In Fixing Those 9,553 EHR "Issues", Southern Arizona’s Largest Health Network is $28.5 Million In The Red

At my Nov. 9, 2013 post <style type="text/css">H3 { margin-bottom: 0.08in; }H3.cjk { font-family: "Droid Sans Fallback"; }H3.ctl { font-family: "Lohit Hindi"; }P { margin-bottom: 0.08in;</style>"<b>We’ve resolved 6,036 issues and have 3,517 open issues" </b>(<a href="http://hcrenewal.blogspot.com/2013/11/weve-resolved-6036-issues-and-have-3517.html">http://hcrenewal.blogspot.com/2013/11/weve-resolved-6036-issues-and-have-3517.html</a>) I wrote about "issues" (i.e., "glitches" including potentially injurious or deadly bugs and malfunctions) the organization was having with a new EHR at University of Arizona Health System.<br /><br />Now we know part of the cost of resolving those 9,553 "issues."<br /><br /><blockquote class="tr_bq"><a href="http://azstarnet.com/news/science/health-med-fit/tucson-area-s-largest-area-network-racks-up-nearly-million/article_44d05d04-0acf-5fbc-8561-68d4bef3b577.html">http://azstarnet.com/news/science/health-med-fit/tucson-area-s-largest-area-network-racks-up-nearly-million/article_44d05d04-0acf-5fbc-8561-68d4bef3b577.html</a><br /><b>Tucson area's largest health network racks up nearly $30 million in losses</b></blockquote><div class="publish-meta clearfix"><blockquote><div class="date left"><span class="pubdate">June 01, 2014 </span> •  <span class="byline">By <a class="open-tooltip" href="http://azstarnet.com/users/profile/Emily%20Bregel">Emily Bregel</a>, <a class="open-tooltip" href="http://azstarnet.com/users/profile/Stephanie%20Innes">Stephanie Innes</a></span></div></blockquote><div class="date left"><blockquote><span class="byline"> <style type="text/css">P { margin-bottom: 0.08in; }A:link { }</style> </span><br /><div style="margin-bottom: 0in;">Southern Arizona’s largest health network <b>is $28.5 million in the red so far this fiscal year, and officials say a costly electronic medical records system is largely to blame.</b></div><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">The operating loss is unprecedented for the four-year-old University of Arizona Health Network, which includes two local hospitals.</div><div style="margin-bottom: 0in;"></div></blockquote><br />Stellar management was clearly responsible for this wonderful outcome.  When will the layoffs start, I ask? That's the usual managerial solution for financial losses, and in this case I feel particularly worried about employees who did not obey the "suggestion" to only use "<b>Words that Work</b>" about this EHR (see <a href="http://hcrenewal.blogspot.com/2013/10/words-that-work-singing-only-positive.html">http://hcrenewal.blogspot.com/2013/10/words-that-work-singing-only-positive.html</a>). <br /><br /><blockquote class="tr_bq"><div style="margin-bottom: 0in;">The electronic records system, from Wisconsin-based Epic Systems, has cost an estimated <b>$115 million</b>, including <b>$32 million in unbudgeted costs for the first eight months of the fiscal year,</b> which ends June 30, financial documents show. The extra costs are due primarily to a delay in getting the system live and funding additional training and support, officials said. It was supposed to be up and running by Sept. 1, but wasn’t operational until Nov. 1.</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">$32 million to fix 9,553 "issues", most likely due to implementation incompetence, plus some that perhaps the seller should have at least been partially responsible for...such as these:</div><div style="margin-bottom: 0in;"><br /></div><blockquote class="tr_bq"><ul><li>Pharmacy Medication Mapping Errors <span style="color: red;"></span></li></ul><ul><li>Microbiology Results Mapping Incorrectly </li></ul></blockquote><blockquote class="tr_bq"><ul><li>Prescription printing bugs</li></ul><ul><li>Errors transmitting prescriptions </li></ul></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">I note that real, live patients were the unwitting experimental subjects in this little software debugging project.</div><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">I also note that $115 million <b>could have paid for an entire new hospital or wing</b> - and these startup costs are just the beginning... </div><div style="margin-bottom: 0in;"><br /></div><blockquote class="tr_bq"><div style="margin-bottom: 0in;">... There are other reasons for the network’s weak finances. UA Health Network officials say uninsured patients aren’t getting health insurance coverage through the federal Affordable Care Act as quickly as they’d anticipated, resulting in $11 million less than expected in patient revenue through February.</div><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">The network also lost federal dollars from a program that helped bridge the funding gap created by Medicaid rate cuts and a rise in uninsured patients. The Safety Net Care Pool, which also included Maricopa Integrated Health System and Phoenix Children’s, pumped $33 million into the UA hospitals for the first six months of the fiscal year. But that infusion ended Dec. 31 to coincide with greater health insurance availability through the Affordable Care Act.</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">It's not like these events were entirely unpredictable.  Perhaps priorities could have been rearranged, rather than dumping millions into a known money pit, the implementation of enterprise clinical information technology?</div><blockquote class="tr_bq"><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">... “The issue is more about where we are going and what things are in place to change the trajectory,” Lynn said. “It was an especially difficult time financially because of Epic, there was no choice in the matter. That period of time has fortunately passed and now we can do much better.”</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">There certainly was "choice in the matter."  I also suggest to Mr. Lynn that the "trajectory" might end up being a ballistic one.</div><div style="margin-bottom: 0in;"><br /></div><blockquote class="tr_bq"><div style="margin-bottom: 0in;">... A financial report presented to the network’s board of directors on April 24 says the Epic system’s higher-than-expected expenses this fiscal year were due to “implementation delays, additional training support and planned schedule reductions.” Some of the expenses were originally supposed to be in the prior fiscal year.</div><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">The report attributes $6.8 million of the current year’s losses to physicians spending enough time training to use the new system that they couldn’t see as many patients between November and January. Schedules were back to normal as of February.</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">One wonders just how much increased stress and pressure there is on clinicians with the new system in place.   </div><div style="margin-bottom: 0in;"><br /></div><blockquote class="tr_bq"><div style="margin-bottom: 0in;">... Implementing the new system has hit the network’s finances hard, but over time it <b>should improve patient safety</b> by cutting down on unnecessary testing and medication errors, among other things, officials say. Eventually it is <b>expected to save money</b> because of its added efficiency.</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">"Should?"  Considering the issues I've outlined at this blog and my Drexel University Healthcare Informatics site (<a href="http://cci.drexel.edu/faculty/ssilverstein/cases/">http://cci.drexel.edu/faculty/ssilverstein/cases/</a>), this seems a type of wishful-thinking due diligence performed by those who believe in fairy tales and bargain sales of bridges like the one at <a href="http://www.distancesfrom.com/us/Brooklyn-Bridge-latitude-longitude-Brooklyn-Bridge-latitude-Brooklyn-Bridge-longitude/LatLongHistory/24244.aspx"><span id="MC_GMD_lblLatitude">latitude 40.7045096 N, longitude </span></a><span id="MC_GMD_lblLongitude"><a href="http://www.distancesfrom.com/us/Brooklyn-Bridge-latitude-longitude-Brooklyn-Bridge-latitude-Brooklyn-Bridge-longitude/LatLongHistory/24244.aspx">73.99480549999998 W</a>.</span></div><div style="margin-bottom: 0in;"></div><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">Let me make a realistic projection:  No money will be saved, e.g., see the opinions from Wharton at <a href="http://hcrenewal.blogspot.com/2009/06/wharton-on-healthcare-it-can-i-go-home.html">http://hcrenewal.blogspot.com/2009/06/wharton-on-healthcare-it-can-i-go-home.html</a>.  </div><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">Another projection:  safety will be adversely affected, e.g., see the <b>ECRI Deep Dive study</b> at <a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html">http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html</a>, the <b>Top Ten Healthcare Technology Risks for 2014</b> at <a href="http://hcrenewal.blogspot.com/2014/04/in-ecri-institutes-new-2014-top-10.html">http://hcrenewal.blogspot.com/2014/04/in-ecri-institutes-new-2014-top-10.html</a> and the FDA Internal Memo on H-IT Risks at <a href="http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html">http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html</a>, to name a few sources repeatedly mentioned here.</div><div style="margin-bottom: 0in;"><br /></div><blockquote class="tr_bq"><div style="margin-bottom: 0in;">At the UA Medical Center’s south campus, the Epic system has taken doctors from paper charts and uncoordinated computer records to having all patient information — from angiogram and CT scan results to billing updates — in one place, accessible via iPhone.</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">Try doing medicine on an iPhone screen area...</div><div style="margin-bottom: 0in;"><br /></div><blockquote class="tr_bq"><div style="margin-bottom: 0in;">“This is the future. We have to have electronic medical records,” said Dr. Kwan S. Lee, a cardiologist who is medical director of the UA Medical Center’s south campus.</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">"This is the future!!  We just <i><b><u>have</u> </b></i>to do it!!"  Dr. Lee, I admire your exceptionally well-reasoned and thorough budget justification for putting your healthcare system $30 million in the red.  Congratulations!</div><div style="margin-bottom: 0in;"><br /></div><blockquote class="tr_bq"><div style="margin-bottom: 0in;">... Lee cited a recent case where a patient who had been previously treated at Tucson Medical Center came to the UA Medical Center’s emergency room, having an acute heart attack. The standard of care in such cases is opening the artery within 90 minutes. In a rush against the clock, Lee was able to click on the patient’s record from TMC and see the area where the patient had prior surgery.</div><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">“The patient had consented to share information from Tucson Medical Center and it helped us immensely,” Lee said. “We would have possibly wasted a lot of time. The patient did very well.”</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">A far, far less expensive document image management system could have accomplished exactly the same goal.</div><div style="margin-bottom: 0in;"><br /></div><blockquote class="tr_bq"><div style="margin-bottom: 0in;">One con is that the system is <b>“a little overly complicated”</b> because it tries to be all things to all people, he said.  “It was painful ... <b>A lot of us are technophobes,</b>” he said. “But there was no way we could move forward without adopting it.” </div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">"A little overly complicated?"  Gee, I guess that's why physicians at Athens Regional Medical Center revolted as 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>.  The system was just "a little overly complicated!"</div><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">"A lot of us are technophobes?"  How about "A lot of us are not EHR hyper-enthusiasts, but pragmatists?" (<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>).</div><div style="margin-bottom: 0in;"><br /></div><blockquote class="tr_bq"><blockquote class="tr_bq"><div style="margin-bottom: 0in;">Chief Information Officer Critchley agreed, saying that with the infrastructure in place, the system will be improved as needed over time.</div><div style="margin-bottom: 0in;"><b><br /></b></div><b></b><br /><div style="margin-bottom: 0in;"><b>“For better or worse</b>, only when it’s live are you going to get the doctors and staff to engage and do the fine tuning <b>of what it really means</b>, and what they want to see happen,” Critchley said.</div></blockquote></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">This is a political statement at best.  The assumption here is that this technology itself is some sort of miracle worker, just needing "fine tuning" to reveal its miracles.  In fact, most medical inefficiencies and dangers have nothing to do with documentation at all (e.g., see "<b>Is healthcare IT a solution to the wrong problem?</b>" at <a href="http://hcrenewal.blogspot.com/2010/12/is-healthcare-it-solution-to-wrong.html">http://hcrenewal.blogspot.com/2010/12/is-healthcare-it-solution-to-wrong.html</a>).</div><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;"><b>The only miracle so far has been to put the system $30 million in the red</b>, with more to follow.</div><blockquote class="tr_bq"><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">... The UA Health Network, which began its Epic implementation in 2012, receives a little over $1 million per year in incentive payments, Critchley said.</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">That's nice.   They spent $115 million to qualify for a $1 million annual incentive?  Makes perfect sense to me ...</div><div style="margin-bottom: 0in;"><br /></div><blockquote class="tr_bq"><div style="margin-bottom: 0in;"><b>Adoption of electronic records is voluntary</b>, but hospitals that don’t make the switch by October face Medicare payment cuts of about 1 percent, and increasing reductions each year.</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">At least one reporter reports this factoid accurately.  Hospital and industry execs are fond of misstatements that "EHRs are mandatory."</div><blockquote class="tr_bq"><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">Critchley has worked on at least four other Epic installations around the country as part of his consulting work and says <b>the UA Medical Center’s has been the least expensive</b>, with the most aggressive timeline. He has worked on projects that cost more than <b>a half billion dollars</b>.</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">"Least expensive?"  "Half a billion dollars?"  It sounds like first class care for every underserved person in the United States could have been paid for instead of dumping the money into an unproven, experimental computer technology...</div><div style="margin-bottom: 0in;"><br /></div><blockquote class="tr_bq"><div style="margin-bottom: 0in;">At Tucson Medical Center, a $31 million upgrade to its electronic medical records system — also the Epic system — began to reduce expenses <span style="color: red;"><i><b>[overall net expenses, or just on a limited per-account, cherry-picked basis?  I suspect the latter - ed.]</b></i></span> almost immediately after it went live in 2010. TMC is among 3 percent of hospitals nationwide at the highest stage of electronic records adoption, based on an electronic records ranking system.</div><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">“We started to see efficiencies the first day,” said Frank Marini, TMC’s chief information officer. <b>Transcription expenditures dropped by half, as doctors who had previously dictated patient notes instead documented them directly into the electronic record, he said.</b></div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">And they had to type and/or manually edit the results of Dragon or some other VR software.  That's wonderful!  Save money by firing transcriptionists and <i>making the physicians spend their valuable time and attention on clerical work.</i>  Fine business!</div><blockquote class="tr_bq"><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">TMC began its push to upgrade its partial electronic records system in 2009. The hospital’s early investments in infrastructure, starting in 2002, lowered the cost of adopting a comprehensive system, he said.</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">Thus, in fact, overall expense was probably <i><b>several times the $115 million quoted.  Say, perhaps, half a billion dollars?</b></i></div><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">To any U. Az healthcare employee reading this - remember, if you are experiencing EHR difficulties, only use Words that Work!</div></div><div class="date left"></div><div class="date left"><span class="byline"><br /></span></div><div class="date left"><span class="byline">-- SS</span></div><div class="comment-count right"></div><div class="comment-count right"></div><div class="comment-count right"></div></div>

