Wednesday, July 28, 2010

An Open Question on Moral Authority and Healthcare IT

I recently had the chance to observe a relative's care in a small community hospital.

This was a hospital that, in my relative's last several days there before going back to a nursing home for rehab, went live with a major vendor CPOE.


Just by passing the nursing station/doctor's charting room on my relative's floor and opening my eyes and ears, I saw doctors and nurses struggling to take care of patients while "getting the bugs out of the system."

They had had received some classroom "training" in a static environment, but it was clear they were learning about a lot of "gotcha's" and unanticipated glitches in vivo.

The fact of problems were predictable; I told several of my relative's physicians about my work in studying these issues.

There was some skepticism (maybe in my nearly being in tears about my relative, I came off as a bit melodramatic). However, several later told me they "now knew what I was talking about" upon my relative's discharge, just several days into the go-live.

One story I overheard during go-live especially sticks out in my mind.

A newly-admitted patient who needed urgent heparinization did not receive the medication promptly. The patient's physician could not order it, and could not enter the required weight needed to order it, due to some type of 'glitch' or system malfunction. Physicians found no way to override, despite calls to the help desk, attempts by on site IT people and users from the parent hospital, etc.

In the end, the pharmacist simply provided the med using a weight estimate despite no "official" order having been entered into CPOE. I heard that the delay was on the order of "several hours."

Clearly, both technology and people issues were involved ... but I assure the reader, injured or dead patients really don't care exactly how their injury occurred, after the fact (other than in litigation, which doesn't fix the damage or remediate the suffering).

Here, then, is my question:

Where does the moral authority come
from to subject live, unsuspecting, uninformed patients to the type of risks the patient whose heparin was delayed was subject to?

What right did the hospital have to NOT inform this patient before admission that a new critical CPOE system was going "live" that day
, and that the patient could consider going to another hospital a few miles down the road instead that had no such potential problems?

From the Belmont Report (also see http://ohsr.od.nih.gov/guidelines/belmont.html ), the six fundamental ethical principles for using any human subjects for research are:

  • (1) Respect for persons: protecting the autonomy of all people and treating them with courtesy and respect and allowing for informed consent;
  • (2) Beneficence: maximizing benefits for the research project while minimizing risks to the research subjects; and
  • (3) Justice: ensuring reasonable, non-exploitative, and well-considered procedures are administered fairly (the fair distribution of costs and benefits to potential research participants.)
  • (4) Fidelity: fairness and equality.
  • (5) Non-maleficence: Do no harm.
  • (6) Veracity: Be truthful, no deception.

I would like a straight, unspun answer to this simple question:

On the basis of Belmont Report and other medical ethics regulations, where does the moral authority come from for hospitals to put patients through such risks without informing them ahead of time and offering them an opt-out, even if only the continued use of paper in their care?

I have passed this question on to major American Medical Informatics Association mailing lists and await replies.

-- SS

4 comments:

Anonymous said...

Despicable conduct, also in violation of the Helsinki Accords.

There is not a contraindication (except that computer is in charge and says no) to ordering heparin as follows:

5,000 unit bolus IV followed by continuous drip at 1000 Units per hour. PTT in 6 hpurs. When weight based protocol comes on line, follow it.

Anonymous said...

In business when a system is completely corrupted you call a time out or freeze the operation in place. This does not mean you quit delivering product only that you stop any new system from being introduced.

Medicine has become so corrupted as to now need this action.

Doctors tend to look with laser like focus on a problem. Cancer, broken foot, whatever and they try to fix that specific problem. Today the problems are so interrelated that it will take time and courage to unravel the complex web of issues infecting American medicine.

You would think the UN’s oil for food program would not have anything to do with medicine. Wrong. In this post from Daily Finance we learn:

GE to Pay $23.5 Million to Settle Oil-for-Food Kickback Charges
By MELLY ALAZRAKI Posted 12:08 PM 07/27/10

GE’s medical unit was supplying imaging equipment and other products and paying kickbacks to secure those contracts. This is the same company that is now “partnering” with a major medical society to provide advice on private practice EMR’s.

Medical research has been taken over by the marketing departments of pharmaceutical companies. Even operating under legal supervision will not stop the marketing monster from getting its way, as shown by this post from the WSJ Health Blog:

July 26, 2010, 3:32 PM ET
GSK Apologizes Over Medical Journal Snafu

GSK provided material to a peer review journal and simply did not make it clear the authors were being paid.

In the past low level managers take one for the company and the stockholders pay the fines through lower earnings. What should take place is CEO’s or other C level people should face felony charges.

Doctors who are found to have participated in questionable marketing practices should lose their ability to practice for a period of time. Today we have doctors participating in various marketing programs; presenting company prepared materials as “educational” using their positions as KOL’s. If they want to pursue a marketing career they do not need a medical license.

We have simply created a monster in this country. Bored, elderly patients looking for attention, demand every test and procedure possible because marketing people have told them this is the “smart” way to better health.

Front line doctors find it easier to go along to get along than fight an ever growing system of regulation rigged to put them out of business. Cerner’s marketing plan, as outlined on HCR, to rig compliance so that no existing EMR will qualify is an example of the up hill battle facing the small practice. Doctors find it easier to sell their practice to a hospital where a business orientated computer program is installed that will drive patient count and testing.

In my community there is the constant drum beat of new, hospital owned, medical centers being build with all of the amenities your insurance will pay for, including a health club and juice bar.

All of this “good health” is supported by the medical societies who reap financial gain from each CPOE code or disease of the day.

This system is broken and it will take courage to change. The moment any change is proposed a legion of lobbyist will descend on those who can stop the change. No one stops to consider the millions spent on lobbying is money removed from the system, only how do I get my crumbs.

We are at a breaking point: Good doctors are subjugating their morals and ethics to feed the monster. Patients have become income units, with some blog post, indicating practices are seeing 70 patients per day.

We have to stop before cost exceeds our ability to pay, and patient’s lives are even further endangered.

Steve Lucas

MedInformaticsMD said...

Medicine's past the breaking point. It's good and broken.

GE’s medical unit was supplying imaging equipment and other products and paying kickbacks to secure those contracts.

I worked in mid 1999 for Comdisco Healthcare Group, a division of computer vendor Comdisco inc., a GE competitor in selling reconditioned capital medical equipment such as CT and MRI machines.

Revenue declined, and the healthcare group folded. Then a few years later the company folded altogether.

A nimble, innovative, and family-owned company was destroyed.

I don't think Comdisco was doing kickbacks.

Anonymous said...

Instead of reporting this just to AMIA, what about including the AMA and the American Academy of Medical Ethics?