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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.
While there's problems scheduling at the VA and getting in to see a doctor, they've had EMRs for 50 years. It's all online and easy to search.
Really. ZOMG! LAWYERS!
In the case mentioned, the patient suffered permanent damage because he did not receive appropriate care. It doesn't really matter whether it was the doctor, or a nurse, or improperly maintained equipment, or a frickin' janitor's laziness, or the EMR--the hospital is responsible for providing appropriate treatment to patients.
Yes, I'm sure there's a small number of sleazy lawyers who will latch onto harmless mistakes in the EMR to try to invent a case where there is none, just as they have always done with all mistakes, long before EMRs existed.
But the real problem is not the lawyers. The real problem is the byzantine UIs of these monstrous "Enterprise Medical Record" systems, if you get my pun ;-) After all, some data entry mistakes do cause actual harm.
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.
Part I. 1. People are human and miss things. 2. Lawyers' hindsight is 20/20. 3. Profit (for lawyers) Part II. 1. Open more law schools (profit for law schools) 2. Repeat step I.2. with more lawyers. Hard to say what eventually happens, but more lawyers without jobs probably means people are missing more things.
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..
If physicians have to keep updating the patient's age, then something is wrong. But good news! We have these new fangled things called computers! These computers can calculate the patient's age on the screen at the time the record was entered (by doing this patented new thing called date subtraction to get number of days and thus the age!).
I'll see your senator, and I'll raise you two judges.
Health, becoming and perhaps kludgy
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.
For those that like to RTFA, It might have been
http://www.computerworld.com/a...
or
http://www.healthcareitnews.co...
As someone doing IT (Imaging Informatics...) for a state health system, and having received care from that same system, let me chime in here.
Let me say this: there's 2 sides here.
First, there is the person entering this information. Likely, it will be a receptionist, cheduler, etc... It won't be a doctor. Yes, they've likely gone through training, but this requires attention to detail, EVERY DAY. Why? Because a new patient could very well be coming in at any moment, who has NO information in their system. That was me!
- Example: My last name is a VERY common one. However, it is spelled slightly different. An additional letter, from the common spelling. This was initially input, INCORRECTLY, and I had to have them change it on the spot. Yes, MY NAME. Nevermind my ailments.... The simple fact is, people make these mistakes, and sometimes daily. I'm not sure what would solve this, beyond the person concentrating more and paying more attention to detail. Is there training for that???
Second, is the EHR (electronic health record) systems. This is where things get a bit, convoluted. Getting everything to play nice, for the end 'reviewer' (receptionist, technologist, radiologist, Dr. , surgeon, etc.....) , requires a multitude of databases, and software packages, that don't necessarily play nice with each other. One would think that, on the information exchange side, there would be some cooperation in this environment between software vendors. They do what's set to spec and law, and just enough to get the job done. THAT'S IT!
- For you programmers out there, if you saw some of the code that runs in the present day medical industry, your jaw would hit the floor, and a chill would run up your spine. Yes! It is downright scary that some of this stuff functions the way it does! It can be cludgy, patch-worked, and single-threaded madness (in 2015??). As I said, it will function enough to get the job done. 'Bulletproof', this stuff is not!
However, with all that said, when all of this works as it should, and cleanly, it can be an efficient and impressive system and deliver quality care when time is a factor. Sadly, this is not the case most of the time. If I really truly had to put a finger on where some, if not most, of the faults lie with these systems, it does come back to software. It isn't hardware resources, database access speeds, personnel entering information, or communication issues. When the systems are working as intended, you really get to see just how the software handles things, and often times, the issue is the software itself, and nothing outside that.
I'm not bashing programmers here who have coded these things, because I know for a fact I couldn't code any of this. BUT, in supporting it, and knowing what is being charged for it, and what kind of support I ask for from the software vendors, I expect a much higher standard than what is presently in place.
IMO, the simple fact is, on the tech. side of Medical care, we aren't there yet. It's a work in progress, and my state is apparently one of the ones who is in the lead of these things. And THAT, scares me more than a little, since I'm the one trying to improve it at a rather rapid speed!
Legitimate court rulings that demonstrate real harm as a result of bad software design are a means of achieving change; the alternative is that the providers get to hide behind the claim that they are complying with all the regulations - despite providing a product that doesn't work. Whilst much lawyering is unhelpful, the reality is that SOMETIMES it does enable good things to happen!
