Can decision support tools actually harm patients?

Have you ever encountered an intrusive, insistent popup decision support screen while trying to take care of patients? Found yourself stuck in a dead end electronic hallway without egress? A situation where you had to choose an option that was inappropriate for your patient just to exit the screen?

This is the situation with my local medical institution’s “DVT Advisor,” a mandatory decision support screen for all patients.

DVT Advisor was implemented in response to meaningful use and out of a laudable desire to improve safety. Unfortunately, as constructed, the Advisor has the opposite effect.  In this popup the physician must process through a 5 screen, 9 click process. The first step identifies the patient’s DVT risk level. If the risk level is low, no intervention is required. Yet, inexplicably, the physician must next process through the 4 additional screens to record whether the patient has any contraindications to the interventions which the Advisor has just indicated are not recommended. (!)

I’ve learned how to click through each of these cluttered, non-intuitive screens to get on to the business of taking care of patients, but it is a distraction, and thus hazardous.

I recently had a patient the DVT advisor identified as “high risk.” I was sending him home that day, so no anticoagulation was necessary. Nonetheless I had to wade through each screen, documenting that the patient didn’t have any contraindications to a treatment I wasn’t planning to give. At the end there was a force field where the only option was to choose one of 4 anticoagulant regimens. I could find no other option. There was a button elsewhere on the screen where I could decline the intervention, but doing so simply resulted in the popup reappearing the next time I entered an order, and I had to go back and progress through all 5 screens from the beginning and ultimately choose an anticoagulant for the patient in order to continue writing orders, or finish all of the other orders and then exit when there would be no further orders to trigger the popup yet again. No other way to get around it. No way to be the human being in the equation who had sense and could say this patient doesn’t need this intervention.

One of my colleagues told me that in these (common) situations he selects one of the anticoagulant options, which creates an order for his patient for a medication that is not indicated, and then he goes back in the medication list a few minutes later and discontinues it. Talk about waste. Talk about hazard.

The information in the DVT Advisor can be a useful reference if a physician is uncertain about anticoagulation, but its intrusive and insistent characteristics are based on hope and belief, rather than evidence. The mandatory requirement to prescribe anticoagulation, even when the physician has reasons not to prescribe it, has gone far too far in my view, and has created a systematic occasion for patient harm.

Time spent on such low-value exercises or workarounds is time taken away from other patient care. What 5 minutes of talking with the patient, a colleague or consulting a medical resource, what 5 minutes of deep medical decision making shall I give up in order to move through this poorly constructed, time-consuming low-value work?

The hospital is a large organization, and has heard from many physicians about the form, but still the rigid and mandatory popup persists. Individual physicians do not have control over its design and yet labor under its impact. This is part of the real life harm associated with products that could in theory be helpful. The form was designed in response to the current federal regulatory climate, citing meaningful use and a move to more clinical decision support. The resultant hazard to patient safety may be an unintended consequence of over-reaching regulation but it is a real side effect nonetheless.

Addendum: A week later I had a 91-year-old patient identified as high risk who was already on coumadin. The DVT Advisor would not allow me to exit without ordering enoxaparin or unfractionated heparin. I could find no other way to deal with this except as my colleagues have also done: order the enoxaparin, wait a few minutes for the order to be processed, and then remember to go back in and cancel the order.

Christine Sinsky is an internal medicine physician who blogs at Sinsky Healthcare Innovations

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  • Dr. Drake Ramoray

    EMR vendors use computer programmers with no patient experience and don’t consult physicians on order sets. News at 11.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      That’s not the problem. NASA uses programmers with no spaceflight experience, and it works fine. All off-the-shelf order sets are created by physicians or NPs who are employed by the vendor, and can be (and almost always are) modified by the purchasing institution.

      The problem here is that the “DVT Advisor” is not intended to be an Advisor. Advisors usually have a Close button, as in “I don’t need your advice right now, thank you”. The other problem is that the institution won’t disable the Advisor in spite of the problems reported. And the last problem is that the vendor won’t fix its bugs in a timely manner, assuming this was reported.

      • Dr. Drake Ramoray

        True on the vendors to fix it. Two years into ours and our vendor still had a physical exam finding in the wrong place so that we have to template our exams differently to be able to bill correctly. Still haven’t fixed it.

