War plans

If you’ve followed along, you’ll have seen what I regard as the major problems and what I think are the major solutions for the electronic health-care record in general. But if we want to get anything done, there are major hurdles that are different from one country to the other, mainly due to political system differences. In some countries, you can sell technology on its merits, while in others you sell it on entirely different criteria, and Sweden belongs in that latter category.

The merits in our case would be how effective an EHR system is at helping doctors diagnose and successfully treat patients both directly and indirectly. It would do it directly by making it easier to understand what has historically happened to a patient and how to proceed along a scientifically sound path both in diagnosis and treatment. It would do it indirectly by collecting data for prospective studies and providing epidemiological warnings.

But in Sweden, this is not the major criterion for development and purchasing of systems, largely due to a politicized organization where the decisionmakers are highly motivated by concerns that have nothing to do with the direct application of medical care, and where the top decision-makers are laymen as far as medical care goes. It’s not an environment that is conducive to either good economy, good efficiency, or good healthcare IT.

In Sweden, this results in a lot of projects that have very little benefit for the actual medical care of the patient, but do have all the characteristics of political posturing, such as patient’s access to electronic health care records, massive standardization efforts without declared goals, integration of EHR systems over large areas, investment in cross-border electronic prescriptions, you name it. If it’s large, international, expensive, and photogenic, it’s on.

On the other hand, projects that would, according to the medical profession, seriously increase the direct medical benefit to the patient, such as revamping the EHR to be guideline oriented, better user interfaces for all the different parts of the EHR system, and improved referral systems, are largely ignored. Swedish healthcare IT is, in short, run by a self-serving bunch of laymen bureaucrats who score political hit points by publicly demeaning the needs expressed by doctors and nurses, and that is no way to run something as important as this.

As doctors and as basically well-meaning developers, what can we do to be allowed to improve healthcare, as we know we can? Can we get rid of the bureaucrats? No, it’s the oldest profession in the world, and it will not go away any time soon (you can argue if it’s older than the other oldest profession, or basically the same, no matter to me), so we have to work around it.

When we can, we have to make a case that they cannot resist, pretending to be on their side (it’s a fair assumption they don’t read this, they’ve ignored us so far), or we have to do without them in the form of skunk-works or as scientific projects, which are largely run by other people. We also have to find a way to either eliminate, or go around, or work together with the major vendors that are now the sole beneficiaries of the bureaucrat’s decisions. I’m sure they, in their heart of hearts (it’s a leap of faith to assume they have one, but I think they do), would really like to do a good job, but they aren’t really prepared to risk the goldmine they’ve found, so it will take some tact and planning.

The next couple of posts, I’ll try to suggest a few tactics we can use. If you have other ideas and you don’t want to make them public yourself, send me an email and I’ll pretend I thought of it.

You should also, of course, register on the Vård-IT Forum, where things tend to happen every now and then.