Friday, May 27, 2011

Healthcare Renewal Cited in Pittsburgh Post Gazette on Health IT Issues

Healthcare Renewal was cited in the Pittsburgh Post Gazette today on health IT issues.

Specifically, regarding issues I raised at my May 25, 2011 post "Transplant Team at UPMC Missed Hepatitis Result - Suspicious for Health IT Failure?"

I have several additional amplifying comments.

Doctor, nurse disciplined by UPMC
Failed to detect hepatitis C in kidney donated for transplant
Friday, May 27, 2011
By Jonathan D. Silver and Sean D. Hamill, Pittsburgh Post-Gazette

A surgeon and a nurse were disciplined by UPMC for their roles in missing a positive hepatitis C test result in a kidney donor earlier this month that might have stopped the transplant, the hospital system said Thursday.

The surgeon was demoted and the nurse suspended, though neither has been identified.

In addition, after a discussion with federal officials, the hospital system voluntarily suspended its live-donor liver program as a precaution, three days after shutting down its live-donor kidney program on May 6, following the transplant error. Both programs remain closed.

But while UPMC has taken action against the two staff members, health care technology experts say UPMC's information technology might have played a role in the incident.

"Checking for all types of hepatitis is so ingrained in the culture of doctors," said Scot Silverstein, a medical informatics expert and adjunct professor at Drexel University in Philadelphia. "If they didn't check for hepatitis C, that means they didn't check for hepatitis A or B either, and that means they didn't check for anything."

"That just isn't credible," said Dr. Silverstein, who explored the possible ways the technology played a role in the kidney transplant error in the blog Health Care Renewal.

"There are two possibilities," he said. "Either you have a dozen or more people on that transplant team who are just stupid, or, more plausibly, when they looked at the record the hepatitis C record was just not there or it was incorrect when they saw it."

The incident first came to light May 6, when UPMC notified the Centers for Medicare and Medicaid (CMS) as well as the United Network for Organ Sharing, that it had detected an error in a recent kidney transplant.

It was a living kidney transplant between a woman and a man who are a couple, sources have told the Post-Gazette. The woman did not know she was hepatitis C positive, and she was tested, but the test results were somehow missed by people on the transplant team, and the transplant went forward.

... Because of the error, UPMC had decided on its own on May 6 to shut down the living donor kidney program.

Then, on May 9, when UPMC officials were discussing the situation with the U.S. Health Resources and Services Administration, they mutually decided to shut down the living donor liver program, too, said Michele Walton, a CMS spokeswoman.

Read the entire article.

I strongly feel there is much more going on here than a careless surgeon and nurse. Closing down these transplant programs for now is a major, major step that actually endangers patients on waiting lists. As per an anonymous comment received in my aforementioned May 25 post (link to full comment):

I surely hope they get this figured out soon as there are MANY lives on the line here. A very good friend of mine is on the list there and has myself as a willing paired donor and another mutual friend of ours as a perfect match donor that has one test to be done and then it is a go. With all of the testing that we both have had to go through - and by the way, myself now a second round as it has been more than a year since the original testing and no paired match has been located as of yet, that these things are known as soon as the tests are ran. I would have to agree that this must be beyond human error.

... This needs to be addressed and corrected like YESTERDAY. We have many out their literally dying on the lists.

I was also cited as follows later in the Post Gazette article:

... Dr. Silverstein and other experts say the current electronic health records systems that highly wired hospitals like UPMC have in place routinely flag test results for everyone connected to a surgery to see.

But those systems have been known to cause the same kinds of errors they were designed to prevent over the old-fashioned paper records. [E.g., as per the FDA internal memo on HIT risk I described at this Aug. 2010 post; see tables 4 and 5 - ed.]

I do think the reliability of existing alerting systems has been over-represented. "Flagging" a test result awaiting someone to note the flag amidst a sea of screens, icons and clutter, and setting off aviation-like stall alarms and other fail-safes that nobody can miss, are two different matters.

For the hundreds of millions of dollars spent on health IT by organizations like this, and the hype proffered about this technology, events such as the post-facto discovery of a tainted transplanted organ should truly be considered "cybernetic 'never' events."

One might also wonder if the informational issues, whatever their source, occurred more than once: that is, if prior transplant recipients who participated in these programs need to be checked for tainted organs.

That the Post-Gazette article was published on the one-year-to-the-day "anniversary" of my own mother being cybernetically turned into a train wreck due to the toxic effects of HIT -- in an ED where I once worked in the paper era where I do not recall EOT mistakes of the kind that nearly killed my mother ever happening -- is ironic.


