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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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Looser error
By rippleyaliens on 7/8/2013 3:28:37 PM , Rating: 2
Looser\USER Error, IS typically the case. Because the People are using the gear, are "doctors\nurses" and such, does not mean that they are BETTER users of technology, ACTUALLY they are the worse.
"Teaching old dog new trick syndrome".. Had many Customers, who were Doctors, Lawyers, Engineers.. Some Actually WORLD class Operators in their prospective fields. YET!!!- Could not figure out, how to put paper in printers, or Operate a win7 or Vista Machine, LET-ALONE win8, Tablets, and smart phones..

Its like giving a NEW Marine Recruit a Scoped rifle, SURE he may have played Call of Duty, or Battlefield 3, - Doesnt mean jack- if you are afraid to master the new technology.

ITS always a user error. IF that is not the case, then NO-COMPUTER setup- will ever work.. (training, and fear), are the biggest hurdles, that ALL companies, JUST dont like spending money on.




RE: Looser error
By chris2618 on 7/8/2013 4:14:20 PM , Rating: 2
Always the user never the programmer

Where i work they have just brought in a new system and its not even fit for purpose. Over the past month its been email after email saying; this should now work, downtime for a patch and the list goes on. The main problem is leads and/or programmers lose track of the small stakeholders.

If you build a train and the seat in the drivers compartment is too far away to touch the controls it obvious, the designs is at fault. Programs being overly complicated with too many "features", that's the user fault.

I understand half the time the user has no clue what they want. Sometimes the end user doesn't even get say as management takes over. After all them obstacles its up to the programmer/lead to keep track of the small stakeholder.


RE: Looser error
By DaBoSSs on 7/8/2013 7:19:02 PM , Rating: 2
And what if the scope lens is fogged, is that still user error? Can't use a device that doesn't function properly to begin with. Too many companies don't talk to the doctors, nurses, pharmacists, and many other people involved in creating and using a medical record. If they do, they don't talk early enough, and review it late enough. Or they talk to some professions, but not all. What a nurse needs to handle medication safely is not the same as a physician or a pharmacist.

Yes there is user error, and from my position as a physician and as part of the implementation planning and monitoring for our multihospital system, health care providers are hard to train/retrain to do things in an EHR, BUT programming problems - which include problems at both the hospital system level and the developer level, are a major contributor to the issues. Having a database programing whiz develop a complex database system for the database ignorant (and no desire to learn either) portion of our population requires skills at the interface level that few really can do truly well.

We tend to look down on people who have trouble learning new tech tricks - how would you do at sewing things back together with suture that requires magnification to even see, and having to do it on something moving in multiple directions at the same time, and do it well every time, and do it quickly every time, or the patient may not survive? Don't look down on these people because they don't have your skills, you don't have their skills either, and many of you couldn't develop them if you wanted to. (Just like I'll never have the programming skills most of you probably already have.)


RE: Looser error
By Alexstarfire on 7/8/2013 7:30:20 PM , Rating: 1
quote:
how would you do at sewing things back together with suture that requires magnification to even see, and having to do it on something moving in multiple directions at the same time, and do it well every time, and do it quickly every time, or the patient may not survive?


The difference is that we wouldn't bitch that that is a horrible way to go about saving a person. We'd learn how to do it. When people stop wanting to learn, that's when we have a problem. I'm not saying it's all user error, because that simply isn't true, but I can't count how many times I here people complain about a product simply because they don't know how to use it properly or effectively.

I mean, if you have a gun but try to beat a deer in the head with the butt of the rifle you can't complain that the gun is useless.


RE: Looser error
By DaBoSSs on 7/9/2013 3:57:44 PM , Rating: 2
quote:
When people stop wanting to learn, that's when we have a problem.


Ah, the voice of someone who thinks they can learn and do anything. Learning about something and being truly skilled enough to do it well are 2 entirely different things. It takes a level of skill that even few surgeons have, let alone other specialists, to do what I described. I'm not one of them, but I do things well that few CV surgeons can do well - we all have our own fields of expertise.

