The inevitable downgrading of burdensome, destructive EHRs back to paper & document imaging

In recent days, I've posted about current articles on the destructive nature of today's vastly over-complex, burdensome EHR technology.  These posts included "Physicians Harassed by Overwhelming Levels of Messaging From Electronic Medical Records" at http://hcrenewal.blogspot.com/2018/01/physicians-harassed-by-onerwhelming.html
and "Medical Economics: Highly experienced physicians lost to medicine over bad health IT" at http://hcrenewal.blogspot.com/2018/01/medical-economics-highly-experienced.html.

There are many other earlier articles of a similar nature discussed on this blog, e.g., the May 2017 post  "Death By A Thousand Clicks: Leading Boston Doctors Decry Electronic Medical Records" at http://hcrenewal.blogspot.com/2017/05/death-by-thousand-clicks-leading-boston.html for one, and others retrievable by query links http://hcrenewal.blogspot.com/search/label/healthcare%20IT%20dissatisfaction, http://hcrenewal.blogspot.com/search/label/Healthcare%20IT%20failure and similar.

Here's another recent article along the same lines that just appeared in the prestigious New England Journal of Medicine:

Perspective
Beyond Burnout — Redesigning Care to Restore Meaning and Sanity for Physicians
Alexi A. Wright, M.D., M.P.H., and Ingrid T. Katz, M.D., M.H.S.
January 25, 2018
N Engl J Med 2018; 378:309-311
http://www.nejm.org/doi/full/10.1056/NEJMp1716845

In late 2016, a primary care physician with a thriving practice decided it was time to shut her doors. She felt her retirement was forced on her after she’d spent a year in the grips of her health care system’s new electronic health record (EHR). It was her fourth EHR over her years of doctoring, but this transition felt different. Instead of improving her efficiency, the new system took time away from her patients, added hours of clerical work to each day, and supplanted her clinical judgment with the government’s metrics for “meaningful use” of information technology in health care.

I note that, unlike this primary care physician, many physicians have to learn numerous EHR's and use them simultaneously if they provide services at different healthcare systems. 

Channeling the satirical medical internship novel "House of God" and its "law #11" (https://en.wikipedia.org/wiki/The_House_of_God, full movie at https://www.youtube.com/watch?v=bPllfH9YREA), these poor souls are probably constantly thinking "find me the EHR that only triples my work and I'll kiss your feet."

“We’re spending our days doing the wrong work,” argues Christine Sinsky, a practicing internist and vice president for professional satisfaction at the American Medical Association, who has conducted several studies tracking how doctors spend their time. “At the highest level, we are disconnected from our purpose and have lost touch with the things that give joy and meaning to our work.”

That is a prescription for suboptimal performance and increased risk of harm, on its face.  There is little to argue on that point.  I personally would not want an airline pilot, let alone a physician, providing me services who is "disconnected from our purpose and have lost touch with the things that give joy and meaning to our work.”

Increasing clerical burden is one of the biggest drivers of burnout in medicine. Time-motion studies show that for every hour physicians spend with patients, they spend one to two more hours finishing notes, documenting phone calls, ordering tests, reviewing results, responding to patient requests, prescribing medications, and communicating with staff.¹ Little of this work is currently reimbursed. Instead, it is done in the interstices of life, during time often referred to as “work after work” — at night, on weekends, even on vacation.

That is, quite frankly, an absurd workload deleterious to provider AND patient well-being.

“EHRs can be a double-edged sword, because they give you more flexibility about where you work, enabling physicians to get home for dinner,” argues Tait Shanafelt, professor of medicine at Stanford University and a leading researcher on physician burnout. “But physicians are working a staggering number of hours at night, and this has enabled organizations to continuously increase productivity targets without changing the infrastructure or support system, effectively adding a whole extra workweek hidden within a month.”

Imagine trying to force "a whole (uncompensated) extra workweek hidden within a month" to the workload of a union member of, say, the Transport Worker's Union.  It would result in an instant labor strike ... or worse.

... Beyond the financial toll physician burnout takes on institutions, there are human costs to both doctors and patients. Studies over the past decade have shown that burnout can undermine a physician’s sense of purpose and altruism and lead to higher rates of substance use, depression, and suicidality. Physicians with symptoms of burnout are more likely to report having made a major medical error in the past 3 months and to receive lower patient-satisfaction scores.³

I rest my case on the increased-risk-of-harm issue.

I seem to be one of the first to recognize, or at least start writing openly about, the bad leadership of the health IT field and the dangers of the bad health IT produced as a result.  My observational skills and critical thinking capabilities led me to start writing on these issues circa 1999, after my experiences as postdoc and faculty in Medical Informatics at Yale School of Medicine/Yale-New Haven Hospital and then as CMIO at the Christiana Care Health System in Delaware. 

That writing is largely retained at http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases, in a website I have not updated in several years due to time constraints related to the EHR forensics work I have been doing in the legal and law enforcement sectors.

It is clear my concerns are now proven correct and are now being echoed by large sectors of the physician and nursing communities.   My concerns were obvious, I opine, to anyone of reasonable critical thinking and observational skills, who were not affected by conflict of interest.  That is, those without profitable connections to the health IT industry.

I now make a prediction for the future that, once again, seems obvious to me:

Today's EHRs, especially the sections for narrative clinician documentation, will be downgraded from their "template madness" time-wasting design to document imaging retrieval interfaces to notes written by clinicians on paper.  Perhaps domain-specialized paper forms as I created for invasive cardiology in the late 1990s' as at http://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html, but paper nonetheless.  Data extraction of these notes for financial purposes will be done, once again, by coders.

A small sample of why physicians and nurses burn out from EHRs.

Debate if you will, but that is my prediction for the future.  I feel it inevitable considering the unintended/unexpected terrible consequences and realities of this technology.  "New curtains" (that is, tidying up the user interfaces) will not suffice.  This is a prediction from one of the first Medical Informatics professionals to start openly writing about EHR difficulties almost two decades ago. 

-- SS

Death By A Thousand Clicks: Leading Boston Doctors Decry Electronic Medical Records

Channeling Lyndon Johnson on Walter Cronkite, in clinical medicine, when you've lost Boston (including MGH), you've probably lost the health IT war.

Death By A Thousand Clicks: Leading Boston Doctors Decry Electronic Medical Records
May 12, 2017
By Drs. John Levinson, Bruce H. Price and Vikas Saini
http://www.wbur.org/commonhealth/2017/05/12/boston-electronic-medical-record

It happens every day, in exam rooms across the country, something that would have been unthinkable 20 years ago: Doctors and nurses turn away from their patients and focus their attention elsewhere — on their computer screens.

By the time the doctor can finally turn back to her patient, she will have spent close to half of the appointment serving not the needs of her patient, but of the electronic medical record.

I have observed this myself in my own personal experiences in recent years observing clinicians in situ.  I (unfortunately) have also been on the receiving end of the resultant distractions, via a dead parent, at the very hospital where I did my residency training in pre-HIT days.

Electronic medical records, or EMRs, were supposed to improve the quality, safety and efficiency of health care, and provide instant access to vital patient information.

Instead, EMRs have become the bane of doctors and nurses everywhere. They are the medical equivalent of texting while driving, sucking the soul out of the practice of medicine while failing to improve care.

"Texting while driving" is, in fact, an excellent metaphor.  The practice of medicine is often a highly-demanding activity, cognitively speaking, just as driving is.  Slip up even for a moment, and accidents and catastrophe can occur.

