Is IT Capable of Building a National Electronic Health Records System?

Loraine Lawson

A better electronic medical records system seems like a great idea. In fact, I've long wondered why I couldn't carry a little smart card or USB drive for all of my medical records, so that wherever I wind up, the doctors would have a complete patient history available for downloading.


It's what Star Trek's Bones would've wanted, isn't it?


I once thought so. But after reading Joe Bugajski's harrowing experience with electronic medical records, I think Bones would have scowled and retorted, "Dammit, Jim, I'm a doctor, not a information integration expert."


Bugajski, however, is an information integration expert. To be more precise, he's a senior analyst for the Burton Group in Application Platform Strategies and Data Management Strategies, where he focuses on information integration and quality, enterprise architecture and data-access strategies, among other things.


He's exactly the type you'd expect to support President Obama's plan to build a new electronic health record system for the military.


But in a recent Burton Group blog post, written as an open letter to Obama, Bugajski had this to say about the plan:

Whereas Star Wars and Star Gate movie fantasies provide great fun, witnessing you, a world leader, spew delusional visions of a nation-covering, interoperable, secure, private, reliable, accurate, and instantaneous electronic health care data network is at best terrifying and at worst pernicious.

Bugajski's harsh assessment isn't politically based, at least not in an obvious way. Instead, Bugajski drew this conclusion after investigating the technology shortcomings of electronic management systems after a personal near-death experience. In particular, Bugajski believes there are serious impediments to data modeling in electronic health records management systems:

Good models require stable data and good data modelers. Unfortunately, health care data is unstable. Sadly, good data modelers are scarce.

But in his personal blog, Bugajski widens the net of blame to include:

  • The IT systems architects, whom he said failed to correctly capture business requirements;
  • A lack of a reliable conceptual data model; and
  • Independent software vendors (ISVs), whose products, he writes, "fail to support end-user requirements - real doctors, nurses, technicians, and pharmacists."


He also goes into greater detail about what happened at the urgent care and Stanford Medical hospital, where failings in the electronic health records management system used at both facilities almost cost him his life. Despite the presence of a hospital e-records system, Bugajski had to give 11 full medical histories during his 28 hour stay.


At first, his tale makes you question the competence of Stanford's medical staff. But Bugajski came to believe the technology was actually hindering the staff:

I finally understood the problem everyone was having when the heroic ICU nurse explained what she was doing while working with the hospital's electronic health records system. It explained why so many caring, competent, knowledgeable, and talented medical professionals behaved so strangely when interacting with patients. It was because they were fighting a horrible data model. It was that data model that nearly killed me.

Bugajsk estimated the doctors and nurses wasted between 40 and 60 percent of their time trying to make "the system do something useful for them."


He's not alone in concluding these systems may be more trouble than they are worth. Pediatrician Anne Armstrong-Coben recently outlined her problems with these systems in a New York Times Op-Ed piece, concluding that:

...the computer depersonalizes medicine. It ignores nuances that we do not measure but [that] clearly influence care.

Admittedly, you could argue these are the personal observations of two people. No matter how expert they may be, it's just their opinion. But Bugajski is an analyst, so he didn't just stop with his experience. He researched the problem further:

Since the time of my illness, I met and spoke with a dozen medical professionals and health care IT experts. They unanimously confirmed my sickbed analysis of the faults with electronic health records. Most longed for handwritten charts hanging at the foot of every patient's bed ... now, so do I.

Still, I couldn't help but wonder: Is technology really the problem-or are workers using technology as an excuse for poor customer service? It's a question I've been debating a lot recently, both with myself and some of my IT Business Edge colleagues. It's an important question for us, because it affects how we cover the issue. If it's the former, then you have to focus on improving the technology and getting IT to step up to the plate. But if it's the latter, IT is just the fall guy for bigger business problems, and that's an entirely different article.


Were these doctors really so busy typing information into a system, they couldn't listen to the patient and simply take action?


Or perhaps, as Burton Group analyst Chris Howard suggested after reading Bugajski's post, it's a bad pairing of business culture and technology:

Health care culture and style of work, especially in fast-paced emergency settings, may resist the intrusion of technology beyond that which attaches to the patient's body. To ask a doctor or nurse to divert their attention to data entry or retrieval takes them away from their primary goal, even though that data may contribute to the overall care of the patient. In effect, the technology becomes a distracting third party to the provider-patient relationship.

I suppose the bottom line is that it doesn't matter. Whether it's the technology, the medical staff or a bad mix of the two, electronic medical record systems apparently aren't working.


That raises another question: If these systems don't work in smaller scenarios, are we really ready to launch a national electronic medical records system?


Bugajski seems to suggest not without more work-and lots of it. It's not going to be easy. It promises to be the "biggest data integration challenge ever undertaken by the IT industry," according to Bugajski.


If it is to succeed, Bugajski said Obama will have to send the IT vendors packing and recruit "our nation's best system and data architects to report for duty."
His personal blog post included a long list of suggestions, but on the Burton Group blog, he sums up his recommendations with this:

Mr. President, before your administration pours billions of our grandchildren's yet to be hard-earned dollars into the biggest, scariest, and most wasteful boondoggle of an IT project the world has ever seen, please instruct your health IT experts to carefully analyze the strengths, weaknesses, opportunities, and threats (SWOT) associated with building a national heath information network using today's technology. Tell them to take the simplest steps first. Make them prove results in small projects.

It's good advice. I hope someone's listening, but I also hope other IT analysts and data experts will offer their experience on this issue, before we're stuck with a system that hinders, rather than helps.

