Tuesday, December 1, 2009

Is Healthcare IT a White Elephant? Or Are Semi-Luddites on the Loose?

A curious article in Computerworld, headlined, as you can see above, "Harvard study: Computers don't save hospitals money/Hospital computer systems are often built for administrators, not doctors."

In the piece, reporter Lucas Mearian interviews Dr. David Himmelstein, who healthcare observers know to be one of the leading advocates for single-payer health coverage, a.k.a. British-style socialized medicine. Here at SMS, we are always reluctant to assess people's motives from afar, but a critic might wonder whether Dr. Himmelstein is throwing mud at a healthcare status quo that he doesn't like, for ideological reasons that transcend concerns about the practicality of a certain technology. Or it could be concluded, for reasons that we shall see, that Himmelstein just doesn't like technology very much.

But, we report, you decide. Here's the nut of the Computerworld story:

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 in an interview with Computerworld.

Himmelstein, an associate professor at Harvard Medical School, said that in its current state, hospital computing might modestly improve the quality of health care processes, but it does not reduce overall administrative costs. "First, you spend $25 million dollars on the system itself and hire anywhere from a couple-dozen to a thousand people to run the system," he said. "And for doctors, generally, it increases time they spend [inputting data]."

Himmelstein said that only a handful of hospitals and clinics realized even modest savings and increased efficiency -- and those hospitals custom-built their systems after computer system architects conducted months of research.

The issues of healthcare IT, are, indeed, huge: there's $19 billion in the stimulus package for health IT, just for openers. But how well that money will be spent is subject to debate. This summer, my colleague at the New America Foundation, Phil Longman, wrote a thoughtful piece for The Washington Monthly about the software challenges confronted by the Department of Veterans Affairs. In a nutshell, none of this is easy. And so to the extent that Himmelstein wishes to be a part of the solution--achieving better healthcare outcomes for people--more power to him, even if we don't agree with him on single-payer.

But Himmelstein, who speaks from the authority of Harvard, as well as the medical profession, might wish to try harder to communicate a positive problem-solving tone--lest he be mistaken for a Luddite. A true optimist--and all doctors should be optimists, shouldn't they--would say that these problems can be solved.

But in fact, Himmelstein seems to have a second agenda, in addition to single-payer. He seems to be dubious about the value of health IT:

"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."

That seems to be Himmelstein's bottom line: This IT stuff is unlikely to work, or work well, so don't spend too much time on it. In this sense, Himmelstein is clearly part of a movement within medicine--a movement fitting snugly within the larger Green worldview--that argues that social and political concerns should trump technological advance. That's an opinion, but it is not an opinion supported by the weight of technological history, including med-tech history. And, fwiw, it's certainly a loser, politically, with the American people.

As Americans have always said, "If at first you don't succeed, try, try, again."

And that's the point here: When confronted with a hard challenge to an important goal, the way to solve it is keep pushing forward against challenges. That's the only way to overcome the difficulty. Remember what telephones were once like? And if you remember back to the days of heavy Princess phones, then maybe you're not old enough to remember rotary phones. And few today are old enough to remember the phones that came before rotaries, the "candlestick" phones of yore. It was hard work, every step of the way, to get from there to where we are now. And along the way, there were plenty of critics. But there were many more eager consumers, and so now we all have not just phones, but smartphones.

Here at SMS, we can see many ways to push ahead with healthcare IT, but would say that the challenges of healthcare IT are much more likely to be solved by our mixed economy, by a pluralist and competitive economy that accepts general goals articulated by society and then uses invention and entrepreneurship to find the best way forward. And that the best healthcare outcomes are likely to come from a similar approach on healthcare policy--sorry Dr. Himmelstein.

But every step of the way, in any field of scientific inquiry and engineering improvement, we have seen trial and error, followed by trial and success. Here at SMS, we have made this point many times, most recently concerning swine flu. It's easy to criticize the way that the federal government has handled H1N1, and we should never hesitate to speak truth to power (especially incompetent power), but the greatest laurels should go to those who can solve the problem.