In Fixing Those 9,553 EHR "Issues", Southern Arizona’s Largest Health Network is $28.5 Million In The Red

At my Nov. 9, 2013 post H3 { margin-bottom: 0.08in; }H3.cjk { font-family: "Droid Sans Fallback"; }H3.ctl { font-family: "Lohit Hindi"; }P { margin-bottom: 0.08in;"We’ve resolved 6,036 issues…

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Followup to "CMS does not have any information that supports or refutes claims that a broader adoption of EHRs can save lives"

At my April 16, 2014 post "<b>CMS does not have any information that supports or refutes claims that a broader adoption of EHRs can save lives</b>" (<a href="http://hcrenewal.blogspot.com/2014/04/cms-does-not-have-any-information-that.html">http://hcrenewal.blogspot.com/2014/04/cms-does-not-have-any-information-that.html</a>) I noted that the American Association of Physicians and Surgeons (AAPS) had received a reply from CMS to a FOIA request that:<br /><br /><blockquote class="tr_bq"><i>"We [CMS] do not have any information that supports or refutes claims that a broader adoption of EHRs can save lives."</i> </blockquote><br />Put another way, the country is embarking on a $1 trillion healthcare experiment, and blindly.<br /><br />I mentioned I'd post the letter when received from AAPS.  That just occurred.<br /><br />The letter is below (click to enlarge):<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/AVvXsEhXyGzY3biU0IcibR_jpNBb18X__sIeFWVd7E3T1MoAa300RBg2N_3-t_UMmx2bhlwk3KnobEgycCWCVmwWTy13uQVLGi3VBPFpgdzCHBu_0Qq5-fDamfZIWx-WeLaeYztcEayTGeCU7JIC/s1600/CMS_Letter.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhXyGzY3biU0IcibR_jpNBb18X__sIeFWVd7E3T1MoAa300RBg2N_3-t_UMmx2bhlwk3KnobEgycCWCVmwWTy13uQVLGi3VBPFpgdzCHBu_0Qq5-fDamfZIWx-WeLaeYztcEayTGeCU7JIC/s1600/CMS_Letter.jpg" width="308" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">CMS: "we do not have any information that supports or refutes claims that a broader adoption of EHRs can save lives."  [But let's spend hundreds of billions of dollars anyway.]  Click to enlarge.<b><br /></b></td></tr></tbody></table><br />I've added it as an addendum to the original post, but thought it worthwhile to call out the letter in a post of its own to those who might not revisit the original.<br /><b><br /></b><b><u>An additional thought</u>:</b><br /><br />While CMS may "not have any information that supports or refutes claims that a broader adoption of EHRs can save lives", they <b>do have</b> (or should have made it their business to have) information <b><u>that EHRs cause harm and take lives</u></b> (e.g., via FDA at <a href="http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html">http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html</a> , ECRI at <a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html">http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html</a> and others).<br /><br />-- SS

Followup to "CMS does not have any information that supports or refutes claims that a broader adoption of EHRs can save lives"

At my April 16, 2014 post "CMS does not have any information that supports or refutes claims that a broader adoption of EHRs can save lives" (http://hcrenewal.blogspot.com/2014/04/cms-does-not-have-an…

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CMS does not have any information that supports or refutes claims that a broader adoption of EHRs can save lives?