Poor A/C, the reason is much more simpler than that; sigh. It's for billing purposes.
Well, after reading TFA, I can say nothing that's not in the summary...
It's not limited to electronic medical records -- it's the insane user interfaces in modern software that were obviously coded by a developer who never has to use the systems for work.
I'm not a doctor, but know many. Most of them are not happy at all with the shift to EHR, for the reasons cited. Most of the doctors I see for actual visits are attached to the large state university hospital nearby, and so they all use the same EHR system (I think it's McKesson.) The doctors often spend half the visit clicking through mandatory screens and cursing the computer. The insanely complex workflow is the problem. I work in airline IT, and the main reservation system providers do absolutely everything in their power to eliminate duplicate keystrokes and actions when booking a reservation or doing a check-in. It's optimized so much that agents trained on the system can do the entire transaction in real time while talking to the customer, with very few pauses. The real expert agents can eliminate any delays by using the terminal provided they've memorized the insane commands to do various tasks. The main reason for this is that airlines are insanely stingy, low margin businesses. Any delay for the agent decreases customer throughput and increases the chance they will need to put more agents on a shift.
In the IT world, I can't count the number of crappy end user applications I've integrated, where I've just shaken my head and thanked $deity that I don't have to use them for my job. And also, don't forget the ITIL-driven service desk and change management applications. The big vendors (Remedy, CA, etc.) will sell a company the "cheap" out-of-box package that implements _every single feature_ but charge them millions to customize it. Most companies don't bother, and you end up with systems where you spend almost an hour filling out a change request.
I'll bet most of this problem stems from that "out of box" deployment syndrome...where you get a product that technically functions, but is suicide-inducing unless the customer pays for customizations, in the "light a bag of money on fire" realm. How many hundreds of integration points does an EHR product have? Prescribing systems, records storage, insurance company connections, etc, etc, etc... Doctors must hate it because they can't just order a PA or nurse to do their transcriptions for them like they used to.
I've seen several EMRs and I've never seen one that asks for patient age; it's always Date of Birth. And any one system won't request it a second time, the problem is when a hospital is using multiple systems that don't interface the EMR with each other.
However, long outdated programming practices is the norm in EMRs.
Long-outdated programming practices were traditionally merely the norm in EMRs. But now thanks to subsidies, Meaningful Use requirements, and certification procedures, they are effectively mandated by the federal government.
Welcome to modern software design!
Any time a user has to enter the same information more then once or has to navigate complex boxes, tabs or windows, you've FAILED!!! Software development has become more about the developer and less about the user. It's become more about maintainability and less about functionality and ease of use.
For instance, currently I'm the sole developer of a major (NDA protected), application which carries out automated testing, logging and stressing of almost 70 products. Each of these products requires it's own set of special criteria, it's own set of special resources and it's own set of requirements, it has to be used by workers in 3 countries, including China and it has to log everything back to massively redundant databases. The expected experience of anyone using my software is basically 0, we don't need them to have to any idea about the products, any idea about the databases, any idea about anything, other then pressing two buttons, (Setup and Commit).
The users don't enter manual information, they don't even have to validate test results as that is taken care of in the program. At the end of testing they're given a number which auto posts via secure transfer to us and shipping information is automatically populated and carried through the system, at which point production gets a label and a box. This is how proper and well designed software works!
Now some smart ass is going to say that it can't work this way in the medical field because you require manual entry, well automate as much as you can and use automated systems to the check the rest. In Ontario at least, I'm not sure about other places, everything is fuelled through our health cards, one scan and the hospital knows all about you, everything they need is displayed. This is step one where automation can take over, why not pull that data and auto populate the system, log it back to a database and secure it! Second step would be to collect all the vital stats from all the machines you're tested on and log that against you. Once you have both sets of information, use automated scanning to generate likely issues you could have and etc...
If done right, the user, nurse or doctor should have very little work to carry out, maybe a check box here or there or a line descriptions, but basically everything else can be automated. If software developers aren't going to go the extra mile and make everything a smooth experience and because of that people suffer, that developer is at fault.
"Heatlh" record?
