Health technology must improve patient safety

Health technology must improve patient safetyThis was the dream: We would use technology to create a seamless health care system, one where people, computers and machines would work together to improve patient care in many different ways. Health care would be more efficient, it would be safer, it would be less expensive, we would be able to transfer health-related information quickly and accurately.

After spending three days at a meeting recently with some of the top experts in the field, I am not so certain that the dream is going to come true anytime soon. Perhaps more concerning, the problems — including patient safety issues — that are cropping up in so many areas are very troubling.

The meeting was organized by three federal agencies involved in the oversight of medical devices, applications and health information technology including the Food and Drug Administration, the Office of the National Coordinator for Health Information Technology and the Federal Communications Commission. Those three agencies recently released a report describing their vision for regulation of health information technology. The purpose of the meeting was to extend the discussion.

I came away with a sense that this social-technical ecosystem (their term, which I thought was actually very interesting) that we call health information technology is far more complex and the problems more pervasive than a lot of us understand — even those who work in health care and use these systems every day. The inevitable question is what would people think if they really knew how serious the issues are? More importantly, who is going to fix them?

As a consumer of health care, you probably assume that when you go to your doctor’s office or receive care in a hospital there is a reasonable certainty that the computer systems your hospital and doctor rely on are up to date and work as intended. Well, hopefully, most of the time they do. But how do we even know when they don’t? How do we know they are tested to be safe? How do we know if the latest upgrades have been installed? The answer is apparently we don’t because they aren’t.

For example, the computer programs that these systems rely on are built layer upon layer over years. They are customized in many instances. But the people who provided the original architecture for a particular system — sometimes a long time ago — aren’t around and there is no simple record of what they did. And then we put all sorts of new programs in place on top of the old programs — but they can use different computer languages and don’t always play nice with each other. One hospital computer specialist told us their hospital installed over 600 new applications into their system in just one year. Others told of the complexities of making sure the systems work well together — and that they often don’t.  One unsettling theme mentioned frequently was the fact that some of these situations can become dangerous, especially if the appropriate compatibility and error testing is not done.

Then we get to the machines that are computer driven, and are supposed to integrate within these systems. Most of the time they work, sometimes they don’t. One physician made the point that even setting the time correctly between all the systems and machines is problematic. (And that was while we were sitting in an auditorium that had two “atomic clocks” blinking at us with the absolute, undeniable officially government sanctioned correct time. By the way, we all checked and set our watches accordingly.)

Interoperability is becoming a key operational word in this morass of systems. Being able to exchange information accurately from one computer to another or from a machine to a computer can actually be a huge challenge. Since the computer and the machine are likely made by different companies using different standards, there is at times a “no man’s land” in between when it comes to figuring out who is responsible to make this work. We are finding that this is not an easy problem to solve given the vagaries of the multitude of systems and processes.

Make no mistake that the most disturbing moments of the meeting were public comments from physicians who talked about patients harmed and loss of life because of computer malfunctions. Wrong doses of medication, missing critical problems that the computers were supposed to address, alarms systems that were turned off: The list goes on and on.

And it’s not all about the computer systems not functioning correctly. There are human issues as well, such as who enters the information into the computer, how simple it is to enter information, whether the information is accurate and how the information is displayed to those using the computers — all of these contribute to the problems.

I certainly don’t have an answer as to how we are going to make all of this work. Suffice to say, it is going to be much more difficult than many of us had thought. It has been hard to demonstrate using all of this technology has resulted in the anticipated cost savings, improvement in patient safety or making care more effective. Oversight of these systems is going take a lot of resources, including time and money — and there isn’t a lot of either to go around these days.

Even as I wrote this blog, someone coincidentally shared with me an incident that happened that very day where a system failed to flag an incorrect order that would have resulted in a massive drug overdose to a patient. Whether the issue was faulty data entry, the computer not transmitting the information correctly or failing to flag the order or some other issue, the event was real and could have had tragic consequences had not a diligent pharmacist intervened. The patient never knew what happened, but the nurse and the physician involved were shaken and disturbed by the experience.

