Retaliation against physicians reporting EHR flaws that cause use errors? Physicians subpoenaed in Rhode Island, allegedly after reporting EHR risks

It appears that way to my eye.  First, on use errors (as opposed to user errors from carelessness):

“Use error” is a term used very specifically by NIST 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, misuse of color-coding conventions, omission of information, etc. From "NISTIR 7804: Technical Evaluation, Testing and Validation of the Usability of Electronic Health Records." It is available at http://www.nist.gov/healthcare/usability/upload/Draft_EUP_09_28_11.pdf (PDF).

Now this:

Becker's Hospital Review
Physicians subpoenaed in Rhode Island, allegedly after reporting EHR risks
Jessica Kim Cohen
January 25, 2019
https://www.beckershospitalreview.com/legal-regulatory-issues/physicians-subpoenaed-in-rhode-island-allegedly-after-reporting-ehr-risks.html

The Rhode Island Department of Health reportedly has served at least four emergency room physicians at Providence-based Rhode Island Hospital with subpoenas, according to the Politico Morning eHealth newsletter.

The subpoenas allege the physicians participated in behaviors that fall under the umbrella of medical misconduct, on account of mistakes the physicians reported themselves. The mistakes, which didn't injure any patients, reportedly were meant to draw attention to risks associated with the hospital's EHR.

This is outrageous if accurate, especially considering the issues I raised in my Nov. 4, 2011 post "Lifespan (Rhode Island): Yet another health IT 'glitch' affecting thousands - that, of course, caused no patient harm that they know of - yet" at https://hcrenewal.blogspot.com/2011/11/lifespan-rhode-island-yet-another.html.

The RI Dept. of Health owes the public an explanation.

The subpoenas primarily relate to medical scans, such as X-rays, which were mistakenly ordered by the physicians. EHR experts who spoke with Politico said these errors are common because it's easy to click on the wrong icon or patient name in complex system interfaces.

That is classic "use error" and results from poorly-designed, mission-hostile user interfaces of bad health IT as defined by myself and Australian informatics expert Dr. Jon Patrick at at http://cci.drexel.edu/faculty/ssilverstein/cases/:

Bad health IT is IT that 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, compromises patient privacy, lacks evidentiary soundness permitting concealment of alterations, or otherwise demonstrates suboptimal design and/or implementation. 

I covered the issue of 'mission-hostile health IT' at a 10-part series in 2009 at http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-idiots-part-1.html

Physicians and EHR safety researchers have raised concerns over the subpoenas, suggesting that the department's response could discourage future clinicians from voluntarily reporting medical errors.

Not "could." 

Will, and likely by design in my opinion.  The ultimate motive for the subpoenas and those behind them, which may extend outside the DOH, needs to be determined.

"Anyone punishing individual providers for these events is punishing the wrong thing," Jason Adelman, MD, chief patient safety officer at NewYork-Presbyterian Hospital in New York City, told Politico. "These are system issues, not the provider being reckless. The focus should be on things like EHR usability and safety."

I am aware of patient injuries and deaths as a result of mis-clicks due to mission-hostile user interfaces that confuse users and lack appropriate safety alerts and notifications.  This includes ER mistakes.

The corporate response followed the expected boilerplate:

When asked about the subpoenas Jan. 25, Rhode Island Hospital spokesperson David Levesque [Director of Media Relations, Lifespan, https://www.lifespan.org/news-events/news/media-contacts] provided the following statement to Becker's Hospital Review:

"Rhode Island Hospital is deeply committed to the safety of our patients and the continual improvement of our healthcare environment, including the processes our caregivers and staff follow. Furthermore, the hospital's culture of transparency remains a point of pride and is unwavering. Rhode Island Hospital supports our world-class physicians, nurses and other staff and appreciate their tirelessly work in providing world-class healthcare."

As one colleague of mine observed, "the hospital's culture of transparency remains a point of pride" seems to mean that "you can prosecute staff for being transparent, and it is not a contradiction."

I wrote Mr. Levesque regarding this story:

From: S Silverstein
Date: Tue, Jan 29, 2019 at 10:07 AM

Subject: Re: Physicians subpoenaed in Rhode Island, allegedly after reporting EHR risks

"Rhode Island Hospital is deeply committed to the safety of our patients and the continual improvement of our healthcare environment, including the processes our caregivers and staff follow. Furthermore, the hospital's culture of transparency remains a point of pride and is unwavering. Rhode Island Hospital supports our world-class physicians, nurses and other staff and appreciate their tirelessly work in providing world-class healthcare."

Really? 

After the debacle I documented at https://hcrenewal.blogspot.com/2011/11/lifespan-rhode-island-yet-another.html , I think this is an outrage.

I am passing this story on to trial lawyers who will likely pass it to the national trial lawyer's listserv.  I believe these actions are retaliation against the physicians.

I am aware of patient injuries and deaths following "wrong clicks" in ER's.

Sincerely,

Scot Silverstein MD

The stated source of the subpoenas, DOH, seems odd.  The hospital should strongly defend its doctors against DOH if the DOH was the sole source of the subpoenas and accusations of medical misconduct, not just provide boilerplate.  If DOH was influenced by some other party to take this action, that needs to be revealed.

I hope I am wrong about the retaliation issue, and that this has all been a misunderstanding.  Perhaps Mr. Levesque will clarify.  Perhaps the subpoenas against the physicians who reported the EHR use error issue were issued by the DOH to gain more information about the alleged EHR problems.  If not, I hope they will be summarily dropped. 

If not, I hope the matter gets wider attention, especially at a time when bad health IT is contributing considerably to clinician burnout per numerous studies and reports (see for instance my Jan. 23, 2019 post at https://hcrenewal.blogspot.com/2019/01/experts-declare-physician-burnout.html).  Burnout increases risk of medical error for everyone.

Supposed accusations of any type of "professional misconduct" are outrageous, and will have a chilling effect on other like-minded, candid clinicians (including nurses) confronting bad health IT.

-- SS

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

New HHS Secretary, rather than singing unabashed praise for EMRs like his predecessors, states the obvious. However, the "solutions" are the usual boilerplate.

In the past, politicians on both sides of the aisle have generally sung unfettered and uncritical praise for electronic medical records and other health IT systems.

