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

"Hot Spot For User Entry Error": Hawaii missile alert: How one employee ‘pushed the wrong button’ and caused a wave of panic

A short post.

I believe this WaPo story vividly demonstrates issues I've seen in what Australian colleague Dr. Jon Patrick & I call "bad health IT." 

We came up with the simple-to-comprehend terminology "Good health IT/Bad health IT" in his living room in Sydney after my presentation to the Health Informatics Society of Australia in 2012 on health IT trust (http://hcrenewal.blogspot.com/2012/08/my-presentation-to-health-informatics.html), to replace my earlier terms "health IT done well" vs. "done poorly."

It was not just "one employee who pushed the wrong button."  A team of apparently incompetent IT personnel and utterly incompetent IT managers - completely devoid of any understanding of human-computer interaction - were, in essence, standing behind this this employee and guiding his hand.

The Hawaii mishap vividly demonstrates bad IT in the most critical of settings - badly conceived, designed & implemented, lacking appropriate safeguards, usually by people who do not know the domain, and often who are, dare I say, lacking common sense.

Questions that the incident raises include:

• How [in God's name] were such critical items as "Test missile alert" and "Missile alert" (the real thing) residing in the same menu?  Who came up with such bad, terse labeling as well?  [A "hot spot" for user entry error] 
• Why were there no reasonable safeguards? 
• Why was it easy for anyone to make a big mistake?
• Why was no system in place for rapid retraction?

The answers translate back to - well, I probably don't need to say it.

Hawaii missile alert: How one employee ‘pushed the wrong button’ and caused a wave of panic

Washington Post

Amy B Wang  

January 14, 2018
https://www.washingtonpost.com/news/post-nation/wp/2018/01/14/hawaii-missile-alert-how-one-employee-pushed-the-wrong-button-and-caused-a-wave-of-panic/

... Around 8:05 a.m., the Hawaii emergency employee initiated the internal test, according to a timeline released by the state. From a drop-down menu on a computer program, he saw two options: "Test missile alert" and "Missile alert."

This is  a classic example of what can be called a "hot spot for user entry error."

... He was supposed to choose the former; as much of the world now knows, he chose the latter, an initiation of a real-life missile alert.

... "Based on the information we have collected so far, it appears that the government of Hawaii did not have reasonable safeguards or process controls in place to prevent the transmission of a false alert," Pai said in a statement.

... Part of what worsened the situation Saturday was that there was no system in place at the state emergency agency for correcting the error, Rapoza said...."In the past there was no cancellation button. There was no false alarm button at all,"

.... "Part of the problem was it was too easy - for anyone - to make such a big mistake," Rapoza said. "We have to make sure that we're not looking for retribution, but we should be fixing the problems in the system.

It would not be unreasonable to predict that U.S. armed forces were put on alert, perhaps even scrambling fighter planes near the Korean peninsula - moves that other countries could detect.

This "mishap" could have caused N. Korea or other hostile country to react, and led to catastrophe.

The utterly incompetent IT personnel and their utterly incompetent managers who birthed such a cornucopia of IT atrocities should be severely punished.

-- SS

Jan. 16, 2018.  Update, update.  Who's got the button?

This new WaPo story shows the "unholy" menu - a jumbled mess.

https://www.washingtonpost.com/news/morning-mix/wp/2018/01/16/that-was-no-wrong-button-in-hawaii-take-a-look/?utm_term=.147cc4852c8e

Was this designed by an expert in human-computer interaction?  I think not...

Incredible.

-- SS

=== Post removed by author ===

=== Post removed by author ===

NIST on the EHR Mission Hostile User Experience: Blame the User? Nyet...

I have often had to respond to those who claim that EHR's don't cause medical errors, users do. That subset of the health IT irrationally exuberant seem common in the health IT industry and pundit channels.

NIST (The U.S. National Institute of Standards and Technology) has recently issued a draft report "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).

The report is quite negative concerning the low usability of today's commercial health IT, and recommends significant improvements that have been standard practice in other mission- and life-critical IT sectors for decades.

I will have more to write about this report, but I found a passage and footnote early in the report striking.

Of note, from the new NIST draft report:

This passage, from page 10:

The EUP (EHR usability protocol) emphasis should be on ensuring that necessary and sufficient usability validation and remediation has been conducted so that use error [3] is minimized.

[3] “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.

This passage describes what I have termed a mission hostile user experience.

"Blame the user" as the default, reflex reply to clinical IT-related medical errors, and the "hold vendor harmless for defects" clauses that facilitate this excuse are now heading to the junkpile - in the clinic, hospital, and courtroom.

It is my hope that the the Wild West, free-for-all, cavalier, get out of jail free days of the health IT industry are coming to a close.

Hint to health IT industry: you may actually need to invest in people who know what they're doing, instead of hiring the cheapest labor possible. (See, for example, my Aug. 2010 post
"EPIC's outrageous recommendations on healthcare IT project staffing" for more on that issue.)

-- SS

Oct. 25, 2011 Addendum:

This comment (#5, October 25th, 2011 at 12:38 pm) by "a practicing front-end designer and application developer" over at HIStalk is quite interesting. The writer points out the differences between designers and developers, and opines that:

If you’re going to improve vendor design, it has to begin with an internal commitment to value designers and what they contribute to the product development process. They can not be an afterthought. There are very few companies with this mindset. Almost all HIT companies are developer-driven, so the first thought, and one that is promoted in this report, is to turn developers into designers. This will not work! A developer and a designer require two fundamentally different skill sets that are not easily transposed. Developers are trained to think rationally and analytically; design requires empathy for the user.

In health IT, empathy for the patient as well, I might add.

