Friday, January 14, 2011

ONC Workgroup Document Misindentification - Just the Type of Computer "Glitch" That Can Kill People

A provocative title indeed.

The Office of the National Coordinator's Health IT Standards Committee Implementation Workgroup recently had a meeting, Jan. 10-11, 2010.

They've posted the testimony and supporting documents here: .

I've copied & pasted these document links directly from the site, at 12:45 PM EST 1/14/2011:

The problem is, some of the URL's are simply wrong, including several of the ones I've bolded.

For instance, I tried to download Dr. Willa Drummond's documents:

The links for "Collection of Problem Scenarios from Professional List Serve" and "Ten Commandments for Computerized Healthcare Information Systems" are simply wrong.

They lead to the incorrect documents as of this writing.

By experimentation (borne of experience!), I found I could locate the correct documents by manually altering a number in the URL.

For example, to locate the "Problem Scenarios" document whose URL is linked as:

I had to alter the number 949972 to 949973, like this:

I further had to experiment to find the "Ten Commandments" document, also erroneously listed as at this URL ...

... but actually here at 949971:

Presumably these erroneous indices will be fixed at some point. Are they due to computer and/or software error, or human error -- as in medicine, due to busy schedules, cognitive overload from a suboptimal IT user experience, and other factors?

I do not consider these errors "minor" or at all humorous. Leadership by example - through fine attention to detail - in a supposed "HITECH" paperless-medicine promoting government organization - is what I expect.

Similar "misidentification" errors in EHR systems can and do cause medications to be missed or given to the wrong patient - such as in the example at the Trinity Healthcare System as mentioned in my post "Huffington Post Investigative Fund: FDA, Obama Digital Medical Records Team at Odds over Safety Oversight" where an EHR "upgrade" caused considerable risk:

... Computers at a major Midwest hospital chain went awry on June 29, posting some doctors’ orders to the wrong medical charts in a few cases and possibly putting patients in harm’s way.

The digital records system “would switch to another patient record without the user directing it to do so,” said Stephen Shivinsky, vice-president for corporate communications at Trinity Health System. Trinity operates 46 hospitals, most in Michigan, Iowa and Ohio.

[In other words, data entered by clinicians was going into the wrong charts. How many charts were involved? Does the hospital system even know, I wonder? - ed.]

Less than two weeks later, an unrelated glitch caused Trinity to shut down its $400 million system for four hours at 10 hospitals in the network because electronic pharmacy orders weren’t being delivered to nurses for dispensing to patients, he said.

See the many questions I raised about this episode at the followup post "More on Huffington Post Investigative Fund: "FDA, Obama Digital Medical Records Team at Odds over Safety Oversight." (I understand that the initial "fix" to the problem of "orders going to the wrong chart" was to prevent clinicians from opening more than one chart at a time, thus further interfering with clinicians' work.)

"Glitches" cause sometimes crucial data to be lost, and even patients to be harmed or killed (e.g., see the gray banner at top of my site on HIT failure, and my recent post "EHR Problems? No, They're Merely Anecodotal; the Truth Must Be That I Attract Bad Electrons and Stale Bits" on this blog).

Ironically, the First Commandment in the mislinked Ten Commandments document above is:

"The Computer shall find and collate all data generated by other computers."

Perhaps it should read:

"The Computer shall find and correctly collate all data generated by other computers."

-- SS

1/14 addendum:

I looked specifically for those documents as my first retrievals on the HHS site due to past correspondence with Dr. Drummond. The pinball machine then tilted.

Perhaps it is simply those bad electrons and stale bits that follow me around once more.


Anonymous said...

The ONC can not get it right which is why they conduct their meetings with WRITING and paper.

Theirs is not a matter of life and death. But for the physicians and nurses, these errors do kill and injure, rendering the entire system of care that these devices govern, UNTRUSTWORTHY.

Are these people at ONC ill, or just blindly doing their jobs for the POTUS?

Do they not question the heresy of experimenting on patients without their consent, giving incentives to doctors to implement unproven devices?

InformaticsMD said...

Anonymous at January 14, 2011 11:00:00 PM EST asks:

Do they not question the heresy of experimenting on patients without their consent?

No. In their minds, it seems, it's an experiment that doesn't require consent because, while some patients may be harmed, it's worth it since the net outcome will (not "might be" but "will") be positive.

This view, of course, turns all the lessons learned from medical abuses of the past few centuries on their collective (no pun intended) head. Science as well.

-- SS