Perhaps letters like this one from Jan. 2015, from near 40 major US medical societies bemoaning the injurious effects of health IT on medical practice, have finally had an effect:  http://mb.cision.com/Public/373/9710840/9053557230dbb768.pdf

First page preview of Jan. 2015 medical societies complaint letter to HHS about health IT.  Full letter at http://mb.cision.com/Public/373/9710840/9053557230dbb768.pdf

In any case, this recent article caught me by surprise:

HHS Secretary Price promises reduced health IT burden for physicians
April 27, 2017
Gregory Twachtman
Frontline Medical News
http://www.mdedge.com/acssurgerynews/article/136747/business-medicine/hhs-secretary-price-promises-reduced-health-it 

WASHINGTON – Reducing IT burden for doctors and fostering interoperability are two top tech priorities for Health and Human Services Secretary Tom Price, MD.

"We simply have to do a better job of reducing the burden of health IT on physicians and all health care providers,” Dr. Price said April 27 at Health Datapalooza, an annual conference on health data transparency. “The promise of big data and health information technology is so great and absolutely remarkable but we must not, we cannot continue to get this wrong.”

The burdens have become so onerous that the new HHS secretary made these statements:

EHR requirements are causing some physicians to retire too early, Dr. Tom Price said at Health Datapolooza.

Dr. Price said that the burden being placed on physicians is causing many to leave practice way too early. He noted that his grandfather retired from practice at age 94 and his father retired in his early 80s.

“Now we are seeing physicians leaving the practice of medicine when they are 60 or 55,” he said. “Many of my colleagues, my personal friends who have been practicing, right now they are looking for the exit doors. They are trying to figure out how to get out of practicing medicine and I think it is incredibly important for us as a society to step back and ask, why?”

A significant factor is the shift to electronic health records, which has caused doctors to spend much more time looking at screens and feeling more like data entry clerks than health care providers, he said.

“I know that we have lost more than one physician to retirement because of the kinds of burdens that have been placed on a lot of them and that simply ought to be unacceptable to us,” he said. “You think of the intellectual capital that has been lost by this nation because of the kinds of burdens that clinicians have seen.”

First, an aside on the term "Datapalooza."   Such an injudicious, "let's party" term as "datapalooza" reflects in my opinion the irrational exuberance that has characterized health IT for decades and led to the dilemma faced by physicians in 2017.  I've mentioned this before.  At my May 10, 2012 post "ONC's 'Health Data Palooza' - A Title of Exceptionally Bad Taste" at https://hcrenewal.blogspot.com/2012/05/oncs-health-data-palooza-title-of.html, I observed:

... This title for a government-sponsored meeting is bizarre and tasteless in my opinion.  What is deemed by ONC to be the major source of this data?  Health IT. 

"Palooza?" 

From Urban Dictionary: 

Palooza - http://www.urbandictionary.com/define.php?term=palooza 

An all-out crazy party; partying at one place with a ton of people like there's no tomorrow; The art of throwing a very drunken extravagant party with a plethora of friends

Also, the Secretary reiterates the other hyper-enthusiast-promoted line:

... The promise of big data and health information technology is so great and absolutely remarkable

This is the decidedly un-sober "revolutionizing medicine" claim I've been hearing about health IT for the past several decades.  As I observed at my August 2016 post at http://hcrenewal.blogspot.com/2016/08/ioannidis-what-happens-when.html, Ioannidis et al. wrote about this phenomenon more eloquently than I could regarding Big Data and biomedicine:

What Happens When Underperforming Big Ideas in Research Become Entrenched?
Michael J. Joyner, MD1; Nigel Paneth, MD, MPH2; John P. A. Ioannidis, MD, DSc3
JAMA. Published online July 28, 2016. doi:10.1001/jama.2016.11076
http://jama.jamanetwork.com/article.aspx?articleid=2541515

For several decades now the biomedical research community has pursued a narrative positing that a combination of ever-deeper knowledge of subcellular biology, especially genetics, coupled with information technology will lead to transformative improvements in health care and human health. In this Viewpoint, we provide evidence for the extraordinary dominance of this narrative in biomedical funding and journal publications; discuss several prominent themes embedded in the narrative to show that this approach has largely failed; and propose a wholesale reevaluation of the way forward in biomedical research 

and this:

... The financial and clinical benefits predicted from shifting to EHRs have also largely failed to materialize because of difficulties in interoperability, poor quality, and accuracy of the collected information; cost overruns associated with installation and operation of EHRs at many institutions; and ongoing privacy and security concerns that further increase operational costs.

Those things said:

Regarding Dr. Price's statement that "We simply have to do a better job of reducing the burden of health IT on physicians and all health care providers", I find the statement remarkable coming from the top echelon of government.

It's about time, I opine.

Still more time is needed, however, before the government and organized medicine truly understand health IT enthusiast culture.  One might wonder if Dr. Price read my Aug. 9, 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 - that is, until one reads his proposed solutions:

... He challenged the health IT professionals at the meeting to make their products more user friendly.

“We will work on reducing the burdens at the federal level, but we also need clinicians and IT folks on the ground to help make certain that technology implementation is done in a way that it enhances usability and increases efficiency,” Dr. Price said.

This assumes that complex major information systems such as EHR's can be made significantly more "usable", considering the constraints of time and the cognitive burdens such systems place on already-taxed clinicians. 

As I have pointed out, these "EHRs" are really complex command-and-control systems with dozens of component systems:

The term "EHR"/"EMR" is a misleading anachronism, no longer reflecting a medical file cabinet replacement but a far larger, complex amalgam of information systems.

I do not believe these systems really can be made less burdensome to clinicians to a major degree, no matter how clever the user interaction design.  The user manuals to the best of these systems are hundreds of pages long, and many clinicians user more than one system.  Further, paper will always be far simpler to use than computers, and no information system in a complex field like medicine will ever duplicate that ease-of-use.

The real-world solution to decrease clerical burden on busy and overtaxed clinicians is either to significantly decrease their patient load (unlikely to occur), or to decrease the amount of time they have to spend at computers and the amount of data they are called upon to enter per capita.  That solution cannot be accomplished without help from a significant number of - no surprise here - clerical personnel, for data entry, data abstraction and related mundane tasks.

... [Dr. Price] also called for true interoperability, a common goal that has persisted since electronic health records were mandated under the HITECH Act but remains an elusive target.

“This has always been the goal and it just seems so simple,” he said. “Somehow something has happened between the idea of interoperability and now that has made it so much more challenging.”

