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Pittsburgh Post-Gazette: “Medication Errors in Hospitals Don’t Disappear with New Technology.” Government: “It’s the Doctors’ Fault.”

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Lambert here: Happily, the Post-Gazette cites the author, Doctor Silverstein. I’m also sure readers can supply supporting evidence from their own experiences as patients, observers, or IT specialists!

By Scot M. Silverstein, MD, Medical doctor, and Medical Informatics professional via NIH-sponsored postdoctoral fellowship at Yale School of Medicine 1992-1994, Faculty, Drexel University, College of Information Science and Technology, Philadelphia, PA, and architect of Drexel’s Graduate Certificate Program in Healthcare Informatics. Originally published at Health Care Renewal.

The Pittsburgh Post-Gazette published an article on EHR problems yesterday entitled “Medication errors in hospitals don’t disappear with new technology.” It is based on a recent study by the Pennsylvania Patient Safety Authority, retrievable here: http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2017/Mar;14(1)/Pages/01.aspx

I am cited. Also cited is an HHS official, Dr. Andrew Gettinger, acting deputy national coordinator for health information technology in the U.S. Dept. of Health and Human Services, who disagreed with my views. I am familiar with Dr. Gettinger’s views. More on that later.

Medication errors in hospitals don’t disappear with new technology Steve Twedt Pittsburgh Post-Gazette http://www.post-gazette.com/business/healthcare-business/2017/04/10/medication-error-electronic-health-record-hospitals-patient-safety-authority/stories/201704090072

In the first six months of 2016, Pennsylvania hospitals reported 889 medication errors or close calls that were attributed, at least in part, to electronic health records and other technology used to monitor and record patients’ treatment.

A majority of the errors pertained to dosages — either missed dosages or an administration of the wrong dose. Of the 889 errors, nearly 70 percent reached the patient. Among those, eight patients were actually harmed, including three involving critical drugs such as insulin, anticoagulants and opioids.

The extent of the injuries was not detailed, although no deaths were recorded. Those are the stark numbers in a new analysis by the Pennsylvania Patient Safety Authority, an independent state agency that looks at ways to reduce medical errors.

But interpretations of the report’s significance — and specifically the overall benefits and risks of information technology in a hospital setting — cross a wide spectrum.

The wide spectrum is the gap between those who believe in what might be called cybernetic supremacy (that is, the hyper-enthusiasts who ignore the real-world downsides of technology such as today’s EMRs) versus those who promote what I call cybernetic sobriety (a more candid, mature attitude fostered by actual knowledge of the long history of cybernetic failures and the myriad causes of such failures).

Some view reports such as that of the Pennsylvania Patient Safety Authority (PPSA) in a reasonably patient rights-oriented manner, including the PPSA itself:

“This is the classic ‘tip of the iceberg,'” said pharmacist Matthew Grissinger, manager of medication safety analysis for the Patient Safety Authority in Harrisburg and co-author of the analysis with fellow pharmacist Staley Lawes. “We know for a ton of reasons not every error is reported.”

I’ve written extensively at HC Renewal on the “tip of the iceberg” issue, a phrase also used in the past by the FDA CDER (Center for Devices & Radiological Health) director Jeffrey Shuren MD JD and others. See for example my February 28, 2010 post “FDA on Health IT Adverse Consequences: 44 Reported Injuries And 6 Deaths In Two Years, Probably Just ‘Tip of Iceberg'” at http://hcrenewal.blogspot.com/2010/02/fda-on-health-it-adverse-consequences.html as well as my January 8, 2016 post “Yet another observation that known health IT-caused injuries and deaths are ‘the tip of the iceberg'” at http://hcrenewal.blogspot.com/2016/01/yet-another-observation-that-known.html.

Of course, a PPSA disclaimer was issued, in my view perhaps to placate the health IT industry:

…Mr. Grissinger cautioned that the findings are “absolutely not” an indicator that patients are less safe, as hospitals have moved from paper to electronic records incorporating health information technology…the authors did conclude that technology meant to improve patient safety “has led to new, often unforeseen types of errors” due to system problems or user mistakes.

A more correct statement might have been that “these most current findings are yet another red flag that patients could be less safe with bad health IT, but since there are a ‘ton of reasons’ not every error is reported, we just don’t know – and we truly need to devote a great deal of effort towards filling the gaps in our limited knowledge.”

