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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.

[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: 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?


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

Need I go on?

RE: Looser error
By DaBoSSs on 7/12/2013 2:02:59 PM , Rating: 2
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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