Achieving interoperability among many complex information systems that contain the massively complex datasets of biomedicine, a terminology set containing a massive number of unique concepts and terms, with millions of synonyms and subtleties (cf.:  Unified Medical Language System, https://www.nlm.nih.gov/research/umls/) is NOT so simple:

Scott Adams expressed the misconception here succinctly:

ANYTHING YOU DON’T UNDERSTAND IS EASY TO DO
ExampIe: If you have the right tools, how hard could it be to generate nuclear fission at home?

Further, and even worse:

It is my great concern that, should significant inter-EHR system interoperability be achieved, wholesale import of patient data from one system to the next could (and likely would) encourage 'laziness', e.g., uncritical acceptance of the incoming data as correct.   The propagation of inaccuracies and errors (already a significant issue with intra-system "cut and paste" as one example), would more readily propagate from one clinician and/or facility to another. 

The repeat history-taking and fresh rewriting of a new chart regarding new encounters serves a corrective function that could be bypassed through seamless health IT "interoperability."

As I've written at this blog numerous times, the issue of basic operability is more important towards practical use of EHRs in the real-world care of individual patients (which I consider the heart and soul of medicine) than interoperability.

... He placed that fault on current federal regulation around interoperability and pledged to create an environment that reduces regulatory roadblocks and allows the technology sector to innovate and foster the free flow of data.

This idea is dead in the water if history is any lesson.  The lack of any meaningful regulation of the health IT industry over the past several decades, that is, the unprecedented regulatory accommodation afforded the health IT sector, certainly did not promote meaningful innovation in the technology or in interoperability.   The primary driver and business equation is "proprietary" == locked-in customers.

“From my perspective it seems that what we ought to be doing is deciding the rules of the road,” Dr. Price said. “We are going to drive on the right side. We are going to stop at the red light. This is the language we are going to do. This is what a triangular sign looks like, as opposed to stipulating every single dot... all the way down the line.”

Dr. Price has taken the first (remarkable) step in calling out the severe impact of the burdens placed on clinicians by current health IT systems and practices.

What he and his advisors have not yet done is truly think through the solutions critically.

That needs to occur, for the proposed solutions are no "solution" at all.  They are merely more of the same muddled thinking and hyper-enthusiastic boilerplate that got clinicians into the cybernetic mess they are in to begin with.

-- SS

Our ED wait times wil be longer than usual this weekend (and beyond) so we can attend to the computer.

A hospital system, Pinnacle Health, not all that far from me in the Harrisburg, PA area is rolling out EPIC this weekend.

The following banner is at the top of their homepage at http://www.pinnaclehealth.org/locations-and-providers/:

ALERT: Due to our transitioning of a new computer system this weekend, ER wait times may be longer than normal.  Click to enlarge.

! ALERT: Due to our transitioning of a new computer system this weekend, ER wait times may be longer than normal. If you have a minor illness that doesn’t require a trip to the ER, you can visit one of our Express or FastCare clinics or if unsure where to go, contact our free 24/7 Nurse Advice Line at (717) 988-0074


So, besides delaying affairs in a critical care environment, in order to take care of the computer's needs, they're asking patients to decide if they have "a minor illness that doesn't require a trip to the ER" and, in so doing, redirecting patients with possibly serious problems to a doc-in-the-box urgicare center.

These two matters raise risk on its face.  If patients are harmed or die, then, are their injuries or death considered a worthy sacrifice in the name of achieving cybernetic utopia?

It would seem far more logical - and safe - to roll out a "new computer system" gradually, in a manner that does not require crazy workarounds (e.g., asking patients to decide if they need the ER or not) and causing delays and confusion that, in an ED environment, can and do lead to missed findings, lost information, harm, and death.

This mayhem will go on for far longer than a weekend.

It's stunning how the naive public has been sold the myth/fantasy that computers are a really great thing in medicine, and worth the risks of a massive rollout and the disruptions that causes, when increasingly - as posted in numerous essays on this website and others - the data does not support such declarations, and computers serve as more of a distraction than a boon to busy clinicians.

-- SS

Someone wasn't listening to me at my 2012 Keynote to the Health Informatics Society of Australia

In late July 2012 I gave an invited keynote presentation to the Health Informatics Society of Australia (HISA) at the annual Health Informatics Conference (HIC 2012), that year in Sydney.

I wrote up my presentation at http://hcrenewal.blogspot.com/2012/08/my-presentation-to-health-informatics.html and my slide deck is online at http://cci.drexel.edu/faculty/ssilverstein/HISA2012_Final.ppt.

My message included the following:

• Critical thinking is essential at all times in healthcare ... or your patient's dead.
• Critical thinking is not mindless criticism; on the contrary, it is reflective, inquisitive, logical thinking that is focused on deciding what to believe or do.
• Health IT must be trusted by users and patients [and be free of major downsides] - as a primary step before HIT can optimally benefit healthcare 
• I pointed out I am not suggesting anything new and that, in fact, I am suggesting something old:  "First, do no harm."
• I pointed out the "revolutions" usually have downsides, and IT always produces winners...and losers (per the empirical research of Social Informatics). 

I also asked if health IT was being done well...

I provided links to various evidence that it was not, such as the National Research Council 2009 report on health IT; AMIA's report on its workshop on healthcare IT failure, the 2012 U.S. IOM report on safety, the 2012 U.S. NIST report on usability, work by Australian Professor Jon Patrick of U. Sydney on health IT defects, and other sources as aggregated at this link.

It seems the following organization in Cairns was either absent or not listening, and this debacle is the result.

Just about every point I raised in 2012 was violated or ignored.  The story speaks for itself, and I have nothing further to say about it other than this type of scenario is unfortunately still occurring worldwide.


====================

CAIRNS Hospital’s Digital Hospital program was deemed defective within two weeks of being rolled out with health staff saying it resulted in “significant adverse impacts” upon patient safety and care.

Daniel Bateman
The Cairns Post
September 22, 2016 7:03pm
http://www.cairnspost.com.au/news/digital-hospital-resulted-in-significant-adverse-impacts-upon-patient-safety-in-cairns/news-story/be8b025e3d75f91d8ec3288d2c8bed25?nk=79a33b2ae2e9548ce0191dd739db212e-1474736022

The controversial eHealth software program, which went live earlier this year, has been blamed for putting the Cairns and Hinterland Hospital and Health Service on the path towards its $80 million budget blowout.

The hospital’s board resigned as a result of the gaping deficit on Monday and an administrator is expected to be appointed today.

Results from a staff survey about Digital Hospital leaked to the Cairns Post says the program did not “meet stakeholders’ needs for an intuitive, user-friendly system that supported the provision of personalised patient care at the bedside”.

