Friday, August 05, 2011

Medical Data Mix-up, Major System Error Down Under - But Nobody Harmed, Of Course

This from Down Under. Apparently an American IT system by Cerner was involved:

Medical data mix-up, major system error

Kate Hagan | August 5, 2011

MELBOURNE hospitals have sent incorrect patient records to GPs due to an error with Victoria's troubled health technology program over the past two months.

The discharge summaries from Eastern Health and the Royal Victorian Eye and Ear Hospital mixed patients' names with other patient data, including test results and diagnoses.

[A major patient misidentification error - ed.]

The data was faxed to GPs under the HealthSMART program, which Health Minister David Davis has described as ''the myki of health''.

[I think 'myki' refers to the contactless smartcard ticketing system being introduced on public transport in Victoria, Australia. Did I mention I despise comparisons of healthcare to public transit, having started my career in the latter industry? - ed.]

Mr Davis yesterday said: ''This latest error raises further concerns about [former health minister] Daniel Andrews's judgment when designing the HealthSMART system.''

The Health Department was alerted to the record mix-up last month after two GP clinics raised the alarm.

Department spokesman Graeme Walker yesterday confirmed the bungle and said an investigation found that 13 incorrect discharge summaries were sent out over a seven-week period.

''There was an intermittent error in terms of the sending of discharge summaries in a small number of cases to GPs,'' he said. ''It was the link up between the software and the fax which caused some incorrect collating of material attached to the discharge summaries.''

Mr Walker said no patients suffered as a result of the bungle, which had since been fixed.

AMA Victoria president Harry Hemley said the mix-ups were a major concern. ''When patients are admitted to hospital often their medication is changed and they are given a diagnosis,'' he said. ''Discharge summaries influence our ongoing treatment of the patient. If our [incorrect understanding] is that a patient is on a certain medication, that could have serious implications.''

[Well, yes. How about - injury and death? - ed.]

Mr Davis said yesterday he had been advised of a software fault that led to some patient discharge summaries being distributed to the wrong GP clinics.

''I have sought and received assurances that patient safety has not been compromised,'' he said.

[Patients are NEVER harmed by IT foulups thanks to the Lords of Kobol overseeing the universe of Cybernetica - or something like that - ed.]

Mr Davis told The Age in January that he was considering abandoning the HealthSMART program, which is five years late and has cost the state $405 million, including an $80 million cost overrun.

[He should see what the UK just did with their NPfIT here - they pulled the plug - ed.]

The program, introduced by the former Labor government in 2003, is supposed to link computer systems in hospitals and give doctors immediate access to patient records. But clinical applications are only partially running in four hospitals and doctors say they are costly, outdated and difficult to use.

[That is, they present a mission hostile user experience - ed.]

Victoria's Ombudsman and Auditor-General are currently examining a string of failed information technology projects in Victoria, including HealthSMART, which have run over budget and fall short of their goals despite repeated warnings by the watchdogs.

[Repeated warnings by watchdogs ignored - that is quite familiar to me since my writings on these issues began - in 1999 - ed.]

Dr Hemley said the government needed to take urgent action to implement a system that allowed doctors ready access to patient records, test results and medication details. ''We're sick of hearing how bad [HealthSMART] has been, we're waiting for the Ombudsman to come out with that report so we can get on with this IT business and start it happening so that we can communicate with each other,'' he said.

[I wish them luck. Einstein on insanity: doing the same thing over and over again and expecting different results. - ed.]

''We've got to look at where mistakes have been made, eradicate them and move forward.''

[Yes, it's that simple. Of course, achieving nuclear fission on your kitchen table is easy as long as you have the right components and a pamphlet by Dr. Alfred E. Neuman on the topic - ed.]

Asked whether affected patients had been notified of the error, the Health Department's Mr Walker said that would be done ''at the discretion of either the hospital or GP involved''.

The Eye and Ear Hospital did not return calls from The Age yesterday and Eastern Health referred inquiries to the Health Department.

-- SS


Anonymous said...

Patients are never injured by HIT devices. We have had it drilled into our heads that it is always the users' faults. Whenever anyone implicates the EMRs and CPOEs, the EMR defenders come out of the woodwork to depreciate the user/complainer.

Live it or live with IT said...

Thank goodness no one was harmed, and that providence seems to smile on patients who are not informed of the errors that occurred on their data.

Steve Lucas said...

I read a very positive post on the use of technology on another blog. A person calls his doctor, the day after his pace maker goes off, and ask what to do? The doctor ask if the patient can use the home sending unit to transmit the data from the pace maker to his office and the doctor, who is out, will use his iPhone to review the information. There is an app for that.

The patient does as instructed; the doctor reviews the data and makes changes to the patient’s medication, because the doctor knew the patient. All very nice, fast, and the way the system is suppose to work.

Me, being the wet blanket, am thinking that the doctor did not get paid and the hospital did not get to charge for an ER visit, as mentioned in the post. This will make the insurance company happy and the patient has no co-pays.

So what happens if the insurance company decides they like this, sets up a screening system where all pace maker patients send their data to them, and they in turn off shore the data review to a foreign country, where a group working from a computer generate decision tree, makes a decision.

Disaster. The doctors doing the reviews do not know the patient and the time lag may mean the patient is put in danger. Then we have the issue of a medication change being transmitted to a US doctor and his staff’s ability to notify the patient of the medication changes. We also have an often elderly or confused patient trying to deal with a technology they are not comfortable with in a stress filled environment.

Technology that evolves slowly with great user input may be of value. Technology that is imposed wholesale on a profession will lead to disaster. I am not a doctor, or IT person, but even I can see the pitfalls of attempting some of these IT projects.

Troubling is not only the failure of medical IT, but the failure of so many other IT projects attempting to do the same thing, wholesale use of IT with little or no end user input.

As Einstein said: “Stupidity is doing the same thing over and over and expecting a different outcome.”

Steve Lucas

Anonymous said...

Govt computer glitches make people sick
NT NEWS | August 11th, 2011

FOURTEEN people have been made sicker thanks to glitches in the NT Government's new eHealth system that led to medicine mix ups, it has been revealed.

CLP health spokesman Matt Conlan slammed the Government in Question Time today - accusing them of a cover-up.

Health Minister Kon Vatskalis said every new system had glitches - and the problems were detected and fixed early. But he said two people had suffered "some deterioration", while 12 experienced "moderate deterioration".

Read more on this story in your copy of tomorrow's NT News