I’ve written on the issue of not jumping to health IT safety conclusions, one way or another, based on current data, especially when that data is admittedly limited. For example, see my April 9, 2014 post “FDA on health IT risk: “We don’t know the magnitude of the risk, and what we do know is the tip of the iceberg, but health IT is of ‘sufficiently low risk’ that we don’t need to regulate it” at http://hcrenewal.blogspot.com/2014/04/fda-on-health-it-risk-reckless-or.html.

In that post I noted that a secret 2010 FDA internal report on health IT risk (marked “not for public use”) unearthed by investigative reporter Fred Schulte stated that “…In summary, the results of this data review suggest significant clinical implications and public safety issues surrounding Health Information Technology...The absence of mandatory reporting enforcement of H-IT safety issues limits the number of relevant MDRs [device reports] and impedes a more comprehensive understanding of the actual problems and implications.“

We don’t know what we don’t know, but to date the efforts to robustly learn the truth has been milquetoast to non-existent. “Proof (of safety) by lack of evidence” – in an area where we admit the evidence is likely severely deficient – seems to be the default industry go-to position. “Proof by lack of evidence”, of course, is a logical fallacy.

Back to the Pittsburgh Post-Gazette:

… Frustration with the technology In January 2015, 35 physician groups — including the American Medical Association, the American Academy of Family Physicians and the American Society of Anesthesiologists — sent a nine-page letter about electronic health records to the national coordinator for health information at the U.S. Department of Health and Human Services.

Their purpose was to convey their “growing frustration with the way EHRs are performing,” the letter stated.

“Many physicians find these systems cumbersome, do not meet their workflow needs, decrease efficiency, and have limited, if any, interoperability. Most importantly, certified EHR technology can present safety concerns for patients.”

That Jan. 2015 letter is at http://mb.cision.com/Public/373/9710840/9053557230dbb768.pdf and speaks for itself. Kudos to the Post-Gazette for citing it; the public is largely unaware of its existence.

I am then cited in the Gazette article:

Physician Scot Silverstein, a Philadelphia-based consultant and independent expert in electronic health records and vocal critic of such systems, calls the software “legible gibberish” better designed for handling warehouse inventory than managing and monitoring patient care in a clinical setting.

“Electronic health records are a massively complex computer application, far too complex than is needed for a clinic taking care of patients,” he said in a phone interview. “EHRs need to be toned down, be less complex, and be used less.”

Opportunities for mistakes are numerous, he said, as a physician may have to scroll through multiple screens, while each screen with a dozen or more columns plus an array of drop down menus. Some systems, he said, allow doctors to keep screens on multiple patients open simultaneously, increasing the chances of a medication mix-up.

“The software needs to be designed better.”

I am a vocal critic of bad health IT, and actually called the output of the systems to be “legible gibberish” as at my Feb. 27, 2011 post “Two weeks, two reams” at http://hcrenewal.blogspot.com/2011/02/electronic-medical-records-two-weeks.html, but the quote is close enough.

Indeed, today’s EHRs seem more designed for mercantile, manufacturing and management settings, and “calm, solitary office environments” (channeling Joan Ash) rather than the incredibly complex, poorly bounded and unpredictable environment of clinical medicine. I am quoted accurately on the complexity and overuse issue, although the issue of preventing physicians from having multiple patient screens open was actually a short term workaround known to me to have been put in effect some years back. This was done when a major EHR was unpredictably transposing orders into wrong charts when multiple patient’s screens were open (creating two potential patients at risk). The software indeed needs to be designed better, to meet clinical needs.

Dr. Silverstein, who says his mother’s death was precipitated by a heart medication mix-up involving her electronic health record, cites federal initiatives giving hospitals financial incentive to implement electronic health systems as pushing the programs without sufficient vetting.

“The thinking was, ‘Computers plus doctors equals better medicine,’ period. But the technology was not and is still not ready for that kind of push.”

Indeed it was not ready, being experimental technology. Further, vetting in real-world settings via robust premarket surveillance, and postmarket surveillance of any rigor were, in fact, absent when massive incentives (and penalties) were announced as part of the so-called Economic Recovery Act and its “HITECH” component.