To fix them, hospital administrators and clinicians need to work together to demand better products from EMR manufacturers and to urge government to relax several provisions of the HITECH Act, the 2009 law that spawned many of the problems with EMRs.

I do not think this is feasible, nor do I think it would solve the problems.  More on that below.

How did technology that has increased efficiency in every other industry become such a drag on health care? For starters, people who take care of patients did not design or choose these systems. They were foisted upon us.

Doctors and nurses know that good diagnosis and treatment requires listening attentively to their patients. They spend years learning to parse the clues that patients offer, both the physiological and personal, in order to provide the right care.

The sound of medicine is not the click of a mouse. It is the human voice. Let’s bring it back.

To do this well takes time and undivided attention.

"Undivided attention to the patient" and "use of health IT" under the current paradigms are incompatible.  The terms do not belong in the same sentence.  Again, more on that below.

... Instead of making this easier, most EMRs create extra work. A lot of extra work, thanks to endless prompts with multiple choice answers that hardly ever fit the facts and that demand click after click to get anything done.

Want to order a simple test? That requires getting through multiple prompts. Need to write a prescription -- an exercise that used to take less than 15 seconds? Another set of clicks.

Template madness is the coin of the realm.

Four screens of hundreds, from just one EHR, of many EHRs that a clinician might need to use in practice of medicine.

Typing, filing, mailing results and placing referrals all used to be done by assistants. Now, EMRs put that burden on clinicians, and we must do it during office visits, or “encounters,” as EMRs call them. And when the wrong button is clicked, the wrong test or drug is ordered, or it does not go through at all, delaying medical care.

It’s death by a thousand clicks, and it happens every day.

Another excellent metaphor, a derivation of "death by a thousand cuts."  However, in this case, it is not just referring to death of the ability to maintain medical practice and retain sanity (and health of the practitioner), but also injury and death of patients.

We are frustrated by EMRs because they pull us away from our patients. We are driven mad by the fact that EMRs in different locations do not talk to each other. And we think it’s just wrong that much of the EMR’s busywork is about optimizing billing for the hospital.

The lack of interoperability is likely protective against, in effect, mass copy-and-paste on a grand scale through importation of a chart from one EHR to another, resulting in propagation of errors.  In any case, interoperability needs to take a back seat to operability (usability).

Who is to blame? Start with EMR manufacturers, who lobbied Congress to require every hospital and doctor’s office to install an EMR system; hospital administrators who bought technology that conveniently pushed billing duties onto doctors and nurses; and federal regulators, who imposed on EMRs numerous quality metric requirements that do nothing to improve care.

Everyone in healthcare is to blame, including clinicians who DID NOT SPEAK OUT until obvious issues crated the terrible state clinicians find themselves in now.

We do not want to go backward. We believe that computing is essential to the future of medicine. We simply want all EMRs to live up to their promise of improving care and making patient information readily available.

I've been calling the problems out for close to two decades now.

The issue becomes:  what to do about it?

My area of Medical Informatics research in the early 1990s was to move away from the traditional GUI paradigm of menus, widgets, control buttons, etc to explore novel (and menu-free) paradigms of EHR-based data content visualization, navigation and querying.  The commercial companies, when shown this, had no interest in even considering such ideas.

Other avenues to enhance the traditional GUI interface - e.g., AI-based "wizards" of one sort or another that anticipated likely down-the-line choices from currently entered data and presented the choices to the user, better-designed EHR roadmaps and/or AI based on data entry to-the-moment to  allow simpler and less time-consuming navigation, etc. - all proved not very helpful due to the complexity of the domain, not to mention its specialties and subspecialties.  This experience informed my decision down the line to move to specialized and malleable paper forms for the clinicians, and data entry clerical teams, for high risk and/or high volume procedural or critical care areas such as invasive cardiology, cardiac surgery and the ED.

See my Aug. 2016 post "More on uncoupling clinicians from EHR clerical oppression" at http://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html for a specific, highly successful example.

It is my belief that the "traditional" model - GUI-based EHRs with the typical paradigms, and clinicians doing the bulk of the data entry that itself is bloated relative to the actual clinical need, and tying all human-computer interaction to a computer screen roughly at the resolution of one or two legal-sized pieces of paper, can never be improved to the point of not impairing the clinical workday.

The entire health IT enterprise needs to be rebooted (rethought), especially regarding roles, workflow, and most especially the "data capture load per clinician".

When I was writing about EHR issues in the late 1990s and into the 2000s, I was called a Luddite and alarmist (or worse, e.g., see my 2010 posts "The Dangers of Critical Thinking in A Politicized, Irrational Culture" at http://hcrenewal.blogspot.com/2010/09/dangers-of-critical-thinking-in.html and "More on Perversity in the Healthcare IT World: Is Meditech Employing Sockpuppets?" at http://hcrenewal.blogspot.com/2010/01/more-on-perversity-in-hit-world.html).

It appears I was correct.

My issuing the prediction that the current model of health IT is irreparably broken (or, said differently, that the health IT experiment - and it has been an experiment - under its current paradigms has failed), and needs a top-to-bottom rethinking, will probably be taken the same way.

Until it isn't.

-- SS

An eloquently expressed lesson from Nanaimo (Canada) on electronic medical records failure

Unfortunately, this eloquent piece on EHR failure expresses precisely the major problems with this experimental technology that generic medical managers and other medical bureaucrats are unwilling to hear, and/or unable to fully comprehend.

At my May 31, 2016 post "HIT Mayhem, Canadian Style: Nanaimo (Vancouver Island) doctors say electronic health record system unsafe, should be shut down, non-medical PR hacks say it's perfectly safe" at http://hcrenewal.blogspot.com/2016/05/hit-mayhem-canadian-style-nanaimo.html, I wrote:

... To hell with doctors and nurses and their concerns about horrible health IT.   

That seems the international standard in 2016 regarding their concerns.  There's just too much money to be made in this business to worry about such piddling annoyances as maimed and dead patients.

Doctors, after all, don't know anything about computers, and cybernetic medical experiments on unconsenting human subjects are just good fun.

This new example from Canada:

http://www.theprovince.com/health/local-health/nanaimo+doctors+electronic+health+record+system/11947563/story.html 

Nanaimo doctors say electronic health record system unsafe, should be shut down

By Cindy E. Harnett
Victoria Times Colonist 
May 27, 2016

Implementation of a $174-million Vancouver Island-wide electronic health record system in Nanaimo Regional General Hospital — set to expand to Victoria by late 2017 — is a huge failure, say senior physicians.

Who cares what they say?  They're just doctors, so sayeth the imperial hospital executives..  

Here is an update:

http://www.canadianhealthcarenetwork.ca/physicians/discussions/opinion/a-lesson-from-nanaimo-on-the-human-costs-of-electronic-health-records


A lesson from Nanaimo on the human costs of electronic health records

WRITTEN BY DR. DAVID FORREST ON MARCH 22, 2017 FOR CANADIANHEALTHCARENETWORK.CA

Dr. David Forrest (Dr. Forrest is a Nanaimo internist and the president of the Nanaimo Medical Staff Association.)

For the last 12 months, staff at Nanaimo Regional General Hospital in B.C. have been using a Cerner-based electronic health record (EHR). This includes computer physician order entry, linked to computerized order management, and fully electronic documentation.

