Sunday, February 12, 2012

Those Goddamn Plaintiff's Trial Lawyers Are to Blame for EHRs That 'Tattle' on Doctors - And Harm Patients

It seems the EHR technophiles are starting to notice one of the side effects of EHR technology: the liabilities EHRs impose on users.

Interestingly, those liabilities are presented below as the fault not of a cavalier industry receiving extraordinary governmental and regulatory accommodation compared to other healthcare sectors that, among other issues, have allowed it to (see hyperlinks for more information):


Instead, the liabilities are presented as the fault of plaintiff trial lawyers, who need to be disempowered through yet another special accommodation for health IT.

My comments are interspersed in [red italics]:


Feb. 8, 2012
The Wall Street Journal
MarketWatch
Healthcare IT Expert Exposes Hidden Risks of Lawsuits Due to Electronic Health Record

Spokesperson Says Electronic Health Records May Give Crippling Access to Physician's Actions and Increase the Need for Defensive Medicine

[Crippling access to physician's actions? That is an odd combination of terms - ed.]

DELRAY BEACH, Fla., Feb 8, 2012 (GlobeNewswire via COMTEX) -- Since the American Recovery and Reinvestment Act (ARRA) passed in February 2009 and caused a digital tsunami in the healthcare industry, physicians have been scrambling to comply with the requirement to switch to electronic health record systems. (EHRs) While many in the healthcare industry laud the use of EHRs to improve quality of care and analyzing patient outcomes, Dr. Sam Bierstock, founder of Champions In Healthcare, points out significant concerns regarding increased vulnerability to medical legal claims that may result from the use of EHRs without major tort reform that would relieve physicians of an onslaught of malpractice suits.

"EHRs unquestionably have the potential to improve patient safety and the quality of care delivered, but what few people realize is that using an EHR exposes physicians to an Orwellian level of analysis of every single act while doing their job," said Bierstock, who has advocated and pioneered the use and benefits of EHRs for more than 30 years." EHRs, however, can also be audited to examine how long it took them to act after an abnormal lab result came in, if the doctor checked on on-line references before making a clinical decision, what was said in every email and how long the doctor took to respond, and even how long the doctor looked at a screen or scrolled down to read an entire document.

[Why, exactly, this is a bad thing, I do not understand; it seems hypocritical. After all, any data collected that can help improve healthcare has been deemed golden - up to now - ed.]

Physicians are exposing themselves to an unacceptable level of scrutiny and analysis of their use of computers that may serve to encourage malpractice suits.

["Unacceptable level of scrutiny" is largely a code phrase for
audit trails and other 'metadata', i.e., automatically generated computer data that shows who accessed or modified a document or other data, when, from where, etc. I ask - access to this data is unacceptable to whom? Injured patients? - ed.]

Meaningful tort reform is essential to getting the maximal benefit from these wonderful systems.

[Wonderful systems, when even the IOM admits we don't know the level of harm they cause, the NIST indicates they are poorly usable, and so forth
as here? - ed.]

According to Bierstock, the problem runs even deeper because during his career as an industry consultant with Champions in Healthcare, and as a speaker at healthcare events he has noticed that the vast majority of physicians are still not aware of the complex requirements imposed upon them by the Health Information Technology for Economic and Clinical Health (HITECH) Act even though it has been a law for more than two years.

[I agree with the statement "imposed upon them", but this imposition was largely at the hands of the HIT pundits, the 'Ddulites'
(technophiles who ignore technology's downsides, the opposite of 'Luddites', link), and various species of non-medical profiteers - ed.]

"I talk to many physicians who have no idea they can suffer financial, civil and even criminal penalties (i.e. jail) for non-compliance.," said Bierstock. "I have been asked to speak about this topic many times, but beyond HITECH, it's my opinion that similarly, doctors and hospitals don't yet fully realize their medical legal vulnerability associated with the use of EHRs.

[They will learn, fast, with Medical Informatics specialists such as myself on patients' side instead of on the side of the health IT industry - ed.]

This will be the case until there is major tort reform, which has unfortunately been thwarted by the influence of American Trial Attorneys and their associations."

[You see, it's all the fault of the evil Plaintiff's Bar - ed.]

