healthy4u: Marin Healthcare District

Marin General Hospital's Nurses are Afraid a Defective EMR Implementation Will Harm or Kill Patients .. CEO Cites Defective HHS Paper and Red Herrings As Excuse Why He Knowingly Allows This To Continue

<div style="text-align: center;">- Posted at the Healthcare Renewal Blog on May 30, 2013 - </div> The following appeared in the Marin County Independent Journal about an EHR system so bad the nurses at Marin General Hospital were publicly complaining, putting their careers at risk (see my May 17, 2013 post "<a href="http://hcrenewal.blogspot.com/2013/05/marin-general-hospital-nurses-warn-that.html">Marin General Hospital nurses warn that new computer system is causing errors, call for time out</a>"): <blockquote class="tr_bq">National critic of health care information technology says Marin General should heed nurses' advice <div class="articleByline" id="articleByline"><a class="articleByline" href="mailto:rhalstead@marinij.com?subject=Marin%20Independent%20Journal:"></a> <div class="Byline"><a class="articleByline" href="mailto:rhalstead@marinij.com?subject=Marin%20Independent%20Journal:">By Richard Halstead Marin Independent Journal</a></div></div><div class="articleDate" id="articleDate">Posted:   05/27/2013 04:03:00 PM PDT</div></blockquote> The critic is me.   I spoke to the reporter but did not know he would publish: <blockquote class="tr_bq"> <div class="bodytext">A nationally known critic of electronic health records has harshly criticized managers at Marin General Hospital for their response to a plea by nurses to hold off on a new computer system to prevent potentially dangerous errors.</div> "The executives at the hospital should be taking out extra insurance policies because they're setting themselves up for a massive corporate negligence lawsuit," said Dr. Scot Silverstein, an adjunct professor of health care informatics at Drexel University in Philadelphia. Silverstein, who contacted the Independent Journal after reading about the Marin General situation, doesn't dispute the potential of digital records; but he believes implementation has been rushed. He thinks electronic health records should be regulated by the federal Food and Drug Administration, much like medical hardware or pharmaceuticals. </blockquote> Or regulated by someone with experience in similar mission critical software, and with regulatory teeth.  Paper tigers and bad health IT are a very poor mix where patients' rights are concerned IMO. <blockquote class="tr_bq"> At issue is a new computerized physician order entry system, known as CPOE; doctors place medication orders for patients directly into the system. At a meeting of the Marin Healthcare District board on May 14, a group of Marin General nurses told the board problems with the new computer system were diverting them from their patients and causing errors, such as sending orders to the wrong patients. One nurse reported that a patient had received a medication to which he was allergic. </blockquote> That is a very direct calling out of the potential for harm and death by front line clinical personnel.  To ignore it is grossly if not criminally negligent. <table border="0" cellpadding="0" cellspacing="0" style="width: 100%px;"><tbody><tr><td class="articleBox" style="width: 100%;"><a href="https://www.blogger.com/null" name="top"></a></td></tr></tbody></table><blockquote class="tr_bq">Lee Domanico, who serves as the CEO of both Marin General and the Marin Healthcare District, assured the board that the hospital was safe, despite "glitches" in the new system. Domanico said he was working to fix the problem.</blockquote> Glitches = safe?  The Board must be highly gullible if they believe this  See <a href="http://hcrenewal.blogspot.com/search/label/glitch">http://hcrenewal.blogspot.com/search/label/glitch</a> for more on "safe" glitches. <blockquote class="tr_bq">Silverstein said, "Glitches are a euphemism for life-threatening electronic health record malfunctions and defects." "What they need to do is exactly what the nurses are asking for," Silverstein said. "They need to turn the system off and put it through rigorous testing and confirm the thing is going to work properly with no glitches before they use it on patients."</blockquote> That's not rocket science - its common sense - unless they think their own nurses are lying. Of course, as computers have more rights than patients, and bonuses might be affected, the system will likely continue in full operation, with patients as guinea pigs, and the nurses punished for informing the public that perhaps they should consider other hospitals while the "glitches" in this enterprise clinician command-and-control system are worked out. <blockquote class="tr_bq"> Two days after the Marin Healthcare District meeting, Domanico issued a press release stating, "We have not received any medication error incident reports resulting from the implementation of computerized physician order entry." On Friday, however, Barbara Ryan, a Marin General registered nurse who serves as the California Nurses Association/National Nurses United representative, said, "I can't understand why that statement was made." Ryan said nurses have told her of errors, and information about errors appears in "Assignment Despite Objection" forms that nurses have filed since implementation of the computerized order system began on May 7. Nurses file the forms to document formal objections to an unsafe, or potentially unsafe, patient care assignment. </blockquote> The statement's reason and purpose seems fairly obvious.  <blockquote class="tr_bq">Ryan said Marin General nurses have filed close to 50 such forms so far this month; she said typically 10 to 20 such forms are filed per month at the hospital. "There are still problems with the system," she said. "There are still mistakes being made." Ryan said the hospital needs to boost nurse staffing ratios during the implementation.</blockquote> That would increase costs (and probably decrease the pool of money for bonuses). <blockquote class="tr_bq">Jon Friedenberg, Marin General's chief fund and business development officer, said the hospital is in the process of upgrading computer servers and adding memory to work stations to increase the speed of the new computerized order system. "We completed an upgrade of memory to 200 of the work stations, and 120 of the work stations have been replaced," Friedenberg said.</blockquote> This reminds me of a similar IT fiasco I faced some years ago, when the brilliance of IT personnel really shone through regarding an ICU monitoring system that crashed regularly.  Their solution?  Add more RAM.  (See "Serious clinical computing problems in the worst of places: an ICU" at <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=clinical%20computing%20problems%20in%20ICU">http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=clinical%20computing%20problems%20in%20ICU</a>). <blockquote class="tr_bq">... Silverstein earned a medical degree from Boston University and subsequently completed a two-year fellowship in medical informatics at Yale University School of Medicine. He served as Merck Research Laboratories' director of scientific information in the early 2000s before serving for a time as a full-time professor at Drexel University. Today, in addition to teaching part-time, Silverstein works on [EHR-related - ed.] medical liability cases for plaintiff attorneys. [And the defense too, when asked; I'd rather advise on how to prevent mistakes, in fact, than get involved after the fact when someone's been injured or killed - ed.] </blockquote> What was not mentioned was that I was a CMIO in a major hospital in the mid to late 1990s. But of course, I - and similarly trained Medical Informatics experts - "don't have enough experience" to lead (as opposed to being an 'internal consultant') health IT projects, a refrain I've often heard from hospital executives. <blockquote class="tr_bq">Silverstein said he started assisting on the liability cases after his mother died as the result of an electronic health care record error that resulted in her not being given the proper heart medicine. Silverstein said his mother's case was not an anomaly. </blockquote><blockquote>For example, he pointed to the results of a recent Emergency Care Research Institute study of 36 hospitals conducted over a nine-week period. Asked to report electronic record problems on a volunteer basis, Silverstein said the hospitals reported 170 malfunctions, including eight incidents that resulted in patient harm, three of which may have contributed to patients' deaths.  Although the federal Food and Drug Administration does not regulate health care information technology, some manufacturers have voluntarily supplied data to the FDA. In February 2010, the FDA reported it had been notified of 260 problem events involving health care information technology in the previous two years that were linked with 44 injuries and six deaths. </blockquote> See my Feb. 28, 2013 post "Peering Underneath the Iceberg's Water Level: AMNews on the New ECRI Deep Dive Study of Health IT Events" at <a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html">http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html</a>.  Also see my Aug. 5, 2010 post "Internal FDA memorandum of Feb. 23, 2010 to Jeffrey Shuren on HIT risks. Smoking gun? I report, you decide" at <a href="http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html">http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html</a>. I merely report what ECRI, AMA and FDA have reported. Finally: <blockquote class="tr_bq">In his press release, however, [CEO] Domanico stated that "more than 150 studies conducted since 2007 have confirmed that organizations using health information technology, like CPOE, have seen positive outcomes." </blockquote> I believe he's referring to a highly biased and scientifically defective ONC paper of 154 selected studies: "The Benefits Of Health Information Technology: A Review Of The Recent Literature Shows Predominantly Positive Results." What an unbelievably cavalier attitude. My colleagues and I refuted (dare I say trashed) that paper pretty thoroughly here: <a href="http://hcrenewal.blogspot.com/2011/03/benefits-of-health-information.html" rel="nofollow nofollow" target="_blank">http://hcrenewal.blogspot.com/2011/03/benefits-of-health-information.html.</a> Even worse, the mention of that paper, or EHR benefits in general, is a diversion, an in-your-face red herring (at best; an inability to reason logically at worst), steering away from the real issue:  an EHR implementation about which nurses are complaining ... in the now. <blockquote class="tr_bq"><a href="http://www.nizkor.org/features/fallacies/red-herring.html">http://www.nizkor.org/features/fallacies/red-herring.html</a>:  A Red Herring is a fallacy in which an irrelevant topic is presented in order to divert attention from the original issue. </blockquote> That a CEO of a major hospital relies on one defective paper - one that he most likely lacks the experience and expertise to understand, let alone critically evaluate - and red herrings is a poster example of why medical and medical informatics amateurs should not be running hospitals or clinical IT projects. -- SS