Since shortly after the system was activated, physicians have consistently and increasingly expressed concerns about the safety of the system (with, for example, orders being mistranslated by the system or disappearing) and its inefficiency, which reduces patient access to care. As a consequence, with the support of the B.C. Ministry of Health, the Island Health Board has directed the Health Authority to suspend CPOE and related processes—though Island Health is delaying this.

While the primary issues with iHealth have focused on safety concerns, little attention has been paid to the human costs of the EHR and its implementation.

"Little attention has been paid to the human costs" due to the fact that most of that attention has gone to the entity that seems to have usurped the rights of patients and clinicians, namely, computers.   "Cybnernetics over all" seems the continuing saga of healthcare, as I'd written in the past.

I am increasingly appalled when I read common accounts like this, now ongoing since my entry into medical informatics 25 years ago.  The term "learning organization" that I've been hearing since the 1990's extolled as what healthcare managers claim they aspire to seems a sad joke.

Currently designed EHRs significantly alter processes of care. Computerised order entry is a laborious process, requiring multiple steps to perform simple tasks. As demonstrated in other settings (such as the airline industry), such complex processes are inherently error-prone. Moreover, the inputting of more intricate orders is even more difficult, resulting in “work-arounds” or inaccurate enactment of physician management plans, with additional safety risks.

I've written in past posts that the "atomization" of order entry and other functions into multiple subcomponents with different user interface widgets, rules and "gotcha's" is a monstrous tool created by those without a knowledge of what it's like in chaotic patient care environments.  Those designers also seem, for example, to lack the ability to design tools that parse freetext orders into those atomic parts with little user intervention.  The syntax of the bulk of medical ordering is not all that complicated, for example.

“User error” has become a buzz phrase for system-based processes that result in inability to enact orders as intended by physicians—and physician users are the ones responsible, thus morally if not legally liable not just for order entry but for their management downstream. It is little wonder physicians in Nanaimo since the introduction of the EHR feel uncertain, anxious, frustrated and exhausted.

Two points, the first of which I expressed to the author via email. 

First, "user error" is a buzz phrase for those ignorant of human-computer interaction best practices to lay blame for faulty designs on victimized (and usually compelled) users.

The more correct term in many cases is "use error" - not "user error."  Use error, as defined by the US National Institute of Standards and Technology (NIST) in their study of health IT, is as follows (see also my Oct. 2011 post at http://hcrenewal.blogspot.com/2011/10/nist-on-ehr-mission-hostile-user.html):

“Use error” is a term used very specifically to refer to user interface designs that will engender users to make errors of commission or omission. It is true that users do make errors, but many errors are due not to user error per se but due to designs that are flawed, e.g., poorly written messaging [or lack of messaging, e.g., no warnings of potentially dangerous actions - ed.], misuse of color-coding conventions, omission of information, etc.


The second point I will make regarding clinicians feeling "uncertain, anxious, frustrated and exhausted" is that this health IT fits the definition of bad health IT in terms of its creating stressors:

Bad health IT is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, lacks evidentiary soundness, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation. 

That definition was the result of joint thinking by myself and a colleague, Australian informaticist Jon Patrick, PhD.

This experience is not singular, as a number of studies in the U.S. suggest that EHRs are now the primary cause of physician burnout. This further jeopardises patient care since the presence of an EHR has become a barrier to recruitment and retention of healthcare workers—and not just of physicians.

If this is true, and I believe it largely is, any claimed benefits of EHR technology must be seriously questioned as to the benefit/cost (downsides) ratio.  This is also NOT what the pioneers who taught me during my Medical Informatics fellowship a quarter-century ago intended, and this deviation from their intentions can be accounted for only by numerous social pathologies I will not get to in more depth in this post.

The following is quite eloquent, expressing the problems in a way I rarely recall seeing so lucidly stated:

Documentation changes have also affected patient care. A patient’s journey through illness and during their stay in hospital is a story or narrative—hence our documentation of that narrative as a history. Our understanding of it in this manner is critical not only to diagnosis and management, but to contextualizing it for the individual patient.

“Progress notes” in the EHR no longer describe progression of disease, but document it rather as an episodic and disjointed accounting of the patient’s condition. And the nursing narrative has been eliminated in favour of checklists of patient experience as data points. As a result, we have lost our holistic knowledge of the patient and his/her illness and are unable to transmit this understanding clearly from one provider to another.  This is detrimental to providing high-quality patient care.

Understanding the crucial differences between narrative of a patient's journey and an episodic, disjointed "data dump" as EHRs now foster is perhaps a capability that differentiates those who were able to get the grades necessary for entry into medical school and succeed there through school, internship, residency and perhaps specialty fellowships, from those with lesser abilities to think abstractly and outside narrow mental confines of datapoints as descriptors of the messy real world.

Focus on the collection and inputting of clinical data or struggling with order entry and documentation further dehumanizes patient care. The interaction of healthcare providers and patients is perhaps the most intimate of relationships outside personal or familial ones. This therapeutic relationship is crucial to providing care, whether for cure or for comfort.

To those whose most intimate relationships are with metal boxes with flashing lights, this issue may also be hard to comprehend fully.

An episode of patient care is now primarily defined by interaction with the computer, which detracts from the provision of care. This experience has been corroborated in a recent study from Calgary, documenting that healthcare workers operating in an EHR environment spend up to 90% of their time during clinical work on the computer rather than with the patient.

I have seen this myself while visiting friends in hospital - banks of nurses lined up against a wall of computer workstations, typing away for the bulk of my visits.    It is - I'm sorry to use this term - nuts, and those who are behind such a system of medical work, managerially speaking, lack both competence and common sense.

... Reliance on order sets developed by experienced practitioners is potentially detrimental for trainees, who do not then have the opportunity to learn the clinical thinking processes that underpin them. Given the reliance on order sets to address inefficiency and safety concerns inherent to the ordering processes in an EHR, physicians at the most crucial stages of learning are not able to develop these critical thinking processes that form the basis for the practice of medicine.

The term of art for this is "deskilling."  I am highly concerned about the quality of young physicians training in cybernetic hospitals, who become automatons without the skills to act appropriately when "off-script" (a rather common occurrence in medicine).

Moreover, given the inefficiency of EHR processes, there is reduced time available for clinical teaching. This has been a universal experience (and complaint) of trainees in Nanaimo. In other jurisdictions, trainees have become effective scribes to unburden staff physicians—an activity I do not believe contributes to the educational experience. Additionally, trainees focus on learning to navigate and use the EHR, rather than attending to patient care or clinical education. We are at risk of producing a generation of physicians with poor clinical skills and who are disconnected from patients.

Medicine is becoming outright enslaved to its cybernetic masters.

The loss of bond with patients is mirrored by disconnection within the healthcare team. EHR processes serve to isolate rather than enhance personal interactions between physicians and nurses, pharmacists and allied health professionals. Healthcare requires collaboration and coordination between many types of providers, a process that is not just crucial to optimal patient care but necessary to support and enhance the performance of individual team members. Disruption of the team approach impairs patient care and has demoralized the healthcare community in Nanaimo.

The social bonds and interactions that hold the complex endeavor of medical care together, in reality, have been usurped by (as I've written before) a grand human subject experiment, without consent of the experimental subjects, namely, clinicians and patients.  Both utopian idiocy and old fashioned opportunism are at work (see "Background On The 'Ecosystem' of Commercial Healthcare IT" at http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=ecosystem).