If this is true, the EHR hyper-enthusiasm problem is even worse than I believed.<br /><br />From the April 2014 newsletter of the American Association for Physicians and Surgeons (<a href="http://www.aapsonline.org/index.php/about_us/">http://www.aapsonline.org/index.php/about_us/</a>), an organization that is dedicated "to preserving the sanctity of the patient-physician relationship and the practice of private medicine":<br /><br /><blockquote class="tr_bq"><b>CMS Claims to Have No Information on EHRs</b><br /><br />On Mar. 14, 2014, the Office of Strategic Operations and Regulatory Affairs of the Centers for Medicare and Medicaid Services replied to a Freedom of Information Act (FOIA) request sent Apr. 4, 2012:  The American Recovery and Reinvestment Act of 2009 (ARRA) created the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs.  While our Office of E-Health Standards and Services works to implement the provisions of the ARRA, <b>we do not have any information that supports or refutes claims that a broader adoption of EHRs can save lives."</b></blockquote><br />However, that doesn't stop our government from spending billions of taxpayer dollars on them, when, in fact, we <i>do know</i> of harms they cause.  One can reasonably assume their primary interest is in bookkeeping.<br /><br />With FDA, it's even worse.  Rather than stopping at admitting they simply don't know due to admitted impediments to knowing, they simply leap to a conclusion that the technology is of 'sufficiently low risk' not to warrant their regulatory attention, even if such systems meet the statutory requirements to be a medical device and thus fall under the Food, Drug & Cosmetic Act.<br /><br />See my Apr. 9, 2014 post <b>"FDA on health IT risk: We don't know the magnitude of the risk, and what we do know is the tip of the iceberg, but health IT is of 'sufficiently low risk' that we don't need to regulate it"</b> and its ten-point (and non-comprehensive) summary of risks: <a href="http://hcrenewal.blogspot.com/2014/04/fda-on-health-it-risk-reckless-or.html">http://hcrenewal.blogspot.com/2014/04/fda-on-health-it-risk-reckless-or.html</a>.  Another FOIA request is surely needed...<br /><br />More generally, I know from personal development and implementation experience that when "done well",<span style="font-size: small;"> that is, when</span> <b>good health IT </b>and good implementation practices are offered and with patient safety as a priority, health IT can save lives and improve care.  It's just that the commercial for-profit health IT sector does not meet those expectations, due largely to its leadership model from the merchant-computing culture.  Instead, bad health IT is the norm.  From my academic site at <a href="http://cci.drexel.edu/faculty/ssilverstein/cases/">http://cci.drexel.edu/faculty/ssilverstein/cases/</a>:<br /><br /><blockquote class="tr_bq"><span style="font-size: small;"><b>Good Health IT</b> is IT that provides a good user experience, enhances cognitive function, puts essential information as effortlessly as possible into the physician’s hands, can be easily, substantively and cost-effectively customized to the needs of medical specialists and subspecialists, keeps eHealth information secure, protects patient privacy and facilitates better practice of medicine and better outcomes. <br /><br /><b>Bad Health IT </b>is IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (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 /> I am seeking source material from the AAPS and will post it.<br /><br />-- SS<br /><br /><b>April 26, 2014 Addendum:</b><br /><br />Below is the letter to AAPS from CMS.  Click to enlarge.<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/AVvXsEiSrd8gxZN0QHQd4cLK_aeA3uDI-a9I__6VVZfa32Gz6iCAm8Y-r2APJEzYw_Mav9oJSOWtFXXJYCz3iIELuUPqiJtPt_xtwa1k4hzcXTmEwYOhHSHKmfx6bGUSrXInxG2ax_nK15KLDeDV/s1600/CMS_Letter.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiSrd8gxZN0QHQd4cLK_aeA3uDI-a9I__6VVZfa32Gz6iCAm8Y-r2APJEzYw_Mav9oJSOWtFXXJYCz3iIELuUPqiJtPt_xtwa1k4hzcXTmEwYOhHSHKmfx6bGUSrXInxG2ax_nK15KLDeDV/s1600/CMS_Letter.jpg" width="308" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">CMS:  "we do not have any information that supports or refutes claims that a broader adoption of EHRs can save lives."  [But let's spend hundreds of billions of dollars anyway.]  Click to enlarge.<b><br /></b></td></tr></tbody></table><br /><b><u>An additional thought</u>:</b><br /><br />While CMS may "not have any information that supports or refutes claims that a broader adoption of EHRs can save lives", they <b>do have</b> (or should have made it their business to have) information <b><u>that EHRs cause harm and take lives</u></b> (e.g., via FDA at <a href="http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html">http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html</a> , ECRI at <a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html">http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html</a> and others).<br /><br />-- SS<br /><br />

CMS does not have any information that supports or refutes claims that a broader adoption of EHRs can save lives?

If this is true, the EHR hyper-enthusiasm problem is even worse than I believed.From the April 2014 newsletter of the American Association for Physicians and Surgeons (http://www.aapsonline.org/index.…

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JAMIA: Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems

