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Advocates say systems prevent more errors than they cause

A new report by Bloomberg is highlighting the growing number of medical mistakes due to errors in digital records -- also known as electronic health records (EHRs).  These mistakes range from getting unintended surgeries, to overdosing, to missing medications.

I. Digital Record Adoption, Mistakes on the Rise

Advocates argue that the move to digital records will cut costs and -- ironically -- cut mistakes.  But in a number of cases the converse appears to be true: medical records are causing medical malpractice incidents in unique ways.

A Dec. 2012 study [abstract] by the Pennsylvania Patient Safety Authority shows a strong correlation between hospitals ditching paper records and moving to digital systems.  In 2004 there were only 41 reports of errors due to digital records mistakes.  By 2011, this was up nearly 2800 percent to 1,142 errors -- and that's just in Pennsylvania.

Medical records by year
[Image Source: Pa Patient Saf Advis]

Among the sources of error were:
  • Drop down menus that led doctors to misselect operation types or medication dosages
     
  • Lost information due to text being placed in the wrong input box.
     
  • Transmissions errors (pharmacy not having access to hospital records to check for mistakes, etc.)
     
  • Software bugs leading to medication information disappearing or being transfered to a different patient
Critics point to incidents like Scot Silverstein's 84-year-old grandmother who died in 2011 after Abington Memorial Hospital somehow lost the information on her chart that indicated she required Sotalol -- a medication for rapid heartbeats.  You could say Mr. Silverstein -- Professor Silverstein, more properly -- knows a thing or two about digital records systems and their dangers.  He works as a health-care informatics professor at Drexel University.

He grieves, "I had the indignity of watching them put her in a body bag and put her in a hearse in my driveway.  If paper records had been in place, unless someone had been using disappearing ink, this would not have happened."

II. Problems are Most Severe in Months Right

Some nurses are complaining as well.  Nurses with Contra Costa County, near San Francisco, complained that after spending $45M USD on a digital records system from Epic Systems Corp. medication records began to disappear leading to serious risks.  Rajiv Pramanik, chief medical information officer for the county, acknowledges that there were some errors -- most of which he says came from physicians and other professionals mis-entering information.  But he says "the strengths [of the system] are tremendous" and that the county is seeing "dramatic improvement" in cutting entry errors.

The hospital was one of three in the Californian Bay Area to be fined $50,000 by the California Department of Public Health for endangering patients with errors.

EHR
[Image Source: ID Experts]

The key trend in the Contra Costa County incidents and other problem hotspots appears to be that the errors are most severe immediately after a new system is installed, likely due to staff being unfamiliar with it.  A 2005 journal article [abstract] reports that after the Children’s Hospital of Pittsburgh became an early adopter of digital records back in 2002, mortalities rose from 2.8 percent to 6.6 percent in following months.

The University of Pittsburgh Medical Center attacked this study's methodology as "fundamentally flawed" saying it only examined a small number of patients.  However, there were reports of patients' medications being delayed to restrictions in the system on when doctors could prescribe drugs to incoming patients and due to the number of clicks required to approve medications in critical life-and-death scenarios.

One expert on these early adoption errors is David Bates, a doctor and chief quality officer at Boston’s Brigham and Women's Hospital.  He told Bloomberg, "Any time you computerize a process, it can create new problems, and it typically does."

III. Proponents Fire Back, Defend EHR Bailout Spending

Experts say these tragic incidents and eye-catching lawsuits ignore the bigger picture.  They argue the number of mistakes cut by digital records is much greater than those created, thus far.

The push to digitize medical record keeping has had marquee backing; President Barack Hussein Obama pushed $36B USD of his $787B USD stimulus/"bailout" package to digitize medical records; plus he set up a system of fines for those who did not go digital by 2015.  He made EHR adoption a major pillar of his 2008 election platform.

President Barack Obama
President Obama has spent big on digitizing health records, and it appears the push is working.
[Image Source: Newscom]

The funding seemed to work -- a 2009 study [abstract] in the New England Journal of Medicine found only 17 percent of outpatient clinic doctors and only 9 percent of hospital doctors were using digital records.  By 2012 a fresh study [abstract] published in the journal Health Affairs indicated that 69 percent of U.S. doctors had moved to digital record keeping.

And advocates say that despite the reports of errors, the number of mistakes eliminated are far more astounding.  A Feb. 2013 paper [abstract] in the Journal of the American Medical Informatics Association suggests that digital records deployments in the U.S. are cutting 17 million mistakes.  Medical systems can help remedy traditional errors, such as doctors prescribing drugs with dangerous interactions or misunderstandings due to doctors' sloppy handwriting.