The report also identifies specimen order and collection workflow as a result of the new system as being “convoluted and time consuming, with significant adverse impacts on patient safety and care.”

Cairns Hospital board resigns

The lack of system testing has been identified by stakeholders as the root cause of continual defects after Digital Hospital went live and the report says there has not been adequate support staff to help with problems.

Senior clinicians raised alarm bells about Digital Hospital earlier this year, warning if the problems were not fixed, it would become a major headache for the health service.

Last Friday hospital board chairwoman Carolyn Eagle described Digital Hospital as a “financial challenge” for the health service.

However, the service’s chief executive Clare Douglas said yesterday the program did not contribute to the 2015/16 budget deficit, nor was it a major contributor to the projected budget deficit for the 2016/17 financial year.

“Queensland Health has committed to the establishment of a digital health system and Cairns Hospital is an important part of that system,” she said.

“We are working to improve and embed the system as part of business as usual.”

She said there were benefits of the program, including visibility and ease of access to patient information.

=================================

That's akin to saying there are benefits to train wrecks.  Yes, it gets the tracks and signals fixed.  But....

The myth of cybernetic magic is a devilish one, and must be expunged from healthcare if this technology is ever to meet even a fraction of the promises made about it for decades.

-- SS

Addendum:  it seems American EHR company Cerner was involved here:  https://www.pulseitmagazine.com.au/australian-ehealth/2669-iemr-roll-out-at-cairns-hospital-delayed-as-pah-prepares-to-go-live

-- SS

More on uncoupling clinicians from EHR clerical oppression

At my August 6, 2016 post (link) I wrote of my belief that "best practices" for EHR evolution call for:

... a return to paper (specialized forms depending on the setting) for clinical data capture by busy doctors and nurses, and data entry into a computer via clerical personnel.

I presented a late 1990's real-world experiment in creating such a system for invasive cardiology in the Delaware hospital system, Christiana Care Health System, where I was CMIO at that time.

As at the links http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story and http://webcache.googleusercontent.com/search?q=cache:7XKNh-fTOZ8J:ift.tt/2bd3pLl+&cd=1&hl=en&ct=clnk&gl=us (the latter a May 2002 article in the journal "Advance for Health Information Executives" written by myself and the project executive sponsor at the time), the "experiment" was a deliberate move away from the "doctors as clerical employees" article-of-faith of the health IT enthusiasts.

Enthusiasts seem to ignore the downsides and emphasize a (seemingly) sensible strong belief about efficiency, one of whose principles is that paper must be abolished in medicine.  Is work towards that end beneficial, or deleterious, to the clinical mission?

In fact, an attempt to implement such a paperless system, "Apollo" as the commercial system was known, in a cath lab performing 6,000 procedures/year proved impossible.  The busy clinicians, doctors, nurses and technicians simply did not have enough time to enter data directly into a computer.  Maneuvering around a computer application, dealing with its designber-centric menus, drop-downs, icons, widgets, annoying messages, input limitations, outright crashes with data loss, etc. was both inappropriate, and in fact impossible, in such a setting.

In 2016, one of the largest complaints of hundreds of thousands of U.S. physicians and nurses is that they spend more time interacting with the computer than with patients.  Patients complain they cannot get eye contact from clinicians - who are tethered to a computer screen entering data - during "live" encounters.

It is my belief there is no solution to this problem other than, where appropriate and advantageous, decoupling clinicians from data input and returning to paper for data entry, that is, specialized forms as in the aforementioned post.  Data input needs to be returned to clerical personnel as in the aforementioned invasive cardiology system.

The output side (with, of course, significant user-centered redesign) can remain computerized; as long as the paper forms are also made available via document imaging.

The forms for invasive cardiology looked like this, and were subject to revisions as needed.

Physician's data collection form, side 1.  Click to enlarge.

Physician's data collection form, side 2

Cath technician/nurse's data collection form, side 1

Cath technician/nurse's data collection form, side 2

The EHR itself was freed from "legacy" limitations regarding rapid customization, essential in medicine.  It was designed with the ability to rapidly incorporate changes and modifications to the dataset as needed, matching the changes to the forms.

Below I am showing some of the reports that this system produced regularly, as designed by the team of programmers, executives and cardiologists, under my medical informatics leadership. I used to do "real" informatics, e.g., leading the data modeling of entire clinical subspecialty domains and developing advanced IT based on those models, until seeing that the commercial sector was damaging the field of HIT, and medicine itself, with horribly bad health IT leading to letters such as the January 21, 2015 letter to HHS at http://mb.cision.com/Public/373/9710840/9053557230dbb768.pdf.  It was then, in the early 2000s, that I turned my attention to writing about the industry's deficits.

The major advantage of the cardiology reports shown below concerned accuracy, including the case report itself whose language and organization was also developed for optimal clinical organization and  readability -- unlike the reams of "legible gibberish" that emanates from commercial EHRs then and today.  See my post "Two weeks, two reams" at lhttp://hcrenewal.blogspot.com/2011/02/electronic-medical-records-two-weeks.html for more on that issue.

Quality data input into the system, being freed from the accuracy-impairing aspects of busy clinicians as clerical employees, and the resultant reports saved the organization close to $1 million in the first year and led to a better understanding of what worked and what didn't in treating blocked coronary arteries.

Click to enlarge:

Some statistical reports, and sample computer-generated case report front page

An evaluation of the project by the national organization, the Society for Cardiac Angiography and Interventions, was that the accomplishments were "exceptional."

All this was achieved without direct clinician data entry - and deliberately so due to the distractions of that process having failed in the same setting in prior organizational attempts, without medical informatics expertise.  Perhaps, more accurately, I should say "medical informatics expertise in someone who also thinks critically about all issues involved, including adverse effects, of IT."  Clinicians could supplement each section of the forms data if needed via dictation, which was directly transcribed by humans into the cardiology server.

"Clerical work for clerical employees, clinical work for clinicians" was the theme of the project.

Breaking from the belief that paper is to be abolished at all costs was the key to creating really useful and well-accepted health IT, even in this exceptionally busy critical care setting.  It was still being used over a decade later, ca. 2008 and may still be now.  I have not been back for a visit since then.

One argument might be made that hospitals cannot afford enough clerical employees to do all the data input.  I maintain that, with hospitals spending upwards of $100 million for EHRs, and with the data being used and sold profitably by a wide variety of stakeholders who contribute nothing for the medical data they obtain (EHR makers, insurers, regulators to name just a few), transcriptionists could be afforded.