Instead, he recommends some combination of paper, with paper imaging capability so records are accessible, and electronic systems. “I don’t think paper should or ever will go away completely,” he said.

On this issue, and for a highly successful real-world example, see my August 6, 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.

I note with some irony about the above linked post (regarding a highly successful EMR that protected clinicians from oppressive clerical burdens) that the newly-appointed Director of the Office of the National Coordinator for Health IT (ONC), Dr. Donald Rucker (http://www.healthcareitnews.com/news/donald-rucker-named-new-national-coordinator-onc), was formerly the Chief Medical Officer of Shared Medical Systems, a hospital infrastructure IT provider. He then became CMO of the failed Siemens Healthcare EMR effort after SMS was bought out ca. 2000. Siemens Healthcare officials told me ca. 2007 that the real-world, highly successful invasive cardiology information system I’d developed as shown in the aformentioned Aug. 2016 post was “impractical” for commercial emulation.

Back to the Post-Gazette article. In it, a government health IT official blames the doctors, a line I’ve heard dating back to the early 1990s when I was a postdoctoral informatics fellow at Yale:

A need for better training

Anesthesiologist Andrew Gettinger, acting deputy national coordinator for health information technology in the U.S. Dept. of Health and Human Services, disagrees with Dr. Silverstein.

He identified three key components to a successful electronic health record system — good design and implementation and the users’ good understanding of the system.

I have no disagreement there, only on the route to achieve those goals.

“What we find is that many clinicians who complain vociferously about the software and how many clicks it takes, and how user unfriendly it is, have not actually taken the time to understand the system,” he said.

This seems the “blame the physicians, they’re just complainers and Luddites” canard I’ve written about for almost 20 years now.Gettinger seems to ignore the issue of bad health IT and use error:

  • Bad Health IT is health 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, lacking in evidentiary soundness, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation. (S. Silverstein and J. Patrick).
  • Use error (as opposed to user error) is defined by another U.S. government agency, the National Institute of Standards and Technology (NIST) as follows: “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).

No amount of “training” can compensate for those issues. Further, physicians and nurses just don’t have abundant time for such training about mega-complex systems, on which they’re already spending 50% or more of their time. They especially don’t have the time to learn multiple EHR’s, a situation that exists for clinicians who work on more than one hospital. I possess the physician and nurse user guides for a number of EHRs though my forensics work. A manual for an EHR is as complex as a manual for an office suite like MS Office, or an OS such as Windows.

There’s also the fact that physicians and nurses are not reimbursed for the hours they spend feeding the payers and other profit-makers the data, for free.

“Quite frankly, doctors are not always the best at signing up for training and taking the training…

Blaming the doctors again.

… , and some of the training is not always the best.”

Not that, as mentioned previously, “training” is at the root of the EHR problem.

He allowed that the usability criticism “is a very legitimate thing to look at”…

How kind of Dr. Gettinger to acknowledge what has been known in the IT world for decades about poor usability, e.g., this mid 1980’s wisdom written for the U.S. Air Force on user interfaces:

GUIDELINES FOR DESIGNING USER INTERFACE SOFTWARE ESD-TR-86-278 August 1986 Sidney L. Smith and Jane N. Mosier The MITRE Corporation Bedford, Massachusetts, USA Prepared for Deputy Commander for Development Plans and Support Systems, Electronic Systems Division, AFSC, United States Air Force, Hanscom Air Force Base, Massachusetts. Approved for public release; distribution unlimited.

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.

Back to Dr. Gettinger for a somewhat non-sequitur ‘BUT’ disclaimer:

… BUT he defended the federal incentives, saying they defrayed the cost to hospitals while encouraging vendors to develop better systems.

I would say the incentives, just like the spectacularly failed subprime mortgage market a decade ago, just incented the health industry to waste hundreds of billions of dollars on half-baked, experimental technology, alienating physicians and nurses (cf.: the 2015 Medical Societies letter mentioned above). The incented effort even put some organizations in financial jeopardy, e.g.,

“MD Anderson to cut about 1,000 jobs due to ‘financial downfall officials largely attributed to its EPIC EHR implementation project’” at http://hcrenewal.blogspot.com/2017/01/heath-it-mismanagement-md-anderson-to.html

