Death by 1000 Clicks Redux


Back in the ‘stone ages’ when I (an MIT grad) was an intern, I was called at 4 AM to see someone else’s gravely ill patient because her IV had infiltrated.  I started a new one and drew some blood work to check on her status.  When the results came back (on paper) I (manually) calculated her anion gap.  This is simple arithmetic but I had been up all night and didn’t do it right.

She died. 

On morning rounds the attending assured me that there was nothing I could have done anyway but, of course, in other circumstances it could have made a difference and an EHR could have easily done this calculation and brought the problematic result to my attention.  My passion for EHRs and FHIR apps to improve them really traces back to this patient episode I will never forget.

My criticism of the recent Kaiser Health News and Fortune article Death by 1000 Clicks is generally not about what it says but what it doesn’t say and its tone.

The article emphasizes the undeniable fact that EHRs cause new sources of medical error that can damage patients. It devotes a lot of ink to documenting some of these in dramatic terms. Yes, with hundreds of vendors out there, the quality of EHR software is highly variable. Among the major weaknesses of some EHRs are awkward user interfaces that can lead to errors. In fact, one of the highlights of my health informatics course is a demonstration of this by a physician whose patient died at least in part as a result of a poor EHR presentation of lab test results.

However, the article fails to pay equal attention to the ways EHRs can, if properly used, help prevent errors. It briefly mentions that around a 60% majority of physicians using EHRs feel that they improve quality. The reasons quality is improved deserved more attention. The article also fails to discuss some of the new, exciting technologies to improve EHR usability through innovative third party apps and he real progress being made in data sharing including patient access to their digital records.

The article acknowledges that “medical errors happened en masse in the age of paper medicine, when hospital staffers misinterpreted a physician’s scrawl or read the wrong chart to deadly consequence, for instance.” It misses the opportunity to quantify the awful scope of this problem as the Institute of Medicine (IOM) did in 1999 when it found, based on 1984 data from physician reviews of New York hospital patient medical records, that “as many as 98,000 people die in any given year from medical errors that occur in hospitals.” A 2013 Journal of Patient Safety article reviewing four studies done in 2008-11 indicated that things were actually worse: “a lower limit of 210,000 deaths per year was associated with preventable harm in hospitals”. There is controversy about the exact numbers but little doubt that they are significant. The two studies cited were, of course, well before most of the wide adoption of EHRs funded by the federal HITECH program to fund EHR adoption. Moreover, while the issue is far from settled, there are studies that suggest that hospitals “with automated notes and records, order entry, and clinical decision support had fewer complications, lower mortality rates, and lower costs.” Other studies suggest that EHRs improve physician-patient communications.

Atul Gawande’s excellent article in the November 12, 2018 New Yorker describes the issues physicians have with EHRs in painful detail but it also points out that at his hospital “While some sixty thousand staff members use the system, almost ten times as many patients log into it to look up their lab results, remind themselves of the medications they are supposed to take, read the office notes that their doctor wrote in order to better understand what they’ve been told.” He lists specific quality initiatives his hospital has launched now that its records are digital. These include identifying people who have been on opioids for more than three months and patients who have been diagnosed with high-risk diseases like cancer but haven’t received prompt treatment. He also notes that the ability to adjust protocols electronically allows changes to occur far faster as new clinical evidence comes in.

In addition, the KHN/Fortune article fails to note that a substantial part of the tremendous increase in physician documentation is not caused by EHRs but by the need to obtain more data on the reasons why expensive tests and procedures are being ordered in an attempt to reign in out of control health care costs and for quality measurement and reporting purposes to support new ‘value-based’ reimbursement of care. Clearly, EHRs could be better designed to help with these burdensome new requirements and there are innovations that attempt to do this, but the article gives the impression that EHRs are the sole cause of physician burnout due to added documentation. This is simply not true.

Finally, the article gives no hint at the enormous progress that is being made to fix interoperability so that EHRs can share data meaningfully. It fails to mention that new and innovative third party developed capabilities can now be added to many major EHRs and that, because their records are now digital, many patients can seamlessly access them in support of their own health.

A more balanced article would have pointed to the 21st Century Cures Act and its mandate that EHRs provide patient-facing APIs. APIs are a standard way of retrieving data from a computer. You use them routinely to access data via the Internet and your phone apps use them to access your location or contacts. The patient health APIs will be required to use the new Health Level 7 FHIR® standard according to a proposed rule recently posted for comment by the Office of the National Coordinator for Health Information Technology within the Department of Health and Human Services.

Importantly, FHIR is the basis for SMART®, an EHR agnostic app platform developed with federal support at Harvard’s Boston Children’s Hospital. Using a SMART app, I was recently able to download my digital health record from my health system in less than 5 minutes completely on my own. The only specialized knowledge required was that I knew it could be done. After registering I simply selected my health system from a list and input the same portal credentials that once gave me view-only access to my own health data. Having done that, I now could use other SMART FHIR apps of my choice to manipulate my data in whatever way I find useful.

Using this same API, Medicare now offers its 58,000,000 beneficiaries access to their claims-based health data using apps of their choice and the Veterans Administration now offers its patients similar capabilities using their EHR data. Of perhaps even greater significance, Apple has embraced this new API so iPhone users can aggregate their EHR data even across providers. I know two people who have recently done just that on their own using their portal credentials. Once aggregated the EHR data is available to innovative iPhone health apps along with any data the patient may have collected on their own. Apple is actively supporting developers in creating those new health apps.