Of course:

Physicians with simply too much free time on their hands - the majority, it might seem, based on the behavior of some of the EHR enthusiasts and government pundits - and who enjoy giving away the fruits of their labor for others' profits could still enter data directly into the computer.  If they want to.

I note that if physicians really were empowered, the current status quo of clinicians as (unpaid) data-input personnel for those who profit from the data likely would never have come to pass.

Entering orders would still be done by clinicians, although that process and the process of alerts and reminders also needs a major reworking, such as use of advanced NLP to allow a more natural input of orders.

In summary, in the late 1990s the mantras of eliminating paper from medicine, and of clinicians needing to perform clerical work, were challenged and shown to be injurious to health IT progress in a critical care setting, invasive cardiology.

The lessons learned are more valuable today as they were then, considering that the health IT "experiment" is facing significant opposition today, with significant clinician rancor.  The CEO of the American Medical Association perhaps summed it up best when he referred to HIT as "the digital snake oil of the early 21st century" as at http://www.ama-assn.org/ama/pub/news/news/2016/2016-06-11-a16-madara-address.page.

These are unfortunate and undesired positions for the AMA CEO, and for the aforementioned medical society leaders as expressed in the letter to HHS to express, but this development has its real-world reasons.

Correction calls for modifying/softening cybernetic-enthusiast ideas like "paperless" and a more appropriate allocation of computer-related tasks.  Refocusing on "Clerical work for clerical employees; clinical work for clinicians" would be a good start.

-- SS

Weird emails from Independence Blue Cross via its IT outsourcing partners: showing yet more health IT industry trust-destroying incompetence

In the past week I've received two emails that made me highly suspicious of medical/insurance identity theft.

The emails came from Independence Blue Cross, ibx.com, into the email account I receive normal mailings from them, and seemed to indicate someone had created an unauthorized user account (I redacted my email address below):

Aug. 5, 2016:

From: noreply@ibx.com
Date: Fri, Aug 5, 2016 at 7:19 PM
Subject: User Created
To: [my email address redacted]

User Created With UserId - userId20392, Password - password20392

July 27, 2016: 

From: noreply@ibx.com
Date: Wed, Jul 27, 2016 at 1:59 PM
Subject: User Created
To: [my email address redacted]

User Created With UserId - userId1546, Password - S04bd9u3tR

These userid's and passwords did not work at ibx.com's website, but my concern was that, if these were false accounts, the creator could have logged in and changed the password.

After the first email I left a message with the IBX fraud line, but heard nothing in response.

The metadata (IP headers) of the messages looked like this (I redacted my email address):

Delivered-To: [my email address redacted]
Received: by 10.237.44.68 with SMTP id f62csp1992388qtd;
        Fri, 5 Aug 2016 16:20:27 -0700 (PDT)
X-Received: by 10.36.77.145 with SMTP id l139mr7340323itb.19.1470439227798;
        Fri, 05 Aug 2016 16:20:27 -0700 (PDT)
Return-Path: 
Received: from cnxsgusgma01.cnxuat.com ([216.183.110.200])
        by mx.google.com with ESMTP id q123si19839234iof.67.2016.08.05.16.20.27
        for ;
        Fri, 05 Aug 2016 16:20:27 -0700 (PDT)
Received-SPF: softfail (google.com: domain of transitioning noreply@ibx.com does not designate 216.183.110.200 as permitted sender) client-ip=216.183.110.200;
Authentication-Results: mx.google.com;
       spf=softfail (google.com: domain of transitioning noreply@ibx.com does not designate 216.183.110.200 as permitted sender) smtp.mailfrom=noreply@ibx.com
Received: from IBCSGUSGAA01.cnxuat.com ([192.168.230.147]) by cnxsgusgma01.cnxuat.com with Microsoft SMTPSVC(8.5.9600.16384);
  Fri, 5 Aug 2016 19:19:39 -0400
Received: from ibcsgusgaa01.cnxuat.com ([127.0.0.1]) by IBCSGUSGAA01.cnxuat.com with Microsoft SMTPSVC(8.5.9600.16384);
  Fri, 5 Aug 2016 19:19:58 -0400
From: noreply@ibx.com
To: [my email address redacted]
Message-ID: <1180377472 .11989.1470439198021.javamail.ibcsgusgaa01="" ibcsgusgaa01="">
Subject: User Created
MIME-Version: 1.0
Content-Type: text/plain; charset=us-ascii
Content-Transfer-Encoding: 7bit
Return-Path: noreply@ibx.com
X-OriginalArrivalTime: 05 Aug 2016 23:19:58.0024 (UTC) FILETIME=[E1DD4C80:01D1EF6F]
Date: 5 Aug 2016 19:19:58 -0400

User Created With UserId - userId20392, Password - password20392

After the second, I called IBX.  I was told it is a "malfunction", that these emails were not anything nefarious, other subscribers were affected, and that it "would be corrected soon."

I had already looked up the "Received from" header cnxsgusgma01.cnxuat.com [216.183.110.200]:

# ARIN WHOIS data and services are subject to the Terms of Use
# available at: https://www.arin.net/whois_tou.html
#
# If you see inaccuracies in the results, please report at
# https://www.arin.net/public/whoisinaccuracy/index.xhtml
#
#
# The following results may also be obtained via:
# https://whois.arin.net/rest/nets;q=216.183.110.200?showDetails=true&showARIN=false&showNonArinTopLevelNet=false&ext=netref2
#

Connecture, Inc. INFLOW-7524-7780 (NET-216-183-110-192-1) 216.183.110.192 - 216.183.110.255
Inflow Inc. INFL-AR-1 (NET-216-183-96-0-1) 216.183.96.0 - 216.183.127.255

Other IP's in the header appear to be of local (internal) workstations at the companies involved.

Who are these mysterious companies from which these emails seem to have originated?


Connecture, Inc:

http://www.connecture.com/the-connecture-difference/

Health insurance has entered the consumer age. Be ready. (We are.)

While there is almost universal agreement that health insurance will predominantly be distributed online in the near future, few American consumers have yet to experience it. In fact, most Americans have very little experience shopping for health insurance at all – let alone while making sense of numerous and often deceptively similar plans.

All of that is changing. Reform, the health insurance industry’s efforts to become more efficient, and Americans’ affinity for doing business online are all converging in the form of health insurance exchanges that present users with unprecedented freedom of choice.

