Wednesday, August 12, 2009

Are EMR's More Secure and Trustworthy Than Paper Records?

Contrary to utopian praise of EMR's as more secure than paper records:

Routine complication from surgery turns fatal
Lance Williams, Chronicle Staff Writer
Monday, August 10, 2009

A hospital patient suffers excruciating pain from what turns out to be a routine complication from elective surgery.

As her condition deteriorates, she and her family plead to see the doctor. But no doctor examines her until the next morning, when she goes into shock, is rushed into intensive care and dies.

Then, after her death, the hospital deletes portions of the woman's medical file in what the woman's family says is an attempt to cover up its horrendous mistakes.

Is this possible? Read on:

The allegations, contained in a lawsuit filed in Santa Clara County Superior Court, describe events that seemingly could occur only at an institution that provides medical care at its worst. Instead, the claims concern a 2007 fatality at what is regarded as one of the best hospitals on the West Coast - Stanford University Medical Center in Palo Alto.

The case of Diane Stewart, 70, who died of a bowel obstruction after knee replacement surgery, shows that bad mistakes and worst-case outcomes are possible even at world-renowned hospitals, said her family's lawyer, Christopher Dolan of San Francisco.

Medical errors occur because "we have corporatized medicine and marginalized the professional's role," Dolan said. "We took the same principles used in automation, to do the job cheaper and faster, and applied it to medicine."

Healthcare IT notwithstanding, I believe those observations are accurate. However, a more serious issue is the role of HIT in marginalizing the medical professional with respect to the IT professional, in what I've called (in this blog and elsewhere) a cross-occupational invasion of medicine by the IT profession.

"I believe Stanford is making a concerted effort to obstruct our family from learning the truth about what happened to our mom," he wrote in a complaint to the state Medical Board. In 2008, investigators from the state Department of Public Health found that "relevant" portions of Diane Stewart's computer file had been deleted after her death and that a supervisor instructed a nurse to make postmortem "late entries" to describe her care.

This may be a case where the CIO and other IT leaders need to be called to the stand to testify, possibly on criminal charges, since some cooperation from such personnel would be required if there is merit to allegations of post-death EMR alterations/erasures.

In a written statement, the hospital said that only temporary notes that were never intended to become part of Diane Stewart's permanent record had been discarded.

Never intended to become part of her medical record?

This "Watergate 18 minute gap"-reminiscent explanation raises a number of questions:

  • How did these "Temporary Notes" come to be discarded?
  • What was temporary about them?
  • Does Stanford's EHR have a "Discard Temporary Notes" button?
  • What authority and authentication is required in order for "Temporary Notes" to be discarded?
  • What is Stanford's definition of a "Temporary Note" in an EHR?
  • What might such notes contain?
  • Who might they have been written by, and for what purpose(s)?
  • If they involve decisions made in healthcare, why are they considered "temporary?"
  • Are there notes made in a paper record that are considered "temporary" that can legitimately be discarded after a suspicious patient death?
  • Are there backups that contain these notes, or were they erased too?
  • Was such backup erasure initiated manually (e.g., by a human) or automatically?

Since these notes were discarded (erased), of course, we may never know what they contained.

Electronic records leave no erasure marks, and with collusion of the appropriate personnel, reality can be whatever one wants it to be in the electronic world. This represents yet another sociotechnical obstacle standing in the way of achieving a computer-based utopia in healthcare.

-- SS


Deborah said...

You make some interesting points about inappropriate use of electronic health records.

As a former IT person, I can safely assert that if data is stored on a hard drive (somewhere) and it is later deleted, or erased, it can be recovered if the exact location on the hard drive has not been "written over."

This means yet another aspect of security of electronic health records that must be managed, and can be done with the appropriate IT/technical knowledge. If records are maliciously "erased" or "deleted" and the facility must recover that data, it is possible to do so.

taotechuck said...

Your observations and questions are interesting, but your post suggests that you've already formed your conclusion without fully considering the possibilities.

First of all, it's not unreasonable that some parts of the electronic record would be viewed as temporary. Handoff communication (or shift reports, whatever you want to call them) between inpatient care providers are one obvious example. The shift report is often given verbally, and whatever notes are taken by the incoming clinicians are not typically introduced into the paper record. Along these lines, I know of one hospital that stores its handoff communication electronically, but does not keep these files in their EMR system and purges them after seven days. According to the staff at this hospital, the Joint Commission has blessed this approach.

As for the security of an EMR vs. a paper record, it is no harder to falsify paper documentation than it is to falsify electronic records, provided the staff is complicit in the unethical/illegal behavior. If a few nurses are willing to go along with the plan, how hard is it to replace a patient's actual flowsheet with one that is much friendlier in court?

With that in mind, most EMR systems do leave "erasure marks." The HIPAA Security Rule states that an audit trail must exist within an EMR, although the specifics of these audit controls are not explicitly defined. Thus, it is much more difficult to make an electronic record disappear than it is to make a paper record disappear.

I agree that the policies of Stanford's "temporary files" absolutely must be examined in this case. On the surface, it appears that something unethical was happening. We do tend, however, to make stupid mistakes when we judge things on how they appear on the surface.

MedInformaticsMD said...

Points of last two commenters well taken, but the key statement in the article was this:

"investigators from the State Department of Public Health found that 'relevant' portions of Diane Stewart's computer file had been deleted after her death."

Ignoring for the moment that an unexpected death should probably cause a legal hold to be put on all patient records, electronic permanent, electronic temporary, or otherwise:

The State Dept. of Public Health findings, if reported correctly, suggest there may have been more going on than the hospital simply following retention procedure and erasing "temporary notes" after some set time period.

In the case of a patient death where malpractice might be a factor, any erasure can obviously raise suspicions, and should probably be avoided.

-- SS

Enterprise Version 11 said...

Great Mr. MedInformaticsMD. EMR is more secure than the paper records. But we can give 100%. Because there is few important things to note down. First of all proper training is needed to a person who handles EMR.

Apart from this EMR is best for fast work and reduce cost ....

EMR Medical said...

Great read and discussion..

thanks for the information.