Tuesday, March 15, 2011

What does a "problem list" of typical health IT look like?

Mar. 20, 2011 update: see the much more extensive charts via the link at my followup post "Real" Medical Informatics: What Does a Problem List of Typical Health IT Look Like, Part 2.

What does a high level "problem list" of typical health IT look like?

Like this, from Prof. Jon Patrick at U. Sydney:

This Technology Problem List has been drawn up to collate all the technical problems in the report that have been identified in the Cerner Millenium version used for the FirstNet installations in Emergency Departments in the NSW, Australia.

[Link, as I wrote about in my Mar. 2011 post "
On an EMR Forensic Evaluation by Professor Jon Patrick from Down Under: More Thoughts" and others - ed.]

This is a list of the errors and bugs identified by ED directors in the study published on the 4th March 2011 that seem to have a technical origin, that is we would expect that some change in the underlying technology would solve the problem. The likelihood of resolving the problem is a function of what part of the software the problem is created at. The explanations and dates presented here are postulated based on an interpretation of the likely cause for the fault drawn from the report. I'm happy to be informed whenever these problems are corrected or if new problems arise.




Problem Description

Possible Explanation

Publication Date

Possible Correction Date

1 Problems arise when the documents are saved but not signed. Documents may become difficult to find even for the experts. The First Net trainers state “Never use the save button”. Cerner was asked to remove the save button. However, the answer was that it could not be done.

Button is built into the underlying software

4-03-2011 Never
2 If the record is unsigned and the doctor walks away to an emergency leaving the data on the screen. The unsigned data can be cancelled by the next person who wants to use the computer.




3 The templates are not symptom generated and try to cover every topic and every specialty. Each template is like an index to a comprehensive textbook on socio-economics combined with medicine. You scroll through a list of demographic information, social information, signs and symptoms. As with other templates, you circle or backslash to confirm or deny. However, when this information is converted to prose, it is a series of disconnected phrases that do not provide a grammatically correct easy to read document.
Built into underlying software

4-03-2011 Never
4 The FirstNet templates are a list of words. There are no diagrams although it is possible to find diagrams in another part of FirstNet. The templates do not flow according to usual work practice. They do not act as an aid to memory. They are not user friendly. If a junior doctor tries to use the template, it can take hours to document the record of a single patient.
Design not matched to user requirements. Built into software
4-03-2011 Never
5 Documentation Screen. To add a note click on the note icon and a window opens into which the note can be written. The note is then shown on the screen. Subsequently if you click on the text of the note it then disappears entirely. To add to the note you have to do a right click on the notes icon and then select Open to open the note. The delete process can only be reversed by moving to the top menu bar and selecting Edit and then Undo and without this knowledge new users are lead to the belief that their work has just disappeared and is irrecoverable.
Built into software
4-03-2011 Never
6

1. Triage box allows about 2.5 lines of text or ~50 words. Choosing from the triage problem list of 51 items is not compulsory nor even close to being comprehensive so staff workaround by writing their own entries. The entries are free text and thus not part of a searchable “reason for presentation” database field.

2. Most staff write in a text description of the problem as the problem list is defective with poor wording, "bleed haematuria" or unfamiliar descriptions "orbital disorder" and lacks common usage of terminology.

Configuration of problems list

4-03-2011

4-03-2013
7
The database search for diagnosis or problem requires an exact match and does not assist with finding synonyms or approximate matches not found because of spelling mistakes.

Built into the software
4-03-2011 Never
8 A referral letter needed to be re-sent to a different provider after the weekend. Staff went to the Discharge letter, ticked the box "Correct", and it was then noted that they could make changes to the original letter and save them to the system without needing to make any identification of self as editing the letter. The letter was saved under the name of the original authoring doctor and no record is made that it was the work of a different author or the extent to which it was changed. This means that the EMR does not constitute a valid legal record.
Built into the software
4-03-2011 Never
9 All notes on a patient cannot be seen in one page. In 'Clinical notes', when nurses fill out 'continuation notes', they should read old notes from 'clinical notes' and then see 'pathway' but they have to move to other pages to find this material so it is inefficient.

Built into software

4-03-2011 Never
10 Clinical staff have to sign in to confirm arranging a test for patients, at which time the user name cannot be changed. If one doctor signed on to one workstation and then went away to take care of patient, and during that time, another doctor has come to the workstation and signed the previous doctor off all his work will be lost.

Built into software

4-03-2011 Never
11 There is no button to add new clinical notes. When reviewing 'continuation notes', there is no button to add a new one. It needs to be done in another place, so it is inefficient.