        I feel sorry for my hospital employed colleagues (maybe just a little even though you signed on the dotted line) because in the hospital it just turns into finger pointing. The vendor probably does say you can turn it off. The CPOE committee doesn’t want to turn it off because they might not reach meaningful use. Risk management doesn’t want to turn it off because of liability of someone gets a DVT/PE. Been there. Done that. Never again. Thank you for pointing out my oversimplification though as it was not a true representing of what goes on in all cases.

        If/when I’m forced to write complex insulin orders or dynamic endocrine testing in the hospital I may very well give up my privileges. I signed up for one of the committees (against my own judgement) and they ended up scheduling the meetings at a time I couldn’t attend.

        • Deceased MD

          If you could make the same money retiring now, would you? (I saw your comment about a colleague’s early retirement.) I am so disgusted with all this. But then I have put so much into medicine already.

          • Dr. Drake Ramoray

            Nah. It’s not about the money. It’s about the hassles. I’m moving to be debt completely debt free in the next five years. If the hassles get too bad ill just open a little micro concierge practice while my wife does real estate once the kids are in school. It’s not how things are done here but I would be perfectly happy not making as much with a paid education like they do in other countries. I looked into emigrating to Australia or New Zealand before I got married. Roots and extended family here now. I also might move to an academic center and teach which is a lot of fun.

            Had a first year resident recently, I do some minor teaching on the side. Specialize,

          • Deceased MD

            Well that’s good. i think for many on here, again it is really not the money but the hassles and what medicine has turned into. But I suppose like you say it’s a matter of finding one’s niche.

          • SarahJ89

            In my experience in several fields it’s always the hassle. Most front line workers really WANT to do a good job. It’s only after the door to previous job satisfaction is closed, locked and nailed shut that they begin to agitate for higher wages–because that’s all that’s left to them. Losing your autonomy is not only doom to job satisfaction, it’s a tremendous professional slap in the face. Money is literally the coin of the realm in terms of showing respect in US culture.

          • Deceased MD

            Again so well put. It is all about autonomy and respect. Glad you see that.
            I was just at a hotel where I ran into a woman that said she”teaches doctors”. Her and 40 other contractors were “teaching” –what else how to use the EMR. Does not seem I can even go anywhere without running into this.

      • ssilverstein

        Not a very good argument. NASA also uses safety testing as described at http://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/20040014965.pdf :

        pg. 6-7:

        In order to meet most regulatory guidelines, developers
        must build a safety case as a means of documenting the safety justification of a system. The safety case is a
        record of all safety activities associated with a system throughout its life. Items contained in a safety case include the following:

        • Description of the system/software

        • Evidence of competence of personnel involved in development of safety-critical software and any

        safety activity

        • Specification of safety requirements

        • Results of hazard and risk analysis

        • Details of risk reduction techniques employed

        • Results of design analysis showing that the system design
        meets all required safety targets

        • Verification and validation strategy

        • Results of all verification and validation activities

        • Records of safety reviews

        • Records of any incidents which occur throughout the life of the system

        • Records of all changes to the system and justification of its continued safety

        The problem is design of this EHR component by health IT/user interaction design amateurs (I’m being polite).

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          Dr. Silverstein, let me clarify this once and for all: I fully support full FDA jurisdiction over EMRs and all other medical technology. I don’t believe it will “stifle innovation” and I honestly don’t care if it raises the “barriers to entry”. EMRs have become medical devices a long time ago, and the way the government keeps meddling in their design with the expressed goal of displacing doctors from decision making roles, they will become even more so.
          I think our differences are in that you are concerned with the present state of affairs, while I am frankly terrified of what’s coming down the pike.

    • ssilverstein

      The term of art is “health IT amateur.”

  • FinnHaddie

    This is much more dangerous than the persistent popup screen about the hazards of taking various meds during pregnancy that my doc has to keep clicking through when trying to prescribe for me. Apparently these popups are triggered merely by my gender, because my age (not to mention posthysterectomy status) make it perfectly obvious that I could not possibly be pregnant. Software is only as smart as the person who wrote the code—who is not a doctor.

  • Dr. Drake Ramoray

    All snark aside (yes that’s pretty hard for me) if this is a selected meaningful use criteria for your hospital and your data is submitted with your physicians writing for the medication to only discontinue it later isn’t this fraud for your meaningful use bonus for your institution?

  • goonerdoc

    Are you in medicine? This is hardly an isolated incident.

    • Stacey

      Of course it’s not an isolated incident and I certainly did not suggest that it was.

