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Kludgey Electronic Health Records Are Becoming Fodder For Malpractice Suits
Lucas123 writes The inherent issues that come with highly complex and kludgey electronic medical records — and for the healthcare professionals required to use them — hasn't been lost on lawyers, who see the potential for millions of dollars in judgments for plaintiffs suing for medical negligence or malpractice. Work flows that require a dozen or more mouse clicks to input even basic patient information has prompted healthcare workers to seek short cuts, such as cutting and pasting from previous visits, a practice that can also include the duplication of old vital sign data, or other critical information, such as a patient's age. While the malpractice suits have to date focused on care providers, they'll soon target EMR vendors, according to Keith Klein, a medical doctor and professor of medicine at UCLA. Klein has been called as an expert witness for more than 350 state or federal medical malpractice cases and he's seen a marked rise in plaintiff attorney's using EMRs as evidence that healthcare workers fell short of their responsibility for proper care. In one such case, a judge awarded more than $7.5 million when a patient suffered permanent kidney damage, and even though physicians hadn't neglected the patient, the complexity of the EMR was responsible for them missing uric kidney stone. The EMR was ore than 3,000 pages in length and included massive amounts of duplicated information, something that's not uncommon.
I haven't read the relevant regulations, and I hope I'll never have to -- I'm not sure I have that much time left on Earth -- but I'll bet that there's almost nothing concrete in them about usability.
EMR capture happens in a time- and attention-constrained environment. Any competent development house should be doing task analysis to ensure that their system meets the time constraints found during a doctor visit.
EMR search -- oh, I don't even want to start thinking about this. The relevant tasks could be anything from an auditor fine-toothed-combing records for an insurance claim, to an EMT trying to get a blood type or allergy info before a victim bleeds out.
I've consciously avoided jobs where my code is responsible for life-and-death decisions. The problem, I guess, is that too many other good people have made the same decision, and there aren't enough good people available to do what needs to be done. I'm not sure what to do about this.
This is another example of government not doing their job. We have needed a single, comprehensive standard for the form and format of Medical Health Records (MHR) for a long, long time. They needn't mandate specific products, but those products should all comply with one, universal and constantly-updated standard. But, nooo! We have to let Republicans exercise their fantasy that government can't do it, it has to be the "private sector" (in other words, reward the people who pay them to sit on their hands instead of solving problems). What was once a rich and vibrant marketplace of products has narrowed down to one industry leader who does NOT have patient information reliability and quality on their list of priorities.
We should have seen thermometers and scales and manometers and oxygen-level gauges (all standard tests on any pnysician visit) automated to send the information to the currently-opened patient record in the examining room over secure WiFi a decade ago...insofar as I can see, there are still no such products. These Electronic Medical Record (EMR) software products (especially from the "leader") are designed to impose the maximum load on professional staff, because it's easier to code them that way. I'm surprised they aren't designed to require staff to use green-screen, text-only monitors!
So, yes, lawyers are making money. And, I'm glad those lawyers are starting to attack the EMR system providers. But the Department of Health and Human Services (and, truth be told, the Republicans who think that underfunding government agencies to cripple them is a good idea) are a root cause of the problems..
Army hospitals too. My father worked in the records department of a 13 story giant Army medical center in the '80s and '90s. While the records themselves were fat paper folders, much of the patient information was kept in a database (which I think by the '90s was an AS/400) - and part of the job of the record keepers was to take the new information from the doctors and update the patient files in the database. So while the historical record was all on paper, the most up to date stuff was in the database where it belonged. They had about 30 people doing this kind of data entry full time for a hospital of 100 doctors.
Occasionally living proof of the Ballmer peak.
This is one of those rare instances where the Feds CAN make a difference by mandating specific medical record formats, import and export of data, standard reporting functionality, etc.
Many EMRs are in "island" systems that you can't easily get the data out of or bring data into, stranding important information and raising the costs of moving from provider to provider. How many fucking times have you filled out the stupid medical history forms?
Where the data is kept is up for discussion, but the format and content should be standard across all systems.
When Fascism comes to America, it will call itself Anti-Fascism, and tell you to give up your guns.
Sorry for double posting, but one other thing to note is this...behind all the whizzy new web interface screens, many EHR systems are based on some of the oldest, creakiest standards imaginable, including a programming language-and-database combo called MUMPS. Look it up - it's positively ancient, and it should be obvious why they have trouble finding people willing to specialize in writing code for it.
The VA system has one of the oldest EHR implementations in the country, and even though the GUI is semi modern, the guts of the system are this MUMPS mess. (You can download most of the source code for the system online since it's a government created product. The language was designed in an era where preserving memory was the only concern, all variables are global (!!), and keywords can be abbreviated to one letter...that should tell you enough about MUMPS right there!) Any industry you can think of that has used computers long enough has problems like this -- my area of expertise (airline systems) has standards going back 40-50 years, from when every single byte sent down a communications link was precious.
Most systems like this do a very good job of hiding the complexity from the end user, but it also reduces the amount of spontaneous change you can introduce. For example, in airline reservation systems, no one would dare change the layout of the mainframe emulator screens because so many up-level systems depend on scraping that data exactly the same way they've been doing it for 30 years. Everything an end user sees passes through many layers on the way down to the core, and systems like this are built on nested layers of wrapper code.
I actually am a medical doctor and I can say that the VA EMR is very very good. It's not as shiny or pretty as some others out there, but it's solid, easy to use/learn, interconnected with every VA hospital and it's the same at every VA hospital. The scheduling problems largely revolve around lazy government employees (I'm a govt employee, so I can say that!) and trying to get doctors to work in the VA system. They only recently brought the salaries for physicians, but only for new hires, IIRC. I'm sure THAT's good for morale....
I'm also an armchair bioinformaticist (or whatever) and have seen the coding and modules behind EPIC, one of the most popular and widely-used EMRs around. It IS kludgey! I forget if the inpatient or outpatient systems came first, but the second had to be kludged in. THEN, when you factor in the very widely used radiology information system (PACS) you have to kludge that in. Then you have pathology and lab medicine using an entirely different system (CoPath, Soft, PowerPath, etc) you have to tie that into the EMR and PACS. Sometimes pathology and lab medicine use two entirely different systems, even though they're in the same department!
Yes, it's a mess!