A new article appeared online 20 February 2013 in the Journal of the American Medical Informatics Association entitled "<b>Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems</b>" (<a href="http://jamia.bmj.com/content/early/2013/01/27/amiajnl-2012-001241.full" target="_blank">link to fulltext</a>) by David C Radley, Melanie R Wasserman, Lauren EW Olsho, Sarah J Shoemaker, Mark D Spranca and Bethany Bradshaw.<br /><br />The authors performed a meta-analysis of the literature on Computerized Practitioner Order Entry (CPOE) systems in inpatient settings and concluded:<br /><br /><blockquote class="tr_bq">"Processing a prescription drug order through a CPOE system decreases the likelihood of error on that order by 48% (or in<!--[if gte mso 9]><xml> <w:WordDocument> <w:View>Normal</w:View> <w:Zoom>0</w:Zoom> <w:TrackMoves/> <w:TrackFormatting/> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:DoNotPromoteQF/> <w:LidThemeOther>EN-US</w:LidThemeOther> <w:LidThemeAsian>X-NONE</w:LidThemeAsian> <w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> <w:UseAsianBreakRules/> <w:DontGrowAutofit/> <w:SplitPgBreakAndParaMark/> <w:DontVertAlignCellWithSp/> <w:DontBreakConstrainedForcedTables/> <w:DontVertAlignInTxbx/> <w:Word11KerningPairs/> <w:CachedColBalance/> </w:Compatibility> <w:BrowserLevel>MicrosoftInternetExplorer4</w:BrowserLevel> <m:mathPr> <m:mathFont m:val="Cambria Math"/> <m:brkBin m:val="before"/> <m:brkBinSub m:val="--"/> <m:smallFrac m:val="off"/> <m:dispDef/> <m:lMargin m:val="0"/> <m:rMargin m:val="0"/> <m:defJc m:val="centerGroup"/> <m:wrapIndent m:val="1440"/> <m:intLim m:val="subSup"/> <m:naryLim m:val="undOvr"/> </m:mathPr></w:WordDocument></xml><![endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"> </span> a range of 41% to 55% with ninety five percent confidence).  Given this effect size, and the degree of CPOE adoption and use in hospitals in 2008, we estimate a 12.5% reduction in medication errors, <b>or ∼17.4 million medication errors averted in the USA in one year.</b>" </blockquote><br />It is important to know the potential benefits of CPOE, as the government has been pushing this technology since the foundation of the <a href="http://www.healthit.gov/newsroom/about-onc" target="_blank">Office of the National Coordinator</a> (for health IT) within HHS since 2004.  Indeed, reimbursement penalties on Medicare will start in 2015 for non-adopters of government <a href="http://hcrenewal.blogspot.com/2010/03/on-oncs-proposed-establishment-of.html" target="_blank">certified</a> health IT.<br /><br />It is especially important to get to the truth about CPOE specifically, and health IT in general, in terms of risks, benefits, return on investment, improvements, and alternatives.<br /><br />Not long before this new JAMIA article appeared, an active study of EHR problems with voluntary reporting <span style="font-size: small;"><span style="font-family: inherit;">by<span style="font-size: small;"> </span></span></span>members of the <a href="https://www.ecri.org/Pages/default.aspx" target="_blank">ECRI Institute's</a> Patient Safety Organization (PSO) <a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html" target="_blank">produced some concerning data</a>.  Namely, that over a 9-week period starting April 16, 2012, and ending June 19, 2012, 171 health information technology-related problems were reported from just 36 healthcare facilities, primarily hospitals. <b>Eight of the incidents reported involved patient harm, and three may have contributed to patient deaths.</b><br /><br />Obviously, extrapolating those number to:  1)  a much higher number of hospitals, of which the U.S. alone has <a href="http://www.aha.org/research/rc/stat-studies/fast-facts.shtml" target="_blank">approximately 5,700</a> plus other facilities such as long-term care, and private physician offices; 2)  over a full year, not just 9 weeks;  3) accounting for the perhaps 5% voluntary reporting level (per Koppel) of issues such as medication errors; 4) plus accounting for (per FDA) the issue of lack of recognition of IT as contributing to medical incidents (this list is not all-inclusive) - the results are of concern.<br /><br />Thus, work such as in this new JAMIA article on CPOE is important.  The article can be downloaded in its entirety as of this writing from the link above.  The article describes a methodology that is quite complex, and obviously a great deal of time and effort was put into it.  It appears to be a valiant effort to get us one step closer to the truth.  This should be applauded.<br /><br />I was impressed on first reading of this literature meta-analysis and its statistical calculations. (Actually I needed to read it several times to fully grasp the methodologies involved.)<br /><br />The question arose in my mind, however: can this article's conclusions be true, and the ECRI PSO Deep Dive study be true, at the same time?<br /><br />Prior to going into an analysis and perhaps detailed critique of the methodology, and knowing the difficulties and contradictions the literature on this topic presents, I decided first to look at the source articles selected from the literature for inclusion in the JAMIA meta-analysis.<br /><br />In doing so, issues became apparent that shed light on the difficulties of meta-analyses on topics such as this.<br /><br />The only methodological issue I will mention at this time is that the study used a <a href="http://hcrenewal.blogspot.com/2008/06/criticism-of-surrogate-endpoints-in.html" target="_blank">surrogate endpoint</a> - medication "error" rates before, and after, implementation of CPOE, rather than patient outcomes.  (The reason I put "error" in quotes is that, as the authors describe regarding study limitations, the exact definition varies from site to site and study to study.  They also acknowledge the limitations of using such an endpoint.)  Surrogate endpoints, however, may or may not reflect the actual information being sought regarding outcomes.<br /><br />As Roy Poses noted in a June 2008 post "<a href="http://hcrenewal.blogspot.com/2008/06/criticism-of-surrogate-endpoints-in.html" target="_blank">Criticism of Surrogate Endpoints in Whose Interests?</a>":<br /><br /><blockquote class="tr_bq">... The problem with surrogate endpoints is that they are surrogates for the real thing. In many cases, a treatment may appear beneficial when measured by its affect on such endpoints, but not turn out to be beneficial when measured by its affect on real clinical outcomes, e.g., alleviation of symptoms, improvement of function, and prolongation of survival. There are many reasons why this may be the case. <br /><br /></blockquote>This weakens the present study as a basis for social re-engineering.  The authors responsibly acknowledge that via the statement in the conclusion that:<br /><br /><blockquote class="tr_bq">Future research in this area will be critically important to inform policy and funding decisions regarding the development and implementation of CPOE in care delivery. </blockquote><br />When I reviewed the studies that were used for the meta-analysis, however, my enthusiasm for the results was diminished.<br /><br />The authors write:<br /><br /><blockquote class="tr_bq">Using the search terms of Ammenwerth et al, we updated the search using PubMed in February 2009, identifying 390 studies. Each was reviewed by two study authors (MRW and DCR). After applying the a priori inclusion/exclusion criteria, 10 studies were retained. <span style="color: red;"><i><b>[Listed in footnotes 10–19 - ed.]</b></i></span></blockquote><div id=":1cb"><br />Here are the 10 studies retained, as per footnotes #10 - 19.  Short excerpts (I am trying to keep this post relatively short) and my very brief comments about each of them are as follows.  Hyperlinks to the summaries and in some cases to fulltext are present in the online study itself at the full text link at top of this post<b>.</b><br /><br />First, I note no <i>randomized, controlled clinical trials</i>, the gold standard of medical research.  That lack is not the fault of the authors; it is a general feature in the domain of healthcare information technology.<br /><br />That said:<b> </b><br /><br /><u><b>Included study #1 </b><b>(footnote 10)</b></u><b>:</b><u><b> </b></u><br /><b><br /></b></div><div id=":1cb">Bates DW, Teich JM, et al, The impact of computerized physician order entry on medication error prevention. Brigham and Women's Hospital, J Am Med Inform Assoc 1999;6:313–21.</div><div id=":1cb"><br /><blockquote class="tr_bq">... During the study, the non-missed-dose medication error rate fell 81 percent, from 142 per 1,000 patient-days in the baseline period to 26.6 per 1,000 patient-days in the final period (P < 0.0001). Non-intercepted serious medication errors (those with the potential to cause injury) fell 86 percent from baseline to period 3, the final period (P = 0.0003). Large differences were seen for all main types of medication errors: dose errors, frequency errors, route errors, substitution errors, and allergies. For example, in the baseline period there were ten allergy errors, but only two in the following three periods combined (P < 0.0001).  <b>The study periods were as follows: baseline, 51 days, Oct-Nov 1992; period 1, 68 days, Oct-Dec 1993; period 2, 49 days, Nov-Dec 1995; and period 3, 52 days, Mar-Apr 1997. </b></blockquote><b><br /></b>I note that this was a highly advanced setting with long-standing Medical Informatics expertise, performed by Medical Informatics experts of the highest caliber.  This was an ideal environment for the implementation of good health IT.  The results may thus not be generalizable to facilities without that level of experience.  </div><div id=":1cb"></div><div id=":1cb">Also, the study was a considerable number of years ago, some of it two decades ago.  While one might assume the technology has improved, the increased commercial sector involvement since the 1990's, and especially after the HITECH incentives of 2009, may be creating an increased occurrence of bad health IT, and/or implementation in facilities with far less (if any) informatics expertise.<br /><br />Thus, in my view the study's applicability to current times and to all medical organizations is not extremely strong.<b> </b><br /><br /><u><b>Included study #2 </b></u><b><u>(footnote 11)</u>:</b><br /><br />Medication Administration Variances Before and After Implementation of Computerized Physician Order Entry in a Neonatal Intensive Care Unit, Pediatrics 2008;121:123–8 <br /><br /><blockquote class="tr_bq">... Data on 526 medication administrations, including 254 during the pre-computerized physician order entry period and 272 after implementation of computerized physician order entry, were collected. Medication variances were detected for 19.8% of administrations during the pre-computerized physician order entry period, compared with 11.6% with computerized physician order entry (rate ratio: 0.53). Overall, administration mistakes, prescribing problems, and pharmacy problems accounted for 74% of medication variances; <b>there were no statistically significant differences in rates for any of these specific reasons before versus after introduction of computerized physician order entry.</b></blockquote><br />Here, 'n' is very small, and there is a finding that the CPOE had no effect on administration mistakes, prescribing problems, and pharmacy problems.  Thus, a ringing endorsement for national CPOE implementation this study is (unfortunately) not.<b> </b><br /><br /><u><b>Included study #3 </b></u><b><u>(footnote 12)</u>:</b><br /><br />The effect of computer-assisted prescription writing on emergency department prescription errors, Acad Emerg Med 2002;9:1168–75.<cite></cite><br /><br />Without even a summary, my concern here is that ePrescribing and CPOE are different entities.   Inclusion of ePrescibing in a study of CPOE is not entirely without some risk of conflation of results of one with the other.<b> </b><br /><br /><u><b>Included study #4 </b></u><b><u>(footnote 13)</u>:</b><br /><br />Impact of computerized physician order entry on clinical practice in a newborn intensive care unit, J Perinatol. 2004 Feb;24(2):88-93.