2010 report [abstract] on information submitted to the U.S. Food and Drug Administration (FDA) indicates that of 899,768 reports about medical mistakes, only 436 unique events involved digital records, and only four resulted in deaths.  However, the present situation is murkier -- after all adoption has grown by nearly an order of magnitude since 2009.

The advocates also point to the financial prosperity EHR generates.  The industry has grown to a $24.2B USD a year market in the U.S.  Top providers include the aforementioned Epic, McKesson Corp. (MCK), Cerner Corp. (CERN), Allscripts Healthcare Solutions Inc. (MDRX), and Siemens AG (ETR:SIE).

And traditional tech giants are looking to get in on the game as well.  General Electric Comp. (GE) -- a favorite friend of the Obama administration -- jumped into the market in 2009.  Microsoft Corp. (MSFT), Dell, Inc. (DELL), and International Business Machines Inc. (IBM) are among the other companies keen to leverage this growing space.

The Office of the National Coordinator for Health Information Technology (Health IT), part of the U.S. Department of Health and Human Services (HHS), is the federal agency in charge of confirming the rolled out systems are safe.  ONC policy and planning director Jodi Daniel comments, "So far, the evidence we have doesn’t suggest that health information technology is a significant factor in safety events.  That said, we’re very interested in understanding where there may be a correlation and how to mitigate risks that do occur."

IV. Got to Keep Them Regulated?

Others take an approach somewhere between the critics and the advocates.  Their perspective is that digital records are a good idea, but the implementations have sometimes been poor and medical systems aren't doing a good enough job compensating for the learning curve when it comes to new systems.

Leora Horwitz, a doctor and assistant professor of medicine at Yale University School of Medicine tells Bloomberg, "I would never go back to paper charts -- clearly electronic records are better.  But while they’re good, they’re so far from great it’s astonishing."

Prof. Silverstein agrees, commenting, "My mom would be around right now, bopping around, if they had simply not forgotten to give her $2 of medicine.  I want to fix the technology. The technology can help. But it has to be done right."

Some want to take the process of ensuring safety out of the HHS's hands at a federal level.  They point out that at this point incident reporting to the FDA or HHS is purely voluntary -- while some, such as Cerner and Siemens do report about incidents with their systems, other companies refused to comment on whether they did, hinting that they may not.

FDA food inspector
Some want the FDA to manage EHR safety and institute mandatory incident reporting.
[Image Source: Univ. Penn.]

Critics fear that even if companies do self-report, physicians may not.  Comments Ross Koppel, adjunct professor of sociology at the University of Pennsylvania, "The emphasis on doctors self-reporting errors is ludicrous.  When a locomotive crashes into two apartment buildings, we know about it.  When a patient gets the wrong med, we seldom know about it."

Some argue that medical devices should be regulated by the FDA, just like all other medications and most kinds of medical equipment.  They say the FDA should maintain a federal safety database on EHR, to help improve the systems naturally.

Sources: Pa Patient Saf Advis [abstract], Pediatrics [abstract], JAMIA [abstract], Bloomberg



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It will improve.
By BRB29 on 7/8/2013 12:46:55 PM , Rating: 3
The problems is not the system but the people operating it. It's entirely different than what they are used to. The increase in errors is because more hospitals are adopting the new systems. The major complaints and problems pretty much tells you operating errors. Transition is always hard and sometimes chaotic.

Before an electronic system, everything is hand written or typed up and stored as physical records. The chances of errors would be higher because it's entirely human based. Not only would you have errors writing or filling out the form wrong, you can have errors with people reading and transferring it. With electronic systems, you eliminate reading errors due to hand writings and transfer errors/loss.

If you guys are old enough to remember the time when people transition from typewriters to emails and word processing. A lot of people were fighting hard to keep their typewriters. A lot of people were struggling with word processing.




RE: It will improve.
By bah12 on 7/8/2013 1:55:51 PM , Rating: 3
Fair enough, but if I mistype more on the word processor does it kill anyone?

Take the drop down box example. Sure you may have a hard time reading a doctor's perscription, but if it looks kinda like Tylenol you are probably going to get it correct (or your are going to call for clarification). However if the next option on the drop down list is some alergen, and it is picked by mistake it could literally be life or death. An honest mistake that anyone ever filling out a computerized form, could lead to a very real death.

Both sytems can have errors, but worse case with the paper system is that someone cannot read the order. Whereas they can always read the order on the computer, but it may be flat out wrong.

