Full Moon Friday the 13th: Computers down at Vermont's largest hospital

A health IT "glitch" hit in Vermont on Full Moon Friday the 13th (have some werewolf with your bad luck!)

Dark Shadows' Quentin Collins (David Selby) in a foul full-moon mood.

Note, however, that "bad luck" has little or nothing to do with mission-critical healthcare IT mass outages.  Mismanagement often does:

http://www.wcax.com/story/25773022/computers-down-at-vermonts-largest-hospital

Computers down at Vermont's largest hospital

Posted: Jun 13, 2014 4:12 PM EST Updated: Jun 13, 2014 4:12 PM EST

By WCAX News

BURLINGTON, Vt. -
A major, systemwide computer problem at Fletcher Allen Health Care in Burlington Friday.

The hospital says the computer system went down at 9:45 a.m. The glitch means doctors and nurses could not enter patient information into computers.

"Glitch" is an unfortunate euphemism for potentially harmful or deadly computer malfunctions, often due to mismanagement of that technology. See query link http://hcrenewal.blogspot.com/search/label/glitch.

Hospital spokesperson Mike Noble says information is now being recorded manually [i.e., on paper - ed.] Noble says the staff continues to provide the same care as normal and no surgeries were canceled because of the computer issue.

Noble says the issue appears to be an internal problem and not something from an outside computer provider.

It’s not known when the problem will be corrected.

This is yet another "the systems that revolutionize healthcare against all of paper's ills have all gone down, we don't know when they will be fixed, but patient care has not been compromised because we are resorting to paper" story (more at query link http://hcrenewal.blogspot.com/search/label/Patient%20care%20has%20not%20been%20compromised). 

-- SS

Masters of the Obvious at Athens Regional Medical Center: Lack of clinician input, training, common sense created problems with Athens Regional electronic records system - but mostly lack of common sense

(Note: also see my earlier May 26, 2014 post at http://hcrenewal.blogspot.com/2014/05/i-could-not-make-this-up-if-i-tried.html)

My early medical mentor, Dr. Victor P. Satinsky, had disdain for those whom he called "Masters of the Obvious", who proffered profound words of wisdom that were in fact common-sensical or well-accepted, as if they'd invented those words personally.

I think it's fair to say that after countless publications dating back decades, pointing out the essential role of clinical leadership in the development of clinical tools such as healthcare information technology systems, that such involvement is now a standard of care that reasonable hospital leadership would mandate when spending tens of millions of dollars on potentially injurious or lethal systems.

Yet the physician revolt at Athens Regional Medical Center appears to be a result of its most senior leadership not keeping IT leadership on an appropriately short leash (a phenomenon that falls under the topical heading of "severe mismanagement"):

http://onlineathens.com/local-news/2014-06-14/lack-input-training-created-problems-athens-regional-electronic-records-system 

Lack of input, training created problems with Athens Regional electronic records system

By Kelsey Cochran
Athens Banner-Herald
Updated Sunday, June 15, 2014 

More input in the way Athens Regional Health Systems’ electronic health records system was implemented should have come from the clinicians who use it every day, and fewer decisions should have been made by the hospital’s information technology department, a top hospital administrator and two vice presidents of system vendor Cerner Corp. said this week, in the wake of criticism of the system by a number of physicians.

... Although some daily users of the system were involved in the planning and design process from the beginning, Cerner Vice President Michael Robin, who has worked closely with ARMC since the deal was first made, said his team noticed midway through its implementation that the hospital system’s IT team was leading the project, which is "atypical" of Cerner clients like ARMC, he said.

First, I don't think that IT team control of health IT projects is all that unusual.   Clinicians, even medical informaticists with cross-disciplinary expertise, rarely are more than "internal consultants" who may be ignored, as opposed to true leaders with executive presence and authority (e.g., control of budgets, grants of authority, and IT staff performance evaluation, hire and fire authority).

Second, where was the Board of Directors?  They were ultimately responsible for allowing the IT leadership in at a level beyond their collective heads.