Choice, of course, leads to questions. Which plans does my doctor participate in? Do they address my health needs? What about my family and my children? What happens if I need to go to the emergency room? How much will it cost – not just this month but year round? Am I eligible for a subsidy, and if so how much? In short, what’s the best plan for me and my family?

In health insurance, there are no cookie-cutter answers. That’s why health insurance exchanges and online distribution systems must do far more than enable consumers to enroll for coverage.

That’s where we come in. For more than 15 years we’ve focused on a singular goal: To create online systems and exchanges that empower Americans to choose the right health insurance plan online with confidence the first time, and every time.

Inflow Inc.

http://www.bloomberg.com/research/stocks/private/snapshot.asp?privcapId=105889

As of January 4, 2005, Inflow, Inc. was acquired by SunGard Availability Services, Inc. Inflow, Inc. provides facilities-based information technology outsourcing solutions to companies with critical business and network applications. The company offers its services in three primary lines: application hosting and management, business continuance and disaster recovery, and enterprise data-center management. Its application hosting and management services include application hosting and colocation, multi homed internet access, security services, application and infrastructure management, and network and system development. The company’s business continuance and disaster recovery services consist of business continuance planning/consulting, managed storage services, and content distribution services. Inflow’s enterprise data-center management services comprise onsite data-center management, operational support system management, data-center development, data-center audit services, data-center migration assistance, and business process documentation. Inflow, Inc. was founded in 1997 and was based in Thornton, Colorado.

Emphases mine.

So, perhaps millions of Independence Blue Cross customers are receiving emails that would reasonably cause suspicion in this day and age for identity theft, from companies that gloriously promise:

To create online systems and exchanges that empower Americans to choose the right health insurance plan online with confidence the first time, and every time.

To provide facilities-based information technology outsourcing solutions to companies with critical business and network applications

Confidence is the last thing the emails I received on behalf of ibx.com inspire in me.

If this information is being spilled (to the subscriber's own email account, but who knows where else?), I can only fear that other information is not quite secure, and wonder if these "ghost accounts" are just a glitch, or insiders spying on PHI, or other effects of either massive bugs or hacker attacks.

IT companies and companies that outsource their critical IT to others (including health IT makers and health IT buyers such as hospitals) - and the IT service providers themselves - need to really, really get their houses in order.

They need to stop beta-testing buggy software upon their customers (or live patients in the case of clinical IT).

Problems like this reflect significant and trust-busting incompetence, at best.

-- SS

Two recent stories of EHR un-exceptionalism, and a connection to prior HC Renewal posts including my own experiences

The following stories recently appeared in the press about the "un-exceptionalism" (or, I might more accurately state, the negative exceptionalism) of today's EHR technology.

Regarding each organization mentioned, I have had personal experience that, in retrospect, aligns with views I expressed about the organizations years ago.

First:

EHR safety goes to court
By Lisa Schencker

June 25, 2016

http://www.modernhealthcare.com/article/20160625/MAGAZINE/306259982

One patient's blood pressure plummeted dangerously after he was allegedly discharged with the wrong medications. In another instance, a physician couldn't place a pharmacy order for a newborn to receive vitamin K, which is given to babies to prevent serious bleeding.

On several other occasions, patients weren't accurately tracked, creating potential problems getting drugs to them.

Each of these alleged mishaps occurred at PinnacleHealth, a three-hospital system based in Harrisburg, Pa. PinnacleHealth blames each of the mishaps on its electronic health records vendor, Siemens; Cerner Corp. purchased Siemens' health IT business in February 2015.

The relationship between healthcare system and vendor devolved into this dueling lawsuit:

The incidents came to light as part of a breach-of-contract lawsuit Cerner filed against PinnacleHealth last year after the system, which had used Siemens as a vendor for 20 years, sharply curtailed its relationship and entered into a contract with a competing EHR vendor, Epic Systems Corp. PinnacleHealth related the incidents in its counterclaim; the counterclaim was filed in March of this year in state court in Pennsylvania, where it is seeking damages for Cerner's alleged fraud and breach of contract.

(I am cited in the article with respect to hold harmless clause-related issues not relevant to this blog posting.)

Cerner Corp. purchased Siemens' HIT business in Feb. 2015.  Prior to that, Siemens was an independent vendor of an EHR suite known as Soarian, deployed at PinnacleHealth as early as 2008.

See for instance http://news.usa.siemens.biz/press-release/customer-solutions/soarian-plan-care-assists-clinicians-developing-and-deploying-goal-

Soarian Plan of Care Assists Clinicians in Developing and Deploying Goal-Oriented Plans of Care
Monday, February 25, 2008

Siemens (http://www.usa.siemens.com/healthcareit) today announced that PinnacleHealth, a 750-bed, non-profit hospital and healthcare system serving Central Pennsylvania, and CentraState Healthcare System, a 272-bed, non-profit medical facility located in Freehold, N.J., have each signed on to serve as beta sites for Soarian® Plan of Care, a solution designed to support inter-disciplinary care teams in defining and helping to manage patient problems, interventions and expected outcomes, to provide care in order to achieve desired outcomes and to generate new knowledge at the point of care.

Notwithstanding my warnings on this blog and elsewhere that hospitals should NEVER be "beta testing sites" for experimental HIT software used on live patients without informed consent, that the relationship devolved to dueling lawsuits involving safety is not a surprise to me.

Relating to my own experiences as posted previously on this blog:

On August 20, 2009 I posted "Why Siemens Healthcare Fails" (http://hcrenewal.blogspot.com/2009/08/why-siemens-healthcare-fails.html).  In that post I noted regarding a job posting by Siemens for a "physician consultant" on HIT implementation:

... This [Siemens] job description might better be described as "glorified salesperson." It might be a good exit route for a "techie doc" (usually, someone who knows just enough about HIT to be destructive) who hates the current practice environment. It might also be good for managers who don't want knowledgeable experts pointing out their bad decisions and mismanagement, but I think a global company like Siemens should be setting its sights higher in such a crucial area as electronic medical records and clinical IT consultants.

I would not want such a physician advising or supporting complex HIT projects at my organization.

I also recalled my own Siemens face time:

... I spent time at Siemens Healthcare headquarters in Erlangen in 2000, and was offered gracious hospitality and a position overseeing the Soarian cardiology suite [as a result of my work in development of an extensive cardiology information system as CMIO at Christiana Care in Delaware from 1996-8]. The people I met in Erlangen then seemed extremely competent and informatics-savvy, but I turned the offer down through no fault of Siemens. I'd received a near-simultaneous offer (FAXed to my hotel in Erlangen, in fact) from pharma that involved a much stronger management role.