Progress is not just about patients. Unmentioned in the article are the new SMART FHIR app galleries operated by several of the major EHR vendors discussed in the article. Many apps in those galleries are written by innovative new companies and are generally for physicians and other care providers. Some of them directly address usability issues discussed in the KHN/Fortune article.

CMS administrator Seema Verma is not just talking about fixing these problems, as the article implies, she has called for the use of FHIR for patient, provider and payer applications. The payer community has created the Da Vinci Project, an ambitious collaboration to define an initial set of use cases some of which aim to streamline and largely automate their communication with physicians for preapproval of tests and procedures and quality reporting.

Yes, the health care system has huge issues with patient safety, but it had them before EHRs and there is no evidence I am aware of that they have, in aggregate, made the problem worse and there is evidence that they have made new quality improvement efforts possible. Moreover, unlike paper records, digital health care records can and are being shared. The data they contain is becoming the platform for innovation that is so badly needed to fix EHR usability and efficiency issues and many of the other structural problems in our massively complex, error prone and expensive US healthcare system.

The article got a great deal of attention, so it is regrettable that it is a missed opportunity to give a more nuanced and balanced view of digital healthcare today.

Mark Braunstein, MD developed one of the first electronic medical record systems in the early 1970s. His latest book is Health Informatics on FHIR: How HL7’s New API is Transforming Healthcare.

5 replies »

  1. As far as I can tell, none of the studies or discussions by anyone, include a single nurse, administrator, clerk, scheduler, or anyone else working with patients, all of whom are affected by EHR. Just how do they think the EHR has affected patient care for them? I suppose I am biased, but feel a lot was missed in these articles that seemed to think only physicians matter when it comes to patient care. As a surgical tech for many years, I can say that EHR has helped immensely with preference cards, surgical scheduling (although there have been problems there), etc. Three years ago I left the operating room to join the IT team for the implementation of the new EHR. So I’ve seen both sides. As a ‘clinical’ person I was given the unenviable job of creating the surgical procedure library with accompanying CPT codes, which affect authorization and billing. I was attempting to be methodical and careful as I slogged through the procedures, codes, add-ons and modifiers. However, I was stymied in the attempt. Why? because everyone was in a hurry. There was no emergency, no real reason to hurry. At every corner I was told not to worry that something wasn’t right, it could be fixed later. SIGH! I believe this single thing is the underlying problem with all EHRs since HITECH. Everyone was in a rush to get the carrot being dangled by the government, money. The sooner you got folks signed up, the more you could get and the more money you could make. Let’s not worry if it works properly, let’s just get it out there and fix it later. Unfortunately, you can’t tell a patient that. In all my years in the operating room, I worked by a simple principle, that I believe should be the standard for implementation of any EHR.

  2. Have you visited your local DPS or post office lately? Innovation is driven by capitalism, not discontent. In a free market, the more beneficial a product or service is to your fellow man– the more one profits! The government’s job is to protect the consumer and freedom of choice.
    The reason EHRs hadn’t been adopted wasn’t because physicians were so resistant to technology– its that there was no innovative technology available. When the government intervened and pushed physicians to purchase EMRs– it was no longer a free market. There was no need for INNOVATION. EHR vendors earned massive profits just by meeting meaningful use. Physicians were literally thrown to the dogs.
    The government should’ve stayed out or gone all in and made a single government run EHR. The same private companies could have bid for contracts and at least physicians would’ve purchased a functional product.
    The improvements seen in healthcare that the author points out could have been accomplished without EHRs. Limits that rule out practicing medicine after sleep deprivation would eliminate many miscalculations and charting on paper templates would prevent misread manuscript.

  3. Well put. A breath of fresh thought amidst the stale arguments floating about cyberspace. I also appreciate the comments. Keep them coming! It’s that kind of dissatisfied pressure that drives the vendors to iterate faster. The EHR transition period we are in now is uncomfortable but necessary to get where we need to be.

    Discontent drives innovation.

  4. Not very clear, but it does not appear that you have actually used the current crop of EHRs to care for patients…? Have you?
    The front line experience with EHR and the myriad of ridiculous quality metric clicking, abuse of the MD doing data entry and secretarial work, billions of unnecessary popups and alert fatigue. It it more like death of a million cuts.
    Before you throw out all the unicorn puffery language of the dream of EHRs, it has not been realized nor was the artificial market/crony government funded HITECH mess even close to be effective.
    It has set us back at LEAST a decade and destroyed the lives of MDs and nurses and front line care givers.
    So before you throw out all the wonderful vaporware ideas of the EHR tech industry, try using the current crop of whats out there 10 years after HITECH was born. Its a nightmare that doesn’t end.
    Its time to get the US GOVERMENT out of the way, the metrics, the foolish nonsensical certification, we need less of the EHR industry promotional wishes and real action on the street.

  5. In the meantime, our nation’s population HEALTH declines. And, our nation’s health spending continues to increase. Even though there is now a 2-3 year stable-level of health spending as a portion of our GDP, it is likely to have represented the underlying attributes of a mild recession, largely abated by economic exuberance. We will all benefit from the impending application of AI. Even so, serious problems exist within our institutions and their governance. We should remember that the original Rand study for the Academy of Medicine, now Institute of Medicine, was funded by Epic, Cerner and GE. The resultant institutional codependency has not served us well.