5 minutes.
Yes, Bob, you’re absolutely right; we need to get there. The comments here suggest that perhaps the definition of ‘there’ varies depending on whether you’re researching, billing, regulating, litigating or actually taking care of patients. And, once again, I’ll argue that ‘the view from the trenches’ is substantially different from yours, and it’s a view that doesn’t have the rosiness in the lenses through with you’re looking at EMRs.
You stated: ” I believe that the present strategy is about right. ” Who are you kidding, exactly?
Then, you are saying that surveillance for adverse events is not needed? And, you are saying that RCTs are unnecessary? And, you are saying that the pathetically poor degree of innovation by the manufacturers over the past 20 years is about right? And you are saying that there are not more effective ways of spending $ billions of dollars to improve outcomes?
Well, one may wonder about what are the pressures that compel you, an academic specialist, to ignore the tenets of medical science.
In order for a drug to be sold, it must be approved by the FDA. In order for a prosthetic knee to be sold, it must be approved by the FDA. In order for an EHR and CPOE machine to be sold, it must be approved by no one. Go figure.
What I would like to know is who is getting favors and greenbacks in this scandal?
A question for all to ponder:
Considering the tremendous cost and unknown risk** of today’s health IT (and perhaps the unknown risk of paper, too – I note that in a PubMed search on “risks of paper medical records” not much jumps out), would it not make more sense, and be consistent with the medical Oath, to leave paper in place where it is currently used – and perhaps improve its performance – until we “get the IT right” in controlled, sequestered environments, prior to national rollout?
In other words, slow down and treat health IT as any other medical innovation?
** per IOM, FDA, JC etc.
FYI
There are several lawsuits now against companies that have produced EHR’s.
In Florida there is a potential class action suit that may include the Cerner product.
Allscripts is being sued for its “MyWay” catastrophe. Search for it. It is there, in Florida. Plaintiffs won a small victory in court recently.
I am not aware of a Cerner suit, though that may be in the offing.
I will mention Next Gen (NG). They have produced a new iteration, one that FINALLY, utilized a TEAM of MD’s to produce a well flowing system. I have not been able to try a working version of this. The demo does not seem much better than our current version. However, I am sure I am missing a template or something that would trigger fulfillment of my needs. In the meantime, we are faced with Patient Centered Medical Home (PCMH) requirements that need to be satisfied by June. We are also facing Meaningful Use criteria that needs to be attended to. The places to document all of this is problematic. First, I want a final document that flows from subjective to plan. I want an document that seems to have some spirit and sense of human expression. I do not want a document with footnotes or extraneous data of little value to me. The PCMH concerns for Htn, DM, and Depression, I place information into the main body of the document and THEN, with NG, I have to go back and repeat myself in the templates dealing with these concerns. This is so my work is accounted for in the rigid templates. NG cannot data mind free text, which is common among most EHR’s. So, it cannot be searched for data to satisfy our insurers, unless we use the point and click portions of the templates. NG also cannot communicate with other EHR’s, unless someone volunteers to build an expensive bridge–later broken when a vendor upgrades their respective software. Whoever allowed this boondoggle to grow and fester really needs to have a working clinician’s view of a day in our lives.
As Dr. Wachter notes this appears to be an inflammatory topic. Many good points within. It is hard to argue for the status quo. How many of us would bank at an institution with paper ledgers? What I am hearing are three real questions: first, what IS the best path forward; second, how much “collateral damage” is acceptable as we find our way toward a functional EHR; and finally, how do we keep the various regulatory, legal and financial requirements inherent to ANY medical record from crowding out what we must agree is the most critical kind of functionality, and that is as a support to patient care.
I have to say that in our hospital, where most Medical patients are cared for by hospitalists, the major anxiety is not about the clunkiness of the record, but about the difficulty in piecing together the narrative thread. The docs are actually doing a good job at note writing (notwithstanding the fact that we have had our share of cut-and-paste concerns), but we are in the midst of a major redesign of the Nurse/EHR interaction, cutting out many unnecessary or redundant data sets, reducing the point-and-click and asking our very bright nurses to go back to writing a progress note that focuses on clinically relevant events. It has to be about the team talking, both in the record and I.R.L.
Dr. Grosso,
Re: “who would bank with paper ledgers?”
Who would buy a toaster for $25, when you can buy a Ferrari for $200,000?
My point is, your comparison of banking with health IT is inappropriate and illogical. Banking vs. recording/using/interpreting complex medical data in real time by active clinicians, plus the command-and-control aspect of health IT which now increasingly mediates all transactions of care, are quite different endeavors.
A better question to ask is: why does current health IT fit so poorly the needs of clinicians?
In terms of “collateral damage”, nobody can robustly point to the level of harms caused by paper records, but the downsides of health IT in its present from (largely “bad health IT”) is becoming more apparent (e.g., see Peering Underneath the Iceberg’s Water Level: AMNews on the New ECRI “Deep Dive” Study of Health IT “Events” at http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html .
I believe all assumptions about health IT need to be re-examined … not after an accelerated national rollout, but before.
I agree with Mt Doc point about “Keeping it Simple”, and informaticsMD about re-examining the current solutions. Ideally, the technology should be figured out, with all the kinks worked out before a national roll out, but hindsight is 20/20 and I think the current solution is a step forward in the right direction.