I understand through conversations over the past few years with current and ex-Siemens personnel that most of the Siemens personnel I'd met in Germany in 2000 are no longer with the company. I was told they'd performed suboptimally after the acquisition/merger with Shared Medical Systems (SMS) in Malvern, PA. (I do not find that credible, and would find it far easier to accept that the problems were on the American side, but that is a personal opinion.)

I'd informed my German hosts in 2000 that they'd better be very, very careful about acquisition of an American HIT company due to my experiences with a number of such companies, which I found highly political and highly ignorant of EHR quality issues.

Then, in my Feb. 2016 post "Plaintiff's Lawyers Are The Cause of EHR Problems?" (http://hcrenewal.blogspot.com/2016/02/himss-2016-presentation-plaintiffs.html) I recounted further experience with Siemens:

... an anecdote regarding the health IT Industry in the U.S.: the cardiology information system I developed, linked to above in the 2nd bullet point, was seen in 2000 by German engineers at Siemens Healthcare Erlangen as exemplary, and they offered me a position to further develop it, that I declined due to a simultaneous superior offer from Merck Research Labs.  However, in 2007 when I again spoke to Siemens, this time to Americans at the former Shared Medical Systems in Malvern, PA that had been acquired by Siemens, they found a system that actually produced clear, detailed outputs in a critical care area and was in use at the time in a major healthcare system in the region "impractical" - and never followed up with me.  Pearls before....)

 Finally, Siemens seems to have ignored a well-qualified informatics internal expert on explicit EHR safety warnings, as in my Feb. 8, 2010 post "A Lawsuit Over Healthcare IT Whistleblowing and Wrongful Discharge: Malin v. Siemens Healthcare" (http://hcrenewal.blogspot.com/2010/02/lawsuit-over-health-it-whistleblowing.html):

• Siemens Medical's physician internal consultants (skilled anesthesiologists/informatics specialists), apparently in writing and including a remediation plan, opined that an IT system developed for critical care had numerous severe flaws, of sufficient seriousness that in their opinion the systems could harm or even kill patients if deployed;

• These were warnings of defects and flaws in IT in the worst possible medical environment, critical care with the sickest and most vulnerable of patients, not some ambulatory clinic or primary care office;

• Allegations were raised that the warnings were ignored, with at least one of the physicians, Dr. Malin, who was strongly concerned and vocal about the risks then being told his position was being eliminated. [It is not a surprise to note this rings alarm bells about the possibility of wrongful discharge based on retaliation and/or "greasing the skids" to eliminate potential whistleblowers or "non-team players" who could delay release of the software and affect revenue - ed.];

• The company possibly ignored the remediation plans of their own clinician/informatics experts;

• There were allegations of company misrepresentations about the new system to the FDA;

• There were allegations of decision making on these issues by non-clinician IT managers lacking healthcare or healthcare informatics expertise.

• A wrongful discharge complaint and then lawsuit were filed by Dr. Malin on the basis of violation of the whistleblower protection provisions of the Sarbanes-Oxley Act of 2002 (SOX), 18 U.S.C. § 1514A ("Civil action to protect against retaliation in fraud cases - Whistleblower Protection for Employees of Publicly Traded Companies");

• The suit was dismissed on the apparent technicality that Siemens Medical in the U.S. is not subject to the provision in the SOX Act as is the publicly-traded corporate parent, Siemens AG; from document #4, pg 15:

... Health Services is a wholly-owned subsidiary of Siemens Med ... Siemens Med is a wholly-owned subsidiary of Siemens Corporation, which is indirectly owned, through two intervening layers, by Siemens AG, a German company that is publicly traded as defined by § 1514A of SOX ... Of these entities, only Siemens AG is a publicly-traded company. While both Health Services and Siemens Med are incorporated in Delaware and located in Malvern, Pennsylvania, they are separately incorporated entities.

• Siemens Medical in their response to the suit denied the most severe allegations regarding the IT defects, but this issue was not followed up upon due to the lawsuit's dismissal on SOX issues despite the obvious potential public hazards the allegations of IT defects could represent;

• In fact a US District Judge in the case, Peter J. Messitte, in the period after allowing Malin to prove the validity of SOX towards his case, opined that "No other discovery will be permitted, including but not limited to the alleged safety problems of Defendants’ product", document 4 above, Judge Messitte opinion, US District Court Maryland, pg. 25. [While perhaps understandable from a legal perspective, injured or dead patients don't really care about what legal precedents got them into the injured or dead state - ed.]

• Siemens Medical admitted in their responses to the suit that some of the software in question, actually put in use in hospitals, was in fact "beta" software, i.e., experimental (per Item 38 in 'Siemens Answer to Complaint' document).

There's that "beta-software" issue again.

So, the acquirer (Cerner) of a product of an American Siemens HIT subsidiary that appeared to have what I consider defective HIT talent management practices (as exemplified by the aforementioned JD); bizarre views about successful, high-quality EHR software (seen by their German counterparts a few years prior as exceptional); and that appears to have not been very happy about its own employee warning explicitly of beta ICU software being so bad it could kill patients is now embroiled in litigation regarding safety by a former customer.

None of this is surprising to me at all.  Incompetence can only go so far in healthcare before things blow up.

An unanswered question, of course, is whether patients were harmed or killed as a result of Siemens software, including its beta tests on unsuspecting patients.

---------------------------------

Here is a second story of EHR un-exceptionalism with a personal twist, this article in the Journal of the American Medical Informatics Association (JAMIA):

Comparison of accuracy of physical examination findings in initial progress notes between paper charts and a newly implemented electronic health record, June 28, 2016
http://jamia.oxfordjournals.org/content/early/2016/06/28/jamia.ocw067

Introduction There have been several concerns about the quality of documentation in electronic health records (EHRs) when compared to paper charts. This study compares the accuracy of physical examination findings documentation between the two in initial progress notes.

Methodology Initial progress notes from patients with 5 specific diagnoses with invariable physical findings admitted to Beaumont Hospital, Royal Oak [Michigan, near Detroit -ed.], between August 2011 and July 2013 were randomly selected for this study. A total of 500 progress notes were retrospectively reviewed. The paper chart arm consisted of progress notes completed prior to the transition to an EHR on July 1, 2012. The remaining charts were placed in the EHR arm. The primary endpoints were accuracy, inaccuracy, and omission of information. Secondary endpoints were time of initiation of progress note, word count, number of systems documented, and accuracy based on level of training.