-- SS

Are Health IT Designers, Testers and Purchasers Trying to Harm Patients? Part 1 of a Series

"You should not have to work around something that is not in the way" - S. Silverstein (me)

(Note: Part 1 of this series is here, part 2 is here, part 3 is here, part 4 is here, part 5 is here, part 6 is here, part 7 is here, and part 8 is here. 2011 addendums: a post that can be considered part 9 is here, part 10 is here.)

In effect through superciliousness and complacency, they just might be, along with the people who approve EMR's, CPOE's and other clinical IT for sale, as well as those who actually purchase this IT for healthcare organizations.

The title of this post is deliberately provocative because the stakes of the issues addressed are so high, not to mention a personal motivation.

The issues discussed here and at my academic site on HIT difficulties are not theoretical or speculative. A relative was seriously injured in 2010 as a result of an EMR contributing to a breakdown in clinician communications. They suffered a nearly fatal hemorrhage and major complications due to resultant medication reconciliation failure.

Clearly more "inclusive" approaches by clinicians towards addressing these issues have not succeeded.

I've recently been conversing with a number of correspondents at major healthcare systems about just how bad health IT is. EMR's and CPOE's that confound and intimidate and look as if designed by computing amateurs are the topic of discussion.

Here is a simple first principle:

Clinical IT should under no circumstances present a mission hostile user experience.

I have seen offenses such as clinically important, related data elements scattered far and wide making physicians and nurses go on 'wild goose chases' or "click-o-rrhea" (a term coined by an MD HIT user who wishes to remain anonymous) to relate them; diagnosis lists that place rare diagnoses near the top and common ones a hundred items below; boxes that hide part of diagnostic terms leading to incorrect selections, and many other violations of even the most basic principles of creating a good user experience and of good information science.

Remarkably (and ironically), we as a culture devote far more time and energy debating the user experience presented by Windows XP/Vista/7, vs. Mac OS X, vs. various Linux flavors, and of PDA's, MP3 players and cellphones than of mission critical health IT.

The EHR user experience? Bluntly stated, "let the doctors eat cake" seems to be the Marie Antoinette-like corporate attitude.

What I have seen in production systems actually in use would have earned a failing grade for an undergrad in a course on HCI (human computer interaction) and certainly in my graduate healthcare informatics courses.

Here is mid 1980's wisdom written for the U.S. Air Force on user interfaces:

SIGNIFICANCE OF THE USER INTERFACE

The design of user interface software is not only expensive and time-consuming, but it is also critical for effective system performance. To be sure, users can sometimes compensate for poor design with extra effort. Probably no single user interface design flaw, in itself, will cause system failure. But there is a limit to how well users can adapt to a poorly designed interface. As one deficiency is added to another, the cumulative negative effects may eventually result in system failure, poor performance, and/or user complaints.

Outright system failure can be seen in systems that are underused, where use is optional, or are abandoned entirely. There may be retention of (or reversion to) manual data handling procedures, with little use of automated capabilities. When a system fails in this way, the result is disrupted operation, wasted time, effort and money, and failure to achieve the potential benefits of automated information handling.

In a constrained environment, such as that of many military and commercial information systems, users may have little choice but to make do with whatever interface design is provided. There the symptoms of poor user interface design may appear in degraded performance. Frequent and/or serious errors in data handling may result from confusing user interface design [in medicine, this often translates to reduced safety and reduced care quality - ed.] Tedious user procedures may slow data processing, resulting in longer queues at the checkout counter, the teller's window, the visa office, the truck dock, [the hospital floor or doctor's office - ed.] or any other workplace where the potential benefits of computer support are outweighed by an unintended increase in human effort.

In situations where degradation in system performance is not so easily measured, symptoms of poor user interface design may appear as user complaints. The system may be described as hard to learn, or clumsy, tiring and slow to use [often heard in medicine, but too often blamed on "physician resistance" - ed.] The users' view of a system is conditioned chiefly by experience with its interface. If the user interface is unsatisfactory, the users' view of the system will be negative regardless of any niceties of internal computer processing.

A convincing demonstration of design improvement has been reported by Keister and Gallaway (1983). Those authors describe a data entry application in which relatively simple improvements to user interface software -- including selection and formatting of displayed data, consistency in wording and procedures, on-line user guidance, explicit error messages, re-entry rather than overtyping for data change, elimination of abbreviations, etc. -- resulted in significantly improved system performance. Data entry was accomplished 25 percent faster, and with 25 percent fewer errors.

Two decades later, healthcare IT design remains suboptimal.

In 2009 many physicians using healthcare IT applications have all but "given up" on trying to get major user experience deficiencies corrected and just do as best they can, hoping to avoid burnout and malpractice suits. Physician learned helplessness incarnate.

The products I have been hearing about (which, incidentally, the users believe are "CCHIT certified") are not just bad, but spectacularly bad. IT has been trampling over medicine, a cross-occupational invasion, with doctors' time, professions, and ability to deliver care in essence held hostage.

In future posts in this series I will be presenting mockups showing actual deficiencies I am hearing about (not actual screen shots, unfortunately, since the vendor contracts forbid that on the basis of "intellectual property" protection).

These observations may also help better explain why many organizations seem to choose an EMR or other clinical IT first, and then seek to hire medical informatics expertise later. They need a willing physician with informatics credentials to help hide the sour taste of deficient IT their fellow clinicians are asked (or mandated) to consume.

Non-clinicians may be startled by what their caregivers and the care they provide is being subjected to, without patient consent.

More, along with screen mockups created from actual screen shots (the mockups are necessitated by vendor IP protection clauses) appear in Part 2.

The series is unique to date as far as I can tell.

(Note: part 2 is here and part 3 is here.)

--- SS