Tuesday, May 31, 2016

UK health IT 'glitch': Hundreds of thousands of patients have potentially been given an incorrect cardiovascular risk estimation after a major IT system error

This in the UK.

What is euphemistically referred to as an "IT system error" is, in reality, the mass delivery of a grossly defective medical device adversely affecting hundreds of thousands of patients.  I'm surprised not to see that other kindly euphemism, "glitch" (http://hcrenewal.blogspot.com/search/label/glitch):


Hundreds of thousands of patients have potentially been given an incorrect cardiovascular risk estimation after a major IT system error, Pulse can reveal.

The MHRA has told GPs they will have to contact patients who have been affected by a bug in the SystmOne clinical IT software since 2009.

Of course, this refrain appeared, a corollary of "Patient care has not been compromised" (http://hcrenewal.blogspot.com/search/label/Patient%20care%20has%20not%20been%20compromised) when health IT crashes and outages occur:

The regulator says that means that ‘a limited number’ of patients may be affected, and the risk to patients is ‘low’.

At best, it's good that only a "limited number" of patients were "affected."  I guess they feel they can justify a "limited number" of patient harms for the glory of a medical Cybernetic Utopia.

At worst, how do "the regulators" know exactly who was affected?  Answer: they don't and this is boilerplate BS meant to CYA.

But Pulse has learnt that the 2,500 practices using SystmOne are having lists sent to them of around 20 patients per partner who may need to be taken off statins, or be put on them, after their risk is recalculated.

Statins are not an innocuous medication.  From WebMD at http://www.webmd.com/cholesterol-management/side-effects-of-statin-drugs?page=2#1:

The most common statin side effects include:
Statins also carry warnings that memory loss, mental confusion, high blood sugar, and type 2 diabetes are possible side effects. It's important to remember that statins may also interact with other medications you take.

Not to mention the risks of not being on a statin if you truly need one.

And this number could increase if a practice provides NHS Health Checks routinely. In addition, the lists being sent to practices only go back to October 2015, but practices will be sent further lists potentially dating back to 2009 over the next few weeks.

Wait!  The "regulators" said that ‘a limited number’ of patients may be affected.  They are clairvoyant, I would imagine.  Maybe one of them is Harry Potter?

The "regulators", who have the same powers as the man-wizard above, know through clairvoyance that only a limited number of people were affected, and risk to them low.

A statement from MHRA to Pulse said: 'An investigation has been launched into a digital calculator used by some GPs to assess the potential risk of cardiovascular disease (CVD) in patients.

'We are working closely with the company responsible for the software to establish the problem and address any issues identified.

The problem is incompetence and negligence.  One wonders what testing was performed before this was unleashed on the public in the UK.

TPP told Pulse they were working to address the ‘Clinical Safety Incident’ and that the QRISK calculator was provided as an advisory tool to support decision making. They added they were working to ensure the issues were addressed and GPs are informed of affected patients ‘as soon as possible’.

‘Clinical Safety Incident’ - what a wonderful euphemism for "healthcare IT debacle."

Deputy chair of the GPC’s IT subcommittee Dr Grant Ingrams told Pulse it would be ’loads of work’ to sort out.

He said: ‘It affects everyone who has had a QRISK, and SystmOne are sending out messages to say “look at these patients”. But then you have to see if the change is significant, and whether you would have made a different decision at the time, or put them on a different treatment’

It will probably be more work than if such a system had never been constructed.

Dr Ingrams said: ‘There’s potential harm both ways…What happens when a patient who had been of a high risk and this hadn’t been identified and they’ve now had a stroke or heart attack?  ‘Similarly if someone had a low risk and they’ve been put on a statin and had a side-effect who’s responsible? That’s the clinical risk.’

Answer: the company that produced this grossly defective software, and those "regulators" who allowed it on the market without independent and thorough testing, are responsible.

Dr William Beeby deputy chair of the GPC’s clinical and prescribing subcommittee, said the bug ‘certainly had the potential to impact on patient confidence’ and this could create even more work  ... ‘It’s the tool we’ve been told to use. So if the tool is inaccurate, then you start to lose confidence and the doctors will then lose confidence as well.’

Patient confidence (let alone physician confidence) in cybernetics already took a big hit in the UK several years back, as at my Sept. 2011 post "NPfIT Programme goes PfffT" at http://hcrenewal.blogspot.com/2011/09/npfit-programme-going-pffft.html.

However, it seems, hyper-enthusiast overconfidence in health IT, including that of the "regulators", would not be injured even if bad health IT caused more casualties than the bombings and V2 attacks suffered by the UK in WW2.

After the health IT debacles involving billions of wasted pounds in the UK, perhaps the UK's "regulators" need to look upon health IT as fondly as this piece of technological wizardry.

A TPP spokesperson told Pulse: 'TPP is dealing with the Clinical Safety Incident involving the QRISK2 Calculator in SystmOne. The tool is intended to support GPs in assessing patients at risk of developing cardiovascular disease and in developing treatment plans. The QRISK2 Calculator is presented within SystmOne as an advisory tool.

"Advisory tool"?  That the doctors can safely ignore?  Hogwash.

’We are actively working to ensure the issues identified are addressed and to ensure that clinicians are informed of any patients that may have been affected as soon as possible.’ 

Until the next health IT "bug" arises, that is.

-- SS


Anonymous said...

There will be mass deaths at some point.

Nicola said...

It's appalling that such systems have been implemented without regulatory oversight or accountability - accountability which lies squarely with Simon Stevens whilst in the Blair government introducing technologies with spurious claims of efficacy and yet again doing this after his time at United Health with NHS England.

It's not just a mild case of repeat offending if people die or are harmed but he appears to be teflon coated.