<br /><br />This article studies gentamicin dosing and turn around times and found that:<br /><br /><blockquote class="tr_bq">"...the accuracy of gentamicin dose at the time of admission for 105 (pre-CPOE) and 92 (post-CPOE) VLBW infants was determined. In the pre-CPOE period, 5% overdosages, 8% underdosages, and 87% correct dosages were identified. In the post-CPOE, no medication errors occurred. Accuracy of gentamicin dosages during hospitalization at the time of suspected late-onset sepsis for 31 pre- and 28 post-CPOE VLBW infants was studied. Gentamicin dose was calculated incorrectly in two of 31 (6%) pre-CPOE infants. No such errors were noted in the post-CPOE period. </blockquote><br />My comments are that a NICU is a specialized environment with a high ratio of clinicians/staff to patients.  Findings in such an environment again may not be generalizable.  Also, one should ask if complex CPOE systems are really needed for dosing calculations and turn around time improvements.  Simpler and cheaper human/technological solutions might have achieved similar or better results.  Thus, again, while not demeaning the results achieved by this study's interventions in 2004, I have my concerns that this study is not strong evidence of generalizability of even the CPOE surrogate measurement, namely decrease of med "errors."<b> </b><br /><br /><u><b>Included study #5 </b></u><b><u>(footnote 14)</u>:</b><br /><br />A computer-assisted management program for antibiotics and other antiinfective agents. N Engl J Med 1998;338:232–8.<br /><br /><blockquote class="tr_bq">We have developed a computerized decision-support program linked to computer-based patient records that can assist physicians in the use of antiinfective agents and improve the quality of care. This program presents epidemiologic information, along with detailed recommendations and warnings. The program recommends antiinfective regimens and courses of therapy for particular patients and provides immediate feedback. We prospectively studied the use of the computerized antiinfectives-management program for one year in a 12-bed intensive care unit. RESULTS: During the intervention period, all 545 patients admitted were cared for with the aid of the antiinfectives-management program. Measures of processes and outcomes were compared with those for the 1136 patients admitted to the same unit during the two years before the intervention period. The use of the program led to significant reductions in orders for drugs to which the patients had reported allergies (35, vs. 146 during the preintervention period; P less than 0.01), excess drug dosages (87 vs. 405, P less than 0.01), and antibiotic-susceptibility mismatches (12 vs. 206, P less than 0.01). There were also marked reductions in the mean number of days of excessive drug dosage (2.7 vs. 5.9, P less than 0.002) and in adverse events caused by antiinfective agents (4 vs. 28, P <span style="color: red;"><span style="color: black;">less than 0.02).</span> <b> </b></span><b><i><span style="color: red;">[Several other benefits omitted for brevity - they can be seen at the JAMIA footnote hyperlink -  ed.]</span></i></b><!--0--></blockquote></div><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><br />My thoughts here are that, while the results were commendable, once again this study took place 15 years ago, and was in a high-staff-to-patient specialized ICU environment.  I also wonder if complex, expensive CPOE is needed to accomplish these tasks as opposed to, say, an online DSS and appropriate workflows and process.<b> </b><br /><br /><u><b>Included study #6 </b></u><b><u>(footnote 15)</u>:</b><br /><br />Impact of computerized prescriber order entry on medication errors at an acute tertiary care hospital. Hosp Pharm 2003;38:227–31.<br /><br /><blockquote class="tr_bq">The authors analyzed medication errors documented in a hospital's database of clinical interventions as a continuous quality improvement activity. They compared the number of errors reported prior to and after computerized prescriber order entry (CPOE) was implemented in the hospital. Results indicated that in the first 12 months of CPOE, overall medication errors were reduced by more than 40%, incomplete orders declined by more than 70%, and incorrect orders decreased by at least 45%. Illegible orders were virtually eliminated but the level of medication errors categorized by drug therapy problems remained significantly unchanged. The study underscores the positive impact of CPOE on medication safety and reemphasizes the need for proactive clinical interventions by pharmacists.</blockquote><br />This study appears reasonable for inclusion in a meta-analysis, although ideally there might have been accounting for possible influence of non-intervention (computer)-related pre-post interval changes.  The transition to CPOE, training, increased awareness, etc. can influence results, especially short term.<b> </b><br /><br /><u><b>Included study #7 </b></u><b><u>(footnote 16)</u>:</b><br /><br />Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis. Arch Pediatr Adolesc Med 2006;160:495–8.<br /><br /><blockquote class="tr_bq">Before-and-after study from 2001 to 2004. After CPOE deployment, daily chemotherapy orders were less likely to have improper dosing (relative risk [RR], 0.26; 95% confidence interval [CI], 0.11-0.61), incorrect dosing calculations (RR, 0.09; 95% CI, 0.03-0.34), missing cumulative dose calculations (RR, 0.32; 95% CI, 0.14-0.77), and incomplete nursing checklists (RR, 0.51; 95% CI, 0.33-0.80). There was no difference in the likelihood of improper dosing on treatment plans and a higher likelihood of not matching medication orders to treatment plans (RR, 5.4; 95% CI, 3.1-9.5).</blockquote><br />Again, the results appear commendable.  However:  there was no difference in the likelihood of improper dosing on treatment plans, and worse, there was found <i><b>a higher likelihood of not matching medication orders to treatment plans.</b></i><br /><br />In fact, this article was accompanied by a letter in response entitled "Primum non nocere", David Dickens, MD; Dianne Sinsabaugh, RPh; Brenda Winger, PharmD, Arch Pediatr Adolesc Med. 2006;160(11):1185-1186 (after some digging, text found at <a href="http://archpedi.jamanetwork.com/article.aspx?articleid=486317" target="_blank">http://archpedi.jamanetwork.<wbr></wbr>com/article.aspx?articleid=<wbr></wbr>486317</a>):<br /><br /><blockquote class="tr_bq">Kim et al. demonstrated that in the practice of pediatric oncology, computerized physician order entry (CPOE) reduced improper dosing, missing cumulative doses, and incomplete nursing checklists.  In contrast to these benefits, however, CPOE also resulted in a 5-fold increase in “not matching medication orders to treatment plans.” Although little detail was provided on the nature of these medication order/treatment plan “mismatches,” it implies that chemotherapy ordered through CPOE deviated more often from intended protocol therapy as compared with paper-ordered chemotherapy. While CPOE ostensibly led to more precise chemotherapy dosing, <i><b>it increased the risk of that chemotherapy being the wrong chemotherapy.</b></i></blockquote><br />The author did respond: "Mismatches between treatment plan and orders at point of therapy increased, but were intercepted and clarified at POC. <b><span style="color: red;"><i>[By people - ed.]</i></span>.  </b>No incorrect meds were given.<br /><br />On its face, this is not an entirely dispositive proof of CPOE beneficence and raises significant concern that, sooner or later, a person might miss the discrepanc(ies) resulting in unintended adverse consequences.<b> </b><br /><br /><u><b>Included study #8 </b></u><b><u>(footnote 17)</u>:</b><br /><br />Effects of an integrated clinical information system on medication safety in a multi-hospital setting. Am J Health Syst Pharm 2007;64:1969–77.<br /><br /><blockquote class="tr_bq">This study took place at Lifespan health care system that includes Rhode Island Hospital (RIH), a private, 719-bed, not-for-profit, acute care hospital and academic medical center that has a pediatric division, the Hasbro Children’s Hospital; and The Miriam Hospital (TMH), a 247-bed, not-for-profit, acute care general hospital.<br /><br />Methods. <b>The integrated systems selected for implementation included computerized physician order entry, pharmacy and laboratory information systems, clinical decision-support systems (CDSSs), electronic drug dispensing systems (EDDSs), and a bar-code point-of-care medication administration system.</b> The indicators for CPOE with inherent CDSSs demonstrated a significant effect of this functionality on reducing prescribing error rates for three of the four indicators measured: drug allergy detection, excessive dose, and incomplete or unclear order. <b>The fourth indicator measured, therapeutic duplication, did not show a significant effect on prescribing error rates.</b> For the rules engine software CDSS, the <b>colchicine indicator did not show a statistically significant effect on prescribing error rate</b>, but a significant decrease in prescribing errors related to metformin use in renal insufficiency was observed after implementation of the rules engine software and integration with CPOE. </blockquote><br />Again, these are commendable results, but on its face the technologies involved went far beyond just CPOE, and the results were not uniform.  The actual reduction figures for seven categories were mostly in 50% range, one at 86% (allergy), but the duplicates issue at 8%, not felt statistically significant.<br /><br />Of more concern, there was this in the news in 2011.  A software bug at this organization <b>led to thousands and perhaps tens of thousands of prescription errors</b> that could have (and without definite proof, despite organization denials I would be concerned did) led to injury and death.  I wrote about the malfunction at <a href="http://hcrenewal.blogspot.com/2011/11/lifespan-rhode-island-yet-another.html">http://hcrenewal.blogspot.com/2011/11/lifespan-rhode-island-yet-another.html</a>.  The bug was not discovered for about a year.<br /><br />Other organizations, especially those new to CPOE and/or health IT, face similar risks.<br /><br />Again, this is not a caveat-free endorsement of national CPOE rollout in 2013.<br /><br /><u><b>Included study #9 </b></u><b><u>(footnote 18)</u>:</b><br /><br />Effect of computer order entry on prevention of serious medication errors in hospitalized children. Pediatrics 2008;121:e421–7.<br /><br />627 pediatric admissions, with 12 672 medication orders written over 3234 patient-days.  <b>T</b>he rate of non-intercepted serious medication errors in this pediatric population was reduced by 7% after the introduction of a commercial computerized physician order entry system,<b> <u>much less than previously reported for adults, and there was no change in the rate of injuries as a result of error.</u></b> Several human-machine interface problems, particularly surrounding selection and dosing of pediatric medications, were identified.<br /><br />The issues of concern here are bolded and underlined above and need not be restated.<br /><br />Lastly:<br /><br /><u><b>Included study #10 </b></u><b><u>(footnote 19)</u>:</b><br /><br />Evaluation of reported medication errors before and after implementation of computerized practitioner order entry. J Health Inf Manag 2006;20:46–53.<br /><br /><blockquote class="tr_bq">While a major objective of CPOE is to reduce medication errors,<b> its introduction is a major system change that may result in unintended outcomes.</b> Monitoring voluntarily-reported medication errors in a university setting was used to identify the impact of initial CPOE implementation on medical-surgical and intensive care units. A retrospective trend analysis was used to <b>compare errors one year before and six months after </b>implementation. <b>Total error reports increased post-CPOE but the level of patient harm related to those errors decreased. </b>Numerous modifications were made to the system and the implementation process. The study supports the notion that CPOE configuration and implementation influences the risk of medication errors. Implementation teams should incorporate monitoring medication errors into project plans and expect to make ongoing changes to continually support the design of a safer care delivery environment.