Built into the software

4-03-2011 Never
12 Functionalities for clinical staff are of limited use. For example: From the list of medical pre-designed documents generated for the patient's electronic record, the index is not clear. Staff have to scroll through an index which has every document in the AHS from across many disciplines. For example, ED staff can choose Botox clinic documents. Staff are required to scroll through hundreds of documents one by one to identify what document they want to use.

Built into the software

4-03-2011 Never
13 Once they have identified the document they want to use such as 'ED discharge summary', there are too many clicks to complete the form, and the process is unnecessarily complicated

Built into the software

4-03-2011 Never





14 Before seeing a patient, a staff member goes to the ‘To be seen’ tab, allocates themselves to the patient. The KPI package pops up and staff insert the ‘seen by time’. Ideally it would be good if there was an arrival time default inserted into this time as a prompt for staff.

Configuration requirement

4-03-2011 4-03-2013
15 The Dr sees the patient and then returns to the computer and documents the interview. If they document in FirstNet when they record the patient’s chart they have multiple clicks to open the chart before they can start documenting.

Built into the software

4-03-2011 Never
16 The Dr can enter a diagnosis via the documentation / diagnosis (chart) or depart process. A diagnosis is nine clicks to enter.

Built into the software

4-03-2011 Never
17 A diagnosis is not flagged or seen on the tracking list so other staff need to search through the entire documentation to find it. This is time consuming as it is not possible to identify externally which note from a set of documents contains the diagnosis.

Configuration requirement

4-03-2011 4-03-2013
18 Dr “seen-time” needs to be on the tracking list (or LOS) since Dr “seen-time” is used to manage dept case load, and ensure triage categories get a balanced throughput.

Configuration requirement

4-03-2011 4-03-2013
19 FirstNet does not work well on differentiating practitioners and MOs, because both of them are assigned patients in the same place.

Configuration requirement

4-03-2011 4-03-2013
20 Unable to see previous observations - Lose ‘feel’ for patient as everything in silos. Configuration requirement 4-03-2011 4-03-2013
21

1. Poor graphical representation - graphing not finite enough to be of use.

2. FirstNet has 'vital signs' functionality but the trends are not finite enough here the important thing for staff in ED is to see the trend. Successive results cannot be displayed together making it far more difficult to get a trend or sequence of processes.

Built into software 4-03-2011 Never
22

Staff will not search for trends because the system is too slow, making staff reluctant to open charts.

Engineering, Configuration and/or installation problem 4-03-2011 Uncertain
23 No prompts for unusual observations, e.g. diabetic BSL or any form of useful alerts. Built into the software 4-03-2011 Never
24

Unnecessarily Difficult to add allergies: Staff think there are too many steps to record allergies and a complex and non-intuitive process. Adding an allergy is a 7 step process. Once the screen is opened it is difficult to work out 'how' to add the allergy. There is no rational flow to the data entry, nor are there prompts to guide the user. Staff are required to be trained or they would take a long time to work out the process.

Built into the software 4-03-2011 Never


This is an EHR slated for Emergency Departments, of all places, not the hemorrhoid clinic.

Do you want your emergency care mediated by such a device?

I don't.

As I wrote here regarding HIT vendor "hold harmless" clauses,
I am aware of major healthcare organizations with "portfolios" of hundreds or thousands of issues and defects (often more "granular" than the above) awaiting remediation.

Worse, the CMIO's are struggling with cavalier bureaucracies who want the doctors even in critical care areas to live with the problems (I've faced that scenario personally), and with vendors who are not in a hurry to fix their products.

Some percentage of those "issues" and defects are deemed by their organizations to rise to the level of "may cause patient harm if uncorrected."

-- SS

3 comments:

Anonymous said...

It remains despicable that there is not any regulation by the FDA. This device should be recalled. It puts patients at undue risk of endangerment, injury, and death.

Anonymous said...

Gees, this list is short compared to what I have seen, but very well written.

Going forward, I would like to see Prof. Patrick present the adverse events and deaths that have occurred from that product, keeping it to patients who died who otherwise would not have died if it were not for Cerner's care record system.

Scot M Silverstein MD said...

The list will be getting longer.

I would like to see Prof. Patrick present the adverse events and deaths that have occurred from that product, keeping it to patients who died who otherwise would not have died

I think "close calls" and "near misses" are highly important as well, as these represent risk that did not turn into a worst case scenario - often merely through serendipity.

-- SS