Full Moon Friday the 13th: Computers down at Vermont's largest hospital

A health IT "glitch" hit in Vermont on Full Moon Friday the 13th (have some werewolf with your bad luck!)<br /><br /><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjV_zdKebiTKhfRJ6uNpkvPKcEBO6KdRLFaX9I2jr_774V1kxcEclGioScEsgplQzaD5ewqWC5zNQeqq2L4uEd62Qt4Hth98npdNSWR5lBv7f_BXtr0hnEZim77eHA10BZwaHDmZ8JjPTaU/s1600/werewolf.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="160" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjV_zdKebiTKhfRJ6uNpkvPKcEBO6KdRLFaX9I2jr_774V1kxcEclGioScEsgplQzaD5ewqWC5zNQeqq2L4uEd62Qt4Hth98npdNSWR5lBv7f_BXtr0hnEZim77eHA10BZwaHDmZ8JjPTaU/s1600/werewolf.jpg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Dark Shadows' Quentin Collins (David Selby) in a foul full-moon mood.</td></tr></tbody></table><br />Note, however, that "bad luck" has little or nothing to do with mission-critical healthcare IT mass outages.  Mismanagement often does:<br /><br /><blockquote class="tr_bq"><a href="http://www.wcax.com/story/25773022/computers-down-at-vermonts-largest-hospital">http://www.wcax.com/story/25773022/computers-down-at-vermonts-largest-hospital</a><br /><div id="WNStoryHeader"><h3 class="">Computers down at Vermont's largest hospital</h3><i class="wnDate">Posted: Jun 13, 2014 4:12 PM EST </i><i class="wnDate">Updated: Jun 13, 2014 4:12 PM EST </i><br /><div id="WNStoryByline"><div class="byline">By WCAX News</div></div></div></blockquote><div class=" withRelated right" id="WNStoryBody"><blockquote><span id="WNStoryDateline">BURLINGTON, Vt. - </span><br />A major, systemwide computer problem at Fletcher Allen Health Care in Burlington Friday.<br /><br />The hospital says the computer system went down at 9:45 a.m. <b>The glitch</b> means doctors and nurses could not enter patient information into computers.</blockquote><br /><b>"Glitch"</b> is an unfortunate euphemism for potentially harmful or deadly computer malfunctions, often due to mismanagement of that technology. See query link <a href="http://hcrenewal.blogspot.com/search/label/glitch">http://hcrenewal.blogspot.com/search/label/glitch</a>.<br /><br /><blockquote class="tr_bq">Hospital spokesperson Mike Noble says information is now being recorded manually <span style="color: red;"><i><b>[i.e., on paper - ed.] </b></i></span>Noble says the staff continues to provide the same care as normal and no surgeries were canceled because of the computer issue.<br /><br />Noble says the issue appears to be an internal problem and not something from an outside computer provider.<br /><br /><b>It’s not known when the problem will be corrected.</b></blockquote><br />This is yet another "the systems that revolutionize healthcare against all of paper's ills have all gone down, we don't know when they will be fixed, but patient care has not been compromised because we are resorting to paper" story (more at query link <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>).  <br /><br />-- SS</div>

Full Moon Friday the 13th: Computers down at Vermont's largest hospital

A health IT "glitch" hit in Vermont on Full Moon Friday the 13th (have some werewolf with your bad luck!) Dark Shadows' Quenti...

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Masters of the Obvious at Athens Regional Medical Center: Lack of clinician input, training, common sense created problems with Athens Regional electronic records system - but mostly lack of common sense

<div style="text-align: center;"><span style="font-size: x-small;">(Note: also see my earlier May 26, 2014 post at <a href="http://hcrenewal.blogspot.com/2014/05/i-could-not-make-this-up-if-i-tried.html">http://hcrenewal.blogspot.com/2014/05/i-could-not-make-this-up-if-i-tried.html</a>)</span></div><br />My early medical mentor, Dr. Victor P. Satinsky, had disdain for those whom he called "<b>Masters of the Obvious</b>", who proffered profound words of wisdom that were in fact common-sensical or well-accepted, as if they'd invented those words personally.<br /><br />I think it's fair to say that after countless publications dating back decades, pointing out the essential role of <b>clinical leadership</b> in the development of clinical tools such as healthcare information technology systems, that such involvement is now a<b> </b>standard of care that reasonable hospital leadership would mandate when spending tens of millions of dollars on potentially injurious or lethal systems.<br /><br />Yet the physician revolt at Athens Regional Medical Center appears to be a result of its most senior leadership not keeping IT leadership on an appropriately short leash (a phenomenon that falls under the topical heading of "severe mismanagement"):<br /><br /><blockquote class="tr_bq"><a href="http://onlineathens.com/local-news/2014-06-14/lack-input-training-created-problems-athens-regional-electronic-records-system">http://onlineathens.com/local-news/2014-06-14/lack-input-training-created-problems-athens-regional-electronic-records-system</a><b> </b><br /><br /><b>Lack of input, training created problems with Athens Regional electronic records system</b><br /><br />By Kelsey Cochran<br />Athens Banner-Herald<br />Updated Sunday, June 15, 2014<b> </b><br /><br /><b>More input in the way Athens Regional Health Systems’ electronic health records system was implemented should have come from the clinicians who use it every day, and fewer decisions should have been made by the hospital’s information technology department</b>, a top hospital administrator and two vice presidents of system vendor Cerner Corp. said this week, in the wake of criticism of the system by a number of physicians.<br /><br />... Although some daily users of the system were involved in the planning and design process from the beginning, Cerner Vice President Michael Robin, who has worked closely with ARMC since the deal was first made, said his team noticed midway through its implementation that <b>the hospital system’s IT team was leading the project,</b> <b>which is "atypical" of Cerner clients</b> like ARMC, he said. </blockquote><br />First, I don't think that IT team control of health IT projects is all that unusual.   Clinicians, even medical informaticists with cross-disciplinary expertise, rarely are more than "internal consultants" who may be ignored, as opposed to true leaders with executive presence and authority (e.g., control of budgets, grants of authority, and IT staff performance evaluation, hire and fire authority).<br /><br />Second, where was the Board of Directors?  They were ultimately responsible for allowing the IT leadership in at a level beyond their collective heads. <br /><br />Third, it's just a bit odd that the leader of the (failed) $20 billion National Programme for IT in the NHS, Richard Granger, said almost exactly the same thing about listening to end-users ca. 2007 (see <a href="http://hcrenewal.blogspot.com/2007/07/clinical-it-mayhem-is-good-for-it.html">http://hcrenewal.blogspot.com/2007/07/clinical-it-mayhem-is-good-for-it.html</a>).  I as well as numerous other authors had similar observations, in some cases dating to the 1960's.  For example,  see my essays, some dating to the late 1990s at <a href="http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases">http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases</a>, and Dr. Donald Lindberg's quotes from 1969 at the page below from Morris Collen's book "A History of Medical Informatics in the United States 1950-1990."<br /><br /><br /><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgcn4aLX1NGS_wG4FsSop81xaYmy9OeDKeiW-6qndwAvRWTmR6Sa4pwXyBuG02j4jKhifXdjSbcCcLcFngrkv6lYcip-V6DQvXzAsPCHdqMity4UopLN1lptK4OjgvBQIMUurTDLVb4l7Jr/s1600/collen168.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgcn4aLX1NGS_wG4FsSop81xaYmy9OeDKeiW-6qndwAvRWTmR6Sa4pwXyBuG02j4jKhifXdjSbcCcLcFngrkv6lYcip-V6DQvXzAsPCHdqMity4UopLN1lptK4OjgvBQIMUurTDLVb4l7Jr/s1600/collen168.jpg" width="210" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">EHR pioneer Dr. Donald A.B. Lindberg (<a href="http://www.nlm.nih.gov/od/roster/lindberg.html">http://www.nlm.nih.gov/od/roster/lindberg.html</a>), 1969:  "Computer engineering experts per se have virtually no idea of the real problems of medical or even of hospital practice, and furthermore have consistently underestimated the complexity of the problems ... in no cases can these jobs be done, simply because they have not been defined with a physician as the continuing major contributor and user of the information." (Click to enlarge)</td></tr></tbody></table><br />The essential nature of clinicians actually having input (and at a leadership level) into the design and implementation of clinical tools such as health IT is patently obvious.  <b>Only in the perverse control-mentality of business information technology</b> (a.k.a. MIS or management information systems, see <a href="http://hcrenewal.blogspot.com/2008/05/seedie-society-for-exorbitantly.html">http://hcrenewal.blogspot.com/2008/05/seedie-society-for-exorbitantly.html</a> for the possible pre-electronic computer, tabulator-based roots of that culture)<b> could such a precept even be questioned, let alone ignored.</b><br /><blockquote class="tr_bq"><br />... Moore, who took over as administrative lead on the electronic health record system after Thaw resigned, said some of the issues outlined in the physicians’ letter were real, and some were “theoretical.”</blockquote><br />Translation: some of the complaints were accidents waiting to happen.<br /><br /><blockquote class="tr_bq"><i>..."To the best of our knowledge, there was not patient harm or patient death.” </i></blockquote><br />In other words, this is yet another story where the common, feel-good and ignorant refrain "but patient care has not been compromised" has reared its ugly head.  (I've made this type of claim a topical header at this blog.  See query link <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> for others.) <br /><br />Assuming that's true - note that the impact of bad health IT can be delayed due to delayed effects of bad or missing information - this statement is, let me be impolite, vacuous on its face.<br /><div class="headword" id="headword"><blockquote class="tr_bq"><h2><span style="font-size: small;">vac·u·ous (<a href="http://www.merriam-webster.com/dictionary/vacuous">http://www.merriam-webster.com/dictionary/vacuous</a><b><span style="font-weight: normal;">)</span></b></span></h2><span class="main-fl"><i>adjective</i></span> <span class="pr">\<span class="unicode">ˈ</span>va-kyə-wəs\</span> </blockquote><div class="ld_on_collegiate"><blockquote><div class="bottom_entry">: having or showing a lack of intelligence or serious thought : lacking meaning, importance, or substance</div></blockquote></div></div><br />It seems some simple facts apparently need to be explained to these geniuses.   I'll put it in caps just to make sure they understand some basic issues:<br /><br /><ul><li>A HOSPITAL IS NOT A PLACE FOR RISKY INFORMATION TECHNOLOGY EXPERIMENTATION.   UNNECESSARY RISK IN HEALTHCARE IS A VERY, VERY BAD THING.<b> </b></li></ul><ul><li><b>THE GOAL OF HOSPITALS IS NOT TO SUBJECT PATIENTS TO RISK VIA MISMANAGEMENT OF HEALTHCARE IT</b>, AND THEN PROCLAIM "NOBODY WAS INJURED OR KILLED" AFTER THE PERPETRATORS OF THE MISMANAGEMENT ARE UPROOTED. </li></ul><ul><li>CLINICIANS DO NOT TOIL IN HOSPITALS TAKING CARE OF SICK PATIENTS SO THAT INFORMATION TECHNOLOGY PERSONNEL CAN HAVE COMFY JOBS AND COOL COMPUTERS.</li></ul><br />One wonders if these points might be above the intellectual pay grade of those running hospitals - including boards - in 2014. <br /><br />If nobody was injured or killed, it was due to<i><b> happenstance</b></i>, not due to appropriate due diligence and adherence to the standards of care essential in this healthcare sector - that is, healthcare information technology.<br /><br />Depending on happenstance is not a good healthcare management strategy. <br /><br />-- SS<br /><br />

Masters of the Obvious at Athens Regional Medical Center: Lack of clinician input, training, common sense created problems with Athens Regional electronic records system - but mostly lack of common sense

(Note: also see my earlier May 26, 2014 post at http://hcrenewal.blogspot.com/2014/05/i-could-not-make-this-up-if-i-tried.html ) My early me...

