Health 2.0

Errors of Omission

I am a rural Family Physician who has been in solo practice for more than 22 years.  I am neither a technophobe nor an information technology Luddite.  I have been using electronic prescribing for over 6 years and am in the market for an EHR that is net-based, scalable, interoperable and linked to a nationwide patient database.

While I wait, over the years I am seeing more and more patient care that is less co-ordinated and even thwarted by the very health information technology (HIT) that is supposed to increase efficiency. In my opinion, this is leading to decreased information transfer that is wasting precious time and putting patients at risk with errors of omission.

I will give anecdotal and real examples of HIT run amok that I suspect are more common than generally appreciated.  Alarmed by the lack of awareness of the potential frequency of these errors, I am writing this hoping that the blogosphere can somehow counter the momentum of an all-powerful HIT cerebrosphere.

1.     e-Prescribing (ERX): While mandated alerts about potential drug interactions in this software is often life-saving, it can also be life impairing.  There are two reasons for this:  1) at point of care, the warnings are just too darn sensitive and I’m being conditioned to ignore 90 percent of them.  I am afraid that this will cause me to click the “ignore” pop-up at the wrong time.  For instance, doxycycline and Dilantin have an interaction and a prescription of one in the presence in the other always prompts a warning.  When I researched this, I found the plasma concentration of doxycycline is decreased by a clinically negligible amount.   2) at the pharmacy window, the warnings can override physician judgment. A colleague of mine described to me how he prescribed a fluoroquinolone antibiotic to a patient on Coumadin and, aware that there was an interaction,  ordered the appropriate follow up testing and dosage modifications.  The pharmacist not only refused to fill the prescription,  they also did not notify him.  Instead, he asked the patient to call the doctor.  Two days later the patient was admitted to an ICU with life-threatening sepsis.  In both cases, needed prescriptions were omitted.

2.     Electronic Health Records (EHR):  In the old days, when I received a consultant’s letter, (unless it was an internist with OCD who was so thorough, he put a 3rd year medical student to shame) I could always count on an easy-to-read last paragraph that clearly stated the impression, plan, and suggestions.  What’s more, if there was something really important, the consultant often gave me a call.  Now I am typically faxed a 15 page electronic note in various and sundry fonts packed with 2 years of medical detritus from previous notes and labs.  I often cannot find an impression or plan.  This is a time consuming and opaque breeding ground for clinical errors of omission.

3.     Centralized Scheduling:  Instead of being able to directly call a consultant’s office for an urgent patient referral, I am now obliged to use centralized computerized scheduling that is basically transforming them into big box specialty centers.  It seems that most of the smaller independent cardiologists, gastroenterologists, orthopedists, vascular surgeons and other specialists have now banded together in large group practices protected by a phalanx of  centralized schedulers, often at an off-site call center.  Now instead of “send the patient right down and we’ll squeeze them in”, it becomes “fax the pertinent records to our intake coordinator and we will call the patient back in 48 hours to schedule an appropriate appointment”.  Aside from the fact, that I now have to call the patient in 48 hours to see if they got an appointment, I also often have to send the patient with suspected appendicitis or acute renal failure to an emergency room .  Last but not least, these systems cannot handle patient-specific nuances.  For example, a patient who may need a carotid stent may not be scheduled with the specialist expert in that procedure.  In other words, poorly functioning scheduling systems can lead to important lapses in connecting the right patient to the right doctor at the right time.
.
4.     Radiology Precertifications:  Last week I saw a patient with severe flank pain and bloody urine.  Thinking that a kidney stone was the most likely diagnosis, I wanted to order a CT scan to confirm an obvious diagnosis.  After going through a web-based electronic precertification process, I was informed that an answer to my request would be made available in 24 hours.  Of course the hospital refused to schedule the test without an approval number.  My office notified me of the situation and, after additional time consuming calls, I was able to force an expedited review by a live on-call person.  In this instance, a precertification system led to an unnecessary delay in an important test.