I do think we can be better off here, but regulation is key. Problem is I think the standards are not strict enough. This is one area where I don't feel free market can service, and does require one end-all-be-all supplier. It needed to be a very rigid system, so the same exact screen at one hospital is the same everywhere in the country. From what I've seen there are standards, but each medical software tech company sells you their product. That is a recipie for widely umpredictable learning curves if I'v ever seen one.


RE: It will improve.
By BRB29 on 7/8/2013 2:26:09 PM , Rating: 2
Nobody said it doesn't have errors. Both systems does. The electronic one have less errors because it eliminates more human factors.

You're just proving my point that that it's operator error. You can easily write the wrong prescription/brand by mistake. It's the doctor's job to proof read his work and make sure it's right. It's your job as a patient to listen to your doctor and read the prescription also. Doctors have a lot of patients and write prescriptions all day. They are also usually older so their memory can slip. They'll get it right almost all of the time but don't expect any human to be perfect so if he said he'll prescribe you percocet and wrote ridilin instead then say something instead of being an idiot expecting everyone around you to be perfect.

It's redundant at the pharmacy as well for your protection. That's why pharmacists gets paid a lot of money to make sure you are getting the right drugs. Even the clerks are decently paid. They have to learn a lot about medical knowledge to qualify for the job. Don't you ever ask yourself why pharmacists always ask you questions and explain the drugs instead of just giving you the drugs?

Sure the numbers of mistakes looks big but compare that to the total number of prescription and it's a tiny percentage. A single pharmacy can give out 10s of thousands of prescription a year. There's a ton of pharmacies around.

The last safety precaution is that any drugs that is considered high on the caution side, the pharmacists always ask you what it's for. I have not seen a pharmacy that doesn't. If your pharmacy does not ask you a quick general question or explain what the drug is used for and how, then you should not go to that pharmacy. Every pharmacists I've seen make sure I know what the drug is for and why it is used so I can confirm I'm getting what I am supposed to get.

You have got to be really dumb or on the ignorant side about your own health if you got the wrong medication. I always read the paperwork that comes with the drugs and do some research first before taking any drugs because I understand no human is perfect. My life is in my hands and my responsibility.


RE: It will improve.
By Alexstarfire on 7/8/2013 3:44:55 PM , Rating: 2
What if the doctor says the wrong prescription and writes/enters that? Sure, if it's a prescription for something completely different then you can pick up on it, but if it's very similar, with only a slight difference in how it interacts with your body and/or other meds, then it might, and probably would, go unnoticed.

I agree with what you said, but I'm also pointing out that it's not always so simple or obvious.


RE: It will improve.
By bah12 on 7/8/2013 3:52:16 PM , Rating: 2
Like I said I agree we are better off with it, but your implication that it is just a bunch of old technophobe hold outs that are the problem, just isn't accurate. There are real problems with both methods.
quote:
You have got to be really dumb or on the ignorant side about your own health if you got the wrong medication. I always read the paperwork that comes with the drugs and do some research first before taking any drugs because I understand no human is perfect. My life is in my hands and my responsibility.
I was more thinking along the lines of hospital orders not take home perscriptions. In emergency situations where you may not be able to review what is being given to you. When the nurse walks in with a platic cup and says here is that pill you and your doctor talked about, then how do you know he didn't mis click the drop down.


RE: It will improve.
By Samus on 7/8/2013 5:18:29 PM , Rating: 4
The problem is most EMR software is crap and its constantly changing. Nobody knows how to use it. A lot of it is custom-made in India and the support is terrible. Lytec was a really popular one at the turn of the century and people finally got used to using it but after healthcare reform, it was no longer compatible with new Medicare forms and people had to switch to something new. Porting the older SQL databases to something standard like EPIC was very expensive, and data entry people are still making a ton of mistakes with the newer software which is inherently completely different.

But it isn't all about software. The average "paperwork" for a Medicare\Medicaid patient is three-four hours and starting next year most practices will be forced to accept them.


RE: It will improve.
By Alexstarfire on 7/8/2013 6:53:56 PM , Rating: 2
Yea, pretty much none of the EMR software used in the US is made in India.

Also, I'm not sure what is included in the average "paperwork" for a medicare/medicaid patient but I can tell you if it's taking 3-4 hours it's not all done by one person. I was a bit surprised to figure out all the "paperwork" that gets done.


RE: It will improve.
By Samus on 7/9/2013 1:26:50 PM , Rating: 1
None of the mainstream software (hospitals) but smaller practices have been using software from HCS, Lytec, etc, all companies with headquarters in the USA, but software and support handled entirely through India.