This has been made worse by the adversarial relationship created when a majority of medical staff who have found continued use of the computerized order management processes unacceptable are opposed by physicians, some allied health professionals and administrators who do not. Some of our most experienced physicians and allied health professionals have retired or changed practice. To say the effects on the health care community in Nanaimo have been destructive is not an understatement. This also means that collaborative work on care needs for our community beyond iHealth has largely stalled.

I believe that the physicians who truly like today's EHRs are in the minority.  As to administrators, if they are not clinicians, they have no business overruling their clinicians on such matters.

What is being eloquently described in this essay is a mass failure of bad health IT that is disrupting medical documentation, medical care (likely resulting in numerous bad outcomes), medical communications, medical education, medical morale, medical esprit de corps, medical recruting and retention, and the health of the community - among others.

Other than those minor drawbacks, everything is fine.

-- SS

Back to Paper After U.S. Coast Guard EHR Debacle: Proof of Hegel's Adage "We Learn From History That We Do Not Learn From History"?

I have become blue in the face writing about healthcare information technology mismanagement over the years.  In fact, the original focus of my 1998 website on health IT (its descendant now at http://cci.drexel.edu/faculty/ssilverstein/cases) was on HIT project mismanagement.

If this industry actually had learned anything from history, I would not be reading nor writing about brutally mismanaged HIT endeavors in 2016.  Sadly, that is not the case.

The Coast Guard, founded by Alexander Hamilton, has this as its motto and mission:

http://www.gocoastguard.com/about-the-coast-guard
Semper Paratus - Always Ready.

The Coast Guard is one of our nation's five military services. We exist to defend and preserve the United States. We protect the personal safety and security of our people; the marine transportation system and infrastructure; our natural and economic resources; and the territorial integrity of our nation–from both internal and external threats, natural and man-made. We protect these interests in U.S. ports and inland waterways, along the coasts, on international waters.

We are a military, multi-mission, maritime force offering a unique blend of military, law enforcement, humanitarian, regulatory, and diplomatic capabilities. These capabilities underpin our three broad roles: maritime safety, maritime security, and maritime stewardship. There are 11 missions that are interwoven within these roles.

It seems the Coast Guard personnel need personal protection from the HIT industry, for the motto of that industry, sadly appears to be something like "Stupra Acetabulus" (Screw the Suckers).

From Politico, one of only a few publications that in recent years has taken a critical approach to this industry and pulls no punches:

http://www.politico.com/story/2016/04/ehr-debacle-leads-to-paper-based-care-for-coast-guard-servicemembers-222412

EHR debacle leads to paper-based care for Coast Guard servicemembers
By Darius Tahir
04/25/16

The botched implementation of an electronic health records system sent Coast Guard doctors scurrying to copy digital records onto paper last fall and has disrupted health care for 50,000 active troops and civilian members and their families.

Five years after signing a $14 million contract with industry leader Epic Systems, the Coast Guard ended its relationship with the Wisconsin vendor, while recovering just more than $2.2 million from the company. But it couldn’t revert back to its old system, leaving its doctors reliant on paper.

This state of affairs is simple inexcusable.  It represents gross negligence and severe multi-axial incompetence at best - but likely primarily not by the Coast Guard, whose core competency does not include HIT.

There’s no clear evidence the EHR disaster has harmed patients, and a Coast Guard spokesman said the use of paper records hasn’t affected “the quality of health care provided to our people.”

Proof by lack of evidence is not reassuring in a debacle of this kind.  However, the Coast Guard admits that paper records aren't the clear and present danger the IT pundits make them out to be.

Politico is skeptical of the claim:

That seems unlikely. Without digital records, if a patient goes outside a Coast Guard clinic, it can take weeks for the paper record to follow him or her back to the Coast Guard, says Michael Little of the Association of the United States Navy. And since the Coast Guard primarily provides outpatient, rather than hospital, services, many of its patients seek outside care.

“It’s one thing if you’re doing paper-based [care] in Ohio, but what about if you’re on paper records in [an] icebreaker or cutter in Alaska, and you need your gall bladder removed?” said Little, the organization’s director of legislative affairs.

In this case, I disagree that the lack of records is so dangerous.  There's the telephone, FAX machines, the patient himself or herself, and the hand-carried note.  Used with care, those serve care reasonably well. 

With the Department of Veterans Affairs weighing whether to buy a top-of-the-line commercial electronic health record and the Pentagon beginning a multibillion-dollar EHR implementation, the Coast Guard case displays how poorly the process can go for the government, even when the biggest names in health IT are involved.

Not just the government.  I'd also argue that this shows that the "biggest names" are, at best, overextended, and at worst, badly needing external investigation as to their software development, customization, implementation and support practices, as well as hiring practices (e.g., see my August 15, 2010 post "EPIC's outrageous recommendations on healthcare IT project staffing"
at http://hcrenewal.blogspot.com/2010/08/epics-outrageous-recommendations-on.html) and contracting.

Reversion to a purely paper-based system is a rare event in the recent annals of electronic records, said Thomas Payne, a health IT expert at the University of Washington. “I can think of examples where that has happened, but in the last decade that is much less common.”

I believe that is because of the general invisibility of, and immunity from, the risks and harms that occur from "making do" with bad health IT due to financial pressures.  Hence one sees hair-raising examples like I wrote of at my Nov. 17, 2013 post "Another 'Survey' on EHRs - Affinity Medical Center (Ohio) Nurses Warn That Serious Patient Complications 'Only a Matter of Time' in Open Letter"at http://hcrenewal.blogspot.com/2013/11/another-survey-on-ehrs-affinity-medical.html where going back to paper to allow a complete rethinking of the EHR implementation would likely have been the safe response.

See also, for example, my July 2013 post "RNs Say Sutter’s New Electronic System Causing Serious Disruptions to Safe Patient Care at East Bay Hospitals" at http://hcrenewal.blogspot.com/2013/07/rns-say-sutters-new-electronic-system.html (there are links there to still more examples).

The Coast Guard is tight-lipped about the causes, timeline and responsibility for the debacle. “Various irregularities were uncovered, which are currently being reviewed,” a spokesman said.

The causes are all covered at http://cci.drexel.edu/faculty/ssilverstein/cases/, and have been since the late 1990s.  In the alternative, the book "Managing Technological Change: Organizational Aspects of Health Informatics" (http://www.amazon.com/Managing-Technological-Change-Organizational-Informatics/dp/0387985484) by Lorenzi & Riley does likewise for an even longer period, since the mid 1990s - for those willing or able to learn from history and from the pioneers

There’s no shortage of candidates: the service relied on five separate vendors to build the new system, and its own planning seems to have been at fault.

Lawmakers are looking into the matter, said a spokesman for the Senate Appropriations Committee, which is “monitoring the situation."

This is symptomatic, in my view, of the fact that there are a lot of "Beltway Bandit" IT consultant companies doing business, few of them very good.

Bungled implementation, followed by chaos

In September 2010, the Coast Guard bid out the contract to Epic Systems, then added an array of other contracts to software vendors and consultants to help implement it. Since 2010, the agency spent, on net, just more than $34 million on health IT.

In a January 2011 speech, Coast Guard Chief Medical Officer Mark Tedesco cited the success of Epic installations at Kaiser Permanente and Cleveland Clinic. He predicted that the Epic implementation would improve the health of its population and save money.

“Overall it’s a cheaper system for us to run than to upgrade to [the next generation military EHR], because of what that would’ve meant to us infrastructure-wise and support-personnel wise,” he said.