And that's the mission of the Serious Medicine Strategy: To help develop a framework through which we can achieve the best possible medical and healthcare outcomes, for all Americans, and for the peoples of the world.


  1. Yet another consequence of the third-party payer system: Messy business systems that compromise the capability of market incentives to drive doctors and patients toward efficiency on the business side of medicine. The systems are built to serve three masters -- provider, patient, and payer -- instead of two. As in every sector of the economy, money talks, so the technology serves the payer more than the user or the customer. The only computer system worse than a private one built for third party purposes could be a government one. When was the last time you heard about a successful government-run technology program? The main reason the SEC's XBRL program was successful was that most of the work was outsourced to the private companies and accounting firms responsible for complying with standard rules. Perhaps the government might select better industry standards for medicine (hint: read XBRL for Dummies, available on Amazon), but if medicine becomes another government technology project, watch out.

  2. Paul's point is well-taken. It's why the real answer to healthcare reform is to junk the income-tax system so that employer-provided insurance is taken out of the system. That will provide the opportunity both for financing innovation (including direct contracting between patients and physician/provider groups for care) and further IT and medical innovation.

  3. "Computer systems are often built for administrators, not doctors .... the nut of the Computerworld story."

    Jim: Clearly your headline usage of Semi-Luddites is right on the money.
    Computer systems are built for many peoples today including doctors, nurses and PATIENTS!
    One system can be used for cross purposes. Reminds me of the time here in town I saw a RR Silver Cloud III carrying on its roof 2x4s from the lumber yard. Yup, a lot of $$ here but no ‘Klass’ ;)

    When my mother was a child, she and her sibs weren't allowed to call anyone a Jerk. So, they used the term "KREJ" (pronounced 'kred-ge').
    Jim: Himmelstein is a "KREJ" for saying:
    "And for doctors, generally, it increases time they spend inputting data" and "only a handful of hospitals and clinics realized even modest savings and increased efficiency."

    Gee guess the guy doesn’t use a PDA or sync it to his subsystem at the Nurses Station! How about “Voice” programming? You know the stuff doctors use to dictate their notes into electronic case charts or how about Steven Hawking, the famous British physicist with ALS uses?

    I say go ask Einstein, Cornell, Kettering, Mayo & Hopkins if they think Himmelstein's statements are accurate or delusional? I believe they will say the latter. And that we have an on going challenge to employe computer usage even more!

    "Himmelstein wishes to be a part of the solution."
    ...... Really? I think he is fooling himself.

    Himmelstein says: "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. 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."

    The KREJ is blind. Look at our productivity improvements. We are the "most' in the world at it. It's not because of our increasing birth rate! Gee Doc what could it be?
    How about a blackberry into all the drugs that can be used for each disease + contra indications for heart patients, diabetics, etc.
    Where does he think robotic operations came from? or Lasik surgery?

    Good systems are built for Users by programmers under Systems Analysts' directions. IT Systems or as we called it in IBM, DP Systems are built for customers. The Pan American Reservation System (PARS) was the 1st built in in the world and became the user system for many other airlines. Pan Am paid for the whole system and all of IBM's customers who bought it for their companies paid IBM who kicked back 20% to Pan Am until Pan Am re-cooped its outlays. After 5 sales, it was all gravy for IBM. Very similar can be done and probably is right now in Medicine.
    ‘In the olden days’ when we wanted to test our system before bringing it on line, we had the 'dumbest ' User give it its last shake down tests because they would come up with system use tests that we 'smarties' would never have conceived of to bomb the system.
    Use of organizational IT architecture today eliminates computer storage redundancies and actually assists (forces) the re organizing of corporations so they will function more efficiently.
    My vote is for Himmelstein as the 'dumbest ' User, a real KREJ.

  4. Great article, it was very helpufl! I just started in this and I'm getting to know it better! Cheers, keep up the good work!