“What is more important in healthcare, computers, or nurses and other human beings? Southcoast Health cutting dozens of jobs on heels of expensive IT upgrade” at http://hcrenewal.blogspot.com/2016/04/what-is-more-important-in-healthcare.html

“Lahey Health: hospital jobs lost, but computer vendors prosper” at http://hcrenewal.blogspot.com/2015/05/lahey-health-hospital-jobs-lost-but.html,

“Monetary losses and layoffs from EHR expenses and EHR mismanagement” (http://hcrenewal.blogspot.com/2013/06/monetary-losses-and-layoffs-from-ehr.html),

“Financial woes at Maine Medical Center: Reading this blog might have saved them millions of dollars, and prevented massive ‘cost saving initiatives'” (http://hcrenewal.blogspot.com/2013/05/financial-woes-at-maine-medical-center.html),

and “In Fixing Those 9,553 EHR “Issues”, Southern Arizona’s Largest Health Network is $28.5 Million In The Red” (http://hcrenewal.blogspot.com/2014/06/in-fixing-those-9553-ehr-issues.html)

I also believe the easy money disincented the vendors from improving the techology, instead selling what they had on hand and acting to discourage innovation and competition to maximize their profits, e.g., see my April 16, 2010 post “Healthcare IT Corporate Ethics 101: ‘A Strategy for Cerner Corporation to Address the HIT Stimulus Plan’” at http://hcrenewal.blogspot.com/2010/04/healthcare-it-corporate-ethics-101.html and my August 31, 2012 post “Health IT Vendor EPIC Caught Red-Handed: Ghostwriting And Using Customers as Stealth Lobbyists – Did ONC Ignore This?” at http://hcrenewal.blogspot.com/2012/08/health-it-vendor-epic-uses-clients-as.html.

Finally, I regrettably note that Gettinger seems to possess a rather hard-nosed attitude about health IT harms. I have contributed, of course, to articles about EHR’s in other publications, including, among many others, Politico. Arthur Allen at Politico wrote me this [via email –lambert] in 2015 regarding my opposition to the toothless “Health IT safety center” concept, and my promotion of a need for true HIT regulation:

On Wed, Jun 17, 2015 at 1:13 PM, Arthur Allen wrote:

I’m putting together a piece on the safety center with some notes from an interview I did with Andy Gettinger a few weeks ago. I asked him whether he though the RTI panel (which RTI named, apparently) would have come to the same consensus – that the safety center should be a safe harbor, not an investigatory agency – if you [i.e., me – Scot – ed.] had been on the panel.

He said,

“he [i.e., me – Scot – ed.] may have heard what we were intending and been able to step back from specific things relative to his mother’s care and gotten to a space to see that this initiative has the potential of making real change in the EHRs used throughout the country. I would have loved to have Scot at the table.”

Any response?

In other words, if only I was able to “step back” from my mother’s severe injury, year’s worth of horrible suffering as a cripple before she died as a mentally-impaired vegetable, and my lovely mother being taken away from my home in a body bag as a result of a health IT mishap, I’d be able to see just how wonderful a toothless HIT safety center would be. (Also, I was never asked to be “at the table”.)

What a kind comment that was.

In conclusion:

While I wish the Pittsburgh Post-Gazette article was longer, in its limited space its author did touch upon the major relevant issues well regarding the PA Patient Safety Authority study and its implications towards national Health IT policy.

ONC’s Dr. Andrew Gettinger’s responses, however, seems to reflect an unwillingness of he and the government to acknowledge Bad Health IT. His repsonses also appear to show a lack of appreciation of the complaints about EMRs from nearly 40 medical societies. “It’s the doctors fault” for not training enough.

He does acknowledge that better IT would be a good thing, but to date the best HHS could come up with to achieve that goal is a toothless Safety Center. Healthcare IT would be the only healthcare device sector afforded that extraordinary regulatory accommodation.

The notion that all that is needed to solve EMR problems is clerical training of (resistant) physicians seems that of a computing dilettante, and/or a health IT hyperenthusiast. Such a view ignores decades of knowledge of bad IT, and in multiple sectors.

The blaming of physicians is also decidedly unhelpful towards the reputation of the technology and its enthusiasts in government. Bad enough that physicians are already spending 50% or more of their time at computers, distracting from patient care. Gettinger’s “solution” also fails to acknowledge that physicians often work in multiple hospitals with different EHRs. They don’t have the time to become clerical experts in multiple mega-complex systems.

