Showing posts with label healthcare IT crash. Show all posts
Showing posts with label healthcare IT crash. Show all posts

Another day, another EHR outage: MEDSTAR EHR goes dark for days

At my March 2, 2015 post "Rideout Hospital, California: CEO Pinocchio on quality of patient care during hospital computer crash" (http://hcrenewal.blogspot.com/2015/03/rideout-hospital-california-ceo.html) I highlighted a stunning example of when the light shone through the corporate B.S. about health IT outages, thanks to a letter to the editor by a family member of an affected patient:

Letter: Re: Rideout Hospital computer problems

http://www.appeal-democrat.com/opinion/letter-re-rideout-computer-problems/article_4a408cc0-be47-11e4-9b7b-93c22da930d4.html 

Friday, February 27, 2015 

I am writing in regard to comments made by the CEO of Rideout Hospital regarding its recent computer crash. 

He said quality of care for patients had not been compromised during this incident. He is lying.

My spouse went to Rideout almost two weeks ago and had a Lexiscan of her heart when the computer system went down. The hospital doctor released her and assured her that if anything were wrong, the radiology department would spot it and she would inform us.

Here it is two weeks later and now they are saying because of the computer problem the entire test didn't get to her cardiologist until today. They think she may have had a minor heart attack and needs further cardiac intervention.

 Is this the new "open and improved" truths we are getting from this hospital? Rideout CEO Robert Chason misinformed us all. 

I am sure my spouse, who has fallen through the cracks during this inexcusable lapse in Rideout's technical policies, is not the only patient suffering similar situations. 

Shame on Chason for minimizing the effects of this catastrophe at our local hospital. 

Edward Ferreira 
Yuba City

I am aware of another major EHR outage via Politico.com:

4/9/15
http://www.politico.com/morningehealth/0415/morningehealth17818.html

MEDSTAR EHR GOES DARK FOR DAYS: MedStar’s outpatient clinics in the D.C. and Baltimore area lost access to their EHRs Monday and Tuesday when the GE Centricity EHR system crashed. The system went offline for scheduled maintenance on Friday and had come back on Monday when it suffered a “severe” malfunction, according to an email from Medstar management that was shared with Morning eHealth.

“All of a sudden the screens lit up with a giant text warning telling us to log off immediately,” a doctor said. “They kept saying it would be back up in an hour, but when I left work Tuesday night it was still down.”

This doctor told us that the outage was “disruptive and liberating at the same time. I wrote prescriptions on a pad for two days instead of clicking 13 times to send an e-script. And I got to talk to my patients much more than I usually do.

But of course we didn’t have access to any notes or medication history, and that was problematic.” MedStar notified clinicians in the email that any information entered in the EHR after Friday was lost.

I do not know if corporate issued the standard "patient safety was not compromised" line, but can almost predict it was uttered somewhere along the line.

MedStar is a big healthcare system.  An outage for several days at its outpatient clinics is disruptive and will lead to harms in the short term, but also in the long term, that cannot be effectively tallied, due to lost information. 

That includes information put on backup paper that fails to get entered when an EHR goes back up, as well as outright computer data loss as occurred here.

Note the doctor's comments about the "liberating" aspect of being freed from health IT.  He/she could actually practice medicine, not computer babysitting.

How many harms will come of this "major malfunction?"  There is no way to know.  However, hospitals cannot have it both ways.  If these systems are touted as improving safety, then safety is affected when they are down and emergency measures are put into place, resulting in chaos; and certainly when information simply goes to the "bit bucket."

The answer?  Either far more redundancy, or far less reliance on "paperless" systems.

There also needs to be mandatory reporting of EHR outages and root cause analysis so the incidence and the reasons can be studied, at the very least.

-- SS

Rideout Hospital, California: CEO Pinocchio on quality of patient care during hospital computer crash

EHRs and other clinical IT are touted as essential to improving safety, among many other benefits.

Yet when hospital systems crash, the common refrain by hospital executives to the press, when such stories are reported, is "...but quality of care was not compromised."  