</blockquote><br />This study appeared more a study reporting unintended outcomes than benefits. The total medication error reports increased post-CPOE but the level of patient harm related to those errors decreased.   (That decrease might have been due to human factors, or to serendipity, both of which cannot be expected to protect forever.)<br /><br /><b>The reasons for the changes were described this way:</b><br /><b></b><br /><blockquote class="tr_bq">... Contributing causes. To assist in the development of safety interventions, contributing causes were identified for reported errors. The most common contributing cause was <b>noncompliance to policy and procedure, identified in 40 percent of errors</b>. For example, a previous order may not have been discontinued when a new dose change was entered, resulting in two active orders for the same medication with different dosages<br /><br /> The next most common contributing cause was <b>computer entry errors</b>, seen in 25 percent of mistakes. One example was if a <b>medication order was placed on the wrong patient.</b>  <span style="color: red;"><i><b>["Use error" due to confusing user interfaces as recently defined by NIST - as opposed to "user error" - was likely to have contributed to at least some of these errors - ed.] </b></i></span> The next most common error was initial load errors (19 percent). During entry of all current medications on the day of activation, multiple category B errors were made. An example was a written order for sliding scale calcium gluconate “PRN,” which was entered into the CPOE system as “scheduled.”<br /><br /><b>There were also computer design issues that contributed to 10 percent of errors.</b> An example was when the pharmacist received two printouts for methylprednisolone 500 mg IV. He assumed it was a duplicate order, but when he reviewed the CPOE system, he saw that one order was for today and the other was for tomorrow. <b>The dates for these orders were not visible on the order printout from the CPOE system. [<span style="color: red;"><i>This again seems to be 'use error' - ed.]</i></span></b></blockquote><div><div><span style="font-family: Arial;"></span><br /><div><div><br /><span style="font-family: inherit;"><span style="font-size: small;">These issues can and will occur any<span style="font-size: small;">where.  </span>Once again, <span style="font-size: small;">this is </span>not entirely an article, either by itself or in a meta-analysis<span style="font-size: small;">, that <span style="font-size: small;">I find ideal</span> in attempte<span style="font-size: small;">d pr<span style="font-size: small;">oof of CPOE effectiven<span style="font-size: small;">ess and beneficence.</span></span></span></span></span></span><br /><br /><span style="font-family: inherit;"><span style="font-size: small;">In fact, after I reviewed this source, I noted that this study was eliminated from the inclusion set:</span></span><br /><br /><blockquote class="tr_bq"><span style="font-family: inherit;"><span style="font-size: small;">... Based on later expert reviewer feedback, we eliminated one additional study that <b>solely used a voluntary reporting method for error detection</b>,<span style="font-size: small;"> </span>leaving nine studies for our final pooled analysis. </span></span></blockquote></div></div><div><div><span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><span style="font-family: inherit;"><span style="font-size: small;"><span style="font-size: small;">It would probably not be hard to convince critic<span style="font-size: small;">al thinkers of the possibility this</span></span> study was removed for reasons other than stated.</span></span><br /><br /><span style="font-size: small;"><span style="font-family: inherit;">In summary, while one should not and cannot expect perfection in the studies available in a meta-analysis, due to the difficulties in this domain the literature resources utilized were not ideal, and the surrogate endpoint also raises concern.  (I have not reviewed the entire corpus of potential literature myself.)  The authors conducted a difficult and rigorous study, but one cannot turn data "lead" (as in Pb) to gold (as in Au), no matter how hard <span style="font-size: small;">one works</span> or however good one<span style="font-size: small;">'s</span> intentions are.</span></span><br /><br /><span style="font-size: small;"><span style="font-family: inherit;">The authors did note the limitations of the study<span style="font-size: small;">, although their conc<span style="font-size: small;">l<span style="font-size: small;">usion will likely be taken by the industry as a "full steam ahead" signal.   <span style="font-size: small;">(</span>I do note with some irony the proximity of this article's re<span style="font-size: small;">lea<span style="font-size: small;">se to t<span style="font-size: small;">he soon-to-start ma<span style="font-size: small;">ss<span style="font-size: small;">ive <a href="http://www.himssconference.org/" target="_blank">HIMSS <span style="font-size: small;">2</span>013 Annual Confe<span style="font-size: small;">rence & <span style="font-size: small;">Exhibition</span> </span>trade show</a><span style="font-size: small;">, March 3-7<span style="font-size: small;">, 2013 in New Orleans<span style="font-size: small;">, LA.<span style="font-size: small;">)</span>  <span style="font-size: small;">While </span>likely<span style="font-size: small;"> a coincidence, <span style="font-size: small;">my concern is that CPOE vendors will be talking nonstop ab<span style="font-size: small;">out these res<span style="font-size: small;">ult<span style="font-size: small;">s.</span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span> <br /><br /><span style="font-size: small;"><span style="font-family: inherit;">Thus, I agree with the<span style="font-size: small;"> author's</span> conclusion (especially in view of the recent <span style="font-size: small;">voluntary<span style="font-size: small;"><span style="font-size: small;"> </span>reporting<span style="font-size: small;">-ba<span style="font-size: small;">sed </span></span></span></span></span></span>ECRI PSO study) that <i>"</i><b><i>future research in this area will be critically important to inform policy and funding decisions regarding the development and implementation of CPOE in care delivery."</i></b><br /><br /><span style="font-size: small;"><span style="font-family: inherit;">From a clinical <span style="font-size: small;">perspective, </span>"<span style="font-size: small;">p</span>rimum non nocer<span style="font-size: small;">e" and <span style="font-size: small;"><span style="font-size: small;">the </span>avoidance of gambling billions<span style="font-size: small;"> of <span style="font-size: small;">dollars</span></span> </span>applies<span style="font-size: small;">, at least u<span style="font-size: small;">ntil a better understanding of the technology's risk/benef<span style="font-size: small;">it <span style="font-size: small;">ratio</span></span> and <span style="font-size: small;">how to improve it occ<span style="font-size: small;">urs.</span></span></span></span></span></span></span><br /><br /><span style="font-size: small;"><span style="font-family: inherit;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;">A fraction of those billions would pay for more robust<span style="font-size: small;">, <span style="font-size: small;">current</span> </span>studies on<span style="font-size: small;"> the s<span style="font-size: small;">cale needed to <span style="font-size: small;">get closer to the truth<span style="font-size: small;">, such as formal post-market<span style="font-size: small;">, <b><span style="font-size: small;">m</span>andatory</b> </span>sur<span style="font-size: small;">veillance<span style="font-size: small;"> that me<span style="font-size: small;">asures not surrogate <span style="font-size: small;">but</span> <i><b>primary</b></i> var<span style="font-size: small;">iables - s<span style="font-size: small;">uch as outcomes <span style="font-size: small;">both positive and <span style="font-size: small;">negative<span style="font-size: small;">.  A</span>s noted by the authors, voluntary reporting has the least sensitivity towards uncove<span style="font-size: small;">ring</span> error<span style="font-size: small;">:</span> </span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span><br /><br /><blockquote class="tr_bq"><span style="font-size: small;"><span style="font-family: inherit;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;">... Reviewed studies used various medication error detection methods. Research suggests that the highest error rates are found through direct observation, followed by chart review, then automated surveillance, and <i><b>voluntary reporting</b>.</i>  <span style="color: red;"><i><b>[Citations were made to papers by Flynn and Jha regarding these points - ed.] </b></i></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></blockquote><br /><span style="font-size: small;"><span style="font-family: inherit;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;">F<span style="font-size: small;">ormal studies are essential f<span style="font-size: small;">rom</span> the basis of medical (<span style="font-size: small;">e.g.</span>, s<span style="font-size: small;">afety and <span style="font-size: small;">p</span>ublic health</span></span>), business (e.g., ROI and liability), and social policy </span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span><span style="font-size: small;"><span style="font-family: inherit;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-family: inherit;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;">perspectives </span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span>(<span style="font-size: small;">e.g., are we spending the bill<span style="font-size: small;">ions of dollars this technology costs </span>wi<span style="font-size: small;">sely).</span></span><b><i> </i></b><br /><span style="font-size: small;"><span style="font-family: inherit;"><b><i><br /></i></b></span></span><span style="font-size: small;"><span style="font-family: inherit;">-- S<span style="font-size: small;">S</span></span></span><br /><br /><span style="font-size: small;"><span style="font-family: inherit;"><span style="font-size: small;"><b>Addendum</b><span style="font-size: small;"><b>:  </b> </span></span></span></span><br /><br /><span style="font-size: small;"><span style="font-family: inherit;"><span style="font-size: small;"><span style="font-size: small;">I have <span style="font-size: small;"><span style="font-size: small;">often</span> been</span> the <a href="http://hcrenewal.blogspot.com/2013/02/modern-healthcare-health-it-iconoclasts.html" target="_blank">fire-breathing and </a></span></span></span></span><span style="font-size: small;"><span style="font-family: inherit;"><span style="font-size: small;"><span style="font-size: small;"><a href="http://hcrenewal.blogspot.com/2013/02/modern-healthcare-health-it-iconoclasts.html" target="_blank">über-skeptic iconoclast</a> on matters such as this.  Ho<span style="font-size: small;">wever, I will allow a true international expert to take on that role this time, Dr. Richard C<span style="font-size: small;">o<span style="font-size: small;">ok, who had a guest post <span style="font-size: small;">here<span style="font-size: small;"> yester<span style="font-size: small;">day (<a href="http://hcrenewal.blogspot.com/2013/03/dr-richard-cook-on-health-it-sectors.html" target="_blank">link</a>)</span></span></span>.  D<span style="font-size: small;">r<span style="font-size: small;">. Coo<span style="font-size: small;">k<span style="font-size: small;">'s opinion on this JAMIA study (again, reproduced<span style="font-size: small;"> here with permission) was this:</span></span></span></span></span></span></span></span></span></span></span></span><br /><br /><blockquote class="tr_bq"><div><span style="font-family: inherit;"><span style="font-size: small;">A meta-analysis of the literature on the nature of the universe in the mid 1500's would have concluded that the sun revolves around the earth. The data isn't fake, just worthless.  </span></span></div></blockquote><br />-- SS<i><b> </b></i></div></div><span style="font-family: Arial;"></span></div></div>