Claiming the national incentives promoted the vendors to make better health it is also absurd. It actually promoted them to sell the bad health IT they had on hand, and lessened any motivation to improve the technology.

What the issues really boil down to is a conflict between those who believe in cybernetic supremacy (the hyperenthusiasts who ignore the real-world downsides) versus those who promote what I call cybernetic sobriety (a more candid, mature attitude fostered by actual knowledge of the long history of cybernetic failures and the myriad causes of such failures).

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.

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28 comments

  1. Disturbed Voter

    Any doctor knows that there is no panacea. And it is unlikely that the responsibility for malpractice will be transferred from the humans to the AI, or the IT provider. It will remain primarily with the surgeon and the anesthesiologist. Technophiles aren’t so cautious, particularly if they are selling IT. EHR is a part of medical administration. In medical administration I have seen the transition from paper records to EHR … and whatever the difficulties of EHR, they are not as great as paper records, which were chaos at times. Working in medical administration with an EHR … we are tireless in seeking out and correcting individual errors, training medical personnel (who are only human) and cribbing the known problems with our system, though it took time to identify these. The bottom lines are three … did the patient or parent provide us with accurate information at registration (similar names are a problem) … are we admins proactive in being aware of and reactive to any sign of a discrepancy before or after the patient sees the doctor … and are the medical practitioners doing their job (reviewing the complete patient record). Medical team dynamics are trained as … any team member; med tech, nurse or doctor can call a stop … if any of them are uncomfortable with what is happening, so the situation can be reassessed. Human errors will still occur. Medical practice is necessary, but it is also dangerous both to the patient and sometimes to the medical staff.

    1. Anonymous

      Sure, legibility is better with EHR, but the quality of information inside the notes has degraded substantially. Writing notes now requires you to check boxes and boxes and boxes, which inserts a great deal of pre-generated, irrelevant text into the note. None of this is to add to the note’s completion or to better communicate with other physicians who will read it, it’s to justify the billing requirements of some insurer so the health system can maximally up-bill the patient for that particular encounter.

      Notes used to be succinct and contain only the pertinent information so other physicians could understand the writer’s reasoning and plan. Now they’re 90% a billing instrument with a few narrative lines in the assessment/plan that contain the only medically relevant information. Everything else is pre-generated, generic, garbage text.

  2. DH

    I work in engineering. In my experience, the higher up the food chain, the less focus on quality control, quality assurance, and continuous improvement, especially on their own processes. When it comes to integrating IT solutions into the organization, most decision-makers outside of Silicon Valley struggle to do more than turn on their cell phones, so they are incapable of providing solid guidance and are very susceptible to the latest flavor of the month.

    The further down the food chain, the more cumbersome the QC processes get, because, after all these are unlikely to be the people who graduated from the top 10% of their high school class. The outcome often gets turned into parody videos like this: https://www.youtube.com/watch?v=p4Murq5x_pw

    The best companies focus on quality and continuous improvement at all levels. We may not appreciate the finer culinary points of McDonalds cuisine for example, but they have been able to structure streamlined processes that turn out similar products at low cost, quickly with trained staff hired from the local community pretty much anywhere in the world. Other firms have done similar things with their processes. It is unlikely the medical system is putting the same amount of attention to detail in getting the simplicity and quality of their systems at all levels form the hospital management down to the cleaning staff, so we see medical records blunders, hospital infections, etc. at unacceptable levels in an exorbitantly expensive and inefficient system. From a profits standpoint, this still seems to be viewed as a feature, not a bug, so the entire culture is likely to require change.

    Most of the major corporate fails we have seen over the past few years have been managements that are disconnected from what is going on in the lower levels of their organization and just focusing on financial outcomes or other singular metrics (WF fake accounts, Volkswagen diesel emissions, banking trading blunders, United “passenger reaccommodation” , etc.).

    1. Mel

      “Attention to detail” is a tough thing to manage. The management overview of attention to detail necessarily leaves out the details.

  3. RickM

    And then there is the fact that EHR is really intended to make billing “more complete”?

    1. Bob

      True. EHRs are sold mostly to MBA types in the office, who are primarily interested in reimbursement for services rendered. Your sales pitch isn’t helped by claims that your EMR will make life easier for physicians and nurses. But if you can claim that your EMR will bill for and capture more money, you have a sale!