In fact, I've made an indexing term for this refrain.  The following query link retrieves the posts so indexed, numbering almost 30 at present:  http://hcrenewal.blogspot.com/search/label/Patient%20care%20has%20not%20been%20compromised

One hospital in California 40 minutes north of Sacramento had a crash and its CEO made exactly that claim.  However, a patient's husband disagreed, and called the CEO a liar.  Why?  His wife was affected by the crash in a very unsafe manner.

The Appeal-Democrat is a local news source for Sutter and Yuba counties, California, serving readers since 1860.  Emphases mine:

Letter: Re: Rideout Hospital computer problems

http://www.appeal-democrat.com/opinion/letter-re-rideout-computer-problems/article_4a408cc0-be47-11e4-9b7b-93c22da930d4.html 

Friday, February 27, 2015 

I am writing in regard to comments made by the CEO of Rideout Hospital regarding its recent computer crash. 

He said quality of care for patients had not been compromised during this incident. He is lying.

My spouse went to Rideout almost two weeks ago and had a Lexiscan of her heart when the computer system went down. The hospital doctor released her and assured her that if anything were wrong, the radiology department would spot it and she would inform us.

Here it is two weeks later and now they are saying because of the computer problem the entire test didn't get to her cardiologist until today. They think she may have had a minor heart attack and needs further cardiac intervention.

 Is this the new "open and improved" truths we are getting from this hospital? Rideout CEO Robert Chason misinformed us all. 

I am sure my spouse, who has fallen through the cracks during this inexcusable lapse in Rideout's technical policies, is not the only patient suffering similar situations. 

Shame on Chason for minimizing the effects of this catastrophe at our local hospital. 

Edward Ferreira 
Yuba City

Claims that hospital paralysis through health IT outages and malfunctions don't compromise patient care insult my intelligence.  Such claims insult the intelligence of patients and their families, too.  Outages and malfunctions nearly always compromise the quality and safety of care.
  
Patient safety is put at risk because hospitals are not making adequate efforts to keep these systems up 24x7. Many might say they can't afford it.  You don't put in life-critical information systems half-baked, however. Not in medicine, anyway.

Finally, the press, by accepting these Pinocchio-like statements from hospital administrations without severe challenge, only promote cavalier behavior of hospital executives.

Hospital executives:  EHRs are so absolutely essential to patient safety, we spend hundreds of millions of dollars on them. When they crash, however, patient care is never compromised.
-- SS

What in God's Name is Going on With Healthcare IT at Cambridge University Hospitals?

This story about a  UK hospital that recently "went live"with an American electronic health record/enterprise command-and-control system (EPIC) was not only predictable, but expected considering the sorry state of the health IT industry in terms of clinical leadership and regulation.

(It appears this was a "big bang" rollout, see http://www.ehi.co.uk/news/EHI/8845/cambridge-goes-for-epic-big-bang, an implementation method better suited for warehouses and widget suppliers than major hospitals.)

Addenbrooke’s staff blame blood shortage on new eHospital
By CambridgeNews  |  Posted: November 05, 2014
http://www.cambridge-news.co.uk/Addenbrooke-8217-s-staff-blame-blood-shortage-new/story-24513716-detail/story.html

By Freya Leng

Members of staff at Addenbrooke's [hospital, http://www.cuh.org.uk/addenbrookes-hospital] have voiced their concerns about the new IT system which has been blamed for a blood shortage.

Cambridge University Hospitals' eHospital went live on October 26 and is designed to improve the quality of care for patients by allowing clinicians and frontline staff to access patient information wherever they are, at the click of a button.

I must put to rest this lie once again.  The unregulated, generally terrible software being sold by the so-called EHR vendors is NOT simply software to allow clinicians to  "access patient information wherever they are."  

This is enterprise clinician and clinical resource command-and-control software, through which increasingly each transaction related to care must pass.  In other words, ERP packages to manage patient care, as one might manage inventory and shipping in a merchant enterprise:

http://en.wikipedia.org/wiki/Enterprise_resource_planning

Enterprise resource planning (ERP) is a business management software—usually a suite of integrated applications—that a company can use to collect, store, manage and interpret data from many business activities

Unfortunately, the reductionist assumptions behind the conception, design, authoring and implementation of such ERP software - that hospitals and healthcare are linear, predictable processes - are both deadly wrong, and the beliefs of fools and the recklessly cavalier.