The software is fine. The problem is support turnaround is 2-3 days sometimes even longer because a trouble ticket needs to be made and handled by somebody 10,000 miles away. Working in IT as long as I have, I've concluded this model works well for the healthcare industry because there is are more SQL developers in India that will work for less.

I have a buddy that does VOIP installations and his partner and SIP provider is in Madurai, India, who he emails the job to, and 24 hours later has all the custom programming and SIP information finalized for $100 bucks. He then charges thousands to do the on-site phone programming and Windows Server plugin.


RE: It will improve.
By DaBoSSs on 7/8/2013 6:56:43 PM , Rating: 3
Your arguments about knowing what you are taking and being sure you get the right meds are fine, IF you have the educational background and interest in knowing those details. Unfortunately, we all look at the world through our own glasses, and even more unfortunately, most of the world can't see at all through our glasses.

We assume that because we have the knowledge to keep up with what we are taking and why, that most people are the same way. After >35 years in medicine I can tell you emphatically that is not how the real world works!! Most people don't read all the information, and more importantly, they don't understand what they read anyway. All the rules are made people who don't understand how most people think and therefore, the rules don't work for a large portion of our population.

You say you have to be really dumb or ignorant about your health to take the wrong drug, well that is exceedingly common. People take the drug because it was given to them, e.g. they finish a prescription you told to stop, because they paid for it and don't want to waste money - but will they finish the old prescription before they start the new one, or will they start the new, replacement, prescription today and then take both until the old bottle is empty. And many other reasons that people take the wrong prescription. All have, to some degree, trust in the people who wrote and dispensed the prescription as part of the reason. (Doesn't even begin to get into people taking the wrong Rx because they don't trust the system that gave it to them!)

No matter how sophisticated the EHR, it can't make up for the stupid, from our point of view, things they will do. A poorly implemented EHR, and there are more of them than we would like, is simply a way to ampplify and simplify errors. I had an office EHR back in the mid-90's, long before most docs considered the possibility, so go back a long way with EHRs. I am also intimately involved in the rollout of EHR in a multihospital system located across multiple states, it is NOT an easy process, and there are so many ways that an EHR simply amplify errors. Computerization in medicine can simply become a more efficient generator of errors if not done very well.

For instance - you enter an order for a one time "now" order - if the order allows you to enter the order as a one time order, with another field allowed to state it is scheduled, rather than one time, the system MAY place the order as a daily order, rather than a one time order. It may sound simple to avoid those types of scenarios, but it isn't,especially when you consider that medical people aren't tech oriented in the way most of us here are, therefore, they don't understand why the system requires something to be entered a specific way to get what they want. That may be second nature to people who have worked with databases for years, but NOT to medical people.

And speaking of databases, the EHR has transformed what we think of as a medical chart, in fact, it is no longer the medical chart that most medical people grew up with, it is a database system, that all too often doesn't understand what medical people need and has problems presenting the information in a way that works with the medical thought process and has the information needed presented in way that all you need is actually easily accessible. Way too much EHR software is designed by programmers that think a specific feature or way to implement something is "cool" when it actually interferes with the delivery of medical care.

Think of all the bugs (undocumented features) we all see daily in the software we interact with, why should we expect software for medical purposes to not have the same types of issues?? We don't desire it, and certainly demand the publishers to find and eliminate them prior to release, but how many times do we see major bugs not recognized for years after a program or OS has been initially released. (The most recent coming to mind is the 4 year old Android vulnerability that was recently talked about for "Unknown Sources" software we may side load.)

To summarize, people aren't nearly as smart and well educated as we all like to think and believe, and that includes the programmers and suppliers of the EHR software as well.


RE: It will improve.
By informaticsmd on 7/12/2013 10:19:03 AM , Rating: 2
> You ["doctors"] can easily write the wrong prescription/brand by mistake.

Just like you can easily stick your finger into an electrical outlet by mistake. Poppycock.

On the other hand, how's about a computer causing tens of thousands of incorrect prescriptions to be sent out, despite the correct order entered by the doctor?

http://hcrenewal.blogspot.com/2011/11/lifespan-rho...
Computer glitch led patients to receive wrong meds
Senator calls for review of Lifespan

WPRI.com (Providence, RI)
Updated: Thursday, 03 Nov 2011, 5:47 AM EDT
Published : Wednesday, 02 Nov 2011, 11:56 PM EDT
Reported by Steve Nielsen

PROVIDENCE, R.I. (WPRI) - Rhode Island State Senator Jamie Doyle says he is shocked to hear a Lifespan computer glitch caused thousands of patients to receive the wrong types of medication.