The bottom line: Incidents like these may not be as uncommon as we think, and lower confidence that these systems are going to do what those who use them expect them to do and in fact rely on them to do.

The good news is that at the least these questions are being raised. There is a nascent dialogue beginning that must continue. We must have a sense of optimism and commitment that we can find the right blend of oversight to assure all of us that we will not be harmed by that which was intended to help.  But we also must have a sense of urgency that these problems cannot be ignored any longer. We will need the right combination of private initiative, government regulation, and public-private partnerships that encourage the innovation we need while not choking the process with excessively burdensome regulations yet provide reasonable assurance that the systems are safe and will perform in the real world as anticipated when they were designed.

As we all know, achieving that goal will be difficult.  Notwithstanding some of the pessimism that surrounded me, I remain an optimist that at the least we have a solid beginning to make effective medical care and patient safety job #1 when it comes to improving health through computer-based technologies.

J. Leonard Lichtenfeld is deputy chief medical officer, American Cancer Society. He blogs at Dr. Len’s Cancer Blog.

Comments are moderated before they are published. Please read the comment policy.

  • buzzkillerjsmith

    This post should be read by the readers here. Dr. L. makes some excellent points. He won’t come out and say it but I will. Health information technology, including EHRs, is crap, worse than useless in many cases.

    He emphasizes mistakes but we clinicians are probably even more concerned with how these systems make our lives (and therefore your lives) worse. He does have one small paragraph on this. The fact that most of this is for no good medical reason is comically infuriating.

    At least some of this is making its way into the mainstream media. Whether it will penetrate the thick skulls of decision makers is an open question. Assuming that knowledge translates into useful action at all, that is. There are catered lunches to attend, meetings and memos to enjoy, and money to be make. So much easier than seeing sick people.

    Notice the last two paragraphs. Even those he spends the entire post going over how bad HIT is , he retains his sense of optimism. Well, bless his little heart.

    Notice also that this is a common theme in commentary in American society in general, whether it is climate change, or how things are going in DC, or whatever. Even downer commentary usually has a ray of hope at the end, even if the ray of hope is a hallucination. Too much downer commentary puts at risk lunches, memos, meetings, and money.

    No matter how cynical you get, it’s never enough to keep up.

    • Dr. Drake Ramoray

      “Well, bless his little heart.”

      Good rebuttal, little to add other than to inquire as to whether or not your sure you aren’t from the south.

    • Patient Kit

      If you put your last sentence on a t-shirt, I believe you could sell a lot of them. ;-)

  • Patient Kit

    “…The patient never knew what happened, but the nurse and physician involved were shaken and disturbed by the experience…”

    As a patient, this makes me wonder what else I and other patients don’t know. How many undisclosed tech error bullets just missed us? And the overall cumulative effect of wondering how much stuff like this we don’t know: eroding trust.

    • LeoHolmMD

      So much time and effort was spent on the “Obamacare website” by the media. Huge waste of journalism (being generous). When patients ask me about it, I just turn the screen around and let them see for themselves. I think patients sense something is wrong, but there isn’t much validation from the media or medicine. Dr. Lichtenfeld is scratching the surface.

  • DeceasedMD1

    I want what this guy is smoking. In his complex mind, these complicated computer systems certainly are challenging. But it really is as simple as the ABC’s. Let’s go down the list of EHR’s, shall we?

    A is for Allscripts and Athenahealth

    B is for Billing, Billing and more Billing…

    C is for Cerner and Care360

    D is for DocuTap

    E is for Epic and eClinicalWorks

    There are no hidden agendas here folks. The government was improving our healthcare system by funneling billions to EHR companies. Who could have known or even guessed that there would be more than one EHR company?
    We live in a democracy so certainly the government cannot set any sort of expectations on the standards of communications between EHR’s that they are paying for. This is a free country after all. Who would have guessed that all these companies working with different software and computer systems could not communicate with each other?