5.     Offsite Radiology readings:  Last week I ordered a mammogram and a CT of the pelvis on two different patients .  The mammogram was performed at the local hospital, the radiologist took the time to examine the patient and he called me with the results. That patient in question is now scheduled for a biopsy.  On the same day I sent a woman in for a CT of a very enlarged inguinal lymph node.  This was done at the same hospital but was read by a radiology group across the state.  I still have not received the report but I will be going to the office today  (Sunday) to check the fax machine.  This is an example of a delay in getting the results of an important test.

6.     Offsite cardiology studies:  Whenever I can, I try to send my stress tests to the local cardiologist because, if there is an abnormality, I am called and if necessary they will even (gasp) see them for an urgent formal consult after the exam. In contrast, the large institutions often act as technicians only.  It has been more than once that I see a patient 2 weeks after a stress test, call medical records to get a report, and find an abnormal result.  Luckily, there have been no fatalities to date, technically no error was made, but I also consider this an error of omission.

In effect, what I am seeing is not an increase of medical errors.  In fact every prescription, test and consultation is of the same if not better quality.  However, the workflow and communication supporting them seem are being hindered by the HIT.

This may seem counterintuitive to the administrative, policy, informatics, politicians and the academic types but it is my practicing opinion, forged in the real world.

This post originally appeared at Disease Management Care Blog.

Livongo’s Post Ad Banner 728*90

17
Leave a Reply

10 Comment threads
7 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
11 Comment authors
Moshesexskoda superb opinieNate OgdenDaniel Gonzales Recent comment authors
newest oldest most voted
Moshe
Guest

So, don’t you think getting access to unlimited coins and points for FIFA15 is simple?

sex
Guest

I really love your blog.. Very nice colors & theme. Did you build this amazing site yourself? Please reply back as I’m wanting to create my very own blog and would love to learn where you got this from or just what the theme is named. Thank you!

skoda superb opinie
Guest

Good post. I learn something new and challenging on websites I stumbleupon on a daily basis. It will always be helpful to read content from other writers and use something from their websites.

Daniel Gonzales
Guest

You have several valid points here. Technology should not get in the way of person-to-person communication. No matter how efficient or accurate technology can make your data, it cannot stress urgency or explain things in the same way as another human. Personally, I believe that the EHR meaningful use incentives might be a little bit premature. There are several great EHRs that I’ve researched, but there are just as many poorly designed systems being used.

Lynn in SC
Guest
Lynn in SC

Medicine is a complex decision making process involving at least two (maybe more) humans. Communications is another complex human interaction. All organizations have varying degrees of complexity aka bureaucracy because one person can not know and do everything. In health care these interaction and processes are in transition and transformation … we will get through this transition, we’ve learned to use cell phones, email, and ATMs even electronic voting. What I do appreciate is Dr. Sidorov’s thoughtful review and assessment of the current state of the art. I am worried that I never did learn how to program my VCR… Read more »

Dr. Mike
Guest
Dr. Mike

“Look, here’s this great new technology” “I don’t want it.” “But you have to use, it will make you better.” “Oh, all right. But look, it caused these problems.” “That’s because you’re incompetent” The point isn’t that the technology is bad (“guns don’t kill people, gun-owners do”) it is that it has been mandated for reasons that remain largely unproven and without consideration of its potential for harm. You would have to be very ignorant indeed to argue that HIT has not “over-promised and under-delivered.” Give me a reason for each and every piece of HIT other than some mandate.… Read more »

pcp
Guest

“But you have to use, it will make you better.”

Make that:

“But you have to pay for it and use it . . .”

You say:

” I do see value in some areas”

What are those areas?

Dr. Mike
Guest
Dr. Mike

Actually, I don’t pay anything directly. I do have to maintain my computers but fortunately I haven’t met a computer yet that I couldn’t fix and I actually enjoy fixing computers. With Practice fusion I have no server which simplifies things greatly. As to value – I do like having access to the charts wherever I go. I do like seeing the trends in vitals over time. I like the built in coding and the integration with scheduling and billing. We are going to be getting integration with lab and I believe that will be more efficient. I like not… Read more »

Margalit Gur-Arie
Guest

I am. What do you see as the main downsides? And what do you think will improve and/or eliminate those downsides?