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Apr 16, 2009 9:14 AM Betty McAlvany Betty McAlvany  says:

For several years my daughter worked in and managed a "Physicians Scribe" program.  The purpose of the program was to capture critical information the doctors needed but were not themselves in a position to type or write on a chart.  At least that aspect of the problem should be moot, the information needs to be captured by someone, somewhere.  Once you get past that it's a matter of the technology supporting access to the information.  There is always a learning curve involved.  In your article you mention the quote "...may resist the intrusion of technology beyond that which attaches to the patient's body..."  well at some point they had to accept that "intrusion" as life saving even tho it probably wasn't perfect when it was first introduced. 

Apr 17, 2009 8:42 AM Joseph M. Bugajski Joseph M. Bugajski  says:

A national HIT network is feasible if we take time to conceive, design, build, and test it starting with smallish steps. Unfortunately, $20 billion is prize too big for IT vendors to admit that they have no capability to do the job. This is shown by the UK National Health Service that has yet to build thei national HIT network, and while Australia also tried, it admits it failed (see my latest blog post). Most tragically, the costs of failure for HIT are measureable in human life. As IT professionals, we have an obligation to sound the alarm and provide meaningful solutions.

Apr 17, 2009 10:33 AM Frank Millar Frank Millar  says:

Kaiser Permanente might be an organization offering answers here.  Their internally-built healthcare systems seem to be advanced and impressively successful.  I attribute at least part of this success to Kaiser's effective use of architecture practices.

From my point of view, Bugajki's experience argues for Obama's initiative as opposed to exposing the likelihood of its failure.

Frank Millar

Millar Consultants, LLC

Apr 21, 2009 9:38 AM Loraine Lawson Loraine Lawson  says: in response to Frank Millar

Mr. Millar:

Did you work with Kaiser on that project or know of any articles referencing it? I'd like to know more.

You can reply here or email me at loraine dot lawson at gmail dot com.


Apr 21, 2009 11:27 AM Frank Millar Frank Millar  says: in response to Loraine Lawson


My opinion comes not from working with Kaiser directly, but from various other sources:  a steady flow of detailed, subscription contract descriptions over a period of several years;  information (can't find it at the moment) suggesting that their IT department is thousands-strong;  and patients who are friends and willing to put up with detailed interrogations.

Here is one relevant article that might assist:


Frank Millar

Millar Consultants, LLC

Apr 22, 2009 2:03 AM Frank Millar Frank Millar  says: in response to Francis Carden

I have to agree with both Francis and Joe about much of their risk assessments.

Nevertheless, risks are mitigated daily.  Joe's suggestions should be considerations in such mitigations.  Managing risks are a key part of a successful program.  Having worked for years in the PMO of a $B's/year federally funded program, having 10 years experience myself as a program manager, and having EA in my blood, I have the point of view that this program can be done successfully and should proceed.  The strategies, tools, and experienced resources really are out there, many of them idle at the moment.


Frank Millar

Millar Consultants, LLC

Apr 22, 2009 3:36 AM Victor Aaen Victor Aaen  says: in response to Joseph M. Bugajski

Interesting, but he missed.  The problem is not in the organization of the data but in the attitudes of our society toward how personal medical data is utilized and how health care is delivered.  Until we resolve these issues, all the correct data architecture is without meaning.

Apr 22, 2009 5:56 AM Frank Millar Frank Millar  says: in response to Victor Aaen

Victor, if Data Architecture was the sole perspective and sole discipline applied, I'd have to agree.  Today's enterprise architecture starts with and focuses on business strategic goals.  If your concerns can not be addressed in that earliest step due to a void, depending on details, either the project awaits strategy resolution or parallel paths are established while those remaining important strategic goals are settled.


Frank Millar

Millar Consultants, LLC

Apr 22, 2009 11:51 AM Francis Carden Francis Carden  says:

This is an awesome article Loraine and great that Joe took the time to post and not pull any punches.

I personally volunteer for any committee that is setup as the pre-cursor to the wild-ride experience of Obama and his team going ahead with this! There is at a lot a stake, this is too important. If we do it, we cannot and must not fail. I think it can be done, but not using any methods or strategies to date. No way. No way in hell.

I blogged about this a few months ago, on the sheer under-estimation of and complete lack of any understanding of the problem in healthcare and medical records. There are 1000's of ways to get this wrong and only a few (cound on one hand) ways to get it right.

I hope I am counted in. THis could have huge ramifications for cloud computing, privacy, scalability computing the release of the tether from hundreds of repetitive data stores for our personal data.

Keep us posted. This is a hot topic - all round.


Apr 23, 2009 2:12 AM Franklin Guzman Franklin Guzman  says: in response to Frank Millar

I would agree to "the strategies, tools, and experienced resources really are out there" comment.  I have worked in the healthcare industry for over a decade now and have seen paper filing to electronic filing and wondered why the rest of healthcare have not yet achieved this level.  In my experience all documents where scanned and available for review/retrieval to all doctors in over 4 HMO campuses thorughout the state.

Apr 23, 2009 9:15 AM tom groggel tom groggel  says: in response to Joseph M. Bugajski

If we want to crawl before we try to walk we should pick the most structured data model to start with - which would be Medicare.  I agree with you that $20B is far too much to start with - the battle for those dollars - with the attendant political free for all - ensures failure.  We could also use something like the IETF to develop/enforce standards - not the myriad committees that currently exist that have too many members and no clout


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