Wednesday, September 18, 2013

Saving My Mother Again. EMR Problems? No, They're Merely Anecdotal; the Truth Must Be That I Attract Bad Electrons and Stale Bits

My relative, who suffered a major cerebral injury in 2010 contributed to by an EMR's interference with clinicians, fell the other day in the bathroom.

The fall was hard; she struck her back and knocked out one of the mounting posts for the bathroom tissue - completely out of the wall, the wallboard now with a large gaping hole in it.

In an elderly person, falls can result in injuries such as this one, a painful hematoma on her back.

She went to a local hospital, a suburban branch of a large one, where x-rays were done; aside from a large bruise and hematoma (collection of blood under the skin) over her back at the point of impact, miraculously nothing was broken.

At triage I went over her medication list in great detail, ensuring both the data input to the EMR and the resultant triage printout record of her meds were complete and precise. She went home.

The very next day, in mid afternoon she had sudden onset of speech difficulty (expressive aphasia) and right sided weakness, symptoms of possible loss of blood flow to the left side of the brain, while sitting in a chair talking on the phone. The aphasia was the same symptom that led to her May 2010 presentation at the parent hospital and then her travails, with accidental cessation of a critical medication that somehow became "de-listed" in the EMR and thus not administered. This resulted in severe complications, domino-style, including brain hemorrhage.

So into the hospital she went via ambulance again. The ambulance crew copied her meds off a list I keep on my relative's refrigerator onto a scrap of paper. In the hospital the ED nurse reviewed the meds with me from the scrap, but I informed the ED nurse that doing so was not necessary since I'd just carefully checked the ED EMR med list at triage less than 24 hours earlier at the triage station.

The ED nurse then replied - "we're not using the ED EMR med lists right now, the system's been 'glitchy' today."

Me - " 'Glitchy?' What does that mean?"

ED nurse - "Sometimes the EMR pulls up the patient's meds, sometimes it doesn't." (direct quote).

Needless to say, these were not exactly words I enjoyed hearing.

My relative was believed to be having a repeat of the ischemia to the brain or "TIA" (transient ischemic attack, i.e., threatening to have a stroke), only this time the ED EMR itself was also having a TIA.

[As it turned out, it later became apparent she was actually having low-grade seizures from the brain injury of May 2010, and was put on an anti-seizure medication - ed.]
In this progressive "paperless" setting, I was the sole conduit of accurate information about her meds. However, not every elderly patient has an advocate with my background...

My relative's TIA symptoms improved somewhat and she went to ICU, and was set up for a slew of tests to see what should be done, but these "every time I enter a hospital" EMR problems are getting a bit beyond what I consider as mere personal bad luck.

She was then transferred to a tertiary care hospital's critical care floor for neurological problems. Before transfer, I asked to see the results of her neck and brain scans.

A doctor brought them up on the computer screen, but rapidly scrolled down to the impression section. The doctor hoped I didn't see what was at the top of the radiological report. But I did. I saw a statement like this:

"A duplicate medical record number, previously unknown, was discovered for this patient."

Out of exasperation, I did not raise a commotion, but I can only wonder what data might have gone into that "previously unknown" silo.

After transfer to the tertiary hospital, the commercial EMR on a cart on wheels ("COW") outside my relative's room was displaying the EMR main screen, with a "patient worklist" window also open in the screen's center.

(The GUI appeared, by the way, to be that of obsolete Windows 2000 or NT 4.0, although possibly it could have been XP set to display the older GUI appearance, but the icon appearance suggested the former possibility).

Superimposed over the central patient worklist window, though, was a dreaded Microsoft crash window, exactly like this one from the Web:

An error window like this was superimposed on the EMR screens being used to manage my relative's care. Click to enlarge.

In asking the RN about this, I was told this window popped up a lot, and was simply dismissed by users with one of the two buttons. The IT dept. had told clinical staff the problem was due to users "loading illegal software on the hospital computers." (This COW, incidentally, lacked any portals for thumb drives, floppies, etc.) It sounded like IT would fix it when they managed to get around to it. The nurses went about their business, ignoring this screen when it popped up unpredictably but regularly.

Somehow, this did not inspire within me great confidence in the integrity of that EMR and its data, especially the admonition that:

"If you were in the middle of something, the information you were working on might be lost."

As an aside, I remember hearing a story like this over ten years ago in a past life as CMIO of a large hospital, in the Cath Lab as I detailed here:

... The informaticist [a.k.a. me - ed.] first asked to see what had been installed in the cath lab by MIS. The informaticist found workstations running the application under Windows 3.1, an unreliable platform especially unsuited for critical care environments, because "Windows NT and other OS's such as UNIX were not supported by MIS." When shown a short demo of data entry by a nurse after a cardiac cath case, the workstation crashed, displayed a "general protection fault" error and hexadecimal debugging data. It had to be rebooted, with resultant time and data loss.
The informaticist asked the nurse about the crash and was told it happened frequently, up to several times per day per workstation. When the informaticist asked if MIS had requested a detailed log be kept of the crashes and error messages to help resolve the problem, the answer was no. MIS felt diagnosis and repair was the vendor's responsibility. When the informaticist asked the nurse exactly what had been explained to clinicians about the crashes, the nurse replied that cath lab staff had been told by MIS "don't worry about it, you can't understand it, we'll make it better."
The informaticist remembered, from medical school and residency, being told never to say such a thing to patients as it was considered inappropriate and too paternalistic in the modern age of medicine, especially with the elderly. This was an ironic and somewhat perverse scenario for a critical care area, the informaticist thought.

