Wednesday, December 18, 2013

An Idiotically-Designed EHR Medication Discontinuation "Feature"

Over at The Healthcare Blog, Michael Chen, MD, a family physician and EHR designer in Portland, Oregon wrote a piece entitled "Why EHR Design Matters" (  I am cited.

Dr. Chen reports on a major commercial EHR with the following "feature":

... In this well known EHR, you are presented a medication list for a patient. As a physician, you assume that this list is a current medication list and is up to date.  However, the reality is that this EHR system automatically removes a medication from the list when it is determined to be expired even if it should be appearing on the current medication list.

When a physician prescribes a medication from this system, it calculates the duration of usage of the medication based on the instructions, quantity of medication prescribed, and the number of refills. Once the duration exceeds the number of days that has elapsed since the prescription was made, the medication is taken off the current list automatically by the EHR.  

In other words, the EHR drops the medication from the meds list when the time elapsed exceeds the amount of time the total # of doses written for would be consumed.   As any medical student would say, "that's just brilliant."

Now, taken at face value, this sounds like the logical approach to manage a medication list and utilizes the computing power that an EHR will gladly show off as a benefit to physicians.

Misuses, actually, and at the Warp-10 speeds of today's machines, that's a lot of misuse...

Unfortunately, the EHR programmers failed to understand that medications are not taken regularly by all patients all the time. In fact, no physician assumes that at all. So why should an EHR make that assumption? Furthermore, there are plenty of treatments that are to be taken only as needed so how can an EHR account for that? Absolutely, impossible.

Perhaps the designers and programmers, simply brimming with medical degrees and expertise, thought they knew everything about medicine.  After all, you go to see a doctor, the doctor taps on you and squeezes here and there, puts a stethoscope on you, then pulls out a prescription pad and scribbles a few lines.  How hard can medicine be compared to, say, programming?

Here's how this "feature" worked out in the real world:

So I recently treated a patient that reportedly has asthma. I happened to look at a previous note and find out that the patient was denied a refill request for Albuterol, a bronchodialator that is meant to be taken as needed. She ended up in a life threatening asthma flare up and needed emergent care. It turns out the physician on call who was given the refill request several days prior didn’t realize that the EHR removed the Albuterol from her list and subsequently instructed that the patient needed to have a physician visit for having the medication prescribed. After going through 2 different windows and unclicking a check box, I was able to identify that the patient did in fact have an active prescription for Albuterol, but the EHR made it disappear. She has used it infrequently, probably because her asthma was well controlled. Unfortunately, she ended up in worse shape when she needed the medication the most.

It's a good thing the patient didn't go into Status Asthmaticus ( and suffer severe complications, or die ... (if she had, would any of the system designers, programmers and/or purchasers have shared in liability?)

I think it fair to say this EHR "feature" was idiotically conceived, designed and implemented, and that term is the most polite I can come up with.  Failure to know what they were doing, especially in the domain of medicine, compounded by failure to consult someone - even someone with basic medical commonsense -  who would see the folly and danger of such a "feature" is inexcusable. 

The state of clinical IT will improve when such characters are placed very far from any computer that is to be used in life-critical settings, of which medicine is by definition, or at least have their work subject to rigorous testing and validation by those who know what they're doing.

That will not happen, of course, until health IT is more rigorously regulated.

-- SS


Anonymous said...

Toxic EHR, Toxic EHr, Toxic EHR, Toxic EHR.

Sebelius does not get it.

Anonymous said...

Call this the mysterious vanishing medication. Just what clinicians need. Despicable.

Steve Lucas said...

This explains why my wife’s aunt was constantly asked at the hospital for a medication list, often twice during the same visit, for hr uncle. The scary part is the CIO of this hospital was selected as the CEO of an Ivy teaching hospital.

It is not hard to figure out why this stuff keeps happening over and over.

Steve Lucas

InformaticsMD said...

Steve Lucas said...

The scary part is the CIO of this hospital was selected as the CEO of an Ivy teaching hospital.

With or without medical credentials?

Anonymous said...

The electronic prescribing software used by the state agency where I work did this even one better: it included a default order to "stop" the medication after the calculated duration of usage. This new feature was not highlighted (at least to the physicians), nor was it noticed until the absence of continuously prescribed medications on the active medication list was noted. By the way, this electronic prescribing software is considered "the only good thing" about the transition from paper to electronic practice at my clinic. I would not have nearly enough space to begin describing the problems with the EHR...

Steve Lucas said...


There was never a mention of medical credentials, not even a graduate degree.

Steve Lucas