It's stunning to think what this says about the next-generation military EHR.  The previous one was not very good, either (see my June 4, 2009 post "If The Military Can't Get Electronic Health Records Right, Why Would We Think Conflicted EHR Companies And IT-Backwater Hospitals Can?" at http://hcrenewal.blogspot.com/2009/06/if-military-cant-get-electronic-health.html). 

Trouble, apparently, struck quickly. The solicitation for the EHR contract envisioned rolling out the software within six months at two to three pilot sites, before deploying it to a total of 43 clinics and the sickbays aboard the Coast Guard’s fleet.

That didn’t occur; the system never deployed to any clinic or cutter, said Eric Helsher, an executive with Epic. The next missed deadline was March 2012, which Trent Janda — the Coast Guard doctor serving as project leader — announced in a summer 2011 newsletter of the Uniformed Services Academy of Family Physicians.

One can only wonder what penalties the contract called for if the goals and timelines were not met.  That software was not deployed even to any pilot sites is nearly unimaginable to me.

As Janda set the new goal, he acknowledged there had been “multiple hurdles and delays,” and explained that the service had expanded its ambitions.

“Immediately upon award of the contract, we began a comprehensive analysis of the clinical workflows and existing information systems,” Janda wrote. “Many of the weaknesses became apparent as we compared ourselves to industry standards and best practices. Frequently, a weakness would lead to others, ultimately leading to the need for an additional system. The work-flow analysis quickly grew into a system wide re-engineering project like a snowball rolling down the mountainside.”

This sounds like a groundbreaking level of project mayhem and chaos, even for HIT.

The comment reveals that the agency failed to do necessary advance planning, says Theresa Cullen, an informatics executive with the Regenstrief Institute who formerly worked with Veterans Health Affairs and the Indian Health Service.

“They should have done a full needs assessment,” she said. “One would have normally done the workflow evaluation prior to the release of the RFP.”

If true, I believe it was an obligation of EPIC and the multiple contractors to have pointed that out to their future customer, and adjusted their bids accordingly, taking into account the time and resources needed for this type of work - or not placed a bid at all.  Such deficiencies and what they mean towards project progress and failure are obvious - to anyone who's learned from history.

... Cullen also found it odd that the Coast Guard didn’t hire consultants to implement the new system until September 2012. The service ended up hiring Leidos, which also maintained its old EHR.

The Coast Guard further complicated the process by deciding to team up with the State Department. Its original request was complicated enough, with installations spanning six time zones. The partnership with State meant implementing across 170 countries. (A spokeswoman for State said the agency was investigating its options, but refused additional comment).

The sheer number of sites led Cullen to question whether Coast Guard and State had devoted enough resources to the project. Between Epic and Leidos, the project was budgeted for roughly $31 million. That was “an inadequate amount of funding for what you’re asking to do,” she said. Consultants receive roughly $100 an hour, and Epic’s work with clinicians is time-consuming.

Again, those hired knew, should have known, or should have made it their business to know that under such conditions, if true, project failure was the predictable outcome.  They are supposed to be the HIT experts, after all, not the Coast Guard.

While a very efficient health care system could implement the EHR, she said, the Coast Guard lacks that reputation. She speculated that Epic intentionally underbid the contract. (Epic’s Helsher said that “the contract was viable and we were fully motivated to lead a successful install.”)

Someone is right, and someone is wrong.  I leave it to the reader to decide who was correct and who wasn't.

Anecdotes of further delays pepper various newsletters and reports from 2012 through 2015. Server failures scuttled a pilot rollout in 2014, then developed into deeper problems, and last July the systems started failing on a more regular basis.

Perhaps the "anecdotes" need to be turned into "teachable moments" through legal discovery by federal law enforcement.

The Coast Guard advised retirees and dependents that month that, due to incompatibility between its EHR and the Department of Defense’s new medication reconciliation system, they couldn’t get their prescriptions filled at Coast Guard clinics.

Around Labor Day, Coast Guard health care personnel were directed to copy information from electronic files onto paper, for fear of losing their data.

That is just about the most pathetic sentence I've ever had to read in my 24 years in Medical Informatics.

... doctors are frustrated. One complained in the Uniformed Services Academy of Family Physicians newsletter of “unique challenges which seemed to revolve around many electronic record keeping changes.” “The question we pose is, how is this affecting shipboard life?” Little said. “This is the most important thing that’s happening right now in the Coast Guard.”

My advice to the Coast Guard is to treat the IT invaders and consultants as it would a invading maritime fleet from a hostile nation.

The vendors who worked with the Coast Guard either don’t know what went wrong, or aren’t telling. Leidos — also the lead company implementing the Pentagon’s EHR project — declined comment, as did Lockheed Martin, which was contracted to implement access to the EHR through mobile devices, and Apprio, which was to provide credentialing services.

I believe they have a very good idea of "what went wrong", and aren't telling (per the Fifth Amendment)?  If they have "no idea" what went wrong, what, I ask, are they doing in the IT consulting business?

... The EHR giant [EPIC] says it’s not entirely clear why the Coast Guard pulled the plug. But the situation wasn’t Epic’s fault, company executive Eric Helsher said.

They pulled the plug out of fear for their members' well-being, hopefully.

It seems everyone seeks to escape culpability, with the blame placed on the customer.

The Coast Guard spokesman said the decision was “driven by concerns about the project's ability to deliver a viable product in a reasonable period of time and at a reasonable cost.”

It seems there's still some who don't continue down the sunk-cost fallacy road (https://www.logicallyfallacious.com/tools/lp/Bo/LogicalFallacies/173/Sunk_Cost_Fallacy) and are willing to walk away from bad HIT.

... In general, software contracts deserve more scrutiny, said Kingston, who served on the House Appropriations Committee. “These things don’t get the scrutiny a weapons system does.”

Considering the reputation of military costs, that's saying quite a lot.  The lesson that should have been learned from history is that HIT is both exploratory, and a relative free-for-all.

Caveat emptor.

One last piece of (free!) advice for the Coast Guard leadership.

Read this paper:

Pessimism, Computer Failure, and Information Systems Development in the Public Sector.  (Public Administration Review 67;5:917-929, Sept/Oct. 2007, Shaun Goldfinch, University of Otago, New Zealand).  Cautionary article on IT that should be read by every healthcare executive documenting the widespread nature of IT difficulties and failure, the lack of attention to the issues responsible, and recommending much more critical attitudes towards IT.  link to pdf

That may be the most valuable learning experience of all for their next attempt to implement EHRs.

-- SS

Grand Jury: Ventura County, Calif., Mishandled Electronic Health Records Transition

In Ventura County, California, "the function of the Grand Jury is to act as a civil oversight of county and city government, special districts, governing boards, personnel commissions, school districts, and humane officers. It is their responsibility to insure that government is serving the best interests of Ventura County's citizens" (http://www.ventura.org/grand-jury).

Even under such a grand jury, the need for true Health IT experts (instead of amateurs) seems to have gone unnoticed.

A 2013-2014 Ventura County Grand Jury conducted an investigation in response to information received regarding the implementation of a new Electronic Health Records system by the Ventura County Health Care Agency (VCHCA).

