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  (Source: Soundcheck)
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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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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