      Physicians, nurses, and others will all be forced to adapt to the changes that the managers in Administration have placed upon them.

  4. Collin

    The goal of medical school and residency training – a minimum of 7-10 yrs of training after college – is to produce a person capable of diagnosis and treatment from the ground (“Hello, Mrs Ortiz, donde esta su dolor?”) up.

    The goal of the EMR is to itemize justification of the largest bill to Medicare/govt (which mandated EMRs ) possible. The “tell the story” aspect – which docs spent years learning – is abysmal.

    EMR software is ~20 yrs behind common software we all use for travel, bills,…or actually anything that has to survive in the marketplace without a govt mandate and billions of dollars of govt money to subsidize a product that can’t stand on it’s own merits even if it were free.
    The founder of Epic software recently said “I’m married to a doctor. People in my family are doctors. Years ago, I thought ‘the doctors will design and control electronic records, as they should because they know best what’s needed.’ But they didn’t; insurance companies and the govt kept control.”

  5. Jason

    US hospital based physician here. EMR/EHR have been poorly designed from the start — way too complicated — and focused more on collecting diagnosis and procedure codes — and fulfilling regulatory compliance data points with irrelevant documentation/data-entry. Although they improved some legibility issues with documentation — they didn’t improve communication. Paper records may have had problems with legibility at times — but there was rarely ambiguity about the meaning or context of what someone wrote. Now, not only are diagnosis lists confusing, but even medical orders/instructions are open to interpretation given the default choices the computer offers the providers. (For example: the pharmacist and nurse wondering if the doctor really meant to order the first dose of medicine tomorrow morning because the computer defaults it to that time). The biggest problem with EMR/EHR is that it added tons of data-entry time to clinical provider’s time (nurse and doctor) — which pulls them away from face-to-face clinical time and distracts them from important awareness of the patient/family clinical and psychological changes and needs.

    The EHR/EMR needs to be built to help physicians and nurses with clinical workflow — not built to help the business people collect more money and hit all their regulatory compliance targets.

    1. Collin

      But when the entire system has changed from a profession to a business, collections (rather than workflow) is the priority.
      Patients are widgets. Not that there’s anything wrong with that; after all, business is business – isn’t it?

  6. Synoia

    This seems the “blame the physicians, they’re just complainers and Luddites” canard I’ve written about for almost 20 years now.Gettinger seems to ignore the issue of bad health IT and use error:

    Can’t image where I’ve read that before (Microsoft , WIndows 10)….

  7. Ahimsa

    As a physician working in several different health care facilities and maintaining an office, I have had the singular misfortune of having to learn 7 different inpatient EHRs, and 2 outpatient EHRs. So I would like to share some of my observations regarding a very well informed article on the subject. Unnecessary documentation needs to be “deemphasized”. This can very easily be done in the history taking component as well the review of systems. Only positive pertinent physical exam findings need be documented. Implementing these alone would free up a bunch of time and enable the physician to more meaningfully impact on patient care.

    When pharmacist Matthew Grissinger, states “We know for a ton of reasons not every error is reported”, he cannot be more correct. Order entry process is very cumbersome in most EHRs and neither intuitive nor algorithmic. To simplify the process for physicians, order-entry sets are created that are often pages long. This in turn makes it very difficult for nurses. A good example of this would be the treatment of a patient with diabetic ketoacidosis. The treatment of this disorder requires frequent blood tests and multiple changes of IV fluids. Order sets are incapable of dealing with individual patients as they are created by committees that are seeking the lowest common denominator. Thus not only are these orders not individualized, they are difficult to execute. And if errors are made they go undetected or unreported. And this is but one example of a very common but potentially life-threatening disorder that can be so easily mismanaged. There are hundreds of examples that can be given.