Ventura County Grand Jury Final Report "Healthcare Records Processes and Procedures" (full PDF at http://vcportal.ventura.org/GDJ/docs/reports/2013-14/Healthcare_Records-05.29.14.pdf)

From the May 29, 2014 Ventura County Grand Jury Final Report "Healthcare Records Processes and Procedures" (full PDF at http://vcportal.ventura.org/GDJ/docs/reports/2013-14/Healthcare_Records-05.29.14.pdf).  Read the full report.  Any reader of this blog or my Drexel HIT site at http://cci.drexel.edu/faculty/ssilverstein/cases/ will recognize very familiar patterns.

Here are some highlights:

In April 2012, VCHCA hired an independent Information Technology (IT) consultant to oversee the EHR implementation; however, he was not authorized to be project manager.

An "independent IT consultant" who had no formal Medical Informatics expertise is a likely explanation for all that followed.  (Even if he did, his relegation to "internal consultant" was an attempt to seduce failure into rearing her ugly head.)

The Grand Jury found that, beginning with the authorization of the Cerner contract in October 2011, there was a lack of a dedicated and experienced project manager to oversee, track, and report all tasks related to the EHR implementation. The absence of a recognized standard project plan, as shown in the Project Management Institute’s A Guide to the Project Management Body of Knowledge (PMBOK® Guide), contributed to staff being inadequately prepared for using the new system and to a problematic EHR system implementation by VCHCA.

Lack of a "recognized standard project plan" was likely the least of the problems.

The Grand Jury found hiring of “contract staff” did not support project needs. The Ventura County Board of Supervisors’ (BOS) approval of additional funds allowed for the hiring of deployment staff. Hiring did not commence until August 2012, and continued after the VCHCA system “go-live” date of July 1, 2013. This indicated a lack of planning and diligence in pursuing the necessary qualified staff.

Lack of enough "contract IT staff" was likely the least of the problems.

The Grand Jury found that staff training on the new equipment was insufficient, leading to a lack of experience and knowledge with all components of the EHR system. There was a period of inefficient and delayed patient care.

Billing processes were significantly impacted, requiring manual intervention, taking additional time.

These are symptoms of what was likely truly lacking.

The Grand Jury found that VCHCA ordered the user hardware in May and June 2013, too late to allow proper time for configuring of computers, hardware testing, and user familiarization.
 
The Grand Jury found that VCHCA had until the end of December 2014 to implement the new EHR system to avoid federal penalties.

The Grand Jury found that VCHCA had to be on the EHR system for 90 days prior to September 30, 2013, to qualify for full Meaningful Use funding, therefore July 1, 2013 was selected as its go-live date.

It was all about money.  Still, that was not the likely problem.

The problem was likely leadership by healthcare IT amateurs**, lacking formal cross-disciplinary expertise in medicine and clinical computing.

Without that expertise, empowered in top leadership roles, these projects will fail or will be seriously impaired, at great cost.

If you don't believe me, believe the NIH (http://hcrenewal.blogspot.com/2009/12/onc-defines-taxonomy-of-health-it.html).

While the 'Grand Jury' investigation of a failed health IT project may be a first, and is not a bad development in my mind, perhaps the members of the Grand Jury need to read a bit more.

-- SS

** I am a radio amateur, a formal FCC designation for those licensed to use radio and who have some knowledge, but who are not formal radio telecommunications engineers (unless they have the required formal education, training and experience, of course).

Athens Regional Medical Center: Hospital management is "addressing computer problems" AFTER patients are put at bodily risk, not before, only in response to irate clinicians; then claiming everything will be fixed soon while doctors resign.

(Note: also see my June 16, 2014 followup post at http://hcrenewal.blogspot.com/2014/06/masters-of-obvious-aat-athens-regional.html)

Maybe hospital management gurus could address these computer problems BEFORE turning them loose on patients?

Physicians in Georgia seem to have more guts than their colleagues elsewhere.  Rather than letting patients be guinea pigs for the naive fantasies of hospital executives about health IT, these physicians said "get these [expletive] computer systems out of our hospital"...

Then they started resigning their appointments:

Athens Regional addressing new computer system problems encountered by doctors

By Donnie Z. Fetter
Friday, May 23, 2014

http://onlineathens.com/health/2014-05-22/athens-regional-addressing-new-computer-system-problems-encountered-doctors

Doctors affiliated with Athens Regional Medical Center (http://www.athenshealth.org/) have expressed concerns that a computer system installed this month at the hospital endangers patients.

Not "may endanger patients."  "Endangers patients."  That's quite direct.

However, the hospital's chief executive said Athens Regional is taking "swift action" to address those concerns.

I'm not impressed.  The executives should perhaps have done due diligence and taken action BEFORE this bad health IT was set loose on live, unsuspecting patients.

It's not as if the issues are unknown (as Google or anyone who actually knows what they're doing regarding health IT will easily demonstrate).  Further, those executives have the legal obligation to maintain a safe healthcare environment.

In a letter dated May 15 and provided to the Athens Banner-Herald this week, multiple doctors noted such concerns as “medication errors ... orders being lost or overlooked ... (emergency department) patients leaving after long waits; and of an inpatient who wasn’t seen by a physician for (five) days.”

Any of these issues and the multitude more I can predict exist can lead to severe injury or death, especially in fragile patients and the elderly.  Trust me, I know both professionally and personally...
 

The letter was addressed to ARMC President and CEO James G. Thaw and Senior Vice President and CIO Gretchen Tegethoff. It was signed by more than a dozen physicians, including Carolann Eisenhart, president of the medical staff; Joseph T. Johnson, vice president of the medical staff; David M. Sailers, surgery department chair; and, Robert D. Sinyard, medicine department chair.

The doctor who provided the letter to the Banner-Herald refused a request to openly discuss the issues with the computer system and asked to remain anonymous at the urging of his colleagues.

Refused a request to openly discuss the issues with the computer system and asked to remain anonymous at the urging of his colleagues ... due to fear the executives would then return the doctor's concerns with genuine love and appreciation, and give him or her a generous promotion and pat on the back, no doubt.  (Actually, quite likely was a fear of retaliation, e.g. sham peer review as at http://www.aapsonline.org/index.php/article/sham_peer_review_resources_physicians.)

Note the educational background of CIO Gretchen Tegerhoff, the executive with fiduciary obligations to implement health IT of the highest quality and to have robustly researched all of the issues involved (and whom the Board should have thoroughly vetted as to required background for health IT leadership):

University of Georgia
Terry College of Business, Executive Program, Finance
2014 – 2014 (expected)

The George Washington University - School of Business
Master of Science, Information Systems Technology
2001 – 2003

West Virginia University
BS, Medical Technology
1993 – 1997

Note the career progression that is the envy of, say, someone who's completed the rigors of medical training (premed, medical school, internship/residency, clinical postdocs) and beyond that, completed an additional PhD, MS or post-doctoral fellowship in Medical Informatics at unknown universities such as Harvard, Yale, Stanford, Johns Hopkins, Columbia, etc. (reverse chrono):

Technical Analyst
STG (9 months)
[Provided U.S. Department of State with systems support and application maintenance.]

Clinical Systems Analyst
George Washington University Hospital (3 years 8 months)

Technical Support Specialist/Installer
Intellidata, Inc. (9 months)

Clinical Research Associate
QUINTILES, INC. (9 months)

Information Specialist
THE EMMES CORPORATION (1 year 8 months)

Writer/Editor
ASPEN SYSTEMS CORPORATION (7 months)

Medical Technologist
PROVIDENCE LABORATORY ASSOCIATES (8 months)

This background led directly to:

Chief Information Officer
George Washington University Hospital (6 years 8 months)

and then the current role:

Athens Regional Health System
Vice President and Chief Information Officer
Athens Regional Health System

If you believed that the qualifications required for medical practice - let alone medical leadership roles - is at least an order of magnitude more robust, you'd not be mistaken.

