Thursday, February 12, 2009

Computer Bites Human? Healthcare IT Blamed in Patient Death at UPMC

Just as I'm finishing my semi-tongue in cheek post "Another Human Bites Dog Story? Health Affairs Briefing on Healthcare IT Challenges" on a remarkable new phenomenon of increasing candor from major organizations about the dangers of poorly conceived and implemented health IT, this tragic story crosses my inbox.

My comments are in [bracketed red italics]:

UPMC records blamed in death
By Walter F. Roche Jr.
Wednesday, February 11, 2009

The son of an 89-year-old woman who died on UPMC Montefiore's roof in freezing temperatures charged in court papers Tuesday that a new and untested electronic medical records system was a major factor in her death.

The complaint filed in Allegheny County Common Pleas Court claims the University of Pittsburgh Medical Center implemented the records system at Montefiore a little more than a month before Rose Lee Diggs' death, despite warnings from staffers that it was deficient.

[if you want to know how such warnings from medical personnel can possibly be ignored, read
"Why was this site created?" in the introduction to my website on health IT failure - ed.]

Diggs, a survivor of multiple strokes and under treatment for dementia, was under the care of medical staff struggling with a system that "they were not properly trained on," placing patients "at a severely increased risk of harm and death," the lawsuit states.

[Imagine a jet pilot distracted by clunky, ill designed instruments designed for a submarine, say, by people with no aeronautical background, with skimpy training, and the resultant consequences - ed.]

UPMC spokesman Frank Raczkiewicz said he could not comment because hospital attorneys had not seen the complaint. He noted the hospital implemented an alert system following Diggs' death "to quickly find patients who wander from their units."

Family attorney Rob Peirce charges in the lawsuit that UPMC ignored warnings that the records system could put patients at risk because the health conglomerate has an ownership interest in the company, Cerner Corp., that developed the records system

[Healthcare Renewal, of course, has great disdain for such conflicts of interest and how they ultimately affect healthcare professionals and their patients - ed.]

Security and Exchange Commission records show UPMC received 74,787 shares of Cerner stock in 2005. UPMC and Cerner have been involved in joint efforts to sell the recordkeeping system to health care facilities in the United Kingdom.

[Note: Cerner Millenium has not performed well in the UK, see
this post and its report from the UK House of Commons, Public Accounts Committee, Items 5 and 6 - ed.]

Cerner, which is not named as a defendant in the lawsuit, did not respond to a request for comment.

Diggs wandered from her 12th floor hospital room about 5 p.m. Dec. 2, passing through three doors that should have been locked or outfitted with an alarm, up a flight of stairs and through a boiler room to the hospital roof. According to the lawsuit she was found dead, wearing only a hospital nightgown and slippers.

[Very tragic - ed.]

The lawsuit charges that UPMC officials, following the discovery of Diggs' body about 8 a.m. the next day, attempted a cover-up by removing faulty locks in the midst of a criminal investigation. That investigation by Allegheny County District Attorney Stephen A. Zappala Jr. and Pittsburgh police continues.

"UPMC's main objective was to destroy or tamper with important evidence in order to exculpate itself as opposed to the safety of Mrs. Diggs," the family claims in the lawsuit, which charges that UPMC waited an hour before notifying police after staffers found Diggs.

[if this is true, management changes such as in my first human bites dog posting
Physicians' Unexpected Un-Helplessness: Executives Invited To Leave Nashville-Based Healthcare System" may be in order - ed.]

... In a state report recently made public, UPMC was cited for the malfunctioning door locks and failing to develop a care plan to specifically deal with Diggs' documented history of wandering.

The lawsuit claims a freeze on overtime, and the virtual elimination of a program to provide round-the-clock monitoring of patients with ailments such as dementia, occurred at the same time the recordkeeping system was implemented Oct. 24.

[I would like to know if any clinical or informatics persons made the connection as to the dangers of the temporal issue here, a real no-brainer except to those suffering either terminal Syndrome of Inappropriate Overconfidence in Computers, or terminal stupidity, and if such persons were ignored - ed.]

Sad story ... and nearly unbelievable if true. Then again, the foundational story behind my HIT difficulties website as mentioned above, written up in depth here, could have had equally adverse consequences, especially in an ICU of all places. (Imagine my horror when that administration would not support me, a clinician medical informaticist, against an arrogant, ignorant and lazy business IT department.)

This story is especially tragic since we already knew Bad Informatics Can Kill. Bad informatics in the company of overwork and cutbacks is simply homicidal in my view.

It's also sad that my ten year old website on HIT difficulty and failure, Lorenzi & Riley's book on managing organization change in health informatics, Koppel's articles on CPOE and barcoding, and many other works were publicly available that should have served as cautionary tales on such matters ... if they'd been taken seriously.

Perhaps this lawsuit and others (yet) unknown is a reason for the puzzling change of heart on the proscribed topic of HIT failure that I observed at the aforementioned human-bites-dog story?

-- SS


Anonymous said...

It's so much worse at UPMC than the news papers, or even the lawyers representing dead patients, could believe. It all starts with governance, or lack of it. Why won't the UPMC board of directors act???

InformaticsMD said...

Health IT seems more religion than science. Challenging its dogmas is not easy.