- Posted at the Healthcare Renewal Blog on May 30, 2013 - The following appeared in the Marin County Independent Journal about an EHR system...

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Marin General Hospital nurses warn that new computer system is causing errors, call for time out

<div style="text-align: center;">- Posted on the Healthcare Renewal Blog May 17, 2013 -</div> Of course, the ever-present euphemism for life-threatening EHR malfunctions and defects, i.e., "glitches" are the cause (<a href="http://hcrenewal.blogspot.com/search/label/glitch">http://hcrenewal.blogspot.com/search/label/glitch</a>): <a href="http://www.marinij.com/rosskentfieldgreenbrae/ci_23251638/marin-general-hospital-nurses-warn-that-new-computer"> </a> <blockquote class="tr_bq"><a href="http://www.marinij.com/rosskentfieldgreenbrae/ci_23251638/marin-general-hospital-nurses-warn-that-new-computer">Marin General Hospital nurses warn that new computer system is causing errors, call for time out</a> By Richard Halstead Marin Independent Journal Posted:   05/15/2013 04:07:49 PM PDT Nurses at Marin General Hospital have asked administrators to put implementation of a new computerized physician order entry system on hold until glitches can be worked out and more training provided to nurses and doctors who use it. Nearly a dozen nurses attended the regularly scheduled meeting of the Marin Healthcare District board Tuesday night at Marin General to voice their concerns. The district board oversees Marin General, but it does not involve itself in the hospital's day-to-day operations. "Orders are being inadvertently passed to the wrong patients. People have gotten meds when they've been allergic to them. This is dangerous," said Barbara Ryan, a Marin General registered nurse, who works in pediatrics and the intensive care nursery. "We're not asking you to get rid of it. We're asking you to place it on hold."</blockquote> Orders passed to wrong patients?  No problem, just a glitch!  Meds people are allergic to?  Just a glitch.  Dangerous?  No way.  It's just a glitch! <blockquote class="tr_bq">But Lee Domanico, who serves as the CEO of both Marin General and the Marin Healthcare District, said, "I'm confident that in spite of the implementation issues, we have a system today that is safer for patients than our old paper system, and it will get even safer as we gain experience with it and work to fix some of the glitches we've experienced."</blockquote> Where's the data backing up that assertion, I ask?  The actual risks of paper records don't seem to be robustly documented anywhere. <blockquote class="tr_bq"> Ryan, who serves as the California Nurses Association/National Nurses United representative, was one of four Marin General nurses who spoke during the public comment portion of the meeting. Ryan said the nurses warned in advance of the system's roll-out on May 7 that nurses and doctors had insufficient knowledge of the system. Ryan said due to problems with the software nurses had been unable to open the program at home to practice using it.</blockquote> And yet the rollout happened anyway?  That seems to me to be reckless indifference to the concerns of clinicians. <blockquote class="tr_bq">"Lo and behold the problems that we were worried about have happened," Ryan said. "We're looking at two-hour preps for surgery and two- to three-hour discharges; skilled nursing facilities calling back saying, this really doesn't make sense; the wrong meds ordered on the wrong patients and then given to the wrong patients; the inability for nurses to be able to see what the doctor ordered and double-check it."</blockquote> Of course, I might add, patient safety was not compromised, the other common refrain of EHR glitch-excusers ... see below. <blockquote class="tr_bq">Ryan said nurses have and will continue to file "assignment despite objection" forms due to the system. Nurses file the forms to document formal objections to what they consider an unsafe, or potentially unsafe, patient care assignment. "We will take patients but we will object to the assignment because it is unsafe," Ryan said. "This system is making it unsafe."