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This EHR "glitch" killed three-year-old Samuel Starr - but patient safety was not compromised

Actually, safety was compromised. <br /><br />I have written repeatedly that the term "glitch", an often-seen euphemism (usually accompanied with the phrase <b>"but patient care/patient safety was not compromised"</b>), is really a term for life-threatening health IT bugs and malfunctions.  See query link <a href="http://hcrenewal.blogspot.com/search/label/glitch">http://hcrenewal.blogspot.com/search/label/glitch</a> for examples of health IT "glitches" (retrieves multiple posts).<br /><br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhpyDXrISVqufhC1OX4Qiik6pFNxIueFaUkAZrjyxcKT2cpNF9zcS9pQkHYWyZMp8RxM6gPn8BG3vZAXtqUOUpVbf5Fv4AHrXgzHfB_JoT6Ou4Kup25VRYDSx5S_okwyCWmdy3K5LekH52x/s1600/Main-Samuel-Starr-3204412.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhpyDXrISVqufhC1OX4Qiik6pFNxIueFaUkAZrjyxcKT2cpNF9zcS9pQkHYWyZMp8RxM6gPn8BG3vZAXtqUOUpVbf5Fv4AHrXgzHfB_JoT6Ou4Kup25VRYDSx5S_okwyCWmdy3K5LekH52x/s1600/Main-Samuel-Starr-3204412.jpg" width="150" /></a></div><br /><br />Here's a "glitch" that tragically killed this boy: <br /><br /><blockquote class="tr_bq"><b>Three-year-old boy dies after new NHS computer system delays heart treatment</b><br /><br />Mar 05, 2014<br />By James Tute<br /><br /><a href="http://www.mirror.co.uk/news/uk-news/samuel-starr-death-nhs-computer-3209365">http://www.mirror.co.uk/news/uk-news/samuel-starr-death-nhs-computer-3209365 </a><br /><br />Coroner Maria Voisin rules that new booking system meant he did not receive life-saving treatment<br /><br />A three-year-old boy died in his parents' arms <b>after a new NHS computer system failed to schedule him for a vital heart scan</b>, a coroner has ruled.<br /><br />Samuel Starr was born with a congenital cardiac defect and needed surgery not long after he was born in 2010.<br /><br />Although he made a good recovery doctors said he would need regular tests to check on his progress.<br /><br />But he did not have a scan until 20 months after his first major operation <b>because of a delay following the introduction of a new computer system</b>, Cerner Millennium.<br /><br />When he finally had the appointment doctors found Samuel needed open heart surgery. During the procedure, Samuel had a stroke.<br /><br />A month later, after further complications, he died in the arms of his devastated parents, Catherine Holley and Paul Starr, at Bristol Royal Hospital for Children.</blockquote><br />There are some in my field who would (and have) called incidents like this "anecdotes" or "bumps in the road."<br /><br />Yet, as I've recently posted, an internationally-renowned healthcare safety tester, ECRI Institute (<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>), and the medical malpractice insurer of the Harvard medical community, CRICO (<a href="http://hcrenewal.blogspot.com/2014/02/patient-safety-quality-healthcare.html">http://hcrenewal.blogspot.com/2014/02/patient-safety-quality-healthcare.html</a>), have confirmed cases like this are no mere anecdotes.  I estimate from their numbers, and from cases known to me personally and from descriptions of others, that on the order of ten thousand (that's likely low) patients annually are being injured and/or die as a result of bad health IT in the U.S. alone.  Lack of transparency about such incidents impairs knowing the true numbers.<br /><br /><blockquote class="tr_bq">Ms Holley wept as she told the hearing of the moment she kissed her son goodbye, saying: "He was a kind and gentle boy with a great understanding of the world.<br /><br />"As we read Samuel his favourite stories, he died in our arms."<br /><br />Avon Coroner Maria Voisin, recording a narrative conclusion, <b>ruled the booking system meant Samuel was not seen and did not receive treatment.</b></blockquote><br />This case somewhat reminds me of the case of a newborn whose x-ray test was done, but never looked at due to a bug in the software that scheduled films to be read, see <a href="http://hcrenewal.blogspot.com/2011/06/babys-death-spotlights-safety-risks.html">http://hcrenewal.blogspot.com/2011/06/babys-death-spotlights-safety-risks.html</a>, case #2<br /><br /><blockquote class="tr_bq">Concluding a three-day inquest at Flax Bourton Coroner's Court in North Somerset, Ms Voisin said: "Samuel Starr was born with a complex cardiac disease. "He required surgery and regular check-ups at outpatients to manage his conditions.  "Due to the failure of the hospital outpatients booking system there was a five month delay in Samuel being seen and receiving treatment. "Samuel's heart was disadvantaged and he died following urgent surgery."</blockquote><br />Just a "glitch."<br /><br /><blockquote class="tr_bq">Doctors diagnosed that Samuel had a restricted pulmonary artery - causing blood to easily flow away from his heart to his lungs - during a 20-week scan in pregnancy ... On March 3, 2010, Samuel underwent open heart surgery at Bristol Royal Hospital for Children. He was discharged six days later and referred to the Paediatric Cardiac Clinic at the Royal United Hospital (RUH) in Bath for check-ups.<br /><br />In October 2010, Samuel had his first check-up, in which an echocardiogram, also known as an "echo", was carried out. Ms Holley said she was told the procedure would be next carried out early in the new year.<br /><br />But it did not happen until April 2011 and an echo was not performed.  Paediatric cardiologist Dr Andrew Tometzki told the inquest he did not "deem it necessary" on that day to carry out the echo scan. Dr Tometzki then ordered a further review - where an echo scan would be carried out - in nine months' time.<br /><br /><b>Samuel's parents did not receive information about the check-up and raised their concerns with community children's nurse Clare Mees.</b><br /><br />Ms Mees, who works for Sirona Lifetime Services, <b>said she would chase up the matter</b> with Dr Tometzki's secretary.<br /><br />Medical secretary Annabelle Attridge insisted she had taken details and forwarded them on to a dedicated appointments team.<br /><br /><b>However, the inquest heard <span style="color: red;">"glitch problems"</span> with a new booking system meant the appointment was not logged.  <span style="color: red;"></span></b></blockquote><br />Apparently not due to human fault: <br /><br /><blockquote class="tr_bq">Paediatric clinic co-ordinator Donna McMahon said while Samuel's medical records had been created on the new Millennium computer programme, <b>no appointments had been transferred across.</b></blockquote><br />Just a "glitch."  Just a "bump in the road."<br /><br /><blockquote class="tr_bq">Ms McMahon said she was first aware of the appointment delay when she received an email from nurse Ms Mees in May 2012.<br /><br />Samuel did not have the vital check-up until June 21.<br /><br />Coroner Ms Voisin added: "This overall failure led to a five month delay in Samuel being seen by his cardiologist.<br /><br />"This meant Samuel had not been seen for five months and had not had an echo for 20 months."<br /><br />His parents were horrified when Dr Tometzki informed them Samuel required heart surgery that spring.</blockquote><br />Just a "glitch."  Just a "bump in the road."<br /><br /><blockquote class="tr_bq">... "Just hours before his operation Samuel was dancing around the ward and telling the nurses all about Spiderman - we had to remind him to quieten down," Ms Holley said.<br /><br />Samuel's chest was closed on August 8. As he was brought out of sedation on August 9, he suffered a stroke and cardiac arrests.<br /><br />"It is clear that if the surgery had been performed earlier, the procedure would have been the same," Ms Voisin said.<br /><br /><b>But she said expert evidence found that as time went on "the more complicated the surgery is, as the more disadvantaged the heart is and the more difficult it is to get over the operation".</b></blockquote><br />Delays in care of fragile patients - in this case a young child, but in many other cases, ED and ICU patients of all ages - is very unwise.<br /><br /><blockquote class="tr_bq">Samuel's condition continued to deteriorate and on September 6 his parents were recommended for treatment to be withdrawn after he had a second cardiac arrest.<br /><br />The coroner said she would not write a report making recommendations to the hospital, as changes had already been implemented.</blockquote><br />Likely, workarounds to bad health IT, inviting future catastrophe.<br /><br />In my view, many cases such as this never make headlines, as the findings ignore the role of the IT and blame people, cases are settled with gag clauses, patients (who survive) or family are never told of the role of the IT, or lawsuits prove too expensive or too unpleasant to pursue.<br /><br />But patient safety is never compromised by "glitches", and regulation will just stifle innovation.<br /><br />My condolences to the parents.  I've suffered a death in my own family as a result of health IT, and I'm a specialist in the field.  Laypeople have no chance. <br /><br />One should pray the next child affected in this way is not one's own.<br /><br />-- SS<br /><br /><b>Mar. 25, 2014 addendum:  </b><br /><br />Also see these related posts, the first mentioning <b>"teething problems"</b>, another euphemism for potentially-deadly EHR malfunctions:<br /><br /><blockquote class="tr_bq"><b>Cerner's Blitzkrieg on London: Where's the RAF?</b><br /><b> </b><a href="http://hcrenewal.blogspot.com/2010/08/cerners-blitzkrieg-on-london-wheres-raf.html">http://hcrenewal.blogspot.com/2010/08/cerners-blitzkrieg-on-london-wheres-raf.html</a><b> </b><br /><br /><b>North Bristol Hits Appointment Problems: Another "Our Lousy IT Systems Screwed Up, But Patient Safety Was Never Compromised" Story</b><br /><a href="http://hcrenewal.blogspot.com/2012/01/another-our-crappy-computers-screwed-up.html">http://hcrenewal.blogspot.com/2012/01/another-our-crappy-computers-screwed-up.html</a></blockquote><br />-- SS

This EHR "glitch" killed three-year-old Samuel Starr - but patient safety was not compromised

Actually, safety was compromised. I have written repeatedly that the term "glitch", an often-seen euphemism (usually accompanied w...

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We're Sorry ... Our New EMR May Screw Up Your Care, But Don't Worry ... Patient Safety Has Not Been Compromised

A sign seen at a hospital system recently (name redacted):<br /><br /><br /><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiFv5Vc8MnAwjhlsEA5uP2zO7n0IiSujhj7kGyn2C6ygwzf714UqSrPgQh4-vNNnHBrY1K4NCiRSY3sAOTaeEcP5UL8R0a5dQRr0ILudU-oWkOnTf9uegkc__nrKq6XV-gyuHLGueztsCJC/s1600/we're+sorry+2.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="311" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiFv5Vc8MnAwjhlsEA5uP2zO7n0IiSujhj7kGyn2C6ygwzf714UqSrPgQh4-vNNnHBrY1K4NCiRSY3sAOTaeEcP5UL8R0a5dQRr0ILudU-oWkOnTf9uegkc__nrKq6XV-gyuHLGueztsCJC/s1600/we're+sorry+2.jpg" width="400" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">We're Sorry for any "Delays" as we start using our new EMR system ... But as a patient, you'll notice many benefits.   As to risks, nothing to see here ... move along.   <b>(Click to enlarge)</b></td><td class="tr-caption" style="text-align: center;"><br /></td><td class="tr-caption" style="text-align: center;"><br /></td><td class="tr-caption" style="text-align: center;"><br /></td><td class="tr-caption" style="text-align: center;"><br /></td></tr></tbody></table><br />FirstNet is an EMR system for <b>Emergency Departments. </b><br /><br />What's missing here is this:<br /><br /><ul><li>While "<a href="http://hcrenewal.blogspot.com/search/label/glitch">glitches</a>" that can harm you can happen anytime with these systems, at startup time <a href="http://hcrenewal.blogspot.com/2013/07/rns-say-sutters-new-electronic-system.html">disruptions and malfunctions</a> that could cause injury or death (as reported by <a href="http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html">FDA</a>, <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/Patient%20Safety%20and%20Health%20IT%20prepub.pdf">U.S. Institute of Medicine</a>, ECRI Institute per their <a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html">Deep Dive study of health IT risk</a> and others) are most common;</li></ul><ul><li>Potentially deadly EHR startup "issues" can number in the <b>many thousands</b> (<b><a href="http://hcrenewal.blogspot.com/2013/11/weve-resolved-6036-issues-and-have-3517.html">as at this link</a></b>); </li></ul><ul><li>If you don't want to subject yourself to these delays and/or glitches, you are free to select another hospital for your care. </li></ul><ul><li>(If you are injured or die as a result of the "Delays", then ... we're <i>Extra-Special With Sugar On Top </i>Sorry?)</li></ul><br />In other words, this glib, nonchalant signage is incomplete, and misleading on its face.<br /><br />While I understand its purpose, it ignores patient rights to informed consent and knowledge of a potentially unsafe environment for care, which hospitals have to prevent as an ethical and legal obligation.<br /><br />Of course, "please feel free to ask your caregiver if you have any questions" ... who may in fact be limited by contract or edict to only use <b>"<i>Words That Work</i>"</b> to further soothe unsuspecting patients (<b><a href="http://hcrenewal.blogspot.com/2013/10/words-that-work-singing-only-positive.html">as at this link</a></b>)<b>.</b><br /><br />-- SS

We're Sorry ... Our New EMR May Screw Up Your Care, But Don't Worry ... Patient Safety Has Not Been Compromised

A sign seen at a hospital system recently (name redacted): We're Sorry for any "Delays" as we start using our new EMR system ....