    When Dr Silverstein writes “They especially don’t have the time to learn multiple EHR’s, a situation that exists for clinicians who work on more than one hospital”, nothing can be further from the truth. While my own situation sounds unique, it is actually not. So many internists now moonlight as hospitalists to meet an unfulfilled need and to supplement their income. It is inevitable they end up interacting with multiple systems and often the same system that has been modified to meet the unique needs of that particular institution. How can they possibly learn all the EHRs and their modifications

    When Dr. Gettinger writes “What we find is that many clinicians who complain vociferously about the software and how many clicks it takes, and how user unfriendly it is, have not actually taken the time to understand the system,” he is obviously very naive about how medicine is practiced in the trenches. Not only does he need to pay attention to the points raised above, he also needs to ask how often do organizations invest in retraining their physicians. EHRs undergo periodic updates and information about these updates is provided in innumerable undecipherable bulletins that nobody has time to read. All physicians and nurses have a learning curve when they first start using an EHR and revisiting the EHR after 3-4 months to consolidate, clarify should be a no-brainer. But by the time hospitals have invested in purchasing these enormously costly elephants, and spending on the initial training, they are so financially stressed that refresher courses are out. And the training of new hires is left entirely to so called super-users within the system. And believe me, the turnover especially amongst the nurses who actually deliver the care is very high, so the system is primed for error.

    I could write more but the article itself is excellent and indirectly ends up highlighting the need to homogenize the system, make it simpler and not leave it to the private sector to solve the problem by throwing money at it through the Hi-Tech Act to appease (and enrich!) a certain set of constituents

  8. a different chris

    Only quibble:

    >t actually promoted them to sell the bad health IT they had on hand, and lessened any motivation to improve the technology.

    It is quite hard to get s/w per se approved in the medical industry, then once they’ve -FDA, etc –
    have approved it changes are beyond a nightmare. Now I hate the “suits” as much as anybody, but the engineers can’t improve the product when the cost of getting the next version thru is so high.

    Hmmm, if you look at my post you see that, as usual in the glorious free market we live in, paying –
    that is, touching current profits – for something is arguably the problem.

    1. craazyboy

      I have no idea how bad the industry systems really are, but I suspect there may be no standardization whatsoever. To compare to how the Wintel industry grew and evolved, more or less in the right direction, MSFT and Intel were very active in setting standards, publishing hardware interfaces, defining file formats, publishing application programmer interface specs, inputs into good, standardized, GUI design, etc…Without this industry direction, none of the participating individual companies would have a clue to what to do.

      Seems the FDA would be one key player in performing and certifying the industry products for compliance with the standards.

      Like prolly fer starters, standard form images or maybe PDFs that covered most recording of doctor and nurse inputs and whomever else has scheduling, reporting and data collection duties. Doc, nurse, patient ID, billing and invoicing, and identifying which hand or leg is the “left” one – an arrow icon solves a lot of multi-lingual difficulties here, and uncomfortable, costly errors.

      Then it should be possible to abstract “workflow” rules for many procedures without the process being completely dependent on a particular hospital, clinic and staff. At least cover most cases with decision tree options and options for ordering more tests, which room the patient gets moved to next, follow up appointments w/ newly created relevant medical record, or whatever.

      Then, the oldest and most up to date software packages available in the corporate commercially available software space are accounting and billing systems. They all are supported by well trained consulting firms whom use the pre-written software customization features to fine tune things for a particular organizations needs.

      So if they are nowhere with all this, then here’s where the problem starts. If no one can specify the product, then no programmers, engineers, accountants, etc… will be able to work out the details and code this product. Unless you want programmers telling doctors to do all manner of silly things.

    2. Jim

      A 1,800 + page bill, and we are working in a “Free Market”? I don’t know if a Free Market in health care would solve our problems or not or if we ever actually had one, but we sure as heck don’t have a Free Market in health care right now.

      fixhc.org

    1. craazyboy

      The one that comes without the keyboard and mouse. It’s more secure, and we can access it thru the corporate website. [Dogbert passes out on floor]

  10. Jason Boxman

    Such a train wreck is not surprising. Adoption of these systems is essentially mandatory, with the federal government having offered subsidies to do so.

    The story about the history of the VA’s VistA system linked to a few weeks ago is a stark contrast.

    1. Disturbed Voter

      There were ultimately three problems with the VA VistA. But it was a good try. One … it did’t collect data to a central repository … each hospital is an island. Big Data (latest panacea) doesn’t like that. Two, it is relatively easy to use, because its user interface was designed by doctors … but that doesn’t solve the need for commercial vendors to make a buck off of yet another government money stream, and it can be used as freeware by other organizations (communism). Three, the physician development team can’t keep up with rapidly changing technology (not their fault).