JAMIA: Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems

A new article appeared online 20 February 2013 in the Journal of the American Medical Informatics Association entitled "Reduction in medication errors in hospitals due…

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New York Mayor Bloomberg: Gun Control - Yes, Bad Health IT Control - No?

The Mayor of New York, Bloomberg, calls for anti-gun legislation because accidents and unexpected events such as theft or use by a child can happen, even with legally owned guns (I don't think he believes law-abiding citizens who own them for defense or for sport would break the law with them).<br /><br />Yet the selfsame Mayor uncritically calls for spread of another technology that in its present state is prone to accidents and unintended consequences, and unlike guns, at a level that even the Institute of Medicine has admitted in unknown due to systematic impediments to transparency (see the middle of <a href="http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html" target="_blank">this post</a> for source).<br /><br />From a release at <a href="http://mikebloomberg.com/">MikeBloomberg.com</a>: <br /><br /><blockquote class="tr_bq"><a href="http://www.mikebloomberg.com/index.cfm?objectid=B530DDFC-C29C-7CA2-FF25BD11B52E6F7E" target="_blank">Mayor Bloomberg Announces Expansion of Electronic Health Records Result in Major Health Care Improvements</a><br />Feb 07, 2013 | NYC.gov<br /><br />Mayor Bloomberg, Deputy for Health and Human Services Linda I. Gibbs, Health Commissioner Thomas A. Farley today announced that the use of electronic health records has led to better health outcomes for tens of thousands New Yorkers in the critical areas of high blood pressure management, diabetes and tobacco control.<br /><br />New York City's introduction of electronic health records, which has become a national model, was a result of the Primary Care Information Project, a program that began in 2005 to help medical providers, particularly those with underserved patients, use technology to improve the quality and efficiency of health care. The prompts that electronic health records give doctors, such as signaling a daily dose of aspirin to prevent heart disease or follow up questions for someone who smokes, make a dramatic difference in how aggressively they treat the chronic health conditions of their patients.<br /><br />Through 3,200 primary care providers serving more than three million New Yorkers with electronic health records, over 96,000 additional patients reduced their high blood pressure, 81,000 patients improved their diabetes management and an additional 58,000 smokers were given assistance and successfully quit. The Mayor made the announcement at the “NYC Celebrates Improved Health Through Technology” event at the New York Institute of Technology where he was joined by Centers for Disease Control and Prevention Director Dr. Thomas Frieden, National Coordinator for Health Information Technology Dr. Farzad Mostashari and Director of Health Services Andrea Cohen.</blockquote><br />There is no doubt the technology can accomplish such goals.  The IT I authored or spearheaded at major hospitals improved quality of care in areas such as diabetes and asthma care, invasive cardiology, and others.<br /><br />The release, however, is missing the most important points.<br /><br />The issue is not <i>whether</i> benefits can accrue from health IT.<br /><br />The issues are ... at what level of harms in its present state, since the technology is unregulated and unvetted for potential risks, and also - are there <i>simpler and cheaper ways</i> to accomplish these ends, e.g., so that the underserved can get <b><i>more access </i></b>to care.<br /><br /><b>There is no mention of unintended <u>harms</u>, or even concern about harms, in the release - the very same harms mentioned by Joint Commission, FDA, Institute of Medicine </b>(for example see <a href="http://hcrenewal.blogspot.com/2008/12/joint-commission-sentinel-events-alert.html" target="_blank">JC</a>, <a href="http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html" target="_blank">FDA</a>, <a href="http://hcrenewal.blogspot.com/2011/11/iom-report-on-health-it-safety-nix-fda.html" target="_blank">IOM</a>)<b> and many others.</b><br /><br />That qualifies the press release as propaganda.  It is not balanced, almost like an ad for, say, VIOXX.<br /><br />Apparently, for the Mayor it's OK to have increased risk and innocent victims due to bad health IT (like <a href="http://hcrenewal.blogspot.com/search/label/glitch" target="_blank">these</a> and <a href="http://hcrenewal.blogspot.com/2011/01/maude-and-hit-risk-mother-mary-what-in.html" target="_blank">these</a> and <a href="http://hcrenewal.blogspot.com/2011/09/sweet-death-that-wasnt-very-sweet-how_24.html" target="_blank">these</a> and <a href="http://hcrenewal.blogspot.com/2011/06/babys-death-spotlights-safety-risks.html" target="_blank">these</a>, and others I cannot talk about due to case settlements), but not innocent victims of legally owned but stolen guns.<br /><br />Medicine's tradition for centuries has been "first, do no harm", not "when you have benefits to the many, it's OK to overlook the risks and the roadkill."<br /><br />We don't tolerate that any more from the likes of Merck, Pfizer, or Medtronic (to name a few examples).<br /><br />Why does health IT always get <b>special accommodation</b>, as I have frequently asked?<br /><br /><blockquote class="tr_bq">With new federal funding for 2013, NYC REACH is now working to help behavioral health professionals and specialists with high numbers of Medicaid patients adopt and implement electronic health records to continue to improve care across the City. </blockquote><br />Let's hope they don't have an Avatar rerun (<a href="http://hcrenewal.blogspot.com/2010/11/avatar-fails-no-not-cameron-movie-but.html" target="_blank">link</a>) or Contra Costa meltdown (<a href="http://hcrenewal.blogspot.com/2012/08/contra-costas-45-million-computer.html" target="_blank">link</a>, <a href="http://hcrenewal.blogspot.com/2012/09/in-addition-to-nurses-doctors-now-air.html" target="_blank">link</a>).<br /><br /><b>Note:</b> this post is not about gun control, a complex issue unto itself, but about medical ethics and <i>hypocrisy</i>.  <br /><br />-- SS<br /><br /><b>Feb. 8, 2013 Addendum:  </b><br /><br />Prof. Jon Patrick of U. Sydney opines:<br /><br />I can only say the story is a well crated ANECDOTE.<br /><br />The pertinent text is this:<br /><br /><blockquote class="tr_bq">Between 2008 and 2011, the number of preventive care services participating doctors provided grew, on average, by about 290%, from 39 services per 100 patients to 113 services per 100 patients – nearly a threefold increase.</blockquote><br />Which tells us the only tangible piece of information in that services are increased - where are the figures from the EDs or hospital intakes that show the number of visits for these diseases have gone down?<br /><br />The other interesting point is the valid claim of better analytics - but they don't say how they were used, if at all:<br /><br /><blockquote class="tr_bq">"Patients served by doctors participating in the program were, for example, reminded to take daily aspirin doses to prevent heart disease or counseled to quit smoking. Electronic Health Records also permit doctors to view data on their entire population of patients, which helps them modify their routine office practices to help all of their patients and then evaluate how well those changes work."</blockquote><br />-- SS<br /><br />

New York Mayor Bloomberg: Gun Control - Yes, Bad Health IT Control - No?

The Mayor of New York, Bloomberg, calls for anti-gun legislation because accidents and unexpected events such as theft or use by a child can happen, even with legally owned guns (I don't think he beli…

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George Lundberg, MD: The Promise of Health IT, and a Caveat