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Computer woes hit Banner hospital system: Another large EHR outage ... but patient safety was not compromised

Here is yet another story in the genre of "EHRs go out, but patient care has not been compromised." (See query link at <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>; there are more than 20 posts there now):<br /><br /><blockquote class="tr_bq"><b>Computer woes hit Banner hospital system</b><br />Ken Alltucker, The Arizona Republic 12:30 a.m. EST February 20, 2014<br /><a href="http://www.usatoday.com/story/news/nation/2014/02/19/computer-woes-slam-banner-hospital-system/5630829/">http://www.usatoday.com/story/news/nation/2014/02/19/computer-woes-slam-banner-hospital-system/5630829/</a><br /><br />The Phoenix-based health system used backup paper records to help provide patient care.<br /><br />PHOENIX -- Banner Health grappled with a widespread computer outage Wednesday as hospitals and doctors resorted to backup paper systems to provide care for patients.<br /><br />The Phoenix-based health system did not immediately know what triggered the computer troubles that started just before 10 a.m. PST. An official described the computer troubles as a rolling outage of computer systems at hospitals and other health care facilities in Phoenix, Colorado and Nevada.</blockquote><br />"Not knowing" means that you are not in control of your life-critical information systems; rather, they are in control of you.<br /><br /><blockquote class="tr_bq">By <b>late Wednesday</b>, a spokesman said, technicians had identified the problem and were fixing it. They expect to investigate the root cause of the problem Thursday.</blockquote><br />It took from 10 AM to "late Wednesday" to identify a problem causing a mass outage.  That should give anyone pause about dependency on fragile information systems in the hands of hospital IT departments (whose personnel undergo an ocean's less qualification-vetting than the medical personnel who depend on their work product) for one's medical care.<br /><blockquote class="tr_bq"><br />Banner Health, the Phoenix area's largest health care system, activated "downtime procedures" that included using paper-based systems to track medications and other care provided to patients, officials said.<br /><br />Banner's emergency departments still provided care to patients and accepted new patients.<br /><br />Some non-emergency surgeries and appointments were delayed because of the computer troubles.<br /><br />"There have been some delays and inconveniences, <b>but we are still providing care,</b>" said Bill Byron, Banner Health's senior vice president of public relations.</blockquote><br />In other words, what they are saying is "we really don't need these systems, that cost hundreds of millions of dollars, to provide care with the same degree of safety as with our 'downtime procedures' (a.k.a. paper)" ... and that patient safety was not compromised by this mass outage.<br /><br /><blockquote class="tr_bq">Banner Health, which operates 24 hospitals and several primary-care offices and outpatient centers in more than a half-dozen states, was working to "reboot" the computer systems Wednesday evening through a series of sequential fixes, Byron said.<br /><br />In the meantime, <b>Banner officials were able to retrieve computer-based records that detailed patients' medical histories</b>, including any medications, laboratory results and procedures that were previously performed.</blockquote><br />Officials?  What about line clinicians?  And when did this capability start if the systems needed to be "rebooted?"<br /><br /><blockquote class="tr_bq">Nurses and doctors shifted to writing on paper records after the computer systems experienced trouble Wednesday morning.<br /><br />Information from those paper charts will be keyed into the patients' computer-based health records after the problem is fixed.</blockquote><br />Sure, and nothing will be lost that could adversely affect patients in the future....<br /><br /><blockquote class="tr_bq">Banner Health has been among the most advanced health systems in the nation in converting to computer-based health records.<br /><br />Banner Estrella Medical Center was among the first hospitals to open as an "all-digital" facility in the past decade. Banner's other hospitals have largely completed the final stages of installing computerized record-keeping in areas such as physician order and entry and electronic documentation.</blockquote><br />If they are the most advanced, what does this event say about those less advanced?<br /><br /><blockquote class="tr_bq">Arizona law does not require hospitals to notify state health regulators in the event of such a widespread outage.</blockquote><br />Health IT, as usual, enjoys widespread and extraordinary regulatory accommodation.<br /><br /><blockquote class="tr_bq">However, some hospitals have internal policies requiring that they notify health accrediting organizations or federal regulatory agencies, such as the Centers for Medicare and Medicaid Services, an Arizona Department of Health Services spokeswoman said.</blockquote><br />And how many do?  Not many, I predict.<br /><br />-- SS

Computer woes hit Banner hospital system: Another large EHR outage ... but patient safety was not compromised

Here is yet another story in the genre of "EHRs go out, but patient care has not been compromised." (See query link at http://hcre...

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Martin Health System, Florida: Our EHRs were out for two days, but patient care has not been compromised, sayeth Pinocchio

This is yet another post in my ever-growing "our EHRs went out due to IT incompetence, and chaos ensued, <b>but patient care has not been compromised" </b>series (see query link: <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>):<br /><div class="fontStyle4 storyFontResize"><div class="story last"><br /><blockquote class="tr_bq"><b>Martin Health System looking into network outage that slowed hospital operations</b><br />Posted: 01/24/2014<br />By: Meghan McRoberts<br /><a href="http://www.wptv.com/dpp/news/region_martin_county/martin-health-system-looking-into-network-outage-that-slowed-hospital-operations">http://www.wptv.com/dpp/news/region_martin_county/martin-health-system-looking-into-network-outage-that-slowed-hospital-operations</a><br /><br />MARTIN COUNTY, Fla.-- Martin Health System is looking into what caused some computer hardware to fail Wednesday, leading to network outage in all of the Martin Health System hospitals.<br /><br />Things were back to normal Friday morning, according to hospital spokesperson, Scott Samples. </blockquote><br />Translation: for two days there was a complete network outage, with no EHRs, email, CPOE etc. <br /><br /><blockquote class="tr_bq">But since Wednesday night patients <i>say the atmosphere around the hospital was <b>chaotic.</b></i></blockquote><br />Patients likely noted doctors and nurses running like headless chickens.  I note that chaos and safe medical care are not good bedfellows.<br /><br /><blockquote class="tr_bq">Hospital staff, doctors and nurses <b>access the computer system to read patient charts and medical information.</b> Without it, they were left digging into paper documents.</blockquote><br />The paper documents left laying around would have best had scanty, sparse patient information, since the computer in computerized hospitals has become the primary source of truth.  (One might think such a system, including the network, would be hardened against failure, but a two-day outage, as per other outages at the query link above, show this is often not the case.)<br /><br /><blockquote class="tr_bq">Samples says this led to some minor inconveniences around the hospitals, where some patients received their meals later than normal. Some outpatient appointments could not be scheduled, and extra nurses and administrative staff were brought in to help with the increased work load.<br /><br /><b>No medication or treatment was jeopardized.</b></blockquote><br />There we have it.  In Pinocchio-like fashion we hear the obligatory "we lost all our information systems, which are our central nervous system for patient care, <b>but patient care has not been compromised"</b> statement from hospital PR.<b>  </b>This statement is questionable on its face.  <b></b><br /><b><br /></b><b>The risk of accident was significantly increased on its face.</b><br /><br /><blockquote class="tr_bq">New patients information was taken down on paper, and put into the system on Friday. Samples says there was a back up computer for data from former patients.</blockquote><br />The future will be in question depending on the quality, or lack thereof, of this "backload" of patient information that was collected during what patients themselves described as "chaos."<br /><br />Of course, according to the IT pundits paper itself, even under ideal circumstances, is so risky that tens or hundreds of millions of dollars per hospital has been spent to replace it.  Someone is not being truthful.<br /><br /><blockquote class="tr_bq">The hospitals that experienced the outage were Martin Medical Center, Martin Hospital South, and Tradition Medical Center.</blockquote><br />But patient safety risk was not compromised at any of them, so sayeth the figure below.<br /><br /><br /><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijzbyCRlWSocm_NxvqQwFGt3O9mxxjuSB3JRvq8pGtmEXlJvFwuCpQUINhi6ytR9f43tEIvHDKYNM0BIvvoMEfHnmmIlBzNkAq_yNGg7JYQx2M3b2TR_ViEXeUXiQEEg29GDSf72wQfK3i/s1600/Pinnochio.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijzbyCRlWSocm_NxvqQwFGt3O9mxxjuSB3JRvq8pGtmEXlJvFwuCpQUINhi6ytR9f43tEIvHDKYNM0BIvvoMEfHnmmIlBzNkAq_yNGg7JYQx2M3b2TR_ViEXeUXiQEEg29GDSf72wQfK3i/s1600/Pinnochio.jpg" width="152" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">All our EHRs and other clinical IT were unavailable for two days ... patients reported chaos ... we had to delay or cancel appointments and bring in extra clinical staff to maintain order ... but patient safety was not compromised, except for some late lunches!</td></tr></tbody></table><br />Pinocchio must be working at a lot of hospitals. When EHRs are out, patient safety is compromised. This is not open for debate, it is an "on its face" issue. These systems need hardening so as to be up and available 100%. Period. People responsible for outages need to be held accountable, including in a court of law if patients are injured or die as a result. Period.<br /><br />Finally I note that, with the corporatization of healthcare and with population of executive offices by lightweights with unquestioning faith in "cybernetic miracles", the credo of my early 1970's medical mentor, cardiothoracic surgery pioneer and educator Victor P. Satinsky, MD (<a href="http://articles.philly.com/1997-09-13/news/25550525_1_cardiovascular-institute-cardiovascular-surgery-programs-for-young-people">link</a>) - <b>"Critical thinking, always, or your patient's dead"</b> - is more valuable than ever.<br /><br />-- SS <br /><div><div class="fontStyle10" id="copyrightStoryModule"><br /></div></div></div></div>

Martin Health System, Florida: Our EHRs were out for two days, but patient care has not been compromised, sayeth Pinocchio

This is yet another post in my ever-growing "our EHRs went out due to IT incompetence, and chaos ensued, but patient care has not been ...

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Another in the "Health IT Crashed, But Patient Care Was Not Compromised" Series - NHS Greater Glasgow and Clyde

We must have health IT to prevent stupid doctors and nurses from making mistakes.  Without it, patients are at the mercy of dreaded Paper Records, which by definition cannot ever be used to provide quality care.<br /><br />But when the IT goes down, Patient Care Has Not Been Compromised.  This line should be trademarked, as it's seen so often.  (I even have an indexing tag for it, see this query link: <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>.)<br /><br />Care is never, never compromised when the IT goes belly up en masse due to <i>information technology malpractice</i>.  Care is only compromised by paper, no matter how good the paper records and its human stewards are.<br /><br />Here's the latest example that made it to the news, in Scotland:<br /><br /><blockquote class="tr_bq">1 October 2013<br />BBC News <br /><a href="http://www.bbc.co.uk/news/uk-scotland-glasgow-west-24358107">Appointments postponed after major IT failure at NHSGGC</a> (NHS Greater Glasgow and Clyde)<br /><br />Hundreds of outpatient appointments and a number of operations had to be postponed after <b>computer systems failed at Scotland's biggest health board</b>.<br /><br />NHS Greater Glasgow and Clyde said technicians were working through the night to fix a "major IT problem" which occurred on Tuesday morning.<br /><br /><b>It affected staff access to clinical and administrative systems. </b></blockquote><br />Delaying hundreds of appointments and delaying surgeries at up to 10 major hospitals seems on its face to represent "compromised care."<br /><br /><blockquote class="tr_bq">The health board apologised to patients and said all appointments would be rescheduled.<br /><br />In total, 288 outpatient appointments, four planned inpatient procedures, 23 day surgery cases and 40 chemotherapy sessions were postponed.<br /><br />There was also some delay in calls to the switchboard being answered.<br /><br />The problem may have affected up to 10 major hospitals across the health board area.</blockquote><br />One wonders how these appointments and surgeries were triaged for delay.  Clearly the downed computer was of no help.<br /><br />Here's that wonderful line:<br /><br /><blockquote class="tr_bq"><b>But emergency operations were not compromised - neither were community services.</b></blockquote><br />So when does computer failure actually compromise patient care?  I'd like to see some hospital executive with a spine for once admit that IT malpractice does disrupt patient care, create distractions, and thus create safety risk.  Considering the domain, however, I doubt I'll ever see that.<br /><br /><blockquote class="tr_bq">A spokeswoman said: "Our technical staff are working flat out to resolve this.</blockquote><br />It should never have happened in the first place.<br /><br /><blockquote class="tr_bq">"The problem relates to our networks and the way staff can connect to some of our clinical and administrative systems.</blockquote><br />Well, sick patients really appreciate that explanation.<br /><br /><blockquote class="tr_bq"><b>It was not clear how long the disruption would last.</b><br /><br />NHSGGC said if it did continue, people who were scheduled for treatment would be contacted directly. </blockquote><br />Per a computer guru from my past:  <i>"Either you're in control of your information systems, or they're in control of you."</i><br /><br />In this instance, the latter clearly applies.<br /><br />In healthcare, having your information systems in control of you is, sooner or later, going to be deadly.<br /><br />-- SS<br /><br /><br />

Another in the "Health IT Crashed, But Patient Care Was Not Compromised" Series - NHS Greater Glasgow and Clyde

We must have health IT to prevent stupid doctors and nurses from making mistakes.  Without it, patients are at the mercy of dreaded Paper Re...