In the miasma of bullshit jargon that permeates this industry, an Electronic Medical Record is that thing your doctor uses to keep his records about you. An Electronic Health Record is that mythological thing that contains your complete life-long history and is shared--instantly, seamlessly, yet with complete privacy protection--between all your medical providers.
Any competent development house should be doing task analysis...
Of course they do usability, duh.
But every use case is different: Routine visit? Emergency with patient not breathing? Surgery? There are endless different scenarios to be considered and tons of data that has to be captured.
The reason EMRs are so terrible for patient care is because they were not designed for patient care. The US's fee-for-service model incentives hospitals/doctors to make sure they can bill for every single thing they do. The current set of EMRs were entirely optimized to milk as much money from the insurance companies/medicare as possible. If we can get our act together and get out of a fee-for-service model, the EMRs will have to improve. Until then, they are "billing software" not EMRs.
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.
The embedded link does not work.
Good job Tim!
This. While EPIC is easy to use and does a good job of tracking mistakes, it's real power is giving the hospital a streamlined, easy to use interface for physicians to bill for services. Medical coders might go the way of travel agents.
It is all together proper that this story would show up duplicated in my RSS feed.
I shut up and didn't make any remarks about that poor Thomas Eric Duncan dude . . .
What doctors have you been talking to? Doctors definitely DO NOT like entering text. If they are typing out pages and pages of stuff, hopefully it's because that is relevant information.
That said, I think the summary is talking about when physicians copy and paste histories from one note into the next. The history and presentation probably hasn't changed, so why type it all out again? Just copy and paste! However, then you run into the problem when the history starts off with "Mr Slashdot is a 36 year old man with herpes, etc etc". Then the patient seemingly doesn't age according to the text, but they obviously are in the structured data portion of the EMR... This copy and paste also leads to propagation of errors. I once saw a chart where a patient had received 2 bone marrow transplants in the past (not unheard of). I went back through the chart to find out when those were and what the complications were, and it turns out someone had a made a typo years before and it had continued, not just in one department, but other departments were copying and pasting the same error in their notes too! Madness...
You think you're funny? Laugh it up. An age? Simple subtraction, right? Not quite...
Start with kids under an arbitrary cutoff limit (often customizable by HC org, department, and/or provider whose ages need to be given in months. Then you get bitching from neonatologists who want the age of kids under some other arbitrary limits to be displayed in days. This is for a relatively simple concept.
Now, multiply the whole thing by about 25,000 concepts (many more complex than "age"), riddle the whole thing with massive amounts of subjective judgement, toss in prima dona providers, constantly changing governmental regulations, constantly changing clinical standards, constantly changing knowledge and technology, and you can start to see how stupid your comment about age starts to look. It's a difficult domain to program for - try it sometime and see.
That is all.
I don't think spamming EPIC is going to help. Maybe, a link to its specification page would a good idea?
Riight. More UIs designed by managers who Know How It Should Go, and wouldn't dream of letting a designer or (heaven forfend!) a programmer from talking to end users to find out how they need to *use* the software....
Been there, dealt with that. The Scummy Mortgage* co, of Austin, TX, had software for its collection dept written that in in the late eighties, and the staff avoided using it as much as they possibly could.
mark
* Actual name of co available upon request.
Your comment is a testament to why EHR software are so bad. Because engineers with no knowledge or experience in the field of health care think they can simply decide to automate or standardize stuff, because of "things called computers", without knowing if said things should be automated or standardized. (also, four other engineers without knowledge in the field mod it insightful just like your comment here on slashdot, and consequently bad projects go ahead).
So let me give you just one small reason (among the many) why your comment is not insightful: Data entry during a doctor's visit is meant to be redundant as a safety measure. Everyone knows that the system could calculate the age from the birth date, but simply forcing the doctors to enter the age every visit is a form of multiple data entry that can help to identify many errors that could otherwise have bad consequences.
> "When an electronic medical record is printed out, the amount of repetitive data in it is ridiculous," Printing electronic media onto paper in this day and age is approaching ridiculous as it is. It's no better than printing a movie on paper in many circumstances. I work at an EMR company - I've learned that many of these systems were originally designed by doctors, not software engineers. Several times in the last few months alone we have had software changes being challenged by practicing doctors, since something isn't working the same way it was 20 years ago when they had a hand in a feature's original creation.
Thanks you, have a nice day :)
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