Perhaps even worse, business-IT amateur meddlers in clinical affairs sell the "best practices" that lead to debacles like this, and perhaps to IT-related patient injury and death, via their alphabet-soup "leadership" organizations.  This CIO also holds this credential:

Faculty

CHIME Healthcare CIO Boot Camp (8 months)

It should be noted, and scandalously so considering the negligence that leads to patient endangerment and this kind of physician revolt from the outset, that IT-related patient harms are not uncommon.  For example, per the Harvard community's med mal insurer CRICO, see "Malpractice Claims Analysis Confirms Risks in EHRs" at
http://hcrenewal.blogspot.com/2014/02/patient-safety-quality-healthcare.html, the ECRI Institute, see "ECRI Deep Dive Study of Health IT harms" at
http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html as well as "ECRI Institute's 2014 Top 10 Patient Safety Concerns for Healthcare Organizations" at
http://hcrenewal.blogspot.com/2014/04/in-ecri-institutes-new-2014-top-10.html, "FDA Internal Memo on H-IT risks - for internal use only" (uncovered by investigative reporter Fred Schulte) at http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html, and others as posted at this blog.

“From the moment our physician leadership expressed concern about the Cerner I.T. conversion process on May 15, we took swift action and significant progress has been made toward resolving the issues raised,” Thaw wrote Thursday in an email. “Providing outstanding patient care is first and foremost in our minds at Athens Regional, and we have dedicated staff throughout the hospital to make sure the system is functioning as smoothly as possible through this transition."

This raises several questions:

• How about the moments from the time of decision to acquire the technology?  What safety consideration were in effect during that time? 

• What if the "significant progress" is insufficient to prevent a patient from being maimed or killed due to toxic effects of bad health IT?  Who's responsible? 

• Perhaps most importantly from the human rights perspective - are patients being provided informed consent about these "issues raised" and are they afforded the opportunity to seek care elsewhere until the "swift progress" is completed?  

One wonders if the executives were aware of analytic work on Cerner ED systems such as performed by U. Sydney professor Jon Patrick at "A study of an Enterprise Health information System",  http://sydney.edu.au/engineering/it/~hitru/index.php?option=com_content&task=view&id=91&Itemid=146; or this site on health IT difficulties:  http://cci.drexel.edu/faculty/ssilverstein/cases/, or this blog and others.

It's not as if a simple Google search won't find them, such as https://www.google.com/search?q=healthcare+IT+failure.  Perhaps they need to read more...or hire experts BEFORE go-live.

Back to the article:

The intended goal of the system designed by health care information technology company Cerner is to improve efficiency and connectivity by providing doctors, nurses and other medical professionals with a shared data set and to eventually allow patients online access to their medical records, Athens Regional executives previously said.

Good intentions or not, badly designed and/or implemented technology harms or kills, and those harmed, or the dead, really don't care what the system is 'intended to do.'  Patients are not guinea pigs towards an IT company's or hospital's experiments with computers - regarding which the executives are usually in to at a level way over their collective heads.

But doctors noted the new system often proved too cumbersome to be effective at the time the letter was written.

“The Cerner implementation has driven some physicians to drop their active staff privileges at ARMC,” noted the letter. “This has placed an additional burden on the hospitalists, who are already overwhelmed.

That's just horrendous for safety.

Joint Commission, where are you?
 

Other physicians are directing their patients to St. Mary’s (hospital) for outpatient studies, (emergency room) care, admissions and surgical procedures. ... Efforts to rebuild the relationships with patients and physicians (needs) to begin immediately.”

Doctors voted with their feet.  Bravo.

I suggest they consider the following remedies as well if appropriate, from my post at http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html:

... When a physician or other clinician observes health IT problems, defects, malfunctions, mission hostility (e.g., poor user interfaces), significant downtimes, lost data, erroneous data, misidentified data, and so forth ... and most certainly, patient 'close calls' or actual injuries ... they should (anonymously if necessary if in a hostile management setting):

(DISCLAIMER:  I am not responsible for any adverse outcomes if any organizational policies or existing laws are broken in doing any of the following.)

• Inform their facility's senior management, if deemed safe and not likely to result in retaliation such as being slandered as a "disruptive physician" and/or or being subjected to sham peer review (link).

• Inform their personal and organizational insurance carriers, in writing. Insurance carriers do not enjoy paying out for preventable IT-related medical mistakes. They have begun to become aware of HIT risks. See, for example, the essay on Norcal Mutual Insurance Company's newsletter on HIT risks at this link. (Note - many medical malpractice insurance policies can be interpreted as requiring this reporting, observed occasional guest blogger Dr. Scott Monteith in a comment to me about this post.)

• Inform the Joint Commission (or similar national accreditor of hospital safety if not in the U.S.) via their complaint site at http://www.jointcommission.org/report_a_complaint.aspx . Also consider writing the JC senior officers (link to officer's list), whose awareness of HIT issues I can personally attest to via our correspondences.

• Inform the FDA (or similar healthcare regulator if not in the U.S.) via the FDA Medwatch Form 3500 reporting site at https://www.accessdata.fda.gov/scripts/medwatch/medwatch-online.htm. An example of such an adverse event report I filed myself (when the involved hospital refused) is at this link in the FDA MAUDE (Manufacturer and User Facility Device Experience) database.

• Inform the State Medical Society and local Medical Society of your locale.

• Inform the appropriate Board of Health for your locale.

• If applicable (and it often is), inform the Medicare Quality Improvement Organization (QIO) of your state or region. Example: in Pennsylvania, the QIO is "Quality Insights of PA."

• Inform a personal attorney.

• Inform local, state and national representatives such as congressional representatives. Sen. Grassley of Iowa is aware of these issues, for example.

• As clinicians are often forced to use health IT, at their own risk even when "certified" (link), if a healthcare organization or HIT seller is sluggish or resistant in taking corrective actions, consider taking another risk (perhaps this is for the very daring or those near the end of their clinical career). Present your organization's management with a statement for them to sign to the effect of:

"We, the undersigned, do hereby acknowledge the concerns of [Dr. Jones] about care quality issues at [Mount St. Elsewhere Hospital] regarding EHR difficulties that were reported, namely [event A, event B, event C ... etc.]

We hereby indemnify [Dr. Jones] for malpractice liability regarding patient care errors that occur due to EHR issues beyond his/her control, but within the control of hospital management, including but not limited to: [system downtimes, lost orders, missing or erroneous data, etc.] that are known to pose risk to patients. We assume responsibility for any such malpractice.

With regard to health IT and its potential negative effects on care, Dr. Jones has provided us with the Joint Commission Sentinel Events Alert on Health IT at http://www.jointcommission.org/assets/1/18/SEA_42.PDF, the IOM report on HIT safety at http://www.modernhealthcare.com/Assets/pdf/CH76254118.PDF, and the FDA Internal Memorandum on H-IT Safety Issues at http://www.scribd.com/huffpostfund/d/33754943-Internal-FDA-Report-on-Adverse-Events-Involving-Health-Information-Technology.

CMO __________ (date, time)
CIO ___________ (date, time)
CMIO _________ (date, time)
General Counsel ___________ (date, time)
etc."