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Setback for Sutter after $1B EHR crashes (in followup to post "RNs Say Sutter’s New Electronic System Causing Serious Disruptions to Safe Patient Care at East Bay Hospitals")

At my July 12, 2013 post "RNs Say Sutter’s New Electronic System Causing Serious Disruptions to Safe Patient Care at East Bay Hospitals" (<a href="http://hcrenewal.blogspot.com/2013/07/rns-say-sutters-new-electronic-system.html">http://hcrenewal.blogspot.com/2013/07/rns-say-sutters-new-electronic-system.html</a>) I reproduced a California Nurses Association warning about rollout of an EHR at Sutter:<br /><br /><blockquote class="tr_bq"><b>RNs Say Sutter’s New Electronic System Causing Serious Disruptions to Safe Patient Care at East Bay Hospitals</b><br /><br />Introduction of a new electronic medical records system at Sutter corporation East Bay hospitals has produced multiple problems with safe care delivery that has put patients at risk, charged the California Nurses Association today.<br /><br />Problems with technology are not unique to health care ...  <span style="color: red;"><i><b>[What is unique to healthcare IT is the complete lack of regulation - ed.]</b></i></span><br /><br /><b>In over 100 reports</b> submitted by RNs at Alta Bates Summit Medical Center facilities in Berkeley and Oakland, nurses cited a variety of serious problems with the new system, known as Epic. <b>The reports are in union forms RNs submit to management documenting assignments they believe to be unsafe.</b><br /><br />Patient care concerns included<b> computerized delays in timely administration of medications and contact with physicians, ability to properly monitor patients, and other delays in treatment. </b> Many noted that the <b>excessive amount of time required to interact with the computer system, inputting and accessing data, sharply cuts down on time they can spend with patients </b>with frequent complaints from patients about not seeing their RN.  <span style="color: red;"><i><b>[Note: patients are not given the opportunity for informed consent about the risks, nor opt-out of EHR use in their care - ed.]</b></i></span></blockquote><br />In related posts I'd observed such concerns being ignored by hospital management.  See header of the aforementioned post.<br /><br />Now we have this:  a major system crash.<br /><br /><blockquote class="tr_bq">Healthcare IT News<br /><a href="http://www.healthcareitnews.com/news/setback-sutter-after-1b-ehr-system%20crashes">Setback for Sutter after $1B EHR crashes</a><br /><div class="top">'No access to medication orders, patient allergies and other information puts patients at serious risk'</div><div class="top"><span class="submitted">SACRAMENTO, CA | August 28, 2013</span></div><div class="top"></div><div class="top"><span class="submitted">The nearly $1 billion electronic health record system at Sutter Health in Northern California crashed early this week,<b> leaving nurses and clinical staff unable to access any patient information for a full day. </b><br />he Epic EHR was down Aug. 23 due to a planned upgrade for eight hours during which nurses and other clinical users could read medication orders and patient histories but had to record new data on paper to then be re-entered into the system later, according to reports from the California Nurses Association, part of National Nurses United, the largest nurses union in the U.S. <br /><br />Then, on the morning of Aug. 26 at approximately 8 a.m.,<b> the system crashed completely, at which time nurses, physicians and hospital staff had no access to patient information, including what medications patients were taking or required to take and all vital patient history data.  </b><br />  <br />The Epic EHR went dark at several Sutter Health locations, including Alta Bates Summit Medical Center, Eden Medical Center, Mills-Peninsula Hospital, Sutter Delta, Sutter Tracy, Sutter Modesto and numerous affiliated clinics. <br /><br />"This incident is especially worrisome," said Bonnie Castilla, RN, CNA legislative director, in a news release. <b>"No access to medication orders, patient allergies and other information puts patients at serious risk.</b>  These systems should never be relied upon for protecting patients or assuring the delivery of the safest care."  </span><span class="submitted"><span class="submitted"><i><b><span style="color: red;">[This is no exaggeration.  My mother was nearly killed by such a problem when caused by an EHR defect (</span><a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/detail.cfm?mdrfoi__id=1729552">link</a><span style="color: red;">) that I averted at the last minute by happenstance of showing up at the right time, while she recuperating from another EHR-related disaster - ed.]  </span></b></i></span></span> </div></blockquote><blockquote class="tr_bq"><div class="top"><span class="submitted">Some RNs also reported that Sutter <b>failed to provide adequate support during the blackout and didn't implement adequate backup planning. <br /> </b><br /><b>"All information such as medication administration records and patient histories was outdated by two to three days,</b>" said Mike Hill, Alta Bates Summit RN, in a news release. "There were no orders that could be seen of any kind through the day so nurses called for what they needed."<br /><br />Kevin Sweat, an emergency room RN at Eden Medical Center, a Sutter affiliate, also weighed in on the blackout, saying that in his 12 years as an RN he has never seen a system crash like this.  <br />   </span></div></blockquote>Worse, clinicians must now serve their Cybernetic Master to perfection, or be whipped (apparently to improve morale):<br /><br /><blockquote class="tr_bq">... "We have been on Epic for 5 months now, and we can no longer have incorrect orders, missing information or incorrect or missing charges. Starting on September 1st, <b>errors made in any of the above will result in progressive discipline,</b>" according to another hospital memo sent to staff. </blockquote><br />In the setting of dire warnings by the nurses of EHR dangers several months back that were likely largely ignored, if any patient was harmed or killed as a result of this latest fiasco, the corporate leadership has literally begged to be sued for negligence, in my view.<br /><br />However I'm sure a press release soon will claim that "<a href="http://hcrenewal.blogspot.com/search/label/Patient%20care%20has%20not%20been%20compromised">patient care has not been compromised</a>."<br /><br />Of course this includes now and moving forward, even with informational gaps all over the place.<br /><br />-- SS<br /><br /><b>Aug. 29, 2013 additional thought:</b><br /><br />The punishment for not being a 'perfect' user of this EHR is the ultimate "blame the user" (blame the victim?) game, considering the pressures of patient care in hospitals in lean times - partly due to EHR expense! - and EHRs that have not been formally studied for usability and are poorly designed causing "use error" (that is, a poor user experience promotes even careful users to make errors).  Cf. definition of bad health IT:<br /><blockquote class="tr_bq"><br /><span style="color: black; font-family: Arial; mso-bidi-font-weight: bold;"><b>Bad Health IT</b> ("BHIT") is defined as IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for <span class="SpellE">hypervigilance</span> (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.</span></blockquote><br />The study of usability is getting underway only now via NIST but will likely be done in an industry-friendly way due to health IT politics.<br /><br />-- SS<br /><br /><b>Aug. 29, 2013 addendum</b><br /><br />There have been numerous comments over at HisTalk (at <a href="http://histalk2.com/2013/08/27/news-82813/">http://histalk2.com/2013/08/27/news-82813/</a>) defending the outage as not EPIC's fault.   From the point of view of clinicians - and more importantly, patients - it doesn't matter what component of the hospital's entire "EHR" (an anachronistic term used for what is now a complex enterprise clinical resource and clinician command-and-control system) went down.  <br /><br />Aside from all the EPIC issues the nurses have been complaining about (see earlier July 12, 2013 post linked above), the larger problem is that <b><i>IT malpractice</i></b> occurred.  The term "malpractice" is used in medical mishaps; I see no reason why it does not apply to major outages of mission critical healthcare information technology systems.<br /><br />IT malpractice in healthcare kills.<br /><br />These are the types of nurses I'd want caring for me and mine.  Letting this kind of snafu go "anechoic" does not promote proper management remedial education on Safety 101 and on health IT risk, two areas of education that management appears to desperately need in hospitals.<br /><br />-- SS<br /><br />

Setback for Sutter after $1B EHR crashes (in followup to post "RNs Say Sutter’s New Electronic System Causing Serious Disruptions to Safe Patient Care at East Bay Hospitals")

At my July 12, 2013 post "RNs Say Sutter’s New Electronic System Causing Serious Disruptions to Safe Patient Care at East Bay Hospitals...

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RNs Say Sutter’s New Electronic System Causing Serious Disruptions to Safe Patient Care at East Bay Hospitals