Third, it's just a bit odd that the leader of the (failed) $20 billion National Programme for IT in the NHS, Richard Granger, said almost exactly the same thing about listening to end-users ca. 2007 (see http://hcrenewal.blogspot.com/2007/07/clinical-it-mayhem-is-good-for-it.html).  I as well as numerous other authors had similar observations, in some cases dating to the 1960's.  For example,  see my essays, some dating to the late 1990s at http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases, and Dr. Donald Lindberg's quotes from 1969 at the page below from Morris Collen's book "A History of Medical Informatics in the United States 1950-1990."

EHR pioneer Dr. Donald A.B. Lindberg (http://www.nlm.nih.gov/od/roster/lindberg.html), 1969:  "Computer engineering experts per se have virtually no idea of the real problems of medical or even of hospital practice, and furthermore have consistently underestimated the complexity of the problems ... in no cases can these jobs be done, simply because they have not been defined with a physician as the continuing major contributor and user of the information." (Click to enlarge)

The essential nature of clinicians actually having input (and at a leadership level) into the design and implementation of clinical tools such as health IT is patently obvious.  Only in the perverse control-mentality of business information technology (a.k.a. MIS or management information systems, see http://hcrenewal.blogspot.com/2008/05/seedie-society-for-exorbitantly.html for the possible pre-electronic computer, tabulator-based roots of that culture) could such a precept even be questioned, let alone ignored.

... Moore, who took over as administrative lead on the electronic health record system after Thaw resigned, said some of the issues outlined in the physicians’ letter were real, and some were “theoretical.”

Translation: some of the complaints were accidents waiting to happen.

..."To the best of our knowledge, there was not patient harm or patient death.”

In other words, this is yet another story where the common, feel-good and ignorant refrain "but patient care has not been compromised" has reared its ugly head.  (I've made this type of claim a topical header at this blog.  See query link http://hcrenewal.blogspot.com/search/label/Patient%20care%20has%20not%20been%20compromised for others.)

Assuming that's true - note that the impact of bad health IT can be delayed due to delayed effects of bad or missing information - this statement is, let me be impolite, vacuous on its face.

vac·u·ous (http://www.merriam-webster.com/dictionary/vacuous)

adjective \ˈva-kyə-wəs\

: having or showing a lack of intelligence or serious thought : lacking meaning, importance, or substance

It seems some simple facts apparently need to be explained to these geniuses.   I'll put it in caps just to make sure they understand some basic issues:

• A HOSPITAL IS NOT A PLACE FOR RISKY INFORMATION TECHNOLOGY EXPERIMENTATION.   UNNECESSARY RISK IN HEALTHCARE IS A VERY, VERY BAD THING.

• THE GOAL OF HOSPITALS IS NOT TO SUBJECT PATIENTS TO RISK VIA MISMANAGEMENT OF HEALTHCARE IT, AND THEN PROCLAIM "NOBODY WAS INJURED OR KILLED" AFTER THE PERPETRATORS OF THE MISMANAGEMENT ARE UPROOTED.

• CLINICIANS DO NOT TOIL IN HOSPITALS TAKING CARE OF SICK PATIENTS SO THAT INFORMATION TECHNOLOGY PERSONNEL CAN HAVE COMFY JOBS AND COOL COMPUTERS.

One wonders if these points might be above the intellectual pay grade of those running hospitals - including boards - in 2014.

If nobody was injured or killed, it was due to happenstance, not due to appropriate due diligence and adherence to the standards of care essential in this healthcare sector - that is, healthcare information technology.

Depending on happenstance is not a good healthcare management strategy.

-- SS

Sham Peer Review Issue Goes Mainstream. WaPo: VA Physicians Fear Sham Peer Review

The paper's words this time, not mine:

From the Washington Post, "VA docs concerned about retaliation", June 12, 2014, http://www.washingtonpost.com/blogs/federal-eye/wp/2014/06/12/va-docs-concerned-about-retaliation/:

Retaliation from management is a real concern among Department of Veteran Affairs (VA)  employees ...  James Martin, a physician and a representative of the American Federation of Government Employees National VA Council, told the gathering  that sham peer reviews are a problem in the department. In a later interview, he elaborated, saying, “orchestration of facts” related to issues involving contact with patients [in other words, fabricating stories about substandard patient treatment by physicians, cherry-picking minor incidents and exaggerating them, etc. - ed.] is an issue at some facilities.” Sham reviews, he explained, can be used when management wants to replace or punish a doctor.