Results The rate of inaccurate documentation was significantly higher in the EHRs compared to the paper charts (24.4% vs 4.4%). However, expected physical examination findings were more likely to be omitted in the paper notes compared to EHRs (41.2% vs 17.6%). Resident physicians had a smaller number of inaccuracies (5.3% vs 17.3%) and omissions (16.8% vs 33.9%) compared to attending physicians.

Conclusions During the initial phase of implementation of an EHR, inaccuracies were more common in progress notes in the EHR compared to the paper charts. Residents had a lower rate of inaccuracies and omissions compared to attending physicians. Further research is needed to identify training methods and incentives that can reduce inaccuracies in EHRs during initial implementation.

Apparently not covered in the article was the issue of patient harms that might have occurred (and could still occur) due to the "significantly higher rate of inaccurate documentation" in the EHR.   

"Beaumont Hospital" caught my eye, as I had interviewed for the CMIO role there in 2007 or early 2008.  My experiences are memorialized in an anonymized post at my Drexel informatics site which I reproduce in part here (the full essay is at http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=an_expert_says):

Sure, the experts think you shouldn't ride a bicycle into the eye of a hurricane, but we have our own theory

A medical informaticist who formerly held a “Director of Informatics” role a number of years ago in a very large hospital system, and who left the role due to a toxic management environment and lack of authority commensurate with responsibility, was seeking applied Chief Medical Informatics Officer (CMIO) positions once again.  ... He makes the following observations after completing two full rounds of interviews at a prestigious hospital system similar in size to his erstwhile employer, in a very competitive environment, that recently experienced a decline in its clinical quality stats. The organization feels the quality stats themselves were inaccurate, in part due to lack of good healthcare IT.

From what the informaticist was able to gather, their leadership was displeased. Board members were seasoned executives from a heavy-manufacturing industry that is extremely dependent on information technology and concurrent supply chain data. These executives apparently recommended that the organization move quickly on implementing EHRs.

The organization is thus planning to implement EHRs for thousands of physicians, most of whom are not employed by the hospital but are independent private practitioners, and likely to be skeptical or concerned about time impact and “grading” that could affect their livelihoods.  The hospital leaders also wanted to create integrated systems drawing on EHR data to automate quality reporting to regulatory agencies, as well as to support ongoing, funded clinical drug and device trials.

The informaticist was interviewed by the usual mix of clinician eager adopters, clinician skeptics, knowledgeable executives, skeptical executives who knew little about clinical IT, IT personnel who seemed overconfident given the enormity of the tasks at hand, and those who were clearly frightened by the prospect of being held accountable for a project of this magnitude. In the end, the informaticist did not get the position due to the organizational leaders being adamant the incumbent CMIO needed to also practice medicine.  The informaticist had explained on the first round that he believed a leadership role in a project of such magnitude and challenge called for the highest levels of executive presence and freedom from distraction, thus he did not intend to practice medicine (he had not practiced in his former Director of Informatics role for the same reasons).

He’d thought this issue had been settled after the first round of interviews, leading to the invitation for round two. This line of questioning was revisited, however, in round two in a group interview setting. The group interview was attended by a number of people with whom he’d already discussed this issue via individual meetings in round one. This suggested his time was being wasted and was rather annoying, especially considering that the informaticist had flown cross-country not once but twice to an organization not in consensus about a very basic hiring requirement ... It is not as if the organization had a doctor shortage, or that such a role would have ample free time where the incumbent would be idly sitting at their desk unless this time was absorbed seeing patients in the clinic. 

The stated reason for the organization’s wanting the CMIO to practice medicine was “to have credibility with the doctors.”  The informaticist explained that he’d found this not to be the case, that physicians being put “under the gun” of using EHR’s were generally more concerned that the CMIO had the executive authority to best represent their interests and understood medicine from training and practice at some point, not necessarily concurrently with the CMIO role.  Interestingly, there is no empirical research on this point, so the issue was the informaticist’s experience vs. the hospital’s ‘second-guessing’ a seasoned expert.

Ironically, the informaticist was told during his interviews that a CMIO they'd hired a few years ago had left, in part due to being overextended.  He was also told that some of the clinical IT problems he'd solved as a CMIO in the past Director of Informatics position were problems this organization had not been able to solve during the same time frame.

... Regarding underestimation, this organization appeared to have little idea of the difficulties they were getting into

... The informaticist had observed another indication that this organization ‘didn't know what they didn't know.’  He was informed that the organization had selected their EHR vendor prior to seeking a medical informatics expert. This implies they really did not understand what a medical informatics specialist does and can do, which is far more than being a tactical "EHR implementation assistant." ... The informaticist had been there, and had done that in his past role. He found it unrewarding then and actually had decided not to take the risk again, rejecting the new position, even before the organization decided they wanted an (effectively) part-time CMIO who also saw patients.

It was clear this organization, who the informaticist tried to “take to school” based on hard-earned expertise and extensive references on social issues in health informatics (e.g. on this website), felt they were the experts on what was best regarding CMIO background.   This may have been a dysfunctionality satirist Scott Adams once described like this:

Ignoring the Advice of Experts Without Good Reason

Example: Sure, the experts think you shouldn't ride a bicycle into the eye of a hurricane, but I have my own theory.

As I recall, an informatics physician much younger than I and with less experience was hired.  I do not know his fate.  However, I believe that my expertise at that time in EHR issues, and my no-nonsense stance on EHR safety and excellent management, might have averted or minimized the "inaccuracy" problems.

Therefore, it is also no surprise to me that the organization now relates the EHRs were causing significant charting inaccuracies.  It would also not surprise me if close calls and harm occurred. They apparently rode their bicycle into that hurricane, and doing so will usually produce a less than optimal outcome.

In summary, two recent articles on EHR-related lawsuits and operational problems, in my own personal experience, have potentially relevant "backstories" that may help provide context.  Those backstories relate primarily to what I've called "HIT amateurism" (e.g., faulty expertise evaluation) as well as HIT mismanagement (e.g., ignoring explicit internal warnings of dangers.)  I believe my experiences, and that of other such as Dr. Malin, are symptomatic of widespread health IT industry dysfunction.

I also believe that if this industry is ever to learn from its mistakes, it will only occur in the courtroom.  Being that the defense side is usually fierce, however, I am not sanguine needed learning will occur any time in the near future.

-- SS