If health IT is indeed implicated in the UPMC error, and if UPMC knew of system unreliabilities that could have caused the clinical errors, both patients and affected clinicians can likely raise charges of criminal negligence on the part of those responsible for these IT systems.

Politics and an overall 'lawlessness' (per Hoffman & Podgurski) in the health IT sector needs to be replaced with the scientific and regulatory methods of medicine, such as intensive pre-marketing evaluations, clinical trials and post marketing surveillance of these systems.

Perhaps some jail time for the cavalier would remind people these are not toys, gaming computers, or slot machines, and that the subjects of health IT systems are human beings, not lab rats.

-- SS

Addendum May 27, 2011:

A reader reminded me of my 2009 post "UPMC as Proving Ground for IT Tests On Children: Pioneers in Health IT, or Pioneers in Ignoring the Past?"

-- SS


Anonymous said...

UPMC administration with its nepotism has a history of being whimsical and self-serving in punishing its physician and nursing staff.

One wonders when working there, unless one of the favorites, if the place is Libya or Syria.

Say or do something adverse to Romoff's and Concordia's piggy bank and it is off to sham peer review for the medical staff or termination for the employees.

The city is littered with former employees who signed away their rights to tell the truth about life at UPMC for a pittance of a severance.

The reporter of this story is spot on. It is the HIT equipment that is defective...not these two employees who were thrown under the bus.

Anonymous said...

The HIT used by UPMC is at the top of the graph as being user unfriendly.

Most of the HIT that hospitals are being financially incented to purchase is dangerous. Mistakes are increased by virtue of the poor usablility.

The usability of these systems is so bad that the powerbrokers in DC at NIST and ONC are now rounding up the troops to determine how to make this equipment usable (they still ignoring safety and efficacy, and usability overlaps these but is not a surrogate. Just a wee bit late.

This what is known as shutting the gate after the horses ran away.

UPMC would be wise to shut down its entire EHR system and taking heed of this fiasco and the 2005 Pediatrics report from its Children's Hospital that showed a 2.4X increase in baby deaths after Cerner CPOE went live.

Anonymous said...

Do the investigative authorities know how to use EHRs, or, will they ask the UPMC IT experts for a demo?

Anonymous said...

lol @ "off to sham peer review for the medical staff" -- So true, Dick Simmons runs the torture chamber under presby and Billiar wears the black hood.

With like 400,000 docs on board, how do they make sure no one talks?

tips on getting pregnant said...

I would just like to repeat this statements. If health IT is indeed implicated in the UPMC error, and if UPMC knew of system unreliabilities that could have caused the clinical errors, both patients and affected clinicians can likely raise charges of criminal negligence on the part of those responsible for these IT systems.

Live it or live with it said...

It may be more likely that IT is a feint designed to change the focus away from some real problem. From what I read, they are looking at more IT as the answer to some other problem.

Did you see the article claiming that operative complications were at the root of the liver program shutdown?

Afraid said...

Here is the next installmant, apparently, this is not the first time a patient got a HepC organ without notification:

UPMC transplant patient says he was not told the organ he received in 2007 was hepatitis C positive
Sunday, June 05, 2011
By Sean D. Hamill, Pittsburgh Post-Gazette

In the dining room of his parents' home, Matt Wineland reflects on the support of his family, which he said has sustained him following the removal of a transplanted kidney. He speaks of keeping his mind, body and spirit in tune to keep his life in balance through the ordeal.Few people are as incensed about the report that UPMC recently transplanted a hepatitis C positive kidney into a man who didn't know the donor had the virus than Matt Wineland.

That's because, even though UPMC has tried to portray it as a unique failure to inform a recipient about the virus, Mr. Wineland said the same thing happened to him at UPMC in November 2007.

"They acted like it was a one-time incident; it wasn't," said Mr. Wineland, 34, a social worker from Logan near Altoona. Mr. Wineland, who has a bachelor's degree in social work from Juniata College in Huntingdon County, now works part time as a drug and alcohol counselor and is on disability because of his health problems.

Read more:

Anonymous said...

Oh my, UPMC Transplant put on probation:

Transplant error puts UPMC on probation

Federal agency deals rare discipline

Wednesday, November 16, 2011

By Sean D. Hamill, Pittsburgh Post-Gazette

Because of a botched living donor kidney transplant earlier this year, a federal agency on Tuesday put UPMC's transplant program on probation, a rarely used form of discipline handed down for some of the most serious transplant errors.

The federal Organ Procurement Transplant Network (OPTN) said it meted out the discipline not only because of the kidney transplant error, but because UPMC's transplant program was found to have problems in its communication and documentation procedures before.

Read more: