How CPOE violated medical ethics

by MedInformaticsMD

As a result of my mother’s health IT-related cerebral hemorrhage and resultant multi-month hospitalization, with transfers to nursing homes then back to acute care due to setbacks, I recently had the chance to observe her care in a small community hospital.

This was a hospital that, in her last several days there before going back to a nursing home for rehab, went live with a major vendor computerized physician order entry (CPOE) system.  The CPOE was brought in from a parent large hospital where the CPOE had been in use several years.

Just by passing the nursing station/doctor’s charting room on my mother’s floor and opening my eyes and ears, I saw doctors and nurses struggling to take care of patients while “getting the bugs out of the system.”

They had had received some classroom “training” in a static environment, but it was clear they were learning about a lot of “gotcha’s” and unanticipated glitches in vivo. The problems were predictable. In fact, I predicted unexpected difficulties to several of my mother’s clinicians before go live.

There was some skepticism (maybe in my nearly being in tears about my mother, I came off as a bit melodramatic). However, several later told me they “now knew what I was talking about” upon my mother’s discharge, just several days into the go live.

One story I overheard during go live especially sticks out in my mind.

A newly admitted patient who needed urgent heparinization did not receive the medication promptly. The patient’s physician could not order it, as nursing had not yet “admitted” the patient and entered data such as weight. Physicians found no way to override, despite calls to the help desk, attempts by on site IT people and users from the parent hospital.

In the end, the pharmacist simply provided the drug using a weight estimate despite no “official” order having been entered into CPOE. I heard that the delay was on the order of “several hours.”

Clearly, both technology and people issues were involved … but I assure the reader, injured or dead patients really don’t care exactly how their injury occurred, after the fact (other than in litigation, which doesn’t fix the damage or remediate the suffering).

This story sticks in my mind as it was due to disappearance of an anti-arrhythmic med on my mother’s ED admission med list at the parent hospital, without any alerts that a medicine she’d been on for years was somehow removed as an “active medication” that led to her needing heparin acutely. The iatrogenic need for heparinization then led to an iatrogenic cerebral hemorrhage and emergency craniotomy, followed by many complications.

Here, then, is my question.

Where does the moral authority come from to subject live, unsuspecting, uninformed patients to the type of risks the patient whose heparin was delayed was subject to?

What right did the hospital have to not inform this patient before admission that a new critical CPOE system was going “live” that day, and that the patient could consider going to another hospital a few miles down the road instead that had no such potential problems?

From the Belmont Report, the six fundamental ethical principles for using any human subjects for research are:

  • Respect for persons: protecting the autonomy of all people and treating them with courtesy and respect and allowing for informed consent
  • Beneficence: maximizing benefits for the research project while minimizing risks to the research subjects
  • Justice: ensuring reasonable, non-exploitative, and well-considered procedures are administered fairly (the fair distribution of costs and benefits to potential research participants
  • Fidelity: fairness and equality
  • Non-maleficence: do no harm
  • Veracity: be truthful, no deception

On the basis of Belmont Report and other medical ethics regulations, where does the moral authority come from for hospitals to put patients through such risks without informing them ahead of time and offering them an opt-out, even if only the continued use of paper in their care?

MedInformaticsMD is a physician and medical informatics professional who blogs at Health Care Renewal.

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