When A Flawed EHR Threatens Patients - InformationWeek
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Paul Cerrato
Paul Cerrato
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When A Flawed EHR Threatens Patients

When Harvard investigators tried to figure out why a patient nearly died, they discovered that even a sophisticated system of e-reminders and alerts isn't always enough.

When assessing a flawed electronic health record system, "interventions should make it easy to do the right thing and hard to do the wrong thing." That's the advice from three Harvard clinicians on how to fix an EHR system that almost allowed a patient to die.

This story begins with a 53-year-old woman who developed life-threatening complications from pneumococcal sepsis because she wasn't given a vaccine to prevent the infection. The patient presented with the sepsis 10 years after a car accident that required the removal of her spleen.

The vaccine is considered standard for patients who have had a splenectomy because the absence of the organ weakens their resistance to a variety of pathogens, including the one that causes pneumococcal sepsis.

If this tragedy had happened in the pre-electronic age, the clinicians working the case would have just been admonished to be more diligent about applying clinical guidelines. In today's healthcare system, it required IT managers, physician leaders, and patient safety personnel to figure out whether the hospital's EHR system was at fault, and if so, how to stop such mistakes from happening in the future. The resulting investigation can help inform your next EHR redesign.

Self-Critical Approach

The investigation revealed that the patient had been cared for during the entire 10-year period within the same healthcare system. So in theory all the docs had to do was give this patient the vaccine somewhere along the line to prevent disaster. But it turns out that the splenectomy was never noted in the EHR's problem list. Had it been listed, the patient may have been given the vaccine because the system issues reminders to give such patients the drug every five years.

The operative words are "may have." Studies have found that only about six out of 10 patients with the term splenectomy on their problem list actually get the vaccine.

Having limited faith in the reminder approach, the Harvard clinicians considered creating what they call an "active interruptive prompt" that more or less shouted: Give the vaccine! Another option was to send routine reports to all providers on patients who had had the surgery, encouraging them to send letters to those patients about the need for the vaccine.

Unfortunately, even if the system were tweaked this way, it wouldn't have helped our sepsis patient because her primary care physician had implemented the EHR system after the car accident, so the splenectomy wouldn't have been included in her problem list at that time. And it was never added to her record after the fact.

So essentially, IT managers and the clinicians they work with are faced with a twofold dilemma: Many patients who have their spleens removed have that fact listed in the EHR problem list, but no one pays attention. And some patients who have had the surgery never have that information entered in the record.

What's The Solution?

In their New England Journal of Medicine case summary and analysis, Tejal Gandhi, MD, and his colleagues suggest a few partial solutions. They hope that these measures will in fact make it "easy for clinicians to do the right thing and hard for them to do the wrong thing." Among their suggestions:

-- Establish an electronic link between operative notes and the EHR problem lists. Doing so would automatically insert "splenectomy" in the latter.

-- Use billing data to identify patients who have had the surgery and let the billing data "talk" to the physician through the EHR system, prompting the physician to add that fact to the problem list.

I don't think these electronic fixes are enough. The real solution is one that nobody in the healthcare reform camp wants to hear: Short of implanting a microchip in every doctor's head, the simple truth is each clinician needs to see fewer patients and spend more than the typical eight minutes with each of them. And they need more time to manage all the thousands of tasks they have to perform daily. Obviously, this isn't going to happen anytime soon. But that doesn't make it any less true.

Find out how health IT leaders are dealing with the industry's pain points, from allowing unfettered patient data access to sharing electronic records. Also in the new, all-digital issue of InformationWeek Healthcare: There needs to be better e-communication between technologists and clinicians. Download the issue now. (Free registration required.)

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User Rank: Guru
10/24/2011 | 10:07:44 PM
re: When A Flawed EHR Threatens Patients
The national health insurance data base that is often used is not under HIPPAA so errors can't get corrected. Due to blatant and on-going theft inside many govt health plans claims processors, often the theft is facilitated by altering the diagnosis codes on the claims to circumvent the claim being referred to the liable party, such as approved workers comp, etc. Insiders estimate that the total theft to medicare is over a trillion and is $4 million and rising on my claims alone as one claim, that is theft since their are two primary payers ahead of medicare, is turned into 17 and the monies pocketed according to 500 named witnesses who have reported this but their contractor who is financially interlocked with the thieves won't forward the reports in violation of their federal contracts. US Dept of labor has accepted the complaint against Medicare coordination of Benefits for altering the official info from US dept of labor bi weekly but so far they haven't been stopped. Their is almost a monopoly claims processing company in the USA for Medicare and they also process another federal and state plans. This is where the alteration of codes takes place. Then when one ends up in an emergency room or sees a doctor that tries to rely on the national data base for info terrible medical errors can occur. it happened to me twice. Instead of suing the doctor or hospital; investigation led to the problem. Until Congress allows internal audits of and criminal investigations and prosecutions of govt contractors again; we are all at risk as govt contractors will be regulating all our health plans as of 2014. the criminal investigators assigned can't do anything until Congress permits it. The total theft to medicare is about the amount of the budget cuts to the doctors pay. This started in 1994 when the Secreatary of HHS Donna Shalala suspended the enforcement of conditional payments under Medicare and set up a system of contracts with employers and agencies to post the official employment status and insurance to the Medicare computer owned by Group Health's subsidiary, MCOB. No one is to alter that posting but the company with some legal change. Immendiately, the insurance liability industry and any other primary payers, etc. began faxing and calling to change the offiical records. Three medciare judges have ruled ta the offiical posting on me is accurate after the Hearing judge got the internal documents and verified them. This exposed a theft of a million dollars that was to be put in trust for my permanent medcial care at office of personnel management whose contractor controls the federal employee health plans ( they will be in charge of all in 2014.) This is where the million seems to have disappeared and the federal investigators are stopped from investigating. ACS employee misread the computer coding and told the only oxygen supplier in my area that I had a million dollars given to me to pay them direct. I have nothing but a death panel order : Let her die. and don't pst my file or pay bills ACS from a convicted criminal in the Jack Abramoff bribery scandal. Although approved for life by all three health plans. our son hauls tanks and we pay to fill them or I would be dead as ordered. Changes have to be made in the new health care so the govt contractors in charge of our right to live are accountable to the laws and constitution. The first appeals are done by the contractor and often aren't answered; and they are limited so addressing constitutional issues isn't available. patients are liable for the stolen monies even though its beyond their control to stop it. since 2005, Social Security was to be able to issue those letters of waiver by agreement with CMS; SSA has never implemented it and my request goes unanswered and files, now in custody of Affiliated Computer Services has disappeared numerous times. They don't want their illegal activities reviewed? Even Lynn Blodgett, CEO personally lied to Christina Stark the Us Dept of Labor workers comp regional manager that she was accessing my entire owcp file when even files and orders coming from appellate judges have disappeared inside their company and never posted. Recently, I had to send in yearly expenses. All but the Oxygen bills were processed on an offline system and said some third party should pay, etc. But the oxygen bills disappeared along with a decade of them never responded to from me or any of the oxygen suppliers I have had. HHS Civil rights complaints have disappeared also from the Dallas regional office without any response except the post office certified mail receipt. The manager called and bamblasted me for exposing the on- going corruption when I first filed over three years ago against several parties. ( not my doctors) HIPPAA complaints don't help as govt contractors aren't subject to them. Linda Joy Adams with files and monies missing in 5 agencies under ACS control.
Medicare case # M09-1406; OWCP: 02-0600326 date of injury 1/10/89 ( published)
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