</blockquote> These will be exceptionally helpful in court to any patients injured or killed as a result of these "glitches" and EHR rollout that occurred despite direct warnings from clinical experts. <blockquote class="tr_bq">Marin General nurse Susan Degan said, "This is not about resistance to change. It's about accountability. My most important role is that of patient advocate. I am held accountable when errors are made." Domanico acknowledged there have been some technical problems with the Paragon system, including making it possible for nurses to open from home. And he said the software is not faster than the old paper system.  [Considering it's acknowledged all the way up to the highest levels of HHS that current EHR's slow physicians down, one wonders if anyone in this organization thought an EHR would actually increase speed? - ed.]</blockquote> About the "resistance to change" canard, see my essay "Doctors and EHRs: Reframing the 'Modernists v. Luddites' Canard to The Accurate 'Ardent Technophiles vs. Pragmatists' Reality" at <a href="http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html">http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html</a> . <blockquote class="tr_bq"> "So yes," Domanico said, "it is causing stress for nurses who have heavy workloads, who are learning how to use it, particularly in areas where we need to speed up the computer."</blockquote> What?  "Speed up the computer?"  They've spent tens if not hundreds of millions for an EHR, and the computer's too slow? Actually, I think what this CEO in an obvious display of health IT ignorance is trying to say is that we have to do something about the system's poor usability, which sort of mimics what the Board Chair of the American Medical Assocation just said (<a href="http://hcrenewal.blogspot.com/2013/05/ama-finally-on-board-with-ehr-views.html">http://hcrenewal.blogspot.com/2013/05/ama-finally-on-board-with-ehr-views.html</a>). Also - clinician stress promotes error. <blockquote class="tr_bq">But Domanico challenged the suggestion that patient safety at Marin General had been compromised.</blockquote> In fact, there is no way the issues described above cannot be compromising patient safety, on its face. (<a href="http://hcrenewal.blogspot.com/search/label/Patient%20care%20has%20not%20been%20compromised">http://hcrenewal.blogspot.com/search/label/Patient%20care%20has%20not%20been%20compromised</a>). <blockquote class="tr_bq">"I would have no hesitation about entering this hospital tonight," he said.</blockquote> As a VIP, of course, this CEO would get special treatment.  Thanks a lot. I would NOT want to be a patient there under these conditions, unless perhaps I had a 24x7 medically-skilled advocate/bodyguard. <blockquote class="tr_bq">Board member Ann Sparkman, who previously served as in-house counsel at Kaiser Permanente, said nurses at Kaiser struggled at first when a new computer system was introduced there. Sparkman said, "It's just to be expected."</blockquote> This seems a rather bizarre appeal to common practice (<a href="http://www.nizkor.org/features/fallacies/appeal-to-common-practice.html">http://www.nizkor.org/features/fallacies/appeal-to-common-practice.html</a>). The stunning ignorance of this board member about proper mission-critical IT safety testing and implementation, such as performed in pharma, aerospace, etc. is, quite frankly, shocking. Further, an attitude that life-threatening "glitches" are "just to be expected" by a member of the Board of Directors, with fiduciary responsibilities regarding hospital operations, is grossly negligent in my opinion, and completely ignores patient's rights. Unbelievable. One wonders if any formally-trained medical informatics experts were in leadership roles in this project. -- SS

Marin General Hospital nurses warn that new computer system is causing errors, call for time out

- Posted on the Healthcare Renewal Blog May 17, 2013 - Of course, the ever-present euphemism for life-threatening EHR malfunctions and defec...

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