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January 6, 2000

"Observations on Information Technology based Knowledge Management in Canadian Health Care - The Pen and Paper Debate"

"........... the stakes are too high when you are dealing with human lives to use technology of dubious merit and reliability."

Dan Taylor IDSA Dan@DanTaylor.com www.DanTaylor.com

Dan Taylor 1543 Bayview Avenue, # 407 Toronto, Ontario, Canada M4G 3B5 +1 416-925-1668 Telephone   Facsimile # upon request

Question: How can Knowledge Management (KM) and Information Technology (IT) replace pen and paper in the Hospital?

Healthcare. If you were to poll the Canadian public as to what Healthcare meant to them, you would receive the following responses: Medicare, doctors, nurses, hospitals, declining standards of treatment, needs to be privatized, needs more public money, etc.

Not surprisingly, the issue of Information Technology (IT) or IT based Knowledge Management (KM) would not be raised by the public. In this article IT refers to all types of Information Technology functions: electronic patient records, computer networking and networks, internet, equipment, software, databases, custom programming, etc. 

When people in the Healthcare field are questioned about IT and KM, you would receive another answer. IT and KM are important but are plagued with problems. A little more investigation revealed the real issues: confusion, mistrust of IT generally, lack of training on how to use the programs and the systems, performance problems, the underlying lack of reliability of the functions, systems and networks themselves.

The first impulse of the health professionals when technology is perceived to be dubious (which in healthcare does translate to dangerous) is to abandon the technology and go back to the trusted pen and paper. Frankly we can't blame them, knowing the hectic pace health professionals keep and the stress of the knowledge that life or death is not an exaggerated outcome of their actions.

Despite coming from a technology company, our group has always focused on people. We believe that one of the dangers of KM is the assumption by IT and KM managers that technology will make it all happen. Our studies show that IT and KM best practices must focus on personal factors and relationships. KM has to focus clearly on best-practice implementation and strategic IT/business plan alignment. Issues in KM will include retaining knowledge in a merger and data acquisition setting, launching communities, innovating and sharing knowledge across the entire organization.

If Amazon.com has a system crash or a performance problem, no one will die. If the IT processed order for blood work or any of a myriad of other IT dependant processes or records errs, there may well be "a serious negative health outcome" as well as serious career damaging recriminations and lawsuits.

The respondents that were medical practitioners repeatedly stated that "the stakes are too high when dealing with human lives to use technology of dubious merit, performance and reliability". As of January, 2000, they are absolutely right. They know that current hospital IT/KM policy coupled with current practices can cause people to be "less than ideally treated".

In North America generally and Canada specifically, most governments have been mute on the subject and shown little leadership to date on the issues.  It is clearly expected by the public that the government set the performance, protocols and reporting formats, that vendors, labs and health practitioners use.  The current variety of standards and protocols is a Gordian Knot that can only be remedied by much needed regulatory and technical reform that must be led by government.

The many Ministers of Health in Canada are likely not aware of the current situation but will be made very aware when a person of prominence dies as a result of dangerous IT practices. The event  will undoubtedly make front page and TV/Radio headline news for both the government and the culpable hospital. This will be followed by a great deal of furor raised in the legislative assembly by the grandstanding opposition parties. The furor will be similar to the continuing fallout from the Walkerton, Ontario PUC e-coli contaminated drinking water tragedy that occurred in 2000. Folks used to erroneously trust the quality of water coming from their taps, now they don't and that breach of trust may be the undoing of the current Ontario government even though the provincial government wasn't at fault. The same thing will happen surely with healthcare. The trust will be broken and there will be severe political fallout at both the Federal and Provincial levels.

The lack of benchmarking and monitoring of healthcare IT/KM performance and security by outside consultants (those without a conflict of interest) should be regarded as a warning that many hospitals may be aware of the dangerously  poor performance and lack of security of confidential medical records and many may be seeking the protection of "plausible deniability" in the event of a "situation".

Recently simple, non invasive, external internet port scans were performed. These are considered to be an indicator of network vulnerability to out-side intrusion, on many hospital internet gateways. The results were revealing. The author had been told during research for this article that at any given time there are many outstanding law suits by the public against hospitals and/or physicians, related to mistakes made as a result of incorrect or untimely patient information. Many of these litigations are directly attributable to mistakes resulting from IT related issues such as systems under-performing, crashing, or simply not having been designed effectively. It is common practice to seal records during litigation and after settlements to ensure the public does not become aware of these events. How many serious, life-threatening mistakes are made each day in our hospitals? This would be an important statistic for organizations such as the Canadian Institute for Health Information to calculate.

There are very large issues at play here and there solutions available if managers, health practitioners and other stakeholders want to be able to handle the ever increasing workload and to reap the much needed benefits of IT and KM. Here are a number of things that must happen.

First, the appropriateness of a given technology or methodology should be determined. Do I really have to tell the reader that this critical function should not be performed by the vendor? Sadly, it usually is. The evaluation of appropriateness should be the job of senior management, the users and arms-length professionals. These arms-length professionals should be truly arms length and not vendors of a competing product. If at the conclusion of the evaluation of this match between needs and technology, new technology and the accompanying implementation program is approved, we move to the next phase 

Always remember that people must be able to trust the performance of the system as much as they trust pen and paper. That is a tall order. A 90%-98% uptime of network and applications might sound adequate but it isn't. Most North American telephone systems have an uptime greater than 99.5%+. It takes 3 seconds to replace a pen or a piece of paper. It can take an hour to do a network or large server reboot. 99.99% uptime is required in the hospital or healthcare network, servers and network applications. I have not found an instance where 99.99% uptime is the current situation. In fact I haven't seen a verifiable 98%.

The obvious first step to improve the hospital's network reliability is to use robust, scalable operating systems such as Linux, FreeBSD, Solaris, AIX, etc. and scalable robust enterprise applications such as Apache, PostgreSQL, MySQL, Oracle and DB2. It is not enough to upgrade the software, hardware and the network. Hospitals should be very wary of vendor owned proprietary IT solutions and government must hold the vendors feet to the fire by forcing liability onto vendor based solutions. It is also very important to remember that the skills of the IT staff must be continuously upgraded as part of their job description.

Second, remote and reliable access to the patient records and other information must be implemented to support off-site doctors offices, patients and other health practitioners. Security of the confidentiality of patient medical information must be maintained at all costs. Most smart cards are old news and can be a vendor heaven, as of this writing, biometric based solutions are the only way to go for too many reasons to discuss here.

Confidentiality of patient information is a nascent issue that will prove to be the biggest, most controversial Healthcare IT/KM issue of all. Indeed confidentiality will be the most contentious issue, second only to the privatization of healthcare debates. Interestingly, after the privatization debates are settled, confidentiality will then become the foremost issue and the legal actions coming out of breaches will likely surpass all other healthcare related lawsuits combined. Breaches of privacy must be dealt with swiftly and effectively if the system is to maintain both integrity and the trust of the public.

Third, everyone who is able to use an Internet browser must be able to learn or be taught how to use the system properly. It takes time and resources to teach people how to have safe and proper computer practices.

These are just the first  few issues that government, hospitals, medical practitioners, vendors, IT and KM managers will have to deal with if they want IT based KM to replace the pen and paper. This will go a long way to enabling an environment where IT/ KM will be able to add measurable benefit to healthcare.