Add the following from <b>Sutter East Bay Hospitals</b> to nurses' and physicians' complaints at<b> Marin General Hospital </b>(<a href="http://hcrenewal.blogspot.com/2013/05/marin-general-hospitals-nurses-are.html">http://hcrenewal.blogspot.com/2013/05/marin-general-hospitals-nurses-are.html</a>), <b>Affinity Medical Center </b>(<a href="http://hcrenewal.blogspot.com/2013/06/affinity-rns-call-for-halt-to-flawed.html">http://hcrenewal.blogspot.com/2013/06/affinity-rns-call-for-halt-to-flawed.html</a>), <b>Contra Costa County</b> (<a href="http://hcrenewal.blogspot.com/2012/08/contra-costas-45-million-computer.html">http://hcrenewal.blogspot.com/2012/08/contra-costas-45-million-computer.html</a>), <b>San Francisco Department of Public Health </b>(<a href="http://hcrenewal.blogspot.com/2010/11/avatar-fails-no-not-cameron-movie-but.html">http://hcrenewal.blogspot.com/2010/11/avatar-fails-no-not-cameron-movie-but.html</a>), and others: <br /><br /><blockquote class="tr_bq"><b>For Immediate Release </b><br /><b>July 11, 2013</b><br /><i>Contact-  Charles Idelson, 510-273-2246</i><br /><h2>RNs Say Sutter’s New Electronic System Causing Serious Disruptions to Safe Patient Care at East Bay Hospitals</h2>Introduction of a new electronic medical records system at Sutter corporation East Bay hospitals has produced multiple problems with safe care delivery that has put patients at risk, charged the California Nurses Association today.<br /><br />Problems with technology are not unique to health care – pilots of the ill fated Asiana airline that tragically crashed at San Francisco International Airport July 6 told federal investigators that an automatic throttle failed to keep the jetliner at the proper speed for landing, the Los Angeles Times reported July 9.  <span style="color: red;"><i><b>[What is unique to healthcare IT is the complete lack of regulation - ed.]</b></i></span><br /><br /><b>In over 100 reports</b> submitted by RNs at Alta Bates Summit Medical Center facilities in Berkeley and Oakland, nurses cited a variety of serious problems with the new system, known as Epic. <b>The reports are in union forms RNs submit to management documenting assignments they believe to be unsafe.</b><br /><br />Patient care concerns included<b> computerized delays in timely administration of medications and contact with physicians, ability to properly monitor patients, and other delays in treatment. </b> Many noted that the <b>excessive amount of time required to interact with the computer system, inputting and accessing data, sharply cuts down on time they can spend with patients </b>with frequent complaints from patients about not seeing their RN.  <span style="color: red;"><i><b>[Note: patients are not given the opportunity for informed consent about the risks, nor opt-out of EHR use in their care - ed.]</b></i></span><br /><br />"EPIC is a system that is so cumbersome to use for nurses and physicians, that we often feel as though we are caring for a computer, not a patient,” said Thorild Urdal, an RN at Alta Bates Summit’s hospital in Berkeley. “It delays care and treatment, the program is naturally counter-intuitive and<b> it was clearly not designed in concert with nurses and physicians</b>." <span style="color: red;"><i><b>[Clinicians end up caring for an "iPatient", as others have noted - ed.]</b></i></span><br /><br />"The Epic program developed and implemented by Sutter is neither nurse or patient friendly,” said Alta Bates Summit Oakland RN Mike Hill. “Epic does not enhance my ability to chart instead it takes time away from the bedside and my patients and preventing me from providing the absolute best care that they and I expect from me as a nurse."<br /><br />Sutter CEO Pat Fry last year told the San Francisco Business Times that Sutter will spend $1 billion on Epic, a system that has sparked controversy at several other hospitals, including a Contra Costa facility where several RNs cited serious medical errors in testimony to county supervisors last August.<br /><br />At Alta Bates Summit specific incidents directly related to Epic problems included:<br /><br />• A patient who had to be transferred to the intensive care unit due to delays in care caused by the computer.  <span style="color: red;"><i><b>[It's happenstance they did not have to be transferred to the morgue - ed.]</b></i></span><br />• A nurse who was not able to obtain needed blood for an emergent medical emergency.<br />• Insulin orders set erroneously by the software.<br />• Missed orders for lab tests for newborn babies and an inability for RNs to spend time teaching new mothers how to properly breast feed babies before patient discharge.<br />• Lab tests not done in a timely manner.<br />• Frequent short staffing caused by time RNs have to spend with the computers.<br />• Orders incorrectly entered by physicians requiring the RNs to track down the physician before tests can be done or medication ordered.<br />• Discrepancies between the Epic computers and the computers that dispense medications causing errors with medication labels and delays in administering medications.<br />• Patient information, including vital signs, missing in the computer software.<br />• An inability to accurately chart specific patient needs or conditions because of pre-determined responses by the computer software.<br />• Multiple problems with RN fatigue because of time required by the computers and an inability to take rest breaks as a result.<br />• Inadequate RN training and orientation.<br /><br /></blockquote>These "incidents" are certainly capable of causing harms or fatalities.  One wonders if hospital executives are providing the usual refrain that these are just <b>"glitches" </b>(<a href="http://hcrenewal.blogspot.com/search/label/glitch">http://hcrenewal.blogspot.com/search/label/glitch</a>) and that <b>patient care has not been compromised</b> (<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>).<br /><br />A bit more background follows: <br /><br /><blockquote class="tr_bq">... Hospitals nationally are spending tens of billions of dollars on technology systems, especially on electronic health records (EHR) programs for which they also receive federal financial incentives. <br /><br />EHR programs are paraded as a panacea for reducing medical errors and cutting costs, but in life the promise is falling short in both areas.<br /><br />A RAND corporation analysis earlier this year said visions of savings and improved efficiency in patient care have had what the New York Times called “mixed results, at best.”<br /><br />The U.S. Food and Drug Administration has acknowledged getting hundreds of reports of problems involving health information technology including numerous patient injuries and deaths.<br /><br />Some examples seen at hospitals across the country:<br /><br />• At Marin General Hospital in Northern California, RNs called on the Marin Healthcare District board to delay implementation of their EHR system. "Orders are being inadvertently passed to the wrong patients. People have gotten meds when they've been allergic to them. This is dangerous," Marin RN Barbara Ryan said in comments reported by the Marin Independent Journal.<br />• In Chicago, the Chicago Tribune in 2011 reported on a patient death at Advocate Lutheran General hospital after an automated machine prepared an intravenous solution containing a massive overdose of sodium chloride — more than 60 times the amount ordered by a physician.<br />• At Affinity Medical Center RNs in Massillon, Oh. RNs in June raised multiple objections to the hurried introduction of an EHR system. Subsequently, they have cited medication errors, delays in care, problems with documentation, computers crashing, and other concerns.</blockquote><br />I am simply the reporter here.<br /><br />-- SS

RNs Say Sutter’s New Electronic System Causing Serious Disruptions to Safe Patient Care at East Bay Hospitals

Add the following from Sutter East Bay Hospitals to nurses' and physicians' complaints at Marin General Hospital ( http://hcrenewa...

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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><br />Of course, the ever-present euphemism for life-threatening EHR malfunctions and defects, i.e., "<b>glitches</b>" are the cause (<a href="http://hcrenewal.blogspot.com/search/label/glitch">http://hcrenewal.blogspot.com/search/label/glitch</a>):<br /><a href="http://www.marinij.com/rosskentfieldgreenbrae/ci_23251638/marin-general-hospital-nurses-warn-that-new-computer"><br /></a><br /><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><br /><br />By Richard Halstead<br />Marin Independent Journal<br />Posted:   05/15/2013 04:07:49 PM PDT<br /><br />Nurses at Marin General Hospital have asked administrators to put implementation of a new computerized physician order entry system on hold until <b>glitches </b>can be worked out and more training provided to nurses and doctors who use it.<br /><br />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.<br /><b><br />"Orders are being inadvertently passed to the wrong patients</b>. <b>People have gotten meds when they've been allergic to them</b>. 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><br /><br />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!<br /><br /><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,<b> we have a system today that is safer for patients than our old paper system</b>, and it will get even safer as we gain experience with it and work to fix some of the glitches we've experienced."</blockquote><br />Where's the data backing up that assertion, I ask?  The actual risks of paper records don't seem to be robustly documented anywhere.<br /><blockquote class="tr_bq"><br />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 <b>nurses warned in advance </b>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 <b>nurses had been unable to open the program at home to practice using it.</b></blockquote><br />And yet the rollout happened anyway?  That seems to me to be reckless indifference to the concerns of clinicians.<br /><br /><blockquote class="tr_bq">"Lo and behold the problems that we were worried about have happened," Ryan said. "We're looking at <b>two-hour preps for surgery and two- to three-hour discharges; </b>skilled nursing facilities calling back saying, this really doesn't make sense; <b>the wrong meds ordered on the wrong patients </b>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><br />Of course, I might add, patient safety was not compromised, the other common refrain of EHR glitch-excusers ... see below.<br /><br /><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.<br /><br />"We will take patients but we will object to the assignment because it is unsafe," Ryan said. "This system is making it unsafe."</blockquote><br />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.<br /><br /><blockquote class="tr_bq">Marin General nurse Susan Degan said, <b>"This is not about resistance to change</b>. It's about accountability. My most important role is that of patient advocate. I am held accountable when errors are made."<br /><br />Domanico acknowledged there have been some technical problems with the Paragon system, including making it possible for nurses to open from home. <b>And he said the software is not faster than the old paper system.</b>  <span style="color: red;"><i><b>[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.]</b></i></span></blockquote><br />About the "resistance to change" canard, see my essay "<b>Doctors and EHRs: Reframing the 'Modernists v. Luddites' Canard to The Accurate 'Ardent Technophiles vs. Pragmatists' Reality"</b> 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> .<br /><blockquote class="tr_bq"><br />"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><br />What?  <b>"Speed up the computer?" </b> They've spent tens if not hundreds of millions for an EHR, and the computer's too slow?<br /><br />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>).<br /><br />Also - clinician stress promotes error.<br /><br /><blockquote class="tr_bq">But Domanico challenged the suggestion that patient safety at Marin General had been compromised.</blockquote><br /><b>In fact, there is no way the issues described above cannot be compromising patient safety, on its face. </b>(<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>)<b>.</b><br /><br /><blockquote class="tr_bq">"I would have no hesitation about entering this hospital tonight," he said.</blockquote><br />As a VIP, of course, this CEO would get special treatment.  Thanks a lot.<br /><br />I would NOT want to be a patient there under these conditions, unless perhaps I had a 24x7 medically-skilled advocate/bodyguard.<br /><br /><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.<br /><br />Sparkman said, <b>"It's just to be expected."</b></blockquote><br />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>).<br /><br />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.<br /><br />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.<br /><br />Unbelievable. <br /><br />One wonders if any formally-trained medical informatics experts were in leadership roles in this project. <br /><br />-- 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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When "Human Error" Causes EHR Downtime, Who is Liable For Patient Injuries That Result?

In the Pittsburgh Post-Gazette was this story of yet another EHR "<a href="http://hcrenewal.blogspot.com/search/label/glitch" target="_blank">glitch</a>":<br /><br /><blockquote class="tr_bq">March 9, 2013 12:17 am<b> </b><br /><br /><b><a href="http://www.post-gazette.com/stories/business/news/business-news-briefs-human-error-the-cause-of-upmc-electronic-issue-678572/" target="_blank">Human error the cause of UPMC electronic issue</a></b><br /><br />A <b>systemwide</b> problem with UPMC's information systems Wednesday left electronic patient records and other data inaccessible for about three hours. A UPMC spokeswoman said the hospitals "immediately went to manual backup systems, and we quickly identified and fixed the problem." <b>She said there was no indication that patient care was compromised by the incident, which was due to human error.</b></blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br />I will presume the "human error" was not a physician or nurse pressing the wrong button, but a "human error" involving the servers or IT infrastructure such as a botched system upgrade, action that caused a server room power fault, etc.<br /><br />UMPC is a very large system as their webpage shows, showing approximately <a href="http://www.upmc.com/locations/hospitals/pages/default.aspx" target="_blank">fifteen major facilities</a>.<br /><br />The now-expected "<i>patient care has not been compromised</i>" line was provided to the Gazette, a line so commonly heard after EHR outages that I  use it as a Healthcare Renewal <b>indexing tag</b> (see this <a href="http://hcrenewal.blogspot.com/search/label/Patient%20care%20has%20not%20been%20compromised" target="_blank">query link</a>).<br /><br />The following questions arise:<br /><br /><ul><li>What, exactly, was the "human error" and why was there no fault tolerance built into these mission-critical systems to account and compensate for it, such as via redundancy? </li></ul><ul><li>If paper is so bad as a record-keeping medium that hundreds of billions of dollars are being spent to replace it, then how can patient care not be compromised, especially when multiple hospitals unexpectedly and without warning have to return to its use? </li></ul><ul><li>How can a very large hospital system rapidly declare that "patient care was not compromised" without a thorough and comprehensive patient review, accounting for possible delayed negative outcomes (by way of just a few simple examples, due to medication or imaging delays?)</li></ul><ul><li> Who is liable for any adverse patient outcomes that occurred related to the sudden unavailability of past records:  the clinicians?  The "human" who committed the computer-related error?  The corporation, either for direct negligence in implementing and mandating use of a system prone to mass outage by human error, or vicariously for the negligence and/or misconduct of its information technology employees and/or agents?</li></ul><ul><li> How many "outages" will it take before some patient is outright, no-doubt-about-it harmed or killed?  Do we want to find out, or is a priority to have redundancies so these systems don't crash?</li></ul>I, for one, would not want to have a family member be "crashing" at the time of a sudden, unexpected system-wide EHR outage.<br /><br />-- SS </div>

When "Human Error" Causes EHR Downtime, Who is Liable For Patient Injuries That Result?

In the Pittsburgh Post-Gazette was this story of yet another EHR " glitch ": March 9, 2013 12:17 am   Human error the cause of UPM...

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Allegheny Health System Computer Crash (Again) and Paper Backups

I reported on a health IT crash in my May 2011 post "<a href="http://hcrenewal.blogspot.com/2011/05/twelve-hour-health-it-glitch-at.html" target="_blank">Twelve Hour Health IT Glitch at Allegheny General Hospital - But Patients Unaffected, Of Course...</a>"<br /><br />Now, there's this at the <a href="http://www.wpahs.org/locations" target="_blank">same healthcare system</a>:<br /><br /><blockquote class="tr_bq"><b><a href="http://www.post-gazette.com/stories/news/health/computer-system-at-west-penn-allegheny-crashes-655866" target="_blank">Computer system at West Penn Allegheny restored after crash</a> </b><br /><b>Liz Navratil<br />Pittsburgh Post-Gazette<br />October 2, 2012 </b><br /><br />The computer system at West Penn Allegheny Health System crashed about noon today, temporarily leaving doctors and nurses to work off of paper records instead.<br /><br />Kelly Sorice, vice president of public relations for the health system, said all systems have since been restored. She said the servers crashed about noon today when the system experienced a power surge.<br /><br /><b>Doctors in the health system keep paper copies of almost all of their records</b> so they can reference them during power outages or scheduled maintenance times, Ms. Sorice said.</blockquote><br />Some systems were up eight hours later and others were expected to come online overnight, according to a report at <a href="http://histalk2.com/2012/10/02/news-10312/" target="_blank">HisTalk</a>.<br /><br />Assuming the statement about "doctors keep paper copies of almost all their records" was not spin control regarding skeletal paper records, a question arises.<br /><br />Why, exactly, spend hundreds of millions of dollars on computing if paper records are kept, and are perfectly sufficient to accomplish the following, the usual refrain in health IT crash scenarios?<br /><br /><blockquote class="tr_bq">Ms. Sorice said she did not know of any procedures that had been rescheduled and added that, <b>"Patient care has not been compromised."</b> </blockquote><br />As a physician/ham radio enthusiast who did an elective in Biomedical Engineering in medical school, I also want to know:<br /><br />1)  What caused the “power surge?”<br />2)  Why were the systems not protected against a “power surge?”<br />3)  Exactly how did the “power surge” affect the IT?<br /><br />Note: I've created a new, searchable indexing term for HIT outage stories with the usual refrain along the lines that <b>"patient care has not been compromised."  </b><br /><br />See <a href="http://hcrenewal.blogspot.com/search/label/Patient%20care%20has%20not%20been%20compromised" target="_blank">this query link</a> using the new indexing term.<br /><br />-- SS<br /><br /><b>Addendum Oct. 3:</b><br /><br />Australian EHR reseacher and professor <a href="http://rp-www.cs.usyd.edu.au/~jonpat/" target="_blank">Dr. Jon Patrick</a> opines:<br /><br /><blockquote class="tr_bq">Even if [the paper records are] skeletal they suggest an endemic lack of confidence. I think the hospital spokesperson hasn't seen the implication of their statement.</blockquote><br />-- SS

Allegheny Health System Computer Crash (Again) and Paper Backups

I reported on a health IT crash in my May 2011 post " Twelve Hour Health IT Glitch at Allegheny General Hospital - But Patients Unaffec...