Retaliation against employee whistleblowers was again the subject of discussion during Thursday’s hearing of the House Veterans Affairs Committee.

Further amplifying the point:

... During the hearing, Republicans Jeff Miller (Fla.) and Dan Benishek (Mich.), both of whom spoke to the NAVAPD conference, asked Robert L. Jesse, the department’s acting under secretary for health, about reports that VA employees were instructed not to talk with members of Congress.

Benishek, a physician and former VA employee, said agency doctors have told him they are “reprimanded and have this retribution if they try to change the system.”

Read the whole article at the link above.

Then, read more on sham peer review at the American Association of Physicians and Surgeons (AAPS) resource site at http://www.aapsonline.org/index.php/article/sham_peer_review_resources_physicians/.

A typical scenario is described like this:

A conscientious doctor reports a quality care problem or patient safety problem to the hospital administration. This might be anything from an anesthesiologist falling asleep during surgery to a malfunctioning piece of equipment which places patients at risk for harm.

Instead of fixing the problem, some hospitals misuse the peer review process to attack and silence the physician whistleblower.

The hospital administration and unethical physician collaborators then search for some pretext upon which to attack the physician whistleblower. This might involve the hospital bringing trumped up charges against the physician or it might involve bringing totally false and/or fabricated charges against the physician. The truth and the facts do not matter in a sham peer review in the hospital since the hospital controls the entire process.

The hospital then goes through the motions of providing a hearing to the accused physician, which they call “fair,” yet the outcome of the hearing is predetermined. The physician’s due process rights are often utterly trampled. At the conclusion of the process, the physician’s privileges to practice at the hospital are terminated. The physician is reported to the National Practitioner Data Bank, and the physician’s career is essentially over. Once a physician receives a negative report in the National Practitioner Data Bank, it is unlikely that physician will ever work in any hospital again anywhere in the nation.

Sham peer view affects all physicians, not just public-sector ones.

It does not help patients when physicians, their supposed advocates, are cowering in fear over destruction of their careers for being "whistleblowers" (for which a better term might be "corporate integrity agents").

Finally, I think this fear helps explain the relatively low levels of complaints about bad health IT, on which hospital executives invest billions of dollars and their reputations.

-- SS

Canada: Province-wide electronic medical record computer system 'glitch' causing patients to be turned away from care

This story describes a very bad scenario for sick Canadians.  I offer just a few pithy comments, as not much more than that is needed:

http://medicinehatnews.com/news/local-news/2014/06/10/system-failure-has-docs-patients-upset/

System failure has docs, patients upset

By Gillian Slade on June 10, 2014

Many patients were turned away from their doctor’s office Monday because a province-wide electronic medical record computer system had collapsed.

Province-wide.  Stunning.  A very big argument against centralization of EHR resources.

“This is the third straight week of issues with the TELUS Wolf system,” said Dr. Donovan Nunweiler at Southlands Medical Clinic. “We feel we were encouraged by government to switch to Wolf and now it’s not working.”

I wonder when someone in the Canadian government is  going to issue that now-famous slogan "but patient safety has not been compromised"...

A year ago 202 physician clinics across Alberta using TELUS Wolf were unable to access patient records for most of the day.

More than 200 physician clinics are blind, deaf and dumb?  Wonder what happens to acute patients on days like that.

On Monday patients arrived only to be told the electronic patient files were not accessible making it impossible to see test results, past medical history and medications.

Paper never goes on strike.  Perhaps elimination of paper completely is not such a good idea?

“This is affecting me big time and affecting my income,” said Ken Hoeppner, a patient at HealthWORX Medical clinic, who had waited 15 days for his appointment. “Every time government touches