      You make me very curious, though. Correct me if I’m wrong, but it appears to be crystal clear what you are against (decision support tools) but what are you for?

      Do you feel that technology is a needless burden and that healthcare should learn its lesson and return to a human-only approach?

  • guest

    An even better title might be “Are there actually any well-designed decision support tools out there?”

  • Yul Ejnes, MD, MACP

    Thank you for sharing this. It is another example of how a potentially helpful technology can get in the way of safe patient care. That a poorly designed decision support tool was implemented is bad enough, but the lack of responsiveness on the part of the hospital after the safety issue was identified is even worse.

  • http://cognovant.com/ W Joseph Ketcherside, MD

    can penicillin actually harm patients? Can surgery actually harm patients? can doctors actually harm patients?

    Seriously, it is not news that a poorly design decision support tool can have a poor outcome. To suggest that this means decision support tool are bad, well doc, I can say the same thing about you if you have ever made a mistake.

    • ssilverstein

      you are engaging in the strawman fallacy. See http://www.nizkor.org/features/fallacies/straw-man.html

      • http://cognovant.com/ W Joseph Ketcherside, MD

        No, I’m not. I’m pointing out that health care has risks, and all the useful tools we use can have a bad outcome. And I see this post is on the AMDIS listserve too.

        There’s no new contribution to science in this blog post. We already know poor implementation of any tool is hazardous. Frankly I’m kinda getting tired of the sane old Health IT bashing by the same folks. How about we focus on making it better.

        • ssilverstein

          Now you’re moving the goalposts when called out on promoting a logical fallacy.

          I do agree on your conclusion, however.

          The contribution of posts like this, however, is significant. It’s called “sunlight” to expose problems long (that is, for decades) kept in the shadows by IT hyperenthusiasts, profiteers and other dysfuntionals in the Health IT ecosystem (http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=ecosystem ).

          “Not making contributions to science” is a frivolous claim.

          Now even the med mal carriers like CRICO are making contributions to the science of medical informatics by revealing the downsides of bad engineering and bad implementation in no uncertain terms. See http://hcrenewal.blogspot.com/2014/02/patient-safety-quality-healthcare.html

          Finally, I’m glad to see it on AMDIS. As a former CMIO myself and one of the first to call out these issues publicly (1998), there needs to be increasing advocacy on the part of current directors of clinical information systems.

          • http://cognovant.com/ W Joseph Ketcherside, MD

            Frivolous? simple statement of fact. The blog contained nothing that has not been previously published extensively and hammered on exhaustively here and on AMDIS, and many other venues.

            Goalposts? Logical fallacy? Wow. I made a simple true statement. Don’t need references (which I know you have posted to others to look at before). Thanks for agreeing with my conclusion.

            Sunshine – Sure, in case someone somewhere hasn’t noticed this. But the plural of anecdote isn’t data. Maybe a more informative post would have been on that contained a good scientific review of the bad IT literature like you and Ross keep posting.

  • ssilverstein

    Christine,

    There is only one word to describe the screens you refer to:

    Deranged.

    And, I might add, inexcusable.

    NO REASON WHATSOEVER FOR THIS TO HAVE GONE LIVE AND TO HAVE REMAINED LIVE for more than 1 day.

    None.

    When someone in a rush does make a mistake and send someone out on unneeded drugs, and a disaster results – as you mention the hospital executives have been put on notice – corporate negligence charges in addition to physician malpractice charges could result. Yes, you and your colleagues are liable for mishaps, even though the IT promotes it.

    Criminal negligence charges might also arise against the hospital leadership for failing to act despite being put on notice:

    Criminal negligence – (law) – recklessly acting without reasonable caution and putting another person at risk of injury or death (or failing to do something with the same consequences).

    Scot Silverstein, MD

  • Gaspere (Gus) Geraci

    What is the process in your hospital for physicians to provide input into the CDS tools put into place? If there is one, it needs to be used every time you or one of your colleagues go through this (yes, that is painful but it won’t get fixed unless you do.) If there is none- shame on the hospital and the medical staff needs to create one for patient safety reasons. It’s a process issue, not a CDS issue. Well designed clinical decision support does good things. Badly designed CDS frustrates clinicians, and can cause patient harm. Does your hospital need to wait until someone forgets to cancel the heparin order and the patient bleeds?

  • ssilverstein

    The title is as it is, likely for the attention-getting nature. The point is clearly about poorly-designed software and inflexibility and recklessness of the executive team controlling it.