If you hate your EHR, think it’s swallowing your information, adding hours to your day, and if you don’t watch it, you’ll make an error, you’re not a Luddite. You’re right. An exhaustive investigation by Fortune and Kaiser Health News (KHN) concludes that it’s ‘an unholy mess’. In fact, even if you are not a physician or clinical staff, it will make you wonder what was going on the collective brains of the digerati, Newt Gingrich, Barack Obama–and the US government–in thinking that EHRs would actually “cut red tape, prevent medical mistakes, and help save billions of dollars each year,” committing $36 billion to pursuing the ‘shovel-ready’ HITECH stimulus in the depths of the 2008-9 recession. Perhaps the shovel should have been used on a body part. Now if only those billions went towards an interoperable, useful, and national system rather than a money giveaway–which even Farzad Mostashari, then ONC deputy director and later director, now admits was “utterly infeasible to get to in a short time frame.” (Mr. Mostashari is now head of Aledade, counseling those mostly independent practices which lined up–hungry or terrified–for meaningful use EHR subsidies on how they can continue to survive.) Even the vendors were a bit queasy, but nothing was stopping HITECH. (Your Editor was an observer of the struggle.)
Now that we have been living with them for over a decade, EHRs have been found culpable of:
- Soaring error rates, especially in medication and lab results
- Increasing patient safety risks in lack of pass-through of critical information
- Corporate secrecy, enforced by system non-disclosures, around failures
- Lack of real interoperability–even with regional HIEs, which only exchange parts of records
- Incomplete information
- A very real cognitive burden on doctors–an Annals of Family Medicine study calculated that an average of 5.9 hours of a primary care doctor’s 11.4 hour working day was spent on the EHR
- Alert fatigue
- Note bloat
- Plain old difficulty or unsuitability (ask any psychiatrist or neurologist)
- A main cause of doctor burnout, depression, and fatigue–right up to high suicide rates, estimated at one US physician per day
- Lack of patient contact (why the scribes are making a good living)
- All those dropdowns and windows? Great until you click on the wrong one and find yourself making a mistake or in the wrong record.
Not even the head of the Centers for Medicare and Medicaid Services is immune. Seema Verma’s husband, a physician, collapsed in the Indianapolis airport. She couldn’t collect his records without great difficulty and piecing together. When he was discharged, he received a few papers and a CD-ROM containing some medical images, but without key medical records.
A long read for lunch or the weekend. Death by a Thousand Clicks: Where Electronic Health Records Went Wrong. Also the accompanying essay by Clifton Leaf.
The 30 year old SXSW conference and cultural event has been rising as a healthcare venue for the past few years. One talk this Editor would like to have attended this past weekend was presented by Eric Horvitz, Microsoft Research Laboratory Technical Fellow and managing director, who is both a Stanford PhD in computing and an MD. This combination makes him a unique warrior against medical errors, which annually kill over 250,000 patients. His point was that artificial intelligence is increasingly used in tools that are ‘safety nets’ for medical staff in situations such as failure to rescue–the inability to treat complications that rapidly escalate–readmissions, and analyzing medical images.
A readmissions clinical support tool, RAM (Readmissions Management), he worked on eight years agon, produced now by Caradigm, predicts which patients have a high probability of readmission and those who will need additional care. Failure to rescue often results from a concatenation of complications happening quickly and with a lack of knowledge that resemble the prelude to an aircraft crash. “We’re considering [data from] thousands of patients, including many who died in the hospital after coming in for an elective procedure. So when a patient’s condition deteriorates, they might lose an organ system. It might be kidney failure, for example, so renal people come in. Then cardiac failure kicks in so cardiologists come in and they don’t know what the story is. The actual idea is to understand the pipeline down to the event so doctors can intervene earlier.” and to understand the patterns that led up to it. Another is to address potential problems that may be outside the doctor’s direct knowledge field or experiences, including the Bayesian Theory of Surprise affecting the thought process. Dr Horvitz discussed how machine learning can assist medical imaging and interpretation. His points were that AI and machine learning, applied to thousands of patient cases and images, are there to assist physicians, not replace them, and not to replace the human touch. MedCityNews
Weekend reading and a banquet for your consideration.
Though computers can and do improve patient safety in many ways, the case of Pablo Garcia vividly illustrates that, even in one of the world’s best hospitals, filled with well-trained, careful and caring doctors, nurses and pharmacists, technology can cause breathtaking errors.
This one began when a young physician went to an electronic health record and set a process in motion that never could have happened in the age of paper.
From The Overdose: Harm in a Wired Hospital by Robert Wachter, MD (Medium.com Backchannel), Part 1 of 4
The situation is a pediatric patient with a severe chronic illness, with multiple symptoms requiring multiple medications to control, admitted to University of California San Francisco (UCSF). The article is a case history of the chain of events, both technological and human, that led to an severe overdose of a routine antibiotic medication, which the patient had already been maintained on for years, nearly killing the child. You will see, with horror, how every check-and-balance failed in the prescribing and dispensing procedure, and why.
Dr Wachter is not only chief of the medical service and chief (more…)