So Much for the Latest Silver Bullet

I just got this sent to me by Ross Koppel, a medical sociologist at the University of Pennsylvania Medical School who is an expert in the unforeseen problems created by health care information technology (HIT).  See his articles in JAMA Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors JAMA. 2005;293:1197-1203.  Ross and I are currenty working on a book that will come out in the fall of 2011 on the blindspots in teh patient safety movement.  One of those blind spots is total faith in the solution of HIT.  So, now on top of Koppel’s other work and that of even more folks, comes this.

Rush to Electronic Health Records Could Cause More Liability Risk

Released: 6/21/2010 3:20 PM EDT
Source: Case Western Reserve University
Case Western Reserve Professors Sharona Hoffman and Andy Podgurski Write New Article Warning of Potential Health Information Technology Hazards
Newswise — Electronic health record systems likely will soon become a fixture in medical settings. Advocates claim they will reduce health care costs and improve medical outcomes, which could be critical since the new health care reform law increases access for millions of Americans. Although benefits of bringing information technology to health records can be substantial, EHR systems also give rise to increased liability risks for health care providers due to possible software or hardware problems or user errors.
Two Case Western Reserve University professors, in a scholarly article published in the Berkeley Technology Law Journal, shed light on liability concerns and electronic health records systems. Until now, such a linkage has received little attention in the legal literature.
Sharona Hoffman, professor of law and bioethics and co-director of Case Western Reserve’s Law-Medicine Center, and her husband, Andy Podgurski, professor of computer science at the university’s School of Engineering, have written “E-Health Hazards: Provider Liability and Electronic Health Record Systems,” which offers a comprehensive analysis of the liability risks associated with use of this complex and important technology.
Hoffman and Podgurski are well known for their research and findings documenting a national need for effective EHR regulation. They analyzed the need for federal regulation of electronic health record systems in the scholarly article “Finding a Cure: The Case for Regulation and Oversight of Electronic Health Record Systems” (Harvard Journal of Law and Technology, 2009). That paper came after two previous publications by the two on security and privacy issues of electronic health records.
“This new piece focuses on health care providers’ liability. Are they at greater risk for malpractice claims? Are they at greater risk for privacy breach claims? And I think the answer to all of that is yes,” Hoffman said in describing the thrust of the article.
“It’s very personal to health care providers,” she said. “It’s what everybody who sits at that computer and uses it to manage patient care needs to know.”
At first glance, a quick transition to digital heath records seems a normal, even overdue part of the wider flow of high-tech change. It may seem surprising that many health care professionals continue to jot down notes and prescriptions on paper.
Even so, many doctors might not be fully aware of the fresh liability risk, Podgurski said. Problems providing are can arise, for example, if an EHR system contains software bugs, if it is too complicated, or if training for users is insufficient.
“Whether or not there is a software bug, in the sense of a clear error that causes a wrong output, the usability of the system may be lacking, and that may lead a user to make mistakes that have safety implications,” he said.
The authors make a strong case that without thoughtful intervention and sound guidance from government and medical organizations, EHR technology may encumber rather than support clinicians and may hinder rather than promote health outcome improvements. Aiming to prevent potential problems, Hoffman and Podgurski propose a uniform process for developing authoritative clinical practice guidelines, and they explore how EHR technology can assist in determining best practices. They offer recommendations to address liability concerns.
Congress has made a $19 billion investment in promoting health information technology, provided through the American Recovery and Reinvestment Act of 2009. The U.S. Department of Health and Human Services seeks to achieve nationwide usage of electronic health records by 2014.
So now is the best time to consider pitfalls. While the new Hoffman-Podgurski article draws attention to concerns over how EHR technology can lead to problems with patient care, the authors also point out that EHR system purchasers may never know about product flaws, because no regulation requires such disclosure, and some vendor contracts even prohibit it.
“If a computer problem causes an error in somebody’s drug prescription, medication dosage or surgical procedure, that can be catastrophic,” Hoffman said.
Case Western Reserve University is among the nation’s leading research institutions. Founded in 1826 and shaped by the unique merger of the Case Institute of Technology and Western Reserve University, Case Western Reserve is distinguished by its strengths in education, research, service, and experiential learning. Located in Cleveland, Case Western Reserve offers nationally recognized programs in the Arts and Sciences, Dental Medicine, Engineering, Law, Management, Medicine, Nursing, and Social Work.

This follows a big article in the New York Times about a week ago relating the death of another silver bullet — the human genome project.  Remember the promises around that one.  We would find a cure to everything by finding the genetic clues to all diseases.  We would even be able to individualize treatments and pills.  You wouldn’t be taking just any antibiotic or medication, you would be taking one specifically tailored to your genetic make up.  Well, know we learn, some tens years later, that the genome project has uncovered lots about genes but very little of it can be used to “fight” disease.  It used to be, to quote George Bush, “bring em on,” and now it’s, well gee…there’s not much we can do.  I want to write more about this in another post.  But for now, the issue is that of making huge promises, and spending huge amounts of money — money that could be spent on more nurses, more primary care docs, more home health aides, but that we don’t have, because we’re so busy trying to scale Everest that we forget that we live life here on the the ground.

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  • Teena M McGuinness

    The electronic medical record (EMR) is extremely useful in my practice as a psychiatric nurse practitioner in a primary care clinic. However, I think we have yet to peek into the Pandora’s Box of ethical and legal issues that will transpire because of it. Thanks for the link to the JAMA article; it is definitely food for thought.
    With only about 11% having adopted EMR (according to a recent paper published on the Health Affairs website), we still have a ways to go. But the next generation of nurses will definitely be dealing with these ethical and legal issues surrounding EMR.

  • Ann Fritz RN

    I have noticed that nursing errors are determined by what is typed into or nottyped into the EMR. You can be a great documentor and give very little patient care. If you type it,and had no time to do it you are safe under your license, but if you do it and don’t get it typed in or type it wrong, you can loose your license and unlike written charting; management can change what you say downto the harddrive by overriding your passcode in some systems. Otherwise, it is great!

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