Yet another observation that known health IT-caused injuries and deaths are "the tip of the iceberg"

I've noted a new observation of the limited data available on health IT harms being the (quote) "tip of the iceberg."

This statement appears in "Electronic Health Record–Related Events in Medical Malpractice Claims", Gruber et al., J. Patient Saf 2015, http://journals.lww.com/journalpatientsafety/Abstract/publishahead/Electronic_Health_Record_Related_Events_in_Medical.99624.aspx (PDF available free from link on right side of page.)

From the abstract:

Background: There is widespread agreement that the full potential of health information technology (health IT) has not yet been realized and of particular concern are the examples of unintended consequences of health IT that detract from the safety of health care or from the use of health IT itself. The goal of this project was to obtain additional information on these health IT-related problems, using a mixed methods (qualitative and quantitative) analysis of electronic health record-related harm in cases submitted to a large database of malpractice suits and claims.

Methods: Cases submitted to the CRICO claims database and coded during 2012 and 2013 were analyzed. A total of 248 cases (less than 1%) involving health IT were identified and coded using a proprietary taxonomy that identifies user- and system-related sociotechnical factors. Ambulatory care accounted for most of the cases (146 cases). Cases were most typically filed as a result of an error involving medications (31%), diagnosis (28%), or a complication of treatment (31%). More than 80% of cases involved moderate or severe harm, although lethal cases were less likely in cases from ambulatory settings. Etiologic factors spanned all of the sociotechnical dimensions, and many recurring patterns of error were identified.

Conclusions: Adverse events associated with health IT vulnerabilities can cause extensive harm and are encountered across the continuum of health care settings and sociotechnical factors. The recurring patterns provide valuable lessons that both practicing clinicians and health IT developers could use to reduce the risk of harm in the future.

Note the statement at pg. 5:

... The actual incidence of harm cannot be reliably estimated from this data; nonetheless, it is generally agreed that safety events represented in malpractice claims are the ‘tip of the iceberg', insofar as the vast majority of cases, even cases that involve harm, do not result in suits.

I've heard claims that up to 95% of potential meritorious medical malpractice suits never make it to the lawsuit stage due to difficulties in, and costs of, prosecution.  Anecdotally, the latter observation corresponds to my own family's experience; several attorneys would not take my mother's EHR-related medical malpractice case initially, due to her age and concerns about expenses.

I note at my post today "Repeated crushing by alligators and crocodiles: ICD-10 has you covered. Harmed by bad health IT? No codes for that" at http://hcrenewal.blogspot.com/2016/01/repeated-crushing-by-alligators-and.html that repeated attacks and crushings by creatures of Order Crocodilia are well-covered by ICD-10, but health IT harms do not appear to be covered by the same mandatory coding system.  My view is that this is likely by design, not due to lack of knowledge of these events by ICD-10 experts involved in creating this coding system.

Below is a checklist of such failure modes causing patient harms from the May 2012 AHRQ Health IT Hazard Manager Report (http://healthit.ahrq.gov/sites/default/files/docs/citation/HealthITHazardManagerFinalReport.pdf).  These should be represented in ICD-10 so that the issues can be further known and studied:

 

AHRQ Health IT Hazard Manager Report - Hazard Modes of Health IT (click to enlarge)

Other taxonomies exist, such as in the 2010 FDA Internal Memo on Health IT harms, "not intended for public use" and unearthed by investigative reporter Fred Schulte.  See my post at http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html and the memo itself at the link below.

Internal FDA Memo ("not intended for public use") on potential dangers of health IT.  Download the full PDF by clicking here.

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• Other use of that same "tip of the iceberg" phrase of which I have written:

FDA CDRH Director Jeff Shuren MD, JD's statement that the known risks are "the tip of an iceberg" was made at the HIT Policy Committee, Adoption/Certification Workgroup on February 25, 2010, where the topic was "HIT safety" (The text is available at http://web.archive.org/web/20120320111030/http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_11673_910717_0_0_18/3Shuren_Testimony022510.pdf):

... In the past two years, we [FDA] have received 260 reports of HIT-related malfunctions with the potential for patient harm – including 44 reported injuries and 6 reported deaths. Because these reports are purely voluntary, they may represent only the tip of the iceberg in terms of the HIT-related problems that exist.