Doyle is now calling for an independent review of all the hospitals Lifespan runs, and a review of the Rhode Island Department of Health.

The DOH is investigating after learning patients who were supposed to receive medications taken once a day instead received medications meant to be taken more than once per day.


RE: It will improve.
By kattanna on 7/9/2013 10:09:45 AM , Rating: 2
quote:
The problems is not the system but the people operating it. It's entirely different than what they are used to. The increase in errors is because more hospitals are adopting the new systems. The major complaints and problems pretty much tells you operating errors. Transition is always hard and sometimes chaotic


and it is compounded by the fact that every hospital or local medical group has their own unique system. clinic A will have it so some procedure is coded one way.. while clinic B has it coded another way.. which can GREATLY add to the confusion.

it kinda reminds me of the way software was on the PC in the DOS era where every program had its own unique interface, and moving from one program to another required massive training.

what the medical records world needs is their version of windows per se.. something that ties and binds them all into a similar interface using familiar methods and codes to reduce confusion and training needs.


RE: It will improve.
By DaBoSSs on 7/9/2013 3:32:23 PM , Rating: 2
Keep in mind that many of the errors reported now are errors that have been in the system for years, but never easy to track or acknowledge with a manual, paper system. We still aren't catching all the errors that occur, people are still afraid to acknowledge that errors occur, even in a non-punitive environment.

As new people in the system grow up with the EHR, many of the problems we have now will go away, because they EHR will be the only method of keeping medical records they know. We have to get through that phase, however.

A lot of resistance is present because many medical people feel it is being forced on them, and it is with Medicare reimbursement penalties if you don't have one coming, and there is no real cross connectivity between systems provided by different companies without, as one commenter below states, paying a large sum every time you want to talk to someone elses system. This in spite of standards in place for many years for medical information exchange. There are still way too many variations.


RE: It will improve.
By informaticsmd on 7/12/2013 10:14:13 AM , Rating: 2
Useless and incorrect information.

NIST is studying health IT and has described "use error" (as opposed to what you describe, "user error") st http://www.nist.gov/healthcare/usability/upload/Dr... as follows:

“Use error” is a term used very specifically to refer to user interface designs that will engender users to make errors of commission or omission. It is true that users do make errors, but many errors are due not to user error per se but due to designs that are flawed, e.g., poorly written messaging, misuse of color-coding conventions, omission of information, etc.

Not that this is news: the Air Force published this in 1986:

http://hcibib.org/sam/

SIGNIFICANCE OF THE USER INTERFACE

The design of user interface software is not only expensive and time-consuming, but it is also critical for effective system performance. To be sure, users can sometimes compensate for poor design with extra effort. Probably no single user interface design flaw, in itself, will cause system failure. But there is a limit to how well users can adapt to a poorly designed interface. As one deficiency is added to another, the cumulative negative effects may eventually result in system failure, poor performance, and/or user complaints.

Outright system failure can be seen in systems that are underused, where use is optional, or are abandoned entirely. There may be retention of (or reversion to) manual data handling procedures, with little use of automated capabilities. When a system fails in this way, the result is disrupted operation, wasted time, effort and money, and failure to achieve the potential benefits of automated information handling.

In a constrained environment, such as that of many military and commercial information systems, users may have little choice but to make do with whatever interface design is provided. There the symptoms of poor user interface design may appear in degraded performance. Frequent and/or serious errors in data handling may result from confusing user interface design [in medicine, this often translates to reduced safety and reduced care quality - ed.] Tedious user procedures may slow data processing, resulting in longer queues at the checkout counter, the teller's window, the visa office, the truck dock, [the hospital floor or doctor's office - ed.] or any other workplace where the potential benefits of computer support are outweighed by an unintended increase in human effort.

In situations where degradation in system performance is not so easily measured, symptoms of poor user interface design may appear as user complaints. The system may be described as hard to learn, or clumsy, tiring and slow to use [often heard in medicine, but too often blamed on "physician resistance" - ed.] The users' view of a system is conditioned chiefly by experience with its interface. If the user interface is unsatisfactory, the users' view of the system will be negative regardless of any niceties of internal computer processing.

A convincing demonstration of design improvement has been reported by Keister and Gallaway (1983). Those authors describe a data entry application in which relatively simple improvements to user interface software -- including selection and formatting of displayed data, consistency in wording and procedures, on-line user guidance, explicit error messages, re-entry rather than overtyping for data change, elimination of abbreviations, etc. -- resulted in significantly improved system performance. Data entry was accomplished 25 percent faster, and with 25 percent fewer errors.


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