To wit:

But since the launch, the News has been contacted by a senior member of staff at Addenbrooke's who said the new IT system was having "serious consequences" on the "operational running of the service".

In a letter, the staff member who does not want to be named [due to potential for retaliation - ed.], said: "The hospital has very little blood available due to transfusion lab technical failures. Truth - the new IT system is responsible."

The letter also states the impact the shortage of blood has had on the hospital including the cancellation of all elective surgery until November 8 as well as impacting on any procedure that holds a risk of blood transfusion and organ transplantation.

"I believe sufficient risk has been placed upon all patients under care of Addenbrooke's," the staff member said. "Someone needs to be responsible for the implementation of the new IT system."

In my experience, the non-clinical executives who often select this technology, and the IT personnel who then implement the technology (often ignoring clinicians), do need to be held responsible for bad outcomes - in the courtroom.

The News also understands the whole system went down for six hours at the weekend with staff reverting back to paper and all major trauma cases diverted elsewhere.

There are numerous cases on this blog of disruptive and patient-endangering EHR system outages.  These are simply inexcusable regarding life-critical computing. The unexpected transitions back and forth between paper endanger patients.

A doctor, who also did not want to be named, said the wifi system which supports all the ward rounds is "unfit for purpose" and is leading to gross inefficiency.

If this is true, it once again represents the cavalier nature of those technologists rarely held accountable for mistakes that, of they occurred in other critical industries (e.g., aviation, nuclear energy) might leave smoldering ruins and radioactive clouds that would result in the end of their careers...at the very least.  Unfortunately, individual injured and dead patients are not quite as visible to the public.

"The general feeling on the ground is that they could not have implemented the system any worse than they have done and without any doubt it has already significantly affected patient care." they said.

This is consistent with my own personal experience with hospital IT departments in the U.S., where mistakes that I could not even have conceived of making, were regularly made - leaving me to have to point out and clean up the mess, at risk to my own career due to the reactions of the non-clinical IT leaders and staff to being shown their own inadequacy regarding clinical affairs.  (This was, of course, an odd reaction by people who'd never gone to medical school, let alone had doctoral or postdoctoral study, research and development experience in Medical Informatics.)

A CUH spokesman said: "eHospital gives our staff more time with patients at the bedside, many of whom are frail, elderly and have complex conditions.

Right, just those patients who are most vulnerable to IT debacles and the cascading errors that can result.

"However, unlike banks, shops or travel agents, we cannot close our doors or stop our services to the hundreds of thousands of people we treat every year. So it was always going to be a challenge to implement such a massive change.

That is a very poor excuse for IT malpractice.  It makes the reader believe everything possible in due diligence was done, that others' experience was completely paid attention to, etc.  The results give me great doubt about that...

"Pathology was affected early last week, which led to a brief reduction in the number of tests, but we are increasingly operating as normal. We did carry out a successful 're-boot' of the system early on Sunday morning.

There we go once again  the typical bureaucratic spin that "the malfunctions were minor, nothing to see here, move along, patient safety was not compromised"  (a recurrent refrain with its own index term on this blog, see the 25+ posts at http://hcrenewal.blogspot.com/search/label/Patient%20care%20has%20not%20been%20compromised) - while at the same time these systems are represented as revolutionizing medicine - except when they malfunction, at which time they have no meaningful effects on care.

"The much bigger challenge we face is that the Trust is incredibly busy and we have limited numbers of beds available, and which need to be kept free for emergency cases. Operations will continue to be rescheduled until the community care for those who no longer need a hospital bed is in place. We do sympathise with the frustration that people feel and apologise for the delay they are experiencing."

In my opinion, patients put at risk, and injured and dead patients need and deserve more than apologies for information technology malpractice.

Especially at Cambridge University, where in my opinion, this whole affair is truly a world-class embarrassment.

-- SS
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