For more on these issues, see my April 9, 2014 essay "FDA on health IT risk: "We don't know the magnitude of the risk, and what we do know is the tip of the iceberg, but health IT is of 'sufficiently low risk' that we don't need to regulate it" at http://hcrenewal.blogspot.com/2014/04/fda-on-health-it-risk-reckless-or.html.

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ECRI Institute:  http://www.healthleadersmedia.com/print/TEC-290834/HIT-Errors-Tip-of-the-Iceberg-Says-ECRI:

HIT Errors 'Tip of the Iceberg,' Says ECRI
Cheryl Clark, for HealthLeaders Media , April 5, 2013

Healthcare systems' transitions from paper records to electronic ones are causing harm and in so many serious ways, providers are only now beginning to understand the scope.

... Karen Zimmer, MD, medical director of the institute, says the reports of so many types of errors and harm got the staff's attention in part because the program captured so many serious errors within just a nine-week project last spring.  The volume of errors in the voluntary reports was she says, "an awareness raiser."

"If we're seeing this much under a voluntary reporting program, we know this is just the tip of the iceberg; we know these events are very much underreported."

On the ECRI Deep Dive study of health IT risk, see my Feb. 28, 2013 essay "Peering Underneath the Iceberg's Water Level: AMNews on the New ECRI 'Deep Dive' Study of Health IT Events" at http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html.

Tip of the iceberg:  ignore it at your peril

 -- SS

Repeated crushing by alligators and crocodiles: ICD-10 has you covered. Harmed by bad health IT? No codes for that.

Your government at work, spending your tax dollars and making your doctors want to retire early due to increasing bureaucratic busywork. The new ICD-10 coding system they must now use has codes like these, in case you get attacked by a crocodile or alligator.

It even has codes for repeat crushing by the critters...

Notably missing: there are no codes for harms caused by defective, mis-designed or badly implemented electronic medical records/ordering/lab review systems, which are occurring as documented in numerous posts on this blog.  (My mother would comment, but she is deceased from ICD-10 code ...uh, oh wait, no code for that...)

From the CMS ICD-10 search page at https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx:

ICD-10 Code    ICD-10 Code Description
W58.11XA    Bitten by crocodile, initial encounter
W58.11XD    Bitten by crocodile, subsequent encounter
W58.11XS    Bitten by crocodile, sequela
W58.12XA    Struck by crocodile, initial encounter
W58.12XD    Struck by crocodile, subsequent encounter
W58.12XS    Struck by crocodile, sequela
W58.13XA    Crushed by crocodile, initial encounter
W58.13XD    Crushed by crocodile, subsequent encounter
W58.13XS    Crushed by crocodile, sequela
W58.19XA    Other contact with crocodile, initial encounter
W58.19XD    Other contact with crocodile, subsequent encounter
W58.19XS    Other contact with crocodile, sequela

Of course, species of Crocodilia matters (https://en.wikipedia.org/wiki/Crocodilia):

W58.01XA    Bitten by alligator, initial encounter
W58.01XD    Bitten by alligator, subsequent encounter
W58.01XS    Bitten by alligator, sequela
W58.02XA    Struck by alligator, initial encounter
W58.02XD    Struck by alligator, subsequent encounter
W58.02XS    Struck by alligator, sequela
W58.03XA    Crushed by alligator, initial encounter
W58.03XD    Crushed by alligator, subsequent encounter
W58.03XS    Crushed by alligator, sequela
W58.09XA    Other contact with alligator, initial encounter
W58.09XD    Other contact with alligator, subsequent encounter
W58.09XS    Other contact with alligator, sequela

Haven't searched ICD-10 for "abduction and experimentation by Roswell Greys" yet.

What's the ICD-10 code for this?

-- SS

Out Goes 2013. Some Year-End Observations on Healthcare IT: The Data Granularity Theater of the Absurd, Be Careful What You Ask For, And a Little Totalitarianism from HIStalk Blog

As 2013 comes to a close, here are some year-end observations on Healthcare IT:

From the Dec. 30, 2013 New York Times article "Roughed Up by an Orca? There’s a Code for That" (http://www.nytimes.com/2013/12/30/technology/medical-billing-nears-a-new-era-of-ultra-specific-codes.html):


1) ICD-10: the Data Granularity Theater of the Absurd

... ICD-9 [used in the United States for medical statistics since 1979 and for billing since 2002] ... has about 14,000 codes to specify diagnoses and 3,000 to specify inpatient procedures.