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UK: Another Example of IT Malpractice With Bad Health IT (BHIT) Affecting Thousands of Patients, But, As Always, Patient Care Was "Not Compromised"

<div class="post-title entry-title" itemprop="name">At my Dec. 2011 post "<a href="http://hcrenewal.blogspot.com/2011/12/yet-another-glitch-affecting-thousands.html" target="_blank">IT Malpractice? Yet Another "Glitch" Affecting Thousands of Patients. Of Course, As Always, Patient Care Was "Not Compromised</a>" and others, I noted:</div><div class="post-title entry-title" itemprop="name"><br /></div><blockquote class="tr_bq">... claims [in stories regarding health IT failure] that "no patients were harmed" ... are both misleading and irrelevant:<br /><br />Such claims of 'massive EHR outage benevolence' are misleading, in that medical errors due to electronic outages <span style="font-weight: bold;">might not appear for days or weeks after the outage</span> ... Claims of 'massive EHR outage benevolence' are also irrelevant in that, even if there was no catastrophe directly coincident with the outage, their was <span style="font-weight: bold;">greatly elevated risk</span>. Sooner or later, such outages will maim and kill.</blockquote><br />Here is a prime example of why I've opined at my Sept. 2012 post "<a href="http://hcrenewal.blogspot.com/2012/09/good-health-it-v-bad-health-it-paper-is.html" target="_blank">Good Health IT (GHIT) v. Bad Health IT (BHIT): Paper is Better Than The Latter</a>" that a good or even average paper-based medical record keeping system can facilitate safer and better provision of care than a system based on bad health IT (BHIT).<br /><br />Try this with paper:<br /><br /><blockquote class="tr_bq"><b><span style="font-size: small;"><a href="http://www.independent.co.uk/life-style/health-and-families/health-news/nhs-coverup-over-lost-cancer-patient-records-8191066.html" target="_blank">NHS 'cover-up' over lost cancer patient records</a></span></b><br /><br />Thousands awaiting treatment were kept in the dark for five months when data disappeared<br /><br />Sanchez Manning<br />The Independent<br />Sunday 30 September 2012<br /><br />Britain's largest NHS trust took five months to tell patients it had mislaid medical records for thousands of people <b>waiting for cancer tests and other urgent treatments</b>. Imperial College Healthcare NHS Trust discovered in January <b>that a serious computer problem and staff mistakes had played havoc with patient waiting lists.</b></blockquote><br />It's quite likely the "serious computer problem" far outweighed the impact of "staff mistakes", as disappearing computer data does so in a "silent" manner.  One does not realize it's missing as there's not generally a trail of evidence that it's gone.<br /><blockquote class="tr_bq"><br />About 2,500 patients were forced to wait longer on the waiting lists than the NHS's targets, and the trust had no idea <b>whether another 3,000 suspected cancer patients on the waiting list had been given potentially life-saving tests</b>. Despite the fact that the trust discovered discrepancies in January and was forced to launch an internal review into the mess, including 74 cases where patients died, it did not tell GPs about the lost records until May.</blockquote><br />That is, quite frankly, outrageous if true and (at least in the U.S.) might be considered <a href="http://legal-dictionary.thefreedictionary.com/Criminal+Negligence" target="_blank">criminally negligent</a> (<i>failure to use reasonable care to avoid consequences that threaten or harm the safety of the public and that are the foreseeable outcome of acting in a particular manner)</i>.<br /><br /><blockquote class="tr_bq">Revelations about the delay prompted a furious response yesterday from GPs, local authorities and patients' groups. Dr Tony Grewal, one of the GPs who had made referrals to Imperial, said doctors should have been told sooner to allow them to trace patients whose records were missing. "The trust should have contacted us as soon as it was recognised that patients with potentially serious illnesses had been failed by a system," he said. "GPs hold the ultimate responsibility for their patient care."</blockquote><br />That is axiomatic.<br /><br /><blockquote class="tr_bq">The chief executive of the Patients Association, Katherine Murphy, added: "This is unacceptable for any patient who has had any investigation, but especially patients awaiting cancer results, where every day counts. The trust has a duty to contact GPs who referred the patients. It's unfair on the patients to have this stress and worry, and the trust should not have tried to hide the fact that they had lost these records. They should have let the GPs know at the outset."</blockquote><br />Unfair to the patients is an understatement,  However, if one's attitude is that <i><b>computers have more rights than patients</b></i>, as many on the health IT sector seem to with their ignoring of patient rights such as informed consent, lack of safety regulation, and lack of accountability, then it's quite acceptable.<br /><br /><blockquote class="tr_bq">The trust defended the delay in alerting GPs, arguing that it needed to check accurately how much data it had lost before making the matter public. It said a clinical review had now concluded that no one died as a result of patients waiting longer for tests or care.</blockquote><br />That would be perhaps OK if the subjects whose "data had been lost" through IT malpractice were lab rats.<br /><br /><blockquote class="tr_bq">Despite this, three London councils – Westminster, Kensington and Chelsea, and Hammersmith and Fulham – are deeply critical of the way the trust handled the data loss. Sarah Richardson, a Westminster councillor who heads the council's health scrutiny committee, <b>said that trust bosses had attempted to "cover up" the extent of the debacle. "Yes, they've done what they can but, in doing so, [they] put the reputation of the trust first,"</b> she said. "Rather than share it with the GPs, patients and us, they thought how can we manage this information internally. They chose to consider their reputation over patient care."</blockquote><br />As at my Oct. 2011 post "<a href="http://hcrenewal.blogspot.com/2011/10/cybernetik-uber-alles-computers-have.html" target="_blank">Cybernetik Über Alles: Computers Have More Rights Than Patients?</a>", to be more specific, they may have put the reputation of the Trust's <i>computers</i> first.  <br /><br /><blockquote class="tr_bq">Last week, it was revealed that Imperial has been fined £1m by NHS North West London for the failures that led to patient data going missing. On Wednesday, an external review into the lost records said a "serious management failure" was to blame for the blunder.</blockquote><br />Management of what, one might ask? <br /><br /><blockquote class="tr_bq">Imperial's chief financial officer, Bill Shields, admitted at a meeting with the councils that the letter could have been produced more quickly. He said that, at the time, the trust had operated with "antiquated computer systems" and had a "light-touch regime" on elective waiting times.</blockquote><br />Version 2.0A will, as again is a typical refrain, fix all the problems.<br /><br /><blockquote class="tr_bq">Terry Hanafin, the leading management consultant who wrote the report, said the data problems went back to 2008 and had built up over almost four years until mid-2011. Mr Hanafin said the <b>priorities of senior managers at that time were the casualty department and finance.</b></blockquote><br />Clinical computing is not business computing, I state for the thousandth time.  When medical data is discovered "lost", the <b>only</b> response should be ... find it, or inform patients and clinicians - <b>immediately.</b><br /><br /><blockquote class="tr_bq">He further concluded that while the delays in care turned out to be non-life threatening, they had the potential to cause pain, distress and, in the case of cancer patients, "more serious consequences" ... The trust <b>said it had found no evidence of clinical harm </b>and stressed that new systems have now been implemented to record patient data. It denied trying to cover up its mistakes or put its reputation before concerns for patients. "Patient safety is always our top priority," said a spokesman.</blockquote><br />"More serious consequences" is a euphemism for horrible <b>metastatic cancer and death</b>, I might add.  The leaders simply cannot claim they "<i>found no evidence of clinical harm</i>" regarding delays in cancer diagnosis and treatment until time has passed, and followup studies performed on this group of patients.<br /><br />This refrain is evidence these folks are either lying, CYA-style, or have no understanding of clinical medicine whatsoever - in which case their responsibilities over the clinic need to be ended in my opinion.<br /><br />I, for one, would like to know the exact nature of the "computer problem", who was responsible, and if it was a software bug, how such software was validated and how it got into production. <br /><br />-- SS<br /><br />Oct. 1, 2012 Addendum:<br /><br />What was behind the problems, according to another source?  <b> </b><br /><br /><b>Bad Health IT (BHIT):</b><br /><br /><blockquote class="tr_bq"><b><a href="http://www.ehi.co.uk/news/EHI/8094/poor-it-behind-imperial-cancer-problems" target="_blank">Poor IT behind Imperial cancer problems</a></b><br />e-Health Insider<br />28 September 2012<br />Rebecca Todd<br /><br />An independent review of data quality issues affecting cancer patient referrals to Imperial College Healthcare NHS Trust has identified “poor computer systems” as a key cause of the problem.<br /><br />The review’s report highlights the trust’s use of up to 17 different IT systems as causing problems for patient tracking.<br /><br />However, it says the trust should be aware of the risks of [replacing the BHIT and] moving to a single system, Cerner Millennium, <b>because of reported problems in providing performance data after similar moves at other London trusts.</b><br /><br />In January 2012, the report says the NHS Intensive Support Team was reviewing the way reports on cancer waiting times were created from Imperial’s cancer IT system, Excelicare.<br /><br />The team discovered that almost 3,000 patients were still on open pathways who should have been seen within two weeks. In May, letters were sent to GPs to try and ascertain the clinical status of around 1,000 patients.</blockquote><br />BHIT must be forbidden from real-world deployments, and fixed rapidly or dismantled (as Imperial College Healthcare NHS Trust appears to be doing), although the "solution" might be just as bad, or worse, than the disease.<br /><br />-- SS

UK: Another Example of IT Malpractice With Bad Health IT (BHIT) Affecting Thousands of Patients, But, As Always, Patient Care Was "Not Compromised"

At my Dec. 2011 post " IT Malpractice? Yet Another "Glitch" Affecting Thousands of Patients. Of Course, As Always, Patient C...

