Saturday, December 04, 2010

Is Healthcare IT a Solution to the Wrong Problem?

In a study published in the Nov. 25, 2010 New England Journal of Medicine entitled "Temporal Trends in Rates of Patient Harm Resulting from Medical Care", Landrigan N Engl J Med 363;22, it was found that medical error rates were not dropping:

In a study of 10 North Carolina hospitals [from January 2002 through December 2007], we found that harms remain common, with little evidence of widespread improvement. Further efforts are needed to translate effective safety interventions into routine practice and to monitor health care safety over time.

Unfortunately, I don't believe that the article differentiated between computerized hospitals and paper-based ones. Nor were the subject hospitals selected on the basis of computerization or non-computerization:

We conducted a retrospective study of a stratified random sample of 10 hospitals in North Carolina ...

... All acute care North Carolina hospitals listed in the American Hospital Association (AHA) database except those providing exclusively pediatric, rehabilitation, or psychiatric care were eligible for selection for the study. These hospitals were stratified according to the AHA’s definition of the facility as small, medium, or large; urban or rural; and teaching or nonteaching. The number of hospitals that underwent randomization for inclusion in each stratum reflected the proportion of national discharges from that type of hospital. If an invited hospital declined to participate, another closely matched hospital was randomly invited to participate in its stead.

While the extent of EHR/CPOE and other clinical IT adoption was not measured, some of the hospitals studied would likely have adopted and/or been using clinical IT in various capacities during the study period. The IT might have been expected to contribute to lower error rates over time.

Although that is admittedly speculation, there is a more important point to be made.

Many of the identified errors seem to have little to do with record keeping, but instead with human factors.

From the New York Times article "Study finds No Progress in Safety at Hospitals" covering the NEJM article:

... Landrigan’s study reviewed the records of 2,341 patients admitted to 10 hospitals — in both urban and rural areas and involving large and small and teaching and nonteaching medical centers ... Among the preventable problems that Dr. Landrigan’s team identified were severe bleeding during surgery, serious breathing trouble caused by a procedure being performed incorrectly, a fall that dislocated a patient’s hip and damaged a nerve and vaginal cuts caused by a vacuum extraction device used to help deliver a baby.

The findings were a disappointment but not a surprise, Dr. Landrigan said. Many of the problems were caused by the failure of hospitals to use measures that had been proved to avert mistakes and prevent infections from urinary catheters, ventilators and lines inserted into veins and arteries.

The chart of "harms" in the article, both those deemed "non-preventable" and those deemed "preventable" reads like a textbook of medicine, e.g.:

Cardiac arrest, shock, myocardial ischemia, acute respiratory failure, acute renal failure, hemorrhage, thromboembolic venous event, hematoma, pancreatitis, ileus, stroke or intracerebral hemorrhage, withdrawal symptoms, catheter-related bloodstream infection, urinary tract infection, surgical-site infection, clostridium difficile colitis, surgical anastomosis failure, wound dehiscence, failed procedure, unplanned return to surgery, fetal neonatal complication associated with delivery, hypothermia, pressure ulcer, catheter complication, etc.

It seems unlikely a missing or illegible chart was the cause of many of these adverse events. (In fact, the study was done retrospectively from the patient charts.)

Thus, expectations for major quality improvements in healthcare from the hundreds of billions spent on health IT might be vastly overstated based on false assumptions about the causes of adverse events.

Many of the above adverse events seem not highly amenable to correction via cybernetic information retrieval systems. They might be amenable, though, to improved nursing and ancillary staffing (perhaps I should say 'elimination of understaffing'), decreased work hours, improved CME, and better supervision of trainees ($100's of billions of dollars being spent for IT would surely buy a lot of those items).

What I found striking was this:

“A third of the errors in the intensive care unit disappear when residents work 16 hours or less,” Dr. Landrigan said, although he noted that senior residents often work longer hours.

That being the case, health IT that created heavier workloads and cognitive overload of residents already struggling under sleep deprivation might actually increase the risk of error.

It would seem national healthcare IT may be a 'solution' to the wrong problems in 2010.

We perhaps should better be focusing on human problems not amenable to cybernetic intervention before we start a national medical IT experiment, in the hope that major changes will somehow be effected by the magic of computers.

-- SS


Anonymous said...

The great wHITe hope is failing miserably. Hey, do ya think that if the wired hospitals had fewer errors and adverse events, such would have been in the headlines?

I suspect that it was the opposite, ie, the traditional care record systems had maximal safety resilience and team communication for complex systems which protected patients.

Just think, with all of this hoopla about HIT as the great wHITe hope for the scourge of errors, that these authors failed, I say failed, to report these findings.

Such silence is deafening.

Scot M Silverstein MD said...

do ya think that if the wired hospitals had fewer errors and adverse events, such would have been in the headlines?

That is an excellent point.

-- SS

jonpat said...

There are a number of worthwhile research investigations needed subsequent to your points
1. To what extent does HIT increase working hours of staff and therefore increase - we know that widespread commentary claims a 20% increase in time at the keyboard compared to paper. Alternatively do staff just complete a shift of fixed duration and so see fewer patients.
2. Are there ways to change the EMR User processes so that they don't cost this extra time - what research has been done to determine if this is possible, or is it just taken as read that the current user interfaces are the best that can be created.
3. Does the increase in time at work push staff over a safe threshold for being able to do their work properly.
4. What increase/decrease occurs in critical incidents before and after the introduction of EMR.