ICD-10, with codes containing up to seven digits or letters, will have about 68,000 for diagnoses and 87,000 for procedures. 

While ICD-9 had a single code for certain repairs to blood vessels in the head and neck, ICD-10 allows specification of the particular vein or artery and the particular procedure used. Extra codes allow recording of whether a patient was visiting the doctor for the first time or a subsequent time for a particular problem, and whether broken arms and some other injuries occur on the left or right side of the body. 

There are dozens of codes dealing just with the big toe — contusion of the right great toe, contusion of the left great toe, with damage to the nail or without, initial encounter or subsequent encounter, blisters, abrasions, venomous insect bites, nonvenomous insect bites, lacerations, fractures, dislocations, sprains and amputation, not to mention the vague “acquired absence of unspecified great toe.” 

ICD-10 has been the subject of jokes, however, for its catalog of possible injury causes, like those burning water skis. There are codes for injuries incurred in opera houses and while knitting, and one for sibling rivalry.

Codes for - injuries in opera houses?  Knitting?  Sibling rivalry?  Right toe vs. left toe contusions?  ... Having been witness/participant in development of a number of taxonomies in specialized areas of medicine, e.g., invasive cardiology, and in genomics, where at least there is significant advantage to a good degree of granularity, I think it can not too unfairly be said that the proponents of ICD-10 are - let's just say, anal fanatics.

... ICD-10 has already been postponed by a year. It was originally scheduled to go into effect this past Oct. 1, which would have coincided with the rollout of the insurance website.

The delays have largely been due to end user difficulties in implementation in the real world, but imagine if the ICD-10 rollout had coincided with the Obamacare insurance website debacle.  The fireworks would have been truly spectacular.

One wonders if there's an ICD-10 code for "injuries to the genitals from medical experiments conducted by space aliens after abduction."  (I guess we'd need several codes - one for each gender at the very least.)

What's the ICD-10 code for injuries from experiments conducted after abduction by space aliens?

2)  Be Careful What You Ask For

In the aforementioned New York Times article,  John Halamka, who in my opinion may qualify for the title "the Galloping Gourmet of Clinical Cybernetics" (a description that occurred to me after seeing him speak a few years ago, see http://www.youtube.com/watch?v=4mY4Qi7J4ag) said this:

... Dr. John D. Halamka, chief information officer at Beth Israel Deaconess Medical Center in Boston, said the need to prepare for I.C.D.-10 and the Affordable Care Act and to achieve so-called meaningful use of electronic health records all at once could overwhelm computer staffs throughout the health care industry. 

“It’s just this collective sum of activities that exceeds the capacity of the system to absorb it simultaneously,” he said. 

He said his hospital was spending $5 million this year on I.C.D.-10, $7 million for the Affordable Care Act, $2 million on meaningful use, and $3 million to comply with a federal health care privacy law. “Basically, I’m not doing anything but federal regulatory mandates,” he said.

(Bureaucracy given an inch, and now wanting a light year?  Whoda thunk it?)

Reminds me of the saying: "be careful what you wish for."

I also really don't think the hospital can complain about the millions being spent to satiate the bureaucrats.  After all, think of all the "Billjuns and Billjuns" of dollars they're saving from these EHRs!

Why is Dr. Halamka complaining about a few million dollars spent on satiating the bureaucrats?  After all, these EHR systems are supposedly saving Billions Upon Billions of Stars, er - dollars.  Right?

I also note the "could overwhelm computer staffs."  How about overwhelming the people who actually take care of patients?

Statements like this give real meaning to my quasi-satirical observation that "computers seem to have more rights than clinicians or patients."

Finally:

3)  A Little Totalitarianism from HIStalk Blog

 In the HIStalk post "Curbside Consult with Dr. Jayne 12/30/13" (http://histalk2.com/2013/12/30/curbside-consult-with-dr-jayne-123013/) the semi-anonymous blogger “Dr. Jayne” notes that getting physicians to enter data into the EHR is difficult:

• We heavily incent our physicians to do the desired workflows and gather specific discrete data. We initially hoped for compliance through altruism or desire for quality, but what made the difference was cash. It’s remarkable what tying an annual bonus to EHR use can do to a physician’s attitude. We phased the requirements in over three years for legacy physicians, but new hires are expected to be immediately compliant.