When it takes 16 hours of preuse training to be allowed to start using the EHR software, and there are some systems that do require that amount of a physician, what are they going to give up to spend 16 hours in training? Remember, support people have specific hours they work and can provide the training. Do we give up patient care for 16 hours in the hospital, give up 16 hours in the office, some combination of the above (which is what usually happens) - then how do you get the income to support your staff for that time? Do you mind being the one to wait for your care or your appointment in order for your physician and his/her staff to get the training mandated? Someone will have to wait. Or do you give up time otherwise set aside for your own CME time and improving your ability to care for your patients, or do you give up family time? Or do you just talk the hospital into having the staff be present at night, and then not sleep for 2-3 nights to get the time in? Where does the time come from to learn how to use the systems, and still keep up with patient care responsibilities, emergencies, medical education, family time, sleep time? Where does the time come from??

It's not that medical people don't want to learn, it is a matter of what you spend your time learning. I would say that few professions spend more time with continuing education than medical professionals who are good at what they do spend. Do you spend your time learning more about what is directly related to patient care within your specialty, or do you want to add learning something that seems peripheral to your primary field, and if you are going to keep up with your primary field, what are you going to give up to learn something in a field you care nothing about, but are forced to learn by the hospital or the government. (via Medicare reimbursement penalties if you don't)


RE: Looser error
By BRB29 on 7/10/2013 8:09:51 AM , Rating: 2
quote:
Ah, the voice of someone who thinks they can learn and do anything. Learning about something and being truly skilled enough to do it well are 2 entirely different things. It takes a level of skill that even few surgeons have, let alone other specialists, to do what I described. I'm not one of them, but I do things well that few CV surgeons can do well - we all have our own fields of expertise.

Bro, we're only talking about a regular Joe recognizing if their prescription is correct or not. It only takes 2 things that anyone can do.

1. Listen to your doctor
2. Read the paperwork that comes with the medication

You're making it seem like people are dumb sheep. I don't think anyone can be that incompetent, they just lack motivation in life. If they are unmotivated about living then Darwanism will take its course.


RE: Looser error
By DaBoSSs on 7/10/2013 6:50:23 PM , Rating: 2
You're assuming they can all read, a large percentage of our population cannot read that well. I have lived in the medical world for >35 years, and these types of things are far more common than you believe. And a huge percentage of people don't understand what the doctor tells them, especially if it is a new problem they perceive as bad, whether it is or not from my standpoint.

Unfortunately, Darwinism won't help, many, if not most, of them already have kids by the time they develop major health problems.


RE: Looser error
By informaticsmd on 7/12/2013 10:24:02 AM , Rating: 2
> Looser\USER Error, IS typically the case. Because the People are using the gear, are "doctors\nurses" and such, does not mean that they are BETTER users of technology, ACTUALLY they are the worse.

The problem with your statements are that they are conjecture. Where are your references from the literature on that point? Where is your bibliography?

Don't have any?

Oh.

By the way, physicians have historically been rapid adopters of complex technology (often difficult to master) that actually saves lives in field such as:

cardiothoracic surgery
invasive cardiology
neurosurgery
OB/GYN
radiology
gastroenterology

Need I go on?


RE: Looser error
By DaBoSSs on 7/12/2013 2:02:59 PM , Rating: 2
quote:
By the way, physicians have historically been rapid adopters of complex technology (often difficult to master) that actually saves lives in field


Agree with your point - the key is "that saves lives" and EHR, with current technology, is not perceived as such, therefore, not worth the specific applied effort by many/most docs to spend the time learning to use it well. It doesn't apply to their daily practice in a way that seems to be of direct benefit to them and their patients. They learn enough to seem to get by with it, since they "have" to use it. Unfortunately, "get by with it" doesn't give the real potential benefits of the technology.

I can't say that I agree with that attitude, but I understand where it is coming from. I'm viewed by many/most of the docs on our staff as rather different in being an early adopter/user of technology as an accessory to patient care. (And I'm not one of the young guys who grew up in a computerized world like most do now days, >30 years since I grad from med school.)


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