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From the University of Chicago EHR Helpdesk Call Line

I was alerted this morning (Aug. 23rd) to this message currently in the telephone message of the <span class="st">CBIS [Chicago Biomedicine Information Services]</span> Service Desk at University of Chicago Medical Center:<br /><br /><blockquote class="tr_bq">"Thanks for calling <span class="st">the CBIS </span>Service Desk.  Your call is very important to us. We are currently experiencing troubles with our Citrix logon.  <b>It may log you on under a different profile. </b> Please check before you go any further when you're logging in to Citrix."</blockquote><br /><a href="http://www.citrix.com/English/ps2/products/product.asp?contentID=1857200&ntref=hp_cat_prod" target="_blank">Citrix</a> is a computer program that allows remote access to information systems.<br /><br />I imagine the meaning of "log you on under a different profile" means "logging you on as a different user."<br /><br />The chances of a security breach (ability of unauthorized user to peer into patient's charts they have no business seeing), unauthorized history/order manipulation, or even misidentification error (e.g., a clinician inadvertently acting upon a patient of some other clinician who has a similar name to their own patient) and other distracting work disruptions due to the inconveniences this "trouble" creates are worrisome.<br /><br />One wonders how every user is being informed of this problem, as not everyone makes it a habit to call the service desk before logging in to clinical systems...<br /><br />But, alas, this is just a <b>"glitch" </b>(the <a href="http://hcrenewal.blogspot.com/2012/08/health-it-difficulties-and.html" target="_blank">euphemism used by technophiles</a> for <b>malignant software defects</b>), and, of course, patient safety <b>is never compromised </b>by "glitches."<br /><br /><br /><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh6NqMEfshKCF7TC4bPKm1jza8y7xQnOiw1MNd58j6pVp85x_OBGy8hPo25yjwa79LCXObcyGT8EQOKFiThEwk3kb5ehX-JoX8QGQR8vHa2cWB2tsaUF5Eitp0DNoM8ykUgb8g87q2DrPEk/s1600/crystal+ball.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="132" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh6NqMEfshKCF7TC4bPKm1jza8y7xQnOiw1MNd58j6pVp85x_OBGy8hPo25yjwa79LCXObcyGT8EQOKFiThEwk3kb5ehX-JoX8QGQR8vHa2cWB2tsaUF5Eitp0DNoM8ykUgb8g87q2DrPEk/s200/crystal+ball.jpg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Patient Safety Will Not Be Compromised, We Predict ... So Say Us All.</td></tr></tbody></table><br /><br />-- SS<br /><b><br /></b><b>8/29/12 Addendum:</b><br /><br />Apparently the problem was finally solved between 5:30 PM and 9 PM CST on August 27.   I first became aware of it at around 8 AM EST August 23.  Brings to life the line <b>"either you are in control of your information systems, or they are in control of you." </b><br /><br />Also, see the comment thread to this post <a href="http://www.blogger.com/comment.g?blogID=9551150&postID=3141136033860089060&isPopup=true" target="_blank">here</a>, specifically the comments starting at August 28, 2012 12:16:00 PM EDT, to see yet another demonstration of the illogic, unserious attitudes and feelings of entitlement towards patient risk and transparency characteristic of the health IT industry.  The anonymous commenter also alleges to have firsthand knowledge of the problem, suggesting they are from U. Chicago, but this cannot be confirmed.<br /><br />-- SS

From the University of Chicago EHR Helpdesk Call Line

I was alerted this morning (Aug. 23rd) to this message currently in the telephone message of the CBIS [Chicago Biomedicine Information Servi...

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ONC and Misdirection Regarding Mass Healthcare IT Failure

In my keynote address to the Health Informatics Society of Australia in Sydney recently, I cautioned attendees including those in government to be wary of <a href="http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html" target="_blank">healthcare IT hyper-enthusiast</a> misdirection and logical fallacy (a.k.a. public relations).<br /><br />In the LA Times story "<a href="http://www.latimes.com/business/la-fi-hospital-data-outage-20120803,0,5302779.story?track=rss&cid=dlvr.it&dlvrit=52116" target="_blank">Patient data outage exposes risks of electronic medical records</a>" on the Cerner EHR outage I wrote of in my post "<a href="http://hcrenewal.blogspot.com/2012/08/massive-health-it-outage-but-of-course.html" target="_blank">Massive Health IT Outage: But, Of Course, Patient Safety Was Not Compromised</a>" (the title, of course, being satirical), Jacob Reider, acting chief medical officer at the federal Office of the National Coordinator for Health Information Technology is quoted.  He said:<br /><br /><blockquote class="tr_bq">"These types of outages are quite rare and there's no way to completely eliminate human error." </blockquote><br />This is precisely the type of political spin and hyper-enthusiast misdirection I cautioned the Australian health authorities to evaluate critically.<br /><br />As comedian Scott Adams <a href="http://www.leany.com/logic/Adams.html" target="_blank">humorously noted</a> regarding irrelevancy, a hundred dollars is a good price for a toaster, compared to buying a Ferrari. <br /><br />Further, when you're the patient harmed or killed, or the victim is a family member, you really don't care how "rare" the outages are.<br /><br /><i><b>Airline crashes are "rare", too.   </b></i>So, shall they just be tolerated as a "cost of doing business" and spun away?<br /><br />(As I once wrote, the asteroid colliding with Earth that caused the extinction of the dinosaurs was a truly "rare" event.) <br /><b><br /></b>It seems absurd for me to have to point out that paper, unless there is a mass outbreak of use of disappearing ink, or <i>locally hosted</i> clinical IT, <b>do not go blank en masse across multiple states and countries for any length of time,</b><b> raising risk across multiple hospitals </b><b>greatly, </b><b>acutely and simultaneously.   </b>Yet, I have to point out this obvious fact in the face of misdirection.<br /><br />Locally hosted health IT, of course, can only cause "local" chart disappearances.  "Local" is a relative term, however, depending on HC organization size, as in the example of a Dec. 2011 regional University of Pittsburgh Medical Center (UPMC) 14-hour outage affecting thousands <a href="http://hcrenewal.blogspot.com/2011/12/yet-another-glitch-affecting-thousands.html" target="_blank">here</a>.<br /><br />Further, EHR's and other clinical IT, whether hosted locally or afar, had better offer truly <i><b>major</b></i> advantages, <i><b>without</b></i> major risks and disadvantages, over older medical records technologies before exposing large numbers of patients to an invasive IT industry and the largest unconsented human subjects experiment in history.<br /><br />Unfortunately, those basic criteria are not yet apparent with today's systems (see for instance this <a href="http://hcrenewal.blogspot.com/2011/02/updated-reading-list-on-health-it.html" target="_blank">reading list</a>).<br /><br />EHR's and other clinical IT, forming in reality an <i><b>enterprise clinical resource management and clinician workflow control apparatus</b></i>, have introduced new risk modes including mass <a href="http://hcrenewal.blogspot.com/2012/06/more-electronic-medical-record-breaches.html" target="_blank">chart theft</a> (sometimes tens of thousands in the blink of an eye); also, mass chart disappearances as in this case - all not possible with paper.<br /><br />At the very least, if hospitals want enterprise clinical resource management and clinician workflow control systems, these should not be relegated to a distant third party.<b>  Patients are not guinea pigs upon whom to test the <a href="http://en.wikipedia.org/wiki/Application_service_provider" target="_blank">ASP software model</a> ("software as a service") that, upon failure for any reason, threatens their lives.</b><br /><br />Finally, these complications are a further example why this industry cannot go on without meaningful oversight.  The unprecedented special medical device regulatory accommodations must end.<br /><br />-- SS

ONC and Misdirection Regarding Mass Healthcare IT Failure

In my keynote address to the Health Informatics Society of Australia in Sydney recently, I cautioned attendees including those in government...

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Massive Health IT Outage: But, Of Course, Patient Safety Was Not Compromised

Having been 'Down Under' in Sydney addressing the Health Informatics Society of Australia on the need to slow down their national health IT program - and on the need to think critically about HIT seller public relations exaggerations and hubris - and being very busy, I missed this quite stunning story of a major health IT outage.<br /><br />Just a typical "<a href="http://hcrenewal.blogspot.com/search/label/glitch" target="_blank">glitch</a>":<br /><br /><blockquote class="tr_bq"><a href="http://ukcampaign4change.com/2012/07/31/lessons-from-a-major-outage/" target="_blank">Some lessons from a major outage</a><br />Posted on July 31, 2012<br />By Tony Collins<br /><br />Last week Cerner had a major outage across the US. Its international customers might also have been affected.<br /><br /><a href="http://www.informationweek.com/news/healthcare/EMR/240004446">InformationWeek Healthcare reported</a> that Cerner’s remote hosting service went down for about six hours on Monday, 23 July. It hit “hospital and physician practice clients all over the country”. <b>Information Week said the unusual outage “reportedly took down the vendor’s entire network” and raised “new questions about the reliability of cloud-based hosting services”.</b><br /><br />A Cerner spokesperson Kelli Christman told Information Week,</blockquote><br /><blockquote class="tr_bq"><blockquote>“Cerner’s remote-hosted clients experienced unscheduled downtime this week. <b>Our clients all have downtime procedures in place to ensure patient safety. <i style="color: red;"> [Meaning, for the most part, blank paper - ed.]</i></b> The issue has been resolved and clients are back up and running. <b>A human error caused the outage.  </b><b><i style="color: red;">[I don't think they mean human error as in poor disaster recovery and business continuity engineering - ed.]</i></b>  As a result, we are reviewing our training protocol and documented work instructions for any improvements that can be made.”</blockquote></blockquote><br /><blockquote class="tr_bq">Christman did not respond to a question about how many Cerner clients were affected. <a href="http://histalk2.com/2012/07/">HIStalk</a>, a popular health IT blog, reported that<b> hospital staff resorted to paper <i style="color: red;">[if that was true, that paper was OK in an unplanned workflow disruption of major proportions, then why do we need to spend billions on health IT, one might ask? - ed.]</i></b> but it is unclear whether they would have had access to the most recent information on patients.<br /><br />One Tweet by @UhVeeNesh said “Thank you Cerner for being down all day. Just how I like to start my week…with the computer system crashing for all of NorCal [Northern California].”</blockquote><br />Tony Collins is a commentator for ComputerWorldUK.com.  He's quoted me, as I wrote in my May 2011 post <a href="http://blogs.computerworlduk.com/the-tony-collins-blog/2011/05/the-national-programme-of-failed-it-in-the-nhs/">Key lesson from the NPfIT - The Tony Collins Blog. </a><br /><br />This incident brings to life longstanding concerns about hospitals outsourcing their crucial functions to IT companies.   <br /><br />Quite simply, I think it's insane, at least in the foreseeable future, as this example shows.<br /><br />It also brings to mind the concerns that health IT, as an unregulated technology, causes dangers in hospitals with inadequate<b> internal</b> disaster and business continuity functions aside from fresh sheets of paper.  Such capabilities would likely be<i> mandatory</i> if health IT were meaningfully regulated.<br /><br />The Joint Commission, for example, likely issued its stamp of approval for the affected hospitals, hospitals who had outsourced their crucial medical records functions to an outside party that sometimes went mute.  If someone was injured or died due to this outage, they would not care very much about the supposed advantages.<br /><br />There's this in the article:<br /><blockquote class="tr_bq"><br />... “Issue appears to have something to do with DNS entries being deleted across RHO network and possible Active Directory corruption. <b>Outage was across all North America clients as well as some international clients.”</b></blockquote><br />Of course, <a href="http://hcrenewal.blogspot.com/2011/12/yet-another-glitch-affecting-thousands.html" target="_blank">patient safety was not compromised</a>.<br /><br />Finally:<br /><br />Imagine being a patient, perhaps with a complex history, in extremis at the time of this outage.   <br /><br />I, for one, <b>do not want my own medical care nor that of my relatives and friends subject to cybernetic recordkeeping unreliability and incompetence like this, and the risk it creates.</b><br /><br />-- SS<br /><br />Aug. 8, 2012 addendum:<br /><br />The Los Angeles Times covered this outage in a story aptly entitled "<b><a href="http://www.latimes.com/business/la-fi-hospital-data-outage-20120803,0,5302779.story?track=rss&cid=dlvr.it&dlvrit=52116" target="_blank">Patient data outage exposes risks of electronic medical records</a></b>."<br /><br />They write:<br /><br /><blockquote class="tr_bq">Dozens of hospitals across the country lost access to crucial electronic medical records for about five hours during a major computer outage last week, raising fresh concerns about <b>whether poorly designed technology can compromise patient care</b>. </blockquote><br />My only comment is that the answer to this question is rather axiomatic.<br /><br />They also quote Jacob Reider, acting chief medical officer at the federal Office of the National Coordinator for Health Information Technology, who said:<br /><br /><blockquote class="tr_bq">"These types of outages are quite rare and there's no way to completely eliminate human error" </blockquote><br />This is precisely the type of political spin and misdirection I cautioned the Australian health authorities to evaluate critically.<br /><b><br /></b>Paper, unless there is a mass outbreak of use of disappearing ink, or locally hosted clinical IT, <b>do not go blank en masse across multiple states and countries for any length of time, </b><b>raising risk across multiple hospitals </b><b>greatly, </b><b>acutely and simultaneously.  </b>(Locally hosted IT outages only cause "local" mayhem; see my further thoughts on this issue <a href="http://hcrenewal.blogspot.com/2012/08/onc-and-irrelevant-comparisons.html" target="_blank">here</a>).<br /><br />-- SS <br /><br /><span style="color: black; font-family: "Arial","sans-serif"; font-size: 11.0pt;"></span>

Massive Health IT Outage: But, Of Course, Patient Safety Was Not Compromised

Having been 'Down Under' in Sydney addressing the Health Informatics Society of Australia on the need to slow down their national he...