• If the hospital or organizational management refuses to sign such a waiver (and they likely will!), note the refusal, with date and time of refusal, and file away with your attorney. It could come in handy if EHR-related med mal does occur.

• As EHRs remain experimental, I note that indemnifications such as the above probably belong in medical staff contracts and bylaws when EHR use is coerced.

These measures can help "light a fire" under the decision makers, and "get the lead out" of efforts to improve this technology to the point where it is usable, efficacious and safe.

More from the article:

Doctors called the time line to install the EHR system too “aggressive” and said there was a “lack of readiness” among the intended users.

For financial incentive reasons in part, I'm sure.  Computers, after all, seem to have more rights than patients...or than physicians and nurses.

Since receiving the letter, Thaw said Athens Regional has added "specialized staff" to meet daily with physicians to discuss computer system and safety issues.

Again, the key word is "AFTER."   A good move, considering the hospital will be up to its head in defections, accreditation inspections and hearings, and possible medical malpractice and corporate liability lawsuits otherwise.

"Regardless of what system we are using, our focus on patient safety is unwavering, and we will never put a system ahead of doing what is right for our patients," Thaw said. "Our team is working around the clock to resolve any remaining issues, and we remain dedicated to delivering outstanding patient care every step of the way."

Feel-good executive boilerplate and an outright lie on its face.  If the focus on safety was unwavering, this problems would not now need emergency remediation.  As I had written many years ago here: http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story, this type of shallow executive puffery and rhetoric only makes clinicians angrier.

And while events like this go on, the industry pundits suggest all that's needed is a Health IT 'Safety Center' instead of regulation like the rest of the healthcare industry ("Feds Call For Health IT Safety Center", May 20, 2014, http://www.govhealthit.com/news/feds-call-hit-safety-center?topic=,26#.U4FVDnYsC).  This is sort of like putting the safety of our country's hospitals in the hands of Consumer Reports.

That's not exactly the ticket to a rapid cure to these problems, which are more common than most physicians have the bravery (or career options in the face of retaliation) to admit.

At least nurses' unions are taking action, as at http://hcrenewal.blogspot.com/2013/11/another-survey-on-ehrs-affinity-medical.html and http://hcrenewal.blogspot.com/2014/05/a-nurses-union-national-nurses-united.html.

Additional thought:  at least the writer of the article did not use the customary euphemism for problems with patient-endangering bad health IT, specifically: "glitches" (http://hcrenewal.blogspot.com/search/label/glitch).

-- SS

May 27, 2014 Addendum:

The CEO has apparently resigned, see http://onlineathens.com/local-news/2014-05-23/thaw-resigns-athens-regional-ceo. 

I also solicit physicians from the area of this hospital to contact me regarding any patient harms that did occur as a result of this debacle, via my email address located here: https://www.blogger.com/profile/03994321680366572701.  I will forward any reports through appropriate legal channels to attorneys who can take action, which in 2014 is probably the only language this industry will actually listen to.

-- SS

May 27, 2014 Addendum 2:

The reader comments at http://onlineathens.com/health/2014-05-22/athens-regional-addressing-new-computer-system-problems-encountered-doctors are interesting, and distressing.

-- SS

May 29, 2014 Addendum:

More here:  http://flagpole.com/news/in-the-loop/james-thaw-out-as-armc-ceo

If I were that's hospital's new leadership, I'd immediately go back to whatever system (whether paper or not) was in place before this implementation, and take the time to implement new health IT properly, safely and carefully.

For at this point, if patient injury or death occurs as a result of a system flaw (whether in design or implementation), I believe charges of criminal negligence against the organization and its leaders would be justified.

The following is an example of one state's statute defining criminal negligence:

''A person acts with 'criminal negligence' with respect to a result or to a circumstance described by a statute defining an offense when he fails to perceive a substantial and unjustifiable risk that such result will occur or that such circumstance exists. The risk must be of such nature and degree that the failure to perceive it constitutes a gross deviation from the standard of care that a reasonable person would observe in the situation.''

I believe other states' statutes are similar.

-- SS

June 13, 2013 Addendum:

My post on Athens Regional Medical Center's physician revolt was accessed today by someone at Cerner; note the referring link:  http://cerner.vertabase.com/project/document/index.cfm?&0.12455576848

Vertabase (http://www.vertabase.com/) makes project management software.

Cerner.vertabase.com/project/document is some sort of password-protected document resource.

I find that interesting - perhaps it's for internal communications and they are learning something from me.

Domain Name		(Unknown)
IP Address		159.140.254.# (Cerner Corporation)
ISP		Cerner Corporation
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Time Zone		UTC-6:00
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 -- SS

Note: also see my June 16, 2014 followup post at http://hcrenewal.blogspot.com/2014/06/masters-of-obvious-aat-athens-regional.html

"EHRs: The Real Story" - Sobering assessment from Medical Economics

From Medical Economics -

"EHRs: The Real Story",  pg. 18-27, Feb. 10, 2014, available here (PDF).

Full issue at http://medicaleconomics.modernmedicine.com/sites/default/files/images/MedicalEconomics/DigitalEdition/Medical-Economics-February-10-2014.pdf - it is large, 12 MB:

... "Despite the government’s bribe of nearly $27 billion to digitize patient records, nearly 70% of physicians say electronic health record (EHR) systems have not been worth it. It’s a sobering statistic backed by newly released data from marketing and research f rm MPI Group and Medical Economics that suggest nearly two-thirds of doctors would not purchase their current EHR system again because of poor functionality and high costs."

Here are other key findings from this national survey:

• 73% of the largest practices would not purchase their current EHR system. The data show that 66% of internal medicine specialists would not purchase their current system. About 60% of respondents in family medicine would also make another EHR choice.

• 67% of physicians dislike the functionality of their EHR systems.

• Nearly half of physicians believe the cost of these systems is too high.

• 45% of respondents say patient care is worse since implementing an EHR. Nearly 23% of internists say patient care is significantly worse.

• 65% of respondents say their EHR systems result in financial losses for the practice. About 43% of internists and other specialists/subspecialists outside of primary care characterized the losses as signifcant.

• About 69% of respondents said that coordination of care with hospitals has not improved.

• Nearly 38% of respondents doubt their system will be viable in five years.

• 74% of respondents believe their vendors will be in business over the next 5 years.

My own views are:

While some might dismiss such surveys as well as reports of harms as "anecdotes" (those same persons conflating scientific discovery with risk management, see http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html), I observe that such articles/surveys are increasing in frequency the past few years and are coming from reasonably capable observers - clinicians - .unlike, say, a Fox News survey of pedestrians on complex political matters.

Another physician survey is here:  http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html.

Here's an interesting ad hoc survey of nurses:  http://hcrenewal.blogspot.com/2013/07/candid-nurse-opinions-on-ehrs-at.html.
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This is not what the Medical Informatics pioneers intended, and is not due to physicians being Luddites (a topic I addressed at http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html).

In my opinion, organizations that have the expertise to change the current trajectory of this technology such as the American Medical Informatics Association (AMIA) needs to leave its tweed-jacket academic comfort zone and become more proactive - or perhaps I should say aggressive - in combating the industry status quo.  

The health IT industry trade associations such as HIMSS have no such qualms about aggressively and shamelessly pushing their version of EHR utopia, an agenda that has led to massive profits for the industry... but to clinician survey results such as above.  And to injured and dead patients.

-- SS