healthy4u: EMR

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

Contrary to utopian praise of EMR's as more secure than paper records: <blockquote> <a style="font-weight: bold;" href="http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2009/08/09/MNN9191UPS.DTL">Routine complication from surgery turns fatal</a> 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.</blockquote> Is this possible? Read on: <blockquote>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."</blockquote> 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. <blockquote> "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. </blockquote> 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. <blockquote>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. </blockquote>Never intended to become part of her medical record? This "Watergate 18 minute gap"-reminiscent explanation raises a number of questions: <ul><li>How did these "Temporary Notes" come to be discarded?</li><li>What was temporary about them? </li><li>Does Stanford's EHR have a "Discard Temporary Notes" button?</li><li>What authority and authentication is required in order for "Temporary Notes" to be discarded?</li><li>What is Stanford's definition of a "Temporary Note" in an EHR?</li><li>What might such notes contain?</li><li>Who might they have been written by, and for what purpose(s)? </li><li>If they involve decisions made in healthcare, why are they considered "temporary?"</li><li>Are there notes made in a paper record that are considered "temporary" that can legitimately be discarded after a suspicious patient death?</li><li>Are there backups that contain these notes, or were they erased too?</li><li>Was such backup erasure initiated manually (e.g., by a human) or automatically?</li></ul> 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

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, Chr...

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Walmart to Become the Healthcare IT Punching Bag?

At "<a href="http://hcrenewal.blogspot.com/2009/03/wal-mart-to-market-ehr-system-to-small.html">Wal-Mart to market Electronic Medical Records? Has Medicine Gone Bananas?</a>" I noted the entry of Walmart into the healthcare IT fray. As I <a href="http://hcrenewal.blogspot.com/2005/03/wash-post-on-cedars-sinai-cpoe-failure.html">observed here</a> in early 2005, HIT is a field where angels fear to tread. Or should fear to tread. Walmart is <a href="http://www.google.com/search?client=firefox-a&rls=org.mozilla%3Aen-US%3Aofficial&channel=s&hl=en&q=walmart+opposition&btnG=Google+Search">not exactly popular</a> in numerous circles, so let me state I buy from them (most recently my Acer Netbook, clothing and various Christmas gifts) and am neutral on most of the issues that create the opposition. My father ran a business, after all. However, he at least stuck to his core expertise, pharmacy. Walmart is trying to market EMR's, a product far beyond their core competencies. The HIT market and "ecosystem" is also far beyond their competencies, and it's not hard to predict they are going to have a rapid and quite unpleasant learning experience about the dark corners of this industry. Felix Fulmer, a correspondent with longstanding expertise in academic and pharmaceutical research environments conveyed to me the following observations about this arrangement: Deficient as its products often are, the HIT industry was built up by entrepreneurs over many years and by much hard work. They are now being challenged by a very large and very powerful entity. The entry of Walmart into EMR represents a tremendous threat to the HIT industry status quo. This initiative is likely to help doctors and patients at the very least by reducing the cost of EMR (even if not improving the performance), putting downward price pressure on the entire industry. It is also likely to change the marketing and consulting practices in the HIT industry as well, driving wages down among other factors. If successful, Walmart's initiative could in fact cause the extinction of the current monopolistic and parasitical HIT establishment. [In my estimate, a 33% - 50% reduction in companies, revenues and personnel in three or four years would not be an unreasonable figure - not that I would be sad to see some of them go - ed.] Mr. Fulmer continues: The HIT industry must realize this and, based on Walmart's history of capturing other markets and putting smaller competitors out of business, the captains of this industry must be quaking in their boots. These entrepreneurs will fiercely act to defend their territory, using every trick in the book [knowing the industry as well as I do, I cannot fail to agree with that assessment - ed.] Walmart is going to be severely punished. The pushback from the HIT establishment will likely consist of three phases: subversion, obstruction, and agitation for litigation (in a collusive manner) to challenge the newcomer. There will be technical, administrative and political angles. The first phase, subversion, will be the establishment's attempt to try to keep the Walmart arrangement from happening. It may occur through the press and through political means. Antitrust complaints, and a negative campaign of badmouthing and panning may occur. It will be insinuated or stated that Walmart doesn't have the required expertise, that they don't know what they're doing, among other claims to discredit, diminish and minimize the initiative. The second phase will likely be obstruction. HIT products Walmart will carry will be sabotaged by other vendors in terms of passive aggressive measures to complicate or prevent data interoperability. There may be issues such as constant "breakdowns" of interfaces, inexplicable technical glitches blamed on Walmart and its supplier, of course. Walmart's HIT products and services will be scrutinized under a microscope and deficiencies highlighted through the media and printed competitive materials. There may also be attempts to intimidate and misdirect physicians not to go with this product through the medical leadership, through back room paid sponsorship of "influential thought leaders" (as in pharma), through "detail people" (e.g., sales reps as in pharma) and other means. Hospital administrations and CIO's may also be influenced by various means to steer physicians away from this offering, perhaps to the level of marginalizing users or refusing to support this product. Finally, there will be litigation, especially regarding the inevitable medical errors that occur when this technology is pushed into small town physicians offices unused to technology of this complexity. Walmart may be shocked to find the "learned intermediary" principle suddenly and mysteriously not be applied. Why would this be a surprise, considering their immensely deep pockets and the disdain of the the left-leaning, anti-big business judiciary system? Mr. Fulmer concludes with this thought: Walmart may think of their entry into the HIT marketplace as a great business plan, but their executives may need to partake of their own medical clinics to deal with the stress the HIT industry pushback will cause. -- SS

Walmart to Become the Healthcare IT Punching Bag?

At " Wal-Mart to market Electronic Medical Records? Has Medicine Gone Bananas? " I noted the entry of Walmart into the healthcare ...

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