Wednesday, August 15, 2012

Contra Costa's $45 million computer health care system endangering lives, nurses say

I am providing a number of editorial comments about this familiar story of health IT difficulties (in red italics), and additionally highlighting familiar themes I have written about at this blog.  This story is rich in those themes:

Contra Costa's $45 million computer health care system endangering lives, nurses say

Updated:   08/14/2012 08:55:52 PM PDT

MARTINEZ -- A new medical computer system used at Contra Costa correctional facilities recommended what could have been a fatal dose of a West County Jail inmate's heart medication last week, an incident that a detention nurse characterized Tuesday as one of many recent close calls with the month-old program.

However, the inmate's nurse was familiar with his medical history, recognized the discrepancy and administered the correct amount of Digoxin.

It's just one of a number of computer errors that medical staffers say have been endangering inmates, medical staff and sheriff's deputies at the county's five jail facilities since Contra Costa switched on July 1 to EPIC, a computer system that links the correctional facilities to the Contra Costa Regional Medical Center and other county health care operations, two nurses and their union representative told the Contra Costa County Board of Supervisors on Tuesday.

"It's dangerous. It's very dangerous," said an emotional Lee Ann Fagan in a phone interview. The registered nurse works at West County Detention Facility in Richmond. "It's hard to work in an environment that's so frustrating.  [Staff frustration increases risk of error and decreases morale, which increases risk of error further - ed.]
"What nurses want is for the EPIC program to go away until it's fixed," she said.

The $45 million EPIC system integrates detention medical records with the other arms of the county health system. The system led to 142 nursing complaints in July, said California Nurses Association labor representative Jerry Fillingim, who told supervisors the system does not mesh well with detention health care.

"I have never in all the time working with the California Nurses Association seen that many (complaints) be filled out," he said. "Each day, these nurses are fearful that they will kill somebody [requiring hypervigilance, which is emotionally and intellectually tiring, increasing risk of error further - ed.] ... I think the county tried to rush it, making it comprehensive for everything."

EPIC has never included corrections in its software and is treating Contra Costa as a "guinea pig," Fillingim said.  [Subjects of this experiment don't get the opportunity for informed consent, I add - ed.]

Guinea pigs to experiments don't give consent

'Just a tool'

The county wanted to create a uniform electronic health record (EHR), and executives said the tool is important, but not the be-all, end-all.

"The EHR is just a tool," said David Runt, chief information officer for the county health services department and who helped phase the system in over 18 months. "It's just one piece of the health care system. The people are the most important part of this process. We can't rely just on a computerized system."  [That's certainly a welcome and much more temperate position than the usual seller and pundit conceit that health IT will "transform" or "revolutionize" medicine.  It is also an especially good observation when the tool is unreliable! - ed.]

... "It's the beginning of a long journey that occurs over time," [i.e., an experiment - ed.] she said. "I think we can do a better job ... at how we communicate everything we're doing to respond to concerns." [The health IT industry has had several decades to "get it right."  When will the experiment end? - ed.]

Management warned

Staff superusers have warned management of EPIC issues, and two training sessions in May and June were inadequate, Fagan said.

"They were next to useless because the program wasn't in place well enough to practice," she said. "Everyone in the classes could see the gross loopholes in information."

Although nurses across the county's health care system have complained [but impediments to diffusion per FDA, IOM etc. prevented the complaints from becoming more widely known - ed.], the problems have been acute in detention, Fagan and Fillingim said.

On Monday, one inmate told a nurse she was supposed to be seen by mental health specialists because she was hearing voices, but the follow-up appointment was not registered in the system. The same patient had a Pap smear scheduled for two weeks ago to test for sexually transmitted diseases, but the appointment disappeared from the system, Fagan said.

Nurses cannot access tuberculosis history for inmates, so when some are transferred to Immigration and Customs Enforcement, staff cannot provide a full medical summary.
"We don't exactly know how that happened; we can't tell," she said.
The kinks will be worked out, and patient safety issues rise to the top of the list, Runt said. ["kinks" is a synonym for that other common, milquetoast euphemism "glitches";  I also ask -  why does the statement that "patient safety issues rise to the top of the list" even have to be made - ever? - ed.]

"When we go live is just a point in time, and now it becomes a period of stabilization and optimization," he said.

I think the line "We don't exactly know how that happened; we can't tell" sums up the dangers of today's "EHR's", in reality enterprise clinical resource management and clinician workflow control systems, very well.

I note that nurses in California may be a bit better prepared to recognize and call out the dangers of ill-designed and ill-implemented health IT than those in other states.  See my post "Health Information Technology Basics From Calif. Nurses Association and National Nurses Organizing Committee."

Regulation, anyone, or shall the experiment continue as-is?

Finally, in my career to date, I have both experienced and heard many stories of this type of medical and organizational chaos that endangers patients.  The usual scenario is one of non-medical, domain-novice IT personnel and executives serving as the industry's defense (as in American football), doing their best to tackle anyone who speaks out.  Two such stories arrived in my inbox in just the past few weeks.

The scenarios are also usually accompanied by amoral misdirection from these personnel away from patient risks via hackneyed excuses and euphemisms such as: it's a rare event, it's just a 'glitch', patient safety was not compromised, it's teething problems, it's a learning experience, we have to work the 'kinks' out, it's growing pains, it's the users' fault, etc.   

Herein is the problem:  the attitude that a clinic full of non-consenting patients is an appropriate testbed for alpha and beta clinical software that puts them at risk is medically unethical, based on the guidelines developed from medical abuses of the past.  There is nothing to argue or debate about this.

It is time to consider that some of the ignorant-to-the-point-of-endangerment or corrupt IT and other healthcare executives who do not listen to the concerns of clinicians, or actively block them from being disseminated and acted upon, should be subjected to charges of gross or even criminal negligence when harm occurs.

Gross negligence: carelessness in reckless disregard for the safety or lives of others, which is so great it appears to be a conscious violation of other people's rights to safety.

Criminal negligencefailure to use reasonable care to avoid consequences that threaten or harm the safety of the public and that are the foreseeable outcome of acting in a particular manner.

Perhaps they'll enjoy experiencing a prison environment with a troublesome EHR firsthand.

-- SS


Anonymous said...

The leaders of this experiment express all of the standard platitudes, as if they are reading from a script prepared by the vendors and HIM$$.

It just goes to show how bad and dangerous HIT is when the users, when complaining, are not easily subject to retaliation because they are protected by the union.

InformaticsMD said...

Anonymous August 15, 2012 3:00:00 PM EDT writes:

It just goes to show how bad and dangerous HIT is when the users, when complaining, are not easily subject to retaliation because they are protected by the union.

A good point. Physicians have no protections like that.

-- SS

Anonymous said...

I worry 24/7 also about what adversity my patients will face due to the whimsical counter-intuitive components of these devices. It is about time that they singled out Epic and its devices. The doctors in Cleveland put up with it, but recognize the extreme difficulty in figuring out a complex case that has been hospitalizied more than a few days.

The "record" has many silos and amny screens of meaningfully useless gibberish.

Stella said...

Whoever leads this experiment must be THE vendor and would just said everything would be OK, while endangering many many lives.