Bierstock noted that in an effort to stimulate physicians and hospitals to install and use EHRs, The American Reinvestment and Recovery Act of 2009 also authorized the Centers for Medicare and Medicaid Services (CMS) to issue guidelines which define what is "Meaningful Use" of an EHR - guidelines which must be met in order for hospitals and doctors to receive financial incentive payments for using EHRs, or be penalized by having Medicare or Medicaid payments reduced for failure to meet the guidelines.

[Unfortunately, they did not formulate guidelines for safety. Thus, as Sharona Hoffman, JD notes in MEANINGFUL USE AND CERTIFICATION OF HEALTH INFORMATION TECHNOLOGY: WHAT ABOUT SAFETY?, "General system safety is a property that is attainable only through rigorous processes for development and evaluation. However, the regulations do not address certification of EHR vendors’ software development processes or even require vendors to analyze and mitigate potential safety hazards. Furthermore, ATCBs will use testing requirements developed by the National Institute of Standards and Technology (NIST) that are apparently intended only to determine whether systems include certain features. Passing such tests is not sufficient to ensure that those features function properly in the long term and under varied operating conditions." - ed.]

Bierstock believes that if physicians are expected to embrace EHRS, they should be allowed to do so in a manner that maximizes the benefits of these systems to the delivery of care and to the benefit of their patients without worrying about giving unlimited ammunition to trial lawyers.

[Perhaps the EHR pundits should have foreseen this eventuality before pushing the current administration to mandate national EHR rollout. It didn't take a rocket scientist to do so - ed.]

"Quite simply, physicians may be in a situation that leaves them vulnerable to litigation and threatens loss of their professional standing and personal assets -- all because an external evaluator [e.g., a trial lawyer, judge or jury -ed.] may not think the physician lived up to arguable standards in the digital age," said Bierstock. "Overall, EHRs are the litigator's proverbial golden goose. They are to malpractice attorneys what the electron microscope is to microbiology."

[In other words, EHRs deserve yet another special accommodation, this time regarding legal Discovery, in addition to the many other special accommodations this industry has received. In fact, EHRs make available only that which they are designed to, and discoverability of that information is a Federal matter under the Federal Rules of Civil Procedure (FRCP) governing e-discovery - "On December 1, 2006 the Federal Rules of Civil Procedure were revised to address numerous e-discovery issues. Rules 16,26,33,34,37 and 45 require attorneys to pay specific attention to electronic discovery issues. E-Discovery practices and strategies need to be reviewed and aligned with the updated rules to ensure compliance." - ed.]

I find requests for additional special accommodations for EHR's over other medical devices and IT in other industries (e.g., airplane black boxes and cockpit recorders that monitor the every move of pilots) to be illustrative of the concept "be careful, you may get what you wish for."

That plaintiff trial lawyers are blamed for quite properly using the Federal Rules of Civil Procedure to assure justice for victims of medical malpractice, including EHR-related medical malpractice, is outrageous.

It seems the pundits might be starting to panic, after realizing the "data utopia" that is going to "revolutionize medicine" has a downside.

-- S. Silverstein, MD

Feb. 14, 2012 Addendum:

It seems the clinical data itself generated by today's health IT - garnered while putting patients at risk and costing many billions of dollars - might not be anywhere near as trustworthy as advertised by the technophiles.

See "It Seems We Are Not The Only Ones Bumping Up Against EHR Data Quality Issues. PCEHR Implications Are Worth Considering" at the Australian Health Information Technology blog by
... If ever there was an example of “garbage in, garbage out” in operation this has to be it. There has to be a great deal of care taken as we move from the most simplest data sharing to more complex efforts.

11 comments:

Anonymous said...

Best advice to doctors_Don't buy, don't buy, don't buy...the HIT devices that increase your errors, increase the chance you will get sued, increase your med mal insurance costs, steal your time, disrupt your cognition, and cause your intellectual power to be devoted to the EMR rather than your patients.

Advice to lawyers_sue, sue, sue the hospitals for buying experimental devices that have not been vetted for safety; and sue the vendors of EMRs for negligence in selling medical devices that have not been approved by the FDA and for their failure to remediate the dangers of the devices raised by the users.

The doctors are limited as learned intermediaries when using devices that are meaningfully unusable.

Anonymous said...

Is the profanity really necessary? Sort of dumbs down the level of meaningful discourse, doesn't it?

InformaticsMD said...

