On EHR Warnings: Sure, The Experts Think You Shouldn't Ride A Bicycle Into The Eye Of A Hurricane, But We Have Our Own Theory

I frequently mention what I call an "irrational exuberance" about health IT affecting the judgment of otherwise intelligent people.

Here's an example where an expert's prescient warning about HIT problems was ignored.

This letter had been FAXed to the CEO and CC'd to the CMO of the hospital on April 21, 2010, where my mother was injured (almost exactly one month later) due to a May 19, 2010 EHR-related error.

Incidentally, they have, to my knowledge, no postdoctorally-trained Medical Informatics specialists on staff, and possibly nobody with substantive formal training in the domain.

Names of people and places have been redacted. To the best of my knowledge, the letter's concerns were ignored:

April 21, 2010

CONFIDENTIAL

[name redacted]
President and CEO
[name redacted] Hospital
[address redacted]

Re: Electronic medical records observations

Dear [CEO name redacted],

I am a Medical Informatics/Electronic Medical Records expert, architect of the Graduate Certificate Program in Healthcare Informatics at Drexel University, and [graduate of a local internal medicine residency]. My postdoctoral fellowship in Medical Informatics was at Yale School of Medicine, where I was also faculty in that field.

I am well known to [many local doctors], if just for having repaired a broken CT scanner’s computer in the middle of the night [years ago at a local hospital], when service was unavailable, to obtain an urgently needed brain CT on a critically ill ED patient.

My mother Betty Silverstein, 84 years of age, receives medical care at [your hospital]. I want to call to your attention a critical issue I’ve noted in regard to my mother’s care, related to your electronic medical records systems.

My mother was in the ED twice last week for complications of a gastrointestinal stricture noted a few months ago by a gastroenterologist.

An attempt was being made to treat the stricture medically, as she is frail, but she failed medical treatment. She required admission for observation, and then a revisit to the ED a few days later before she was stabilized. The ED physician also noted her GI problem in his conversation with me.

The problem was that, on ED-arranged referral back to GI Monday April 19, where a covering physician saw her, and then a referral from GI to colorectal surgery who saw her yesterday, the physicians she saw in follow up could not ascertain the fact of her stricture from your electronic medical records systems or printouts.

I reviewed a printout from the ED system myself, and found a collection of what I call “legible gibberish” (a mass of information as if the EMR system is just a warehouse for clinical data) but no diagnosis of her problem. A nonspecific and non-useful diagnoses of “abdominal pain” was all I could find – and that was on page 8 of an 12 page printout.

If not for my presence with my mother, the physicians would not have known of her problem. I received the impression that the follow up physicians doubted me until in the case of the GI medical physician, she was able to locate with some difficulty the diagnosis on the narrative of a colonoscopy report (not in its conclusion), and the surgeon after performing his own exam.

Clearly my mother cannot be the only patient where this problem occurred. Also, other elderly patients may not have the luxury of being accompanied by a physician-son familiar with the history.

I am concerned that EMR problems may also have contributed to a much delayed diagnosis and treatment of bronchiectasis of the lungs in my mother last year – a diagnosis made only after she called [name redacted; a pulmonary specialist who knows me well] on the phone from her hospital bed [boldface in the original - ed.] after repeated admissions for alleged simple bronchitis.

I’ve also had to stop administration of an antibiotic (Levaquin) in the recent past in the ED that she has had an adverse reaction to (torn rotator cuff), despite my having told ED intake she was allergic to it. She relates that administration of Levaquin was then almost repeated on the floor until she herself refused it during that past admission.

These observations and events cause me to believe your electronic medical records systems are not serving the patients and the physicians properly and could result in patient harm. I would like to meet with you to discuss this further.

I may be reached at [personal phone number redacted].

Sincerely,

Scot M. Silverstein, MD
Adjunct Professor of Healthcare Informatics and IT (Sept. 2007-present)
Assistant Professor of Healthcare Informatics and IT, and Director, Institute for Healthcare Informatics (2005-7)

Drexel University
College of Information Science and Technology
3141 Chestnut St., Philadelphia, PA 19104-2875
(215)661-0491

Email: sms88 AT drexel DOT edu
Bio: http://www.ischool.drexel.edu/faculty/ssilverstein/biography.htm

This letter was unfortunately far too prescient.

One month almost exactly to the day after this letter was sent, on May 19, 2010, my mother turned out to be (at least one of) the patients I predicted could be harmed. An iatrogenic cerebral hemorrhage resulted from a spectacular medication reconciliation failure.

She died a miserable death due to her injuries on June 6, 2011 after almost a year of incapacitation and repeated hospitalizations for complications including agitated delirium.

Irrational exuberance on health IT, I fear, is itself advancing towards outright delirium.

(Also see my Jan. 2011 post "Healthcare IT Delirium.")

-- SS