  11. M.

    There seem to be at least three different types of medication errors going on:

    (A) Poor EHR design leading to sloppy-and-paste leading to treatment errors.

    (B) Communication errors between different institutions due to EHR compatibility problems.

    ( C) Medication errors due to Pharma/PR-influenced training and promotion of new disorders that they’re now trying to blame on EHRs. Here I’m thinking of the whole DSM IV/V fiasco and the recent attempts to rebrand it as a EHR problem. In the past, these were corrected by medical malpractice. However, since malpractice has gone by the wayside, these have blossomed, despite the addition of black box warnings. (To quote one lawyer, “Juries just don’t like psych patients, so we don’t take them.”)

    Among my friends and relatives, ( C) is far and away the number one medication error. I don’t know if it’s because of my age or if it’s because these errors are really far more numerous than (A) + (B). I have known over two dozen people who committed suicide and/or lost their careers/families/lives because of ( C), but only two who died from ( A) + (B).

    I don’t know if this is widespread or not, but the other interesting thing I’ve noticed is that that C seems to directly undermine physician and judicial legitimacy, whereas A and B undermine insurance and hospital legitimacy.

    Now, to be fair, ( C) may be more of an issue for me and mine because we’re millennials and Gen Xers. (A) and (B), which is what this is about, seem to be more of an issue for boomers who are dealing with hospitalized parents who, at the very least, get a correct initial diagnosis.

    This is just one of those issues where there is just so much industry sponsored research (which I view as so biased that I don’t read it at all) that I really don’t quite know where to start.

  12. Ernesto Lyon

    The government wants out personal private medical records stored in centralized databases. Some of our most private and sensitive information can be medical. A happy coincidence for the deep state. No?

  13. d

    well with today’s corporations (k maybe its always been there, just wasnt so prevalent) so they probably did all of the work on the cheap.

  14. Bob

    My favorite study regarding EMR use in the emergency department involved counting the number of mouse clicks during a busy ten hour shift. They actually hired people to count the clicks. You can google “4000 clicks per shift” to find either the actual study or one of the many articles commenting upon it. The shifts were ten hours, so 400 clicks per hour, rather like rats punching a lever to get a morsel of food. My life’s work was in the emergency department. These studies show that ED physicians are spending nearly twice as much time with the EMR as with patients. http://www.beckershospitalreview.com/healthcare-information-technology/4-000-clicks-per-shift-ed-physicians-emr-burden.html

  15. Don't ask

    Follow the money. Epic is an excellent marketing company. They wined and dined docs to convince them that Epic was the best choice for EMR solutions. The result has been blown up IT budgets for implementation projects and ongoing support. Epic has gained the most as a result of EMR adoption, but there have been grumblings that the promised savings have yet to materialize.

  16. Wade Riddick

    If you discovered cost overruns on a construction project and found that substandard materials had been used which jeopardized the integrity of the project, what would you conclude? Embezzlement?

    That factor’s been implicated in at least one of these stories of cost overruns.

    I.T. expenditures are one of the ways health insurers can escape the Obamacare caps on overhead spending, hence it’s a weak spot in the accounting balloon that’s currently expanding.

  17. David Jacobs

    Too many masters at the start will create a broken IT system every time.

    Wanting it THEIR way — Thousands of hospitals, clinics and offices all have their own workflows and demanded that the new EHR system must support THEIR way. This leads to incredibly complex configurations to provide this flexibility.

    Wanting billing improvement automated — This means forcing disambiguation (of billing codes) to the point of data entry. This of course makes it much more complex for the doctors and biases their reporting.

    Administrators wanting the ability to report on everything — This forces more granular data entry which besides making entry more complex, often breaks in corner cases. A simple example is a patient’s name. At its most simple you could have a single field for entering the name. As long as the field is long enough it can handle any name. But systems often break the name into pieces (e.g., last, first, mi). Now there are lots of names that don’t fit that pattern and a judgement call has to be made on what to do.

    I’ve only seen new systems work when you either have a sufficiently charismatic leader prescribing how things will go at the start and getting everyone to follow (e.g., Jobs with the iPhone). Or having a de facto monopoly that everyone must use. The current mandate of migrating to an EHR without the corresponding charismatic leader or monopoly just leads to a mess for a long time.

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