Sunday, January 15, 2012

An "Anecdotal Complaint" About An ICU EHR

An "anecdotal complaint" (see health IT-specific definition of 'anecdotal' at this link) from a practicing medical informaticist on an EMR system being rapidly rolled out - in a neonatal ICU, where a single slip is an ended life or lifelong crippling injury, and a multimillion dollar lawsuit, in the making:

... Having just exited a 4 week “Night call” rotation of q3 nights (16 hours in house) or weekend days (16-26 hour shift in house) call / attesting/checking and signaturing horror show, my first with our “New” {#$@#**%%$@!*&!!*} charting and attesting, etc system [symbolic praise in the original - ed.], I can 100% attest that everything [another colleague -ed.] said is exactly why I’m scared to death of all the UCs [unintended consequences - ed.] of this current effort, when adult outpatient systems hit quaternary NICUs of 50-60 patients, with untested crash [i.e., artificially rushed - ed.] rollouts.

Dozens and dozens>>>>thousands of examples of each and every comment [made by the other colleague on EHR problems - ed.], plus more is exactly what I’m personally suffering. The more is bilateral horrible carpel tunnel flare ups (7-10 clicks and scrolls to get an “overview” of anything) so right now both my hands are numb.

Plus, one to two minute logons, is a lifetime when a baby is suddenly crashing. This is a “coding horror” and a safety nightmare. I live in constant fear of somebody screwing up something important, and perhaps uncorrectable. We do our work in real-time, most of the time. Where is the FDA when you need them? [Scared of hot potatoes as I wrote here - ed.]

And we do still talk to each other – but even that doesn’t always “work out”, because we’ve lost our operational minds (collectively) – the shared-by-all compact, visually all data in one place, and temporally arranged – i.e., the shared nurse/doc/resp flowsheet [traditionally in an ICU, a long tabular scroll of paper for "at a glance" patient status overview - ed.] – where everybody was looking at the same page, which we no longer are – as the team is slowly discovering.

And which required no logon for sign-over bedside rounding (~40 minutes for 20-30 babies was the allotted time). The flowsheet needed only a 10-15 second glance to spot developing problems; “the computer” is effectively inaccessible in the time allotted for the twice daily sign-n-out “rounds”.

A traditional ICU flowsheet (click to enlarge)

One wonders how often this scenario - what I now call a "But ... patient safety is not compromised" scenario in the words of the typical hospital administrator - is being repeated around the country.

Of course, the problem just can't be the software (as in the post at this link). It's those dullard clinicians and hospital IT staff who have misconfigured the cybernetic miracle.

This is certainly an example where the customs, traditions and methodologies of business IT (e.g., implement on-time and on-budget, at all costs, according to a strict timeline with benchmarks) are highly ill-suited for medicine. That assumes that there are not kickbacks or other financial 'incentives' or COI's in play, of course.

In fact, it would not surprise me if the IT vendor, a major company, has insulated itself from liability through a "hold harmless " clause. If so, as I have written in 2009 in JAMA at this link in response to an article by Koppel and Kreda [1], and at my Drexel Univ. health IT difficulties site at this link, having signed such a clause would represent a breach of hospital governance's fiduciary responsibilities to their clinical employees and agents (in effect, laying the liability for EHR-induced malpractice solely on them), and to patients.

I advised this doctor to 'be safe', as I would not want to have to be expert witness for a plaintiff whose child they injured or killed due to EHR-mediated obstacles to accepted professional standards of healthcare.

Finally, if this doctor were to resign, perhaps a case could be made for constructive discharge.

-- SS

[1] Health Care Information Technology Vendors' “Hold Harmless” Clause Implications for Patients and Clinicians. Koppel R, Kreda B. JAMA. 2009;301(12):1276-1278. doi:10.1001/jama.2009.398


Anonymous said...

Tiny preemies need detailed and expedient care.

These EHR and CPOE devices are meaningful impediments to the the above needs of these critically ill babies.

Is that why UPMC Children's Hospital noted a 2.4 fold increase in the death rate as published by HAN in Pediatrics, December 2005?

InformaticsMD said...

Re: Anonymous January 15, 2012 9:06:00 PM EST

I have always maintained that not every medical environment is suitable for EHR's where clinicians do the clerical work of data entry and are fully dependent on electronic screens, not paper.

A NICU (or any ICU) is one such environment. A cath lab is another.

In my own observations, health IT in ICU's was a significant distraction from attention to patient care detail. Worse, when the HIT is mission-hostile in its user design, and/or the physicial implementation of hardware is suboptimal such as tiny single screens, systems that force the user to face away from the patient while performing data entry, etc.

In ED's, document imaging can make the data of prior visits easily available.

True, coding cannot be done from paper without manual abstraction, but that is [should be] the organization's and payer's problem, not the doctor's and nurse's.

-- SS