<span style="font-size: 100%;"><span style="font-family: arial;">I was cited yesterday in a <a href="http://www.medpagetoday.com/" style="font-weight: bold;">Medpage TODAY</a> video by medical internet pioneer </span><a href="http://www.medscape.com/public/bios/bio-georgelundberg" style="font-family: arial;">George Lundberg, MD</a><span style="font-family: arial;">, also former editor of the Journal of the American Medical Association (<a href="http://jama.ama-assn.org/">JAMA</a>). A link was made to Healthcare Renewal as well.</span></span><br /><span style="font-size: 100%;"><span style="font-family: arial;"> </span> </span><span style="color: black; font-family: Tahoma; font-size: 100%;"> </span><span style="font-size: 100%;"> </span> <br /><div style="font-family: arial;"><div style="color: black; direction: ltr; font-family: Arial; font-size: 13px;"><span style="color: black; font-size: 100%;"> </span><br /><h1 dir="ltr" style="color: #003399; font-size: 18px; margin-top: 0px;"><span style="color: black; font-size: 100%;"> </span></h1><blockquote><span style="color: black; font-size: 100%;"><span style="font-weight: bold;">Health IT: Garbage In, Garbage Out</span></span><br /><span style="color: black; font-size: 100%;"><br /></span><span style="color: black; font-size: 100%;">By George Lundberg, MD, Editor-at-Large, MedPage Today</span><br /><span style="color: black; font-size: 100%;">November 15, 2011</span><br /><span style="color: black; font-size: 100%;"><br /></span><span style="color: black; font-size: 100%;"><a href="http://www.medpagetoday.com/Columns/29688">http://www.medpagetoday.com/Columns/29688</a> (video and transcript)</span><br /><span style="color: black; font-size: 100%;"><br /></span><span style="color: black; font-size: 100%;"><br /></span><br /><div style="text-align: center;"><span style="color: black; font-size: 100%;"><a href="http://www.medpagetoday.com/Columns/29688"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5675586219048368530" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhDX_mb_kfYLRA-Yy8d1h1ZIIgjwrZWTev8fCqjRHe0PzceTlZ1rWc0O6m_8LN71p0jSu586pkchWFeq-Ue5hnbguBdwJfghUvZlA9UxQxpaH7g10m-Z06-uEhLLyQzLafRx_o26YRhwrMZ/s320/lundberg.jpg" style="cursor: pointer; display: block; height: 181px; margin: 0px auto 10px; text-align: center; width: 222px;" /></a><span style="font-size: 85%;">Click on picture to link to article/video</span></span></div><span style="color: black; font-size: 100%;"><br /></span><span style="color: black; font-size: 100%;"><span style="font-weight: bold;">Transcript:</span></span><br /><span style="color: black; font-size: 100%;"><br /></span><span style="color: black; font-size: 100%;">Hello and Welcome. I'm Dr. George Lundberg and this is At Large at MedPage Today.</span><br /><span style="color: black; font-size: 100%;"><br /></span><span style="color: black; font-size: 100%;">I started working with computers in medicine in 1963. I was a Captain in the United States Army Medical Corps in San Francisco when a Lieutenant Colonel told me to "automate the California Tumor Tissue Registry."</span><br /><span style="color: black; font-size: 100%;"><br /></span><span style="color: black; font-size: 100%;">I said, "Yes, Sir. How would I do that?" He told me to walk across the Presidio parking lot and go into a building that had a big machine in it that is called a computer.</span><br /><span style="color: black; font-size: 100%;"><br /></span><span style="color: black; font-size: 100%;">I did that, and for the next three months, I took the information that was on a bunch of 3 by 5 cards and converted that data into punch cards, which were then fed into the computer and out came an automated California Tumor Tissue Registry.</span><br /><span style="color: black; font-size: 100%;"><br /></span><span style="color: black; font-size: 100%;">I was hooked and, although never a "techie," I never stopped finding ways to use computers in medicine. The goal was always better, faster, cheaper.</span><br /><span style="color: black; font-size: 100%;"><br /></span><span style="color: black; font-size: 100%;">I remain a strong advocate, and have worked in a string of jobs that strived for that goal. One of the truths I learned early on was "G I G O" -- Garbage In; Garbage Out. That has not changed.</span><br /><span style="color: black; font-size: 100%;"><br /></span><span style="color: black; font-size: 100%;">There are indeed a huge number of medical tasks that computers can do very well if properly programmed, managed, and utilized. The eminent UCSF academic clinician Dr. Bob Wachter was early in recognizing that there were also significant <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1785161/">downsides in applying computers in practice</a>.</span><br /><span style="color: black; font-size: 100%;"><br /></span><span style="color: black; font-size: 100%;">Physicians are very smart. They will quickly adopt new technology that helps them get their job done if it does not waste their time.</span><br /><span style="color: black; font-size: 100%;"><br /></span><span style="color: black; font-size: 100%;">Most American physicians have dragged their feet on implementing computers into their practices, and with good reasons. But now they should get on with it.</span><br /><span style="color: black; font-size: 100%;"><br /></span><span style="color: black; font-size: 100%;">I write this column as it has been announced that 100,000 U.S. physicians and hospitals have signed up for the <a href="http://www.ihealthbeat.org/articles/2011/10/6/more-than-100000-health-providers-sign-up-for-meaningful-use.aspx">"meaningful use" incentive program</a> and thus been able to take the government's money to help automate their organizations.</span><br /><span style="color: black; font-size: 100%;"><br /></span><span style="color: black; font-size: 100%;">I think this is good and I praise Dr. David Blumenthal for his major efforts to make this happen.</span><br /><span style="color: black; font-size: 100%;"><br /></span><span style="color: black; font-size: 100%;"><span style="font-weight: bold;">However, there is another harsh critic worth listening to.<br /><br />His name is Dr. Scot Silverstein, and he seems to have made it his life's work to call attention to really </span><a href="http://hcrenewal.blogspot.com/2011/09/sweet-death-that-wasnt-very-sweet-how_24.html" style="font-weight: bold;">bad problems</a><span style="font-weight: bold;"> that he discovers in this mass move to automation.</span> <span style="font-weight: bold;"><br /><br />Heed his cautions. They are real.</span></span><br /><span style="color: black; font-size: 100%;"><br /></span><span style="color: black; font-size: 100%;">But also recognize that where there is progress, there is trouble; but it can be worth the price.</span><br /><span style="color: black; font-size: 100%;"><br /></span><span style="color: black; font-size: 100%;">That's my opinion. I'm Dr. George Lundberg, At Large for MedPage Today.<span style="font-weight: bold;"><br /></span></span></blockquote><div dir="ltr"><span style="color: black; font-size: 100%;"><span style="color: #666666; line-height: 2em;"> </span></span></div></div></div><br /><span style="font-family: arial; font-size: 100%;">I thank Dr. Lundberg for his caveat, citing me, and agree with his position.<br /><br />My father died in 2000 due to complications of failure to diagnose bilateral renal adenocarcinomas (malignant tumors of both kidneys) for about two years despite numerous warning signs. This occurred in a hospital without electronic medical records and was in part due to impaired clinician communications. <span style="font-weight: bold;">His life could have been longer, and with far less suffering, had there been a safe and effective EHR.</span></span><br /><span style="font-family: arial; font-size: 100%;"><span style="font-weight: bold;"> </span><br />Once discovered -- only due to <span style="font-weight: bold;">my</span> insistence on a renal arteriogram -- the doctors told my father he could not be treated and to "get his affairs in order." (They lost the later malpractice case that ensued.)</span><br /><span style="font-family: arial; font-size: 100%;"><span style="font-weight: bold;"><br /></span>I was able to prolong my father's life for a few years by removing him from that hospital, "<span style="font-weight: bold;">hospital A</span>" and taking him to another hospital where he underwent bilateral heminephrectomies and other treatment. Let's call the other hospital "<span style="font-weight: bold;">hospital B</span>."<span style="font-weight: bold;"><br /></span><br />On the other hand...a caveat of my own:<br /><br />Ironically and tragically, my mother died in June 2011 from complications of a <span style="font-weight: bold;">medical error at "hospital B" </span>that was due to </span><span style="font-family: arial; font-size: 100%;">impaired clinician communications -- caused by an EHR that to my observation was itself <span style="font-style: italic; font-weight: bold;">unsafe and ineffective</span>. </span><span style="font-size: 100%;"><br /><br /><span style="font-family: arial;">Therefore, <span style="font-weight: bold;">my caveat</span> is that we must be very mindful of the adage "</span></span><span style="color: black; font-size: 100%;"><span style="font-family: arial;">where there is progress, there is trouble; but it can be worth the price."<br /><br />The price must respect medical ethics. It must not involve using patients, especially patients who have not been given informed consent and opt-out choices, as test subjects for software debugging.<br /><br />As I wrote back to Dr. Lundberg:</span></span><br /><blockquote><span style="color: black; font-size: 100%;"><span style="font-family: arial;"><br /></span></span><span style="font-family: arial;">Many thanks George. I agree with your assessments [on EHRs].<br /><br />Now we have to work to ensure the pitfalls are habitually avoided.<br /><br />Regards,<br /><br />Scot Silverstein</span></blockquote><span style="color: black; font-size: 100%;"><br /><span style="font-family: arial;">Here is a memorial bench I had erected to my parents at their grave last month, near where they ran a small community pharmacy for almost four decades. </span></span><span style="color: black; font-size: 100%;"><span style="font-family: arial;">My father, a pharmacist, was a go-to source for health information in the <a href="http://articles.philly.com/1986-03-25/business/26081235_1_kelsey-hayes-city-material-manufacturer/2">once-bucolic</a> community of Somerton, in far Northeast Philadelphia, long before chain drugstores appeared in the region.</span></span><br /><span style="color: black; font-size: 100%;"><span style="font-family: arial;"><br /></span></span><span style="color: black; font-size: 100%;"><span style="font-family: arial;">The inscription atop the bench reads "Owners of Lumar Pharmacy. Served This Community 1954 -1991."<br /><br />They, like I, also toiled to safeguard and improve the health of the public.<br /><br />May they rest in peace:<br /></span></span><br /><div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEic0QrFaMJTrHh8lqnr-yXq49hhStOs_KyhL3qpreHoOXjf7sNOjmARDOdsoyHVNb9u5WwTmlVSn_gSp6V4l1950vlGPSOxAkpETxlBgat2RTg1c6Bd3lYYBqi3a6tEBVeFQ7bLvAOvnn24/s1600/Bench.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5675584399345929698" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEic0QrFaMJTrHh8lqnr-yXq49hhStOs_KyhL3qpreHoOXjf7sNOjmARDOdsoyHVNb9u5WwTmlVSn_gSp6V4l1950vlGPSOxAkpETxlBgat2RTg1c6Bd3lYYBqi3a6tEBVeFQ7bLvAOvnn24/s320/Bench.jpg" style="cursor: pointer; display: block; height: 241px; margin: 0px auto 10px; text-align: center; width: 320px;" /></a><span style="color: black; font-size: 100%;"><span style="font-size: 85%;">Click to enlarge.</span></span></div><span style="color: black; font-size: 100%;"><br />-- SS</span><span style="font-size: 100%;"><br /><span style="font-family: arial;"></span></span>

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George Lundberg, MD: The Promise of Health IT, and a Caveat

I was cited yesterday in a Medpage TODAY video by medical internet pioneer George Lundberg, MD, also former editor of the Journal of the American Medical Association (JAMA). A link was made to Healt…

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