Wednesday, July 20, 2011

More On The Impact of Health Information Technology on Medical Practice: Errors of Ommission

Technology meets reality
From time to time, the Disease Management Care Blog is honored to provide a guest post.  The insights from an anonymous colleague below provide some important insights on the pernicious impact of health information technology on the       day-to-day practice of real medicine, involving real patients being taken care of by real doctors.

It doesn't paint a pretty picture.

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.

Image from Wikipedia


Bradley Dean Stephan said...

Excellent, real-world, on-the-ground feedback - just what every shakedown cruise needs. We are in the 'Model T' stage of EHRs, so this is exactly the type of information needed - not to scrap the concept, but to make it better. PS - This FP's experience also underscores the challenge of those remaining in solo practice, while the rest of the physician universe integrates.

Jaan Sidorov said...

Do the Feds and their MU criteria support the notion that this is a shakedown cruise?

Gary M. Levin said...

Physicians and others need to pushback and demand that the EMR incentive program be halted for the time being. The current installed base should be evaluated for at least 24 months. The rush to implement EMR, HIE will be and is counterproductive in the face of health reform. Health reform should not be dependent upon HIT. These examples are very accurate and very common. We all remember when a patient could ask to be put through to the 'doctor's nurse or assistant to be worked in to a busy schedule. This central appointment system has never worked. When it did it could easily be bypassed by a direct call to the clinic.