Anonymous at February 13, 2012 12:14:00 PM EST wrote:

Is the profanity really necessary? Sort of dumbs down the level of meaningful discourse, doesn't it?

No. It emphasizes a point, about how IT pundits and others medical industry stakeholders unfairly abhor plaintiff's lawyers.

My style of writing varies, but PC regarding matters of life and death is not a limitation I always adhere to.

For PC, I suggest the peer-reviewd literature on health IT, where just about all you will see is written from the perspective of the above-quoted expert. This is due to, in part, the equally unfond feeling of the reviewers/technophiles towards 'whistleblowers' on the downsides of the technology.

-- SS

InformaticsMD said...

By the way, Anonymous at February 13, 2012 12:14:00 PM EST ...

Why are you anonymous?

-- SS

Anonymous said...

InformaticsMD said...

My style of writing varies, but PC regarding matters of life and death is not a limitation I always adhere to.

How is this behavior consistent with a physician who advocates responsibly for patients in litigation?

Anonymous said...

Regarding commenters' preferences for anonymity, lack of an easily referencable site privacy policy could be cited as a reason. Behind-the scenes information collected about commenters in blogs can be used in ways that are unacceptable to them. People who are willing to comment here are doing so with unknown risks to privacy.

Roy M. Poses MD said...

Anonymous of 14 February, 12:46 PM -

We allow anonymous comments on this blog mainly to try to prevent harm to commentators who might express views that are frowned upon by the powers that be.

The relevant "privacy policy" is that of Google, since this blog is hosted at Google's Blogspot. None of our bloggers, including yours truly, has access to the identity of anonymous commentators. I cannot say how well protected their identities are within the Google system.

It is strange, though, that it seems as often as not that those who take advantage of what anonymity we can offer do so to protect, not attack the status quo in health care.

InformaticsMD said...

Anonymous February 14, 2012 12:46:00 PM EST writes:

Regarding commenters' preferences for anonymity, lack of an easily referencable site privacy policy could be cited as a reason. Behind-the scenes information collected about commenters in blogs can be used in ways that are unacceptable to them. People who are willing to comment here are doing so with unknown risks to privacy.

That is not unreasonable. The reason I ask, however, is that sometimes we have problems with anonymous people with conflicts of interest, who try to damage our credibility through attacks not on substance, but on form, or logical fallacy. Search this blog on the term "sockpuppet" for an example from an actual health IT seller.

Roy Poses writes:

It is strange, though, that it seems as often as not that those who take advantage of what anonymity we can offer do so to protect, not attack the status quo in health care.

That is also a valid observation.

Of course, our email addresses are available for direct communications, as we are anything but anonymous.

-- SS

InformaticsMD said...

Anonymous February 14, 2012 12:38:00 PM EST wrote:

How is this behavior consistent with a physician who advocates responsibly for patients in litigation?

Sir or Madam,

With all due respect, considering this post has had appx. one thousand "views" (that I know of) largely from plaintiff attorneys following a special link since it appeared, and has resulted in speaking invitations for me, and only one complaint from you, I'm not really sure how to address your question.

If you find my use of the word "Goddamn" in a title as journalistic rhetoric to attract interest offensive, then you, of course, are free to find someone else with my expertise who is willing to stand up for patient rights when patients are maimed by a HIT-related error.

You, of course, have not seen me in action in arbitrations or trials, so don't assume.

You have also not provided any evidence that usage of such a title in a Blog post harms credibility. This is a characteristic of the industry my post addresses...making claims without evidence (and ignoring contrary evidence).

I should add that if you have any issues with the substance or logical consistency of my post, perhaps you could share that with readers of this blog, instead of raising idiosyncratic points on the title's style.

In any case, thank you for your opinion.

-- SS

Afraid said...

I appreciate the capability to maintain my anonymity. I have been whacked too many times by the powers that be, I cant take anymore.

Anonymous said...

The title is really humor.

From another blog-

Humor as a psychological defense mechanism is considered one of the most mature and effective. Sigmund Freud himself, suggested that of all the defenses, "humor is the highest." George Vaillant, in his book The Wisdom of the Ego, states that, "The mechanism of humor is defense so subtle and so elegant that words fail."

Humor requires maturity. It is a creative adaptation to sometimes a dangerous and frightening world. At its best, it is an expression of hope when the unbearable must be born.