Are EMR's More Secure and Trustworthy Than Paper Records?

Contrary to utopian praise of EMR's as more secure than paper records:

Routine complication from surgery turns fatal
Lance Williams, Chronicle Staff Writer
Monday, August 10, 2009

A hospital patient suffers excruciating pain from what turns out to be a routine complication from elective surgery.

As her condition deteriorates, she and her family plead to see the doctor. But no doctor examines her until the next morning, when she goes into shock, is rushed into intensive care and dies.

Then, after her death, the hospital deletes portions of the woman's medical file in what the woman's family says is an attempt to cover up its horrendous mistakes.

Is this possible? Read on:

The allegations, contained in a lawsuit filed in Santa Clara County Superior Court, describe events that seemingly could occur only at an institution that provides medical care at its worst. Instead, the claims concern a 2007 fatality at what is regarded as one of the best hospitals on the West Coast - Stanford University Medical Center in Palo Alto.

The case of Diane Stewart, 70, who died of a bowel obstruction after knee replacement surgery, shows that bad mistakes and worst-case outcomes are possible even at world-renowned hospitals, said her family's lawyer, Christopher Dolan of San Francisco.

Medical errors occur because "we have corporatized medicine and marginalized the professional's role," Dolan said. "We took the same principles used in automation, to do the job cheaper and faster, and applied it to medicine."

Healthcare IT notwithstanding, I believe those observations are accurate. However, a more serious issue is the role of HIT in marginalizing the medical professional with respect to the IT professional, in what I've called (in this blog and elsewhere) a cross-occupational invasion of medicine by the IT profession.

"I believe Stanford is making a concerted effort to obstruct our family from learning the truth about what happened to our mom," he wrote in a complaint to the state Medical Board. In 2008, investigators from the state Department of Public Health found that "relevant" portions of Diane Stewart's computer file had been deleted after her death and that a supervisor instructed a nurse to make postmortem "late entries" to describe her care.

This may be a case where the CIO and other IT leaders need to be called to the stand to testify, possibly on criminal charges, since some cooperation from such personnel would be required if there is merit to allegations of post-death EMR alterations/erasures.

In a written statement, the hospital said that only temporary notes that were never intended to become part of Diane Stewart's permanent record had been discarded.

Never intended to become part of her medical record?

This "Watergate 18 minute gap"-reminiscent explanation raises a number of questions:

• How did these "Temporary Notes" come to be discarded?
• What was temporary about them?
  
• Does Stanford's EHR have a "Discard Temporary Notes" button?
• What authority and authentication is required in order for "Temporary Notes" to be discarded?
• What is Stanford's definition of a "Temporary Note" in an EHR?
• What might such notes contain?
• Who might they have been written by, and for what purpose(s)?
  
• If they involve decisions made in healthcare, why are they considered "temporary?"
• Are there notes made in a paper record that are considered "temporary" that can legitimately be discarded after a suspicious patient death?
• Are there backups that contain these notes, or were they erased too?
• Was such backup erasure initiated manually (e.g., by a human) or automatically?

Since these notes were discarded (erased), of course, we may never know what they contained.

Electronic records leave no erasure marks, and with collusion of the appropriate personnel, reality can be whatever one wants it to be in the electronic world. This represents yet another sociotechnical obstacle standing in the way of achieving a computer-based utopia in healthcare.

-- SS