What a novel concept – paying extremely skilled professionals for their time and labor. Imagine that! Dr. Jayne, I ask you - can you be just a little more patronizing? You’re just too nice in your attitudes towards skilled professionals and compensation for the mass time-add of EHR use.

• Strong governance. We’re not afraid to terminate disruptive physicians or to encourage those who can’t meet our standards [i.e., to use whatever lousy EHR we throw at them - ed.] to leave the organization. Our non-compete is written so that providers can purchase their practices and keep their panels and stay in the same location as long as they don’t go to work for a corporate competitor. This lets those who are not a good fit depart without losing their livelihood. This is rare, but it’s one element of our success.

How generous of your organization’s Commissars – oops, I mean executives to not deny a doctor a living because they can't or won't become slaves to some lousy EHR designed with little or no attention to providing a good user experience, or to clinical time-based realities.

I guess said executives also never heard of what can happen to a clinician whose loss of hospital privileges gets into the National Practitioner Data Bank (http://www.npdb-hipdb.hrsa.gov/).

Here is a little New Year's hint from http://www.walterhav.com/pubs/winter10.pdf by Ohio lawyers Michael J. Jordan and John E. Schiller, from SideBar, a publication of the Federal Litigation Section of the Federal Bar Association:

... Under many circumstances, federal law requires the hospital to report a reduction or revocation of a physician’s medical staff privileges to the National Practitioner Data Bank (NPDP). The NPDP was created two decades ago, when Congress enacted the Health Care Quality Improvement Act of 1986 (HCQIA).

... A report to the NPDB can, for all intents and purposes, end a physician’s career, because without hospital privileges, most physicians have substantially reduced earning capacity. The last hope for a physician who faces the loss of privileges is an action in court. In contesting a loss of privileges in state or federal court a physician immediately faces a hospital’s claim of protection under HCQIA. This protection comes in the form of a limited review of the hospital’s conduct, designed to encourage open and candid self-policing by hospital physicians who serve on peer review committees.

I note that attitudes like this are typical of IT geeks and health IT hyper-enthusiasts, whose arrogance knows few bounds.  Such are the people who dismiss reports of patient injuries and deaths such as at http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html and http://hcrenewal.blogspot.com/2011/06/babys-death-spotlights-safety-risks.html as necessary sacrifices to the Lords of Cobol Kobol, and genuine concerns about the negative consequences of Bad Health IT (which in their minds does not exist, as IT can only create miracles) - as coming from "disruptive physicians."

This may have to do with poor socialization of data processing personnel and computer geeks, and how it impairs their being a true part of the medical team (e.g., see http://dl.acm.org/citation.cfm?id=563354&coll=portal&dl=ACM).

Lastly, some patriotic music for Dr. Jayne and her imperious organizational leaders for the New Year:

Click for Patriotic music!

And with that, Happy New Year, all!

-- SS

12/31/13 addendum:

A commenter made me aware of this ICD-10 code:

http://www.icdvalidator.com/Medical_Data/ICD10/DiagnosisV9733XD.html

ICD-10 Code : V9733XD (V97.33). Sucked into jet engine, subsequent encounter

General information on the “V9733XD” code
Revision: 10th Revision

ICD-10 Code: V9733XD (V97.33)
Code Type: Diagnosis
Description: Sucked into jet engine, subsequent encounter

Chapter/Section : External causes of morbidity (V00-Y99)
Section/BodyPart : Air and space transport accidents
Note : The code is valid for submission on a UB04 

I will surely sleep well tonight knowing this code exists, and still more soundly since I imagine there are separate codes for "sucked into jet engine, initial encounter" as well as for injuries by propeller blades and by rocket engines.

-- SS

1/1/14 Addendum:

A physician reader, extremely technologically savvy and a fellow Ham Radio enthusiast, had this to add:

Happy New Year Scot. Yes, that was MY New Year's Eve blog comment rant last night. As you can imagine, I am totally disgusted with my role as an enslaved peon in this cyclopean madness. I suppose it has something to do with my INTP personality. What's happening is a Bataan style death march for the medical profession.

I opine the infringements on the practice of medicine by bureaucrats and fools also represents a Bataan style death march for very sick patients.

-- SS