BTW, instead of scanning, you could get an e-Fax number and all the faxes will be sitting in the computer. Not sure if PF has this built in or not, but even an outside e-Fax program is better than scanning. Your scanning person could just move files into charts. Of course, any paper that comes in through means other than fax, will need to be scanned, but it shouldn’t be that much.

Dr. Mike
Guest
Dr. Mike

Since you asked…. They are slower for one. It is so incredibly fast to flip open the outpatient chart to find information – the EHR is just as prone to human error and reports have a tendency to be mislabeled or the title is incomplete and you don’t know if the lab report titled “lipid panel” includes a set of LFTs or not and you have to click to find out – oops no it doesn’t, lets try the next one…. but turning pages is so very fast. And when you have had the EHR for awhile the lists get… Read more »

Margalit Gur-Arie
Guest

Thank you. I’ve heard some of these things and a thousand other things many times. I’m sure you know that many of your issues can be fixed rather easily, yet they are not, and the more “regulations” we have, the less real problems that will be addressed. Fore example, the LFTs presence (or not) in a long list can be easily fixed with a large hover that shows the contents before you click. It is so simple it’s infuriating. Won’t be exactly as flipping pages, but darn close and the technology exists and is applied in other software products. When… Read more »

Nate Ogden
Guest
Nate Ogden

Love E-Fax just wish the pricing would stabalize, we have been through 3-4 companies

pcp
Guest

So many points to discuss, but here are a few: 1. This post was not written by Dr. Sidorov 2. We tossed out e-prescribing the day I had to override an “interaction” between Prozac and Proctofoam. All studies show no reduction in errors with e-prescribing. 3. Some posters here love the analogy of airlines with their checklists. What we’ve created is a system in which the pilot has to go back in the cabin during take-off to find who ordered the fruit plate! If we want to reduce errors, set up systems that reduce physician distraction. It seems that IT… Read more »

BobbyG
Guest

I was on a demo webinar the other day for the the new release of Praxis EMR version 5, their ONC certified release. We only have one REC client using it. It’s intriguing. I have to say that the user interface presents by far the lightest “cognitive load” of any of the platforms I have to work with, and navigating around seemed to be a snap. They tout a different approach — no templates.

Dunno. They rank high in the user surveys, but…

Margalit Gur-Arie
Guest

This is a great post and describes reality very well. However, if you read carefully, it seems to me that at least half of the issues described here are due to things other than technology per se, such as consolidation into big practices and the addition of various bureaucracies which are presumed to provide those “economies of scale”, but instead provide anything but a so called “:patient-centered” experience. Unfortunately EHR and HIT in general are now mentally associated with this deterioration in actual patient care. That said, there are very legitimate complaints regarding EHRs, such as those long and practically… Read more »

Tim
Guest
Tim

This trend is really there, of course, but to attribute all these data points to one monolithic thing called “HIT”, “EHR”, is to further confuse. As physicians you know very well, multiple symptoms might be from one pathological process, or more than one. There is no lesion called “HIT”. Your enemy is not technology, but a random combination of the trend toward bureaucracy (which is increasing) and stupidity (which is old.) About stupidity, nothing; but about bureaucracy: it is an inexorable feature of size. Repeat: inexorable. (Max Weber conclusively demonstrated this more than century ago; the central planners have not… Read more »

Dr. Mike
Guest
Dr. Mike

Absolutely correct – each and every one of the authors examples is happening hundreds if not thousands of times a day all across this country. But for the most part they seem to be the type of problems that lay beyond the understanding of those creating our health care future. I think the push for the EHR is the most obvious example of the backwards thinking that leads to these problems. We were told that if physicians and health care providers would only embrace this technology that we would see better communication and co-ordination of care. This has not happened,… Read more »