I find the repeat of a story like this simply stunning.

As probably 2/3 of my healthcare-worker students have related stories of EMR-induced clinical problems in their organizations in the past several courses I've taught [typical
examples of student stories are at this link], and other mentees with worse tales in their CMIO roles, and now with my own experiences getting more and more theatre-of-the-absurdish, I offer this thought:

Perhaps my experiences are merely anecdotal, due to some bad karma that causes me to attract bad electrons and stale bits, disrupting EMR operations.

Yes, that must be it.

-- SS


Anonymous said...

The HIT vendors have quashed any and all reports of the horrific performance of their care controlling machines. The poor doctor and nurse better not complain because they will be gone with the nod of the hospital's CEO.

Ya had to be there said...

I watched a similar story play out today while waiting for treatment (thankfully routine having no medical information needed).

Apparently all the PCs running the EMR had been infected with a computer virus trojen horse that was capable of lifting information (among other things). This didn't seem to be a real concern for the group, but they were concerned that the fix for the problem had included changing the IP addresses of all of their machines and printers (why they don't use DHCP I can't tell you), and now nothing worked. No printing, no data capture from the medical devices, no signature capture from the machine they use to gain your approval for medical things.

At least 2 or three patients were told that although they were holding appointment cards for today that the system didn't have them in today's schedule and they were overbooked and that the system was scheduling new appointments for what they knew to be an upcoming holiday when no one would be there, so rescheduling would have to be redone later (at some unspecified time).

I felt kind of bad for the nurses, docs and clerks having to explain this, but it seemed that they had the whole explanation down because the explanation didn't vary much by explainer and explaineee every time I heard it. So I wonder how chronic the problem was.

I got some unexplained bills from the same group in the past month, so I suggested to the folks turned away that they may want to watch out for a bill even though they were sent away. Another person waiting then mentioned getting bills that didnt seem to relate to any treatments received.

At some point a 20 something in casual clothes walked up asked the receptionist (who was in between personal calls that could be heard by everyone sitting there) what the problem was and she told him the credit card signature machine wasn't working. He fixed that and went away either not knowing or ignoring the other problems that were being reported to the patients.

It was like surreal watching it all. This from an institution on the 'most wired' list.

Anonymous said...

Definitely anecdotal. And every single doc and nurse who has worked with EMRs has similar anecdotes.

Live it or live with IT said...

Nope, the medical media report that it is the docs who are at fault ....

Optimism about meeting meaningful use fades for hospitals

By Pamela Lewis Dolan, amednews staff. Posted Jan. 3, 2011.

Hospital chief information officers are less confident than they were only a few months ago about their ability to meet federal requirements for meaningful use of electronic medical records. The biggest obstacle, they say, is getting physicians to use computerized physician order entry systems.


As a result, many hospital chief information officers are finding that physicians who resist technology and have little to gain financially from embracing it are sometimes slow to change.

Scot M Silverstein MD said...

Re: Ya had to be there said...

I watched a similar story play out today while waiting for treatment (thankfully routine having no medical information needed).

I cannot vouch for the facts, as I was not there; I can vouch for the believability of the scenario, however, based on years of experience and the experience of others who are in my field.

-- SS

Scot M Silverstein MD said...

Anonymous January 12, 2011 10:10:00 AM EST wrote:

Definitely anecdotal. And every single doc and nurse who has worked with EMRs has similar anecdotes.

Charlatans with something to sell, marketers, pseudoscientists, sophists etc. believe that since "anecdotes are not evidence", they should be ignored.

Unfortunately, as is a repeated topic of this blog, far too many of them are in positions of political and scientific influence.

-- SSS

Scot M Silverstein MD said...

Re: Live it or live with IT said...

As a result, many hospital chief information officers are finding that physicians who resist technology and have little to gain financially from embracing it are sometimes slow to change.

1. The article was biased.

2. The AMA is irrelevant; it does not represent the medical mainstream any more.

3. I feel very sorry for the CIO's who just aren't going to get their maximal bonuses thanks to those mean, Luddite doctors who reject garbage in a beige (well, black these days) box.

-- SS

Anonymous said...

"physicians who resist technology"

The zombie lie that will not die. In 35 years in medicine, I've never met a single doc who resists GOOD technology.

Scot M Silverstein MD said...

Anonymous January 13, 2011 1:10:00 PM EST writes:

The zombie lie that will not die

Dare I call the meme of Luddite doctors, in today's decompensated political milieu where even metaphors invite political attack, a "blood libel?"

-- SS