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North Bristol Hits Appointment Problems: Another "Our Lousy IT Systems Screwed Up, But Patient Safety Was Never Compromised" Story

At my Dec. 2011 post "<a href="http://hcrenewal.blogspot.com/2011/12/yet-another-glitch-affecting-thousands.html">IT Malpractice? Yet Another "Glitch" Affecting Thousands of Patients. Of Course, As Always, Patient Care Was "Not Compromised</a>" referencing prior posts, I wrote:<br /><br /><blockquote>... At my Nov. 2011 post "<a href="http://hcrenewal.blogspot.com/2011/11/lifespan-rhode-island-yet-another.html">Lifespan (Rhode Island): Yet another health IT glitch affecting thousands - that, of course, caused no patient harm that they know of - yet</a>" I wrote:<br /><br /><blockquote>There's been yet another health IT <span style="font-weight: bold;">"glitch"</span> that, of course, caused no patients to be harmed. See other <span style="font-weight: bold;">"glitches"</span> <a href="http://hcrenewal.blogspot.com/2011/05/twelve-hour-health-it-glitch-at.html" style="font-weight: bold;">here</a><span style="font-weight: bold;">, </span><a href="http://hcrenewal.blogspot.com/2011/01/orderless-in-seattle-software-glitch.html" style="font-weight: bold;">here</a><span style="font-weight: bold;">, </span><a href="http://hcrenewal.blogspot.com/2010/03/will-it-take-luminosity-of-dozen.html" style="font-weight: bold;">here</a> and at other posts which can be found by searching this blog on the banal term 'glitch'.</blockquote></blockquote><blockquote></blockquote><br />Another "our clinical IT crapped out , BUT ... patient care/safety was never compromised" story just arose:<br /><br /><a href="http://www.ehi.co.uk/news/acute-care/7446/north-bristol-hits-appointment-problems"></a><br /><blockquote><span style="font-size: 130%;"><a href="http://www.ehi.co.uk/news/acute-care/7446/north-bristol-hits-appointment-problems" style="font-weight: bold;">North Bristol hits appointment problems</a></span><br />E-Health Insider<br />11 January 2012<br />Rebecca Todd<br /><br />Clinicians working at North Bristol NHS Trust have expressed concern about disruption to patient care, which they say is caused by appointment problems following the go-live of a new Cerner Millennium electronic patient record system.</blockquote><br />I would have entitled the article "North Bristol hit by IT-created appointment problems."<br /><br /><blockquote>Reported problems include patients being booked into non-existent clinic appointments or not being told about scheduled operations, resulting in some operations being cancelled.</blockquote><br />No patient care compromise possible there. Who, after all, needs a timely operation? It frees up a lot of money for IT golf tournaments to let those of no value to society (i.e., the old, and those who will not admit computers in healthcare with deterministically revolutionize medicine because, well, they're magic) simply die due to delayed or cancelled surgery...<br /><br /><blockquote>Ehealth Insider understands that some of the problems relate to the way the trust configured the EPR system; including setting up dummy clinics for which appointment letters were subsequently sent out. </blockquote><br />It's never the software or computer's fault.<br /><br />As a matter of fact, I have not seen any official response to the work of Dr. Jon Patrick at U. Sydney on the many software engineering flaws of another product of the same company. His work is entitled "<span style="font-weight: bold;">A study of an Enterprise Health information System</span>" and is at this link: <a href="http://sydney.edu.au/engineering/it/%7Ehitru/index.php?option=com_content&task=view&id=91&Itemid=146">http://sydney.edu.au/engineering/it/~hitru/index.php?option=com_content&task=view&id=91&Itemid=146</a>. Do they have Class Action lawsuits in Australia?<br /><br /><blockquote>In a regional BBC news report, aired on Monday evening, <span style="font-weight: bold;">anonymous hospital clinicians called the implementation a “complete shambles”</span> and said it represented a “potential danger” to patients.<br /><br />According to the BBC report, the problems meant patients were being booked for impossible appointment times, such as 12.05 am, and quoted correspondence saying staff and the system were both on the “verge of meltdown."</blockquote><br />The clinician comments are anonymous since non-anonymous reporting would get the clinicians declared health IT apostates, and then excommunicated. Non-anonymous 'whistleblowers' could also fear being sued due to possible <span style="font-weight: bold;">gag clauses</span> - the kind of clause hospital executives sign in violation of their fiduciary responsibilities to their staff and to patients. (See my 2009 JAMA letter to the editor "<span style="font-weight: bold;">Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards</span>"at <a href="http://jama.ama-assn.org/content/302/4/382.1.extract">this link</a> and the much-expanded essay on the same themes "<span style="font-weight: bold;">Health Care Information Technology Vendors' Hold Harmless and Keep Defects Secret Clauses</span>" <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=koppel_kreda">at this link</a>.)<br /><br /><blockquote>Martin Bell, director of IM&T at the trust, confirmed to EHI that North Bristol had experienced some “unexpected problems” in the past few weeks with some of the outpatient appointments and theatre lists.<br /><br />Bell stressed, however, that <span style="font-weight: bold;">patient safety had not been compromised</span> and that this continued to be the top priority.</blockquote><br />There's that line again. Perhaps it's part of some hospital administrator <a href="http://en.wikipedia.org/wiki/JournoList">JournoList-recommended</a> catchphrase for describing how safety was not compromised during a major workflow disruption?<br /><br /><blockquote>He said the problems were not down to the software itself, but due to “implementation and data migration difficulties in some clinics."<br /><br /></blockquote>Right. Quite credible.<br /><br /><blockquote>“Our information management and technology team, supported by our suppliers BT and Cerner, have been working very hard to sort out any initial issues as quickly as possible and <span style="font-weight: bold;">we are already seeing improvements</span>,” he said.</blockquote><br />Congratulations are due. They are seeing "improvements" in dangerous clinical IT malfunctions <span style="font-style: italic;">that should never have to have been seen in the first place</span>, if the statement is true.<br /><br /><blockquote>“Many wards, our two minor injuries units and the Emergency Department, are successfully using the new system." The trust is one of the largest in the South of England, with more than 1,000 beds.</blockquote><br />Just give them time.<br /><br /><blockquote>EHI understands that as part of the Millennium implementation, dummy clinics were set up. Patients were then sent appointment letters for these clinics in error.<br /><br />EHI also understands that some patients had also not turned up for scheduled operations because they had not been informed about the booking.<br /><br /><span style="font-weight: bold;">Bell apologised to patients who had been “inconvenienced during this transition period”</span> and said staff had shown real dedication to continue to deliver patient care.</blockquote><br />What if someone had been inconvenienced into their grave, or ends up there as a result of delays? On what wavelength will the apology be transmitted?<br /><blockquote><br />“We firmly believe that the new system, once fully implemented, will improve services for our patients and provide real value,” he said.</blockquote><br />That seems to be the mantra, but delivery on such promises are rare. See "<span style="font-weight: bold;">Pessimism, Computer Failure, and Information Systems Development in the Public Sector</span>" as <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=other">here</a>, Public Administration Review 67;5:917-929, Sept/Oct. 2007, Shaun Goldfinch, University of Otago, New Zealand. The article is a cautionary article on IT that should be read by every healthcare executive documenting the widespread nature of IT difficulties and failure, the lack of attention to the issues responsible, and recommending much more critical attitudes towards IT.<br /><br /><blockquote>A £69m contract for BT to deliver Cerner Millennium to three new, or ‘greenfield’ sites in the South of England was agreed in April 2010, under the auspices of the National Programme for IT in the NHS. </blockquote><br />That would not be the failed National Programme for IT in the NHS, the <a href="http://hcrenewal.blogspot.com/2011/09/npfit-programme-going-pffft.html">NPfIT what went PfffT</a>, would it?<br /><blockquote><br />North Bristol was the last of these three sites to go-live with the system in December last year.<br /><br />It followed Oxford University Hospitals NHS Trust, which went live a week earlier, and Royal United Hospital Bath NHS Trust, which was the first to go-live in July.<br /><br />Cerner said it was working closely with North Bristol and BT on the recent implementation of Millennium.<br /><br />“In complex and large deployments, especially when migrating from two different systems, <span style="font-weight: bold;">it is always anticipated that it would take time for the new system to bed-in,” it said in a statement.</span></blockquote><br />The patients are given <span style="font-weight: bold;">full informed consent</span> on this issue, right? <span style="font-style: italic; font-weight: bold;">Right?</span><br /><br /><blockquote>“Across much of the trust, the deployment has worked well. However, this is a major change management project and there have been <span style="font-weight: bold;">some difficulties</span> with outpatient appointments.<br /><br />“<span style="font-weight: bold;">Although this is not a problem with the software</span>, Cerner is working in partnership with BT and trust staff to resolve any issue as quickly as possible.”<br /><br />Link: <a href="http://www.bbc.co.uk/news/uk-england-bristol-16469728">BBC News</a></blockquote><br />Right. Perhaps this software and claim needs testing - in a court of law.<br /><br />The only thing missing is the word "glitch", though I am including that term in this posting's index, since I consider it another story in the ever-growing health IT "glitch" series.<br /><br />-- SS<br /><br /><span style="font-weight: bold;">Addendum: </span><br /><br />A reader sent me this comment:<br /><br /><blockquote>How can anyone claim the problems at N. Bristol are unexpected. they are EXACTLY the same problems encountered in Taunton five years ago.<br /><br />The Somerset Trust had sixteen cancelled go live dates and when Cerner 'Millennium" (note: they never defined which Millennium...) was switched on the whole hospital went into slow-motion.<br /><br />Appointments could not be made at out-patient reception desks while patients waited and therefore had to be posted on. Twenty-four whole time equivalent clerks had to be employed to manage the back-up of appointment requests. So much for enhanced efficiency and cost savings.<br /><br />The only possible response to this news is again to remind people of Einstein's famous definition of insanity: "repeating the same thing again and again and expecting a different result."<br /><br />As for other Trusts, why no news of transformed performance by Cerner's systems at other Cerner implemented sites, Berkshire, Newcastle, Kingston, Oxford etc. The only 'good' news we get is that the system has been switched on.<br /><br />If any of this expensive activity had really produced data, efficiency or cost gains, we would be drowning in Cerner press releases, the silence can only mean one thing, that their system is performing as poorly at other sites as it has in the South West.<br /><br />Contrast this with the output and data produced openly by Birmingham University Hospital from its in-house created IT system.<br /><br />Unfortunately one can only draw one serious conclusion about the whole Cerner/ NHS debacle - to paraphrase Mr. Clinton - "It's the (imho substandard) software, stupid!<br /><br />This story needs serious investigation ... Recently US news items have started to discount the supposed efficiency gains for e-Health implementations and started to emphasize data capture and patient safety as the imperative for switch on. Unfortunately for Cerner supporters (and other vendors) the US Institute of Medicine's recent report stated unequivocally that there was (to everyone's apparent surprise) no quality evidence that e-Health improved patient safety.<br /><br />I would contend no drug, therapeutic equipment or operation would or could be implemented in secondary care<span style="font-weight: bold;"> in the</span> <span style="font-weight: bold;">absence of critical and peer reviewed evidence of benefit<span style="color: red; font-style: italic;"> [emphasis mine - ed.] </span></span>that has characterized the rush to switch-on substandard IT solutions in English NHS hospitals.<br /><br /></blockquote>I note that critical, peer-reviewed evidence, especially based on prospective randomized clinical trials as opposed to anecdotal, weak retrospective observational studies, have been deemed unnecessary in health IT.<br /><br />Yet serious case reports of risk and injury from credible sources are deemed the true "anecdotes" and discounted. As I've written before, <span style="font-style: italic;">the science of medicine is nearly entirely lacking in the domain of health IT. </span><br /><br />To put it in the words of James Le Fanu (channeling Sherlock Holmes) in his very apropos essay entitled "<a href="http://www.jameslefanu.com/research/the-case-of-the-missing-data">The Case of the Missing Data: The Dog That Didn't Bark</a>", <span style="font-weight: bold;">details on contrary strands of evidence that could reasonably have been expected to appear in evidential text are absent.</span><br /><br />-- SS

North Bristol Hits Appointment Problems: Another "Our Lousy IT Systems Screwed Up, But Patient Safety Was Never Compromised" Story

At my Dec. 2011 post " IT Malpractice? Yet Another "Glitch" Affecting Thousands of Patients. Of Course, As Always, Patient C...

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