    Below is a short list of the top 100 EHR companies. It comes in 4 parts as all these top EHR names do not fit in one page. There are endless numbers of EHR’s, so this is just the very best 100 we have.

    medicaleconomics.modernmedicine.com

    Well now you know you ABC’s…….

  • DeceasedMD1

    I want what this guy is smoking. In his complex mind, these complicated computer systems certainly are challenging. But it really is as simple as the ABC’s. Let’s go down the list of EHR’s, shall we?

    A is for Allscripts and Athenahealth

    B is for Billing, Billing and more Billing…

    C is for Cerner and Care360

    D is for DocuTap

    E is for Epic and eClinicalWorks

    There are no hidden agendas here folks. The government was improving our healthcare system by funneling billions to EHR companies. Who could have known or even guessed that there would be more than one EHR company?
    We live in a democracy so certainly the government cannot set any sort of expectations on the standards of communications between EHR’s that they are paying for. This is a free country after all. Who would have guessed that all these companies working with different software and computer systems could not communicate with each other?

    Below is a short list of the top 100 EHR companies. It comes in 4 parts as all these top EHR names do not fit in one page. There are endless numbers of EHR’s, so this is just the very best 100 we have.

    medicaleconomics.modernmedicin…

    Well now you know your ABC’s…….

  • LeoHolmMD

    I would suggest two remedies: lawyers and public shame.

    Lawyers are reasonably effective in dealing with issues that cause patient harm and allow dangerous and untested products on the market. Unleash them. Hold vendors accountable. Hold government officials that force health care providers to use faulty products accountable. Expose those who sold interoperability and gave us data mining instead. Do you think the VA was going to change if you asked them nicely? Shame the public officials who ushered this in. Claw back the ill gotten gains from those who soaked the public.

    • DeceasedMD1

      Great post. I was being sarcastic in my comment, but my point was how corrupted this is as well. The gov’t funneled billions into EHR’s and at that point in time it was clear with all the hundreds of EHR companies, there would be no communication between systems and it was a mess.

      Finally I noticed there was a bill proposed for crisis psychiatric laws after how many mass killings? But I have no idea how this EHR corruption can get attention. Even doctors like the one writing this, seem clueless!!!! Hence my post full of sarcasm.

      it would even seem from this conference where they mention system errors causing deaths that there would be lawsuits. but have you heard of any? Any ideas how to get lawyers and public involved?

      • LeoHolmMD

        Hold harmless clauses prevent real legal action. The public would need to be notified by the standard relentless media coverage.

  • LeoHolmMD

    Right. Apparently no one at ONCHIT learned any lessons from decades of observing the history of technology. Almost every single “disaster” was completely predictable. Any dork kid who played video games his whole life could tell you.

  • ssilverstein

    Dear Dr. Lichtenfeld,

    You observe that “It is going to be much more difficult than many of us had thought.”

    In my field, Medical Informatics, there were those of us having that same thought – 20 or more years ago. See http://cci.drexel.edu/faculty/ssilverstein/cases/ for instance.

    Unfortunately, the health IT industry ignored us, organized medicine ignored us, line physicians exhibited learned helplessness, and now instead of proceeding cautiously as with any experimental technology, we have a huge societal mess.

    As the son of a parent who did pay the price you fear from bad health IT, and who knows of numerous others, I do have one answer: physicians need to resist bad health IT. Firmly and squarely. Critical thinking, or your patient’s dead.

    It is starting to happen, such as at Athens Regional Medical Center recently. See http://hcrenewal.blogspot.com/2014/05/i-could-not-make-this-up-if-i-tried.html .

    We can’t stop the train, but we can slow it down and put the businessmen on notice that they need to fix these problems before using live patients as software debugging laboratories…or they will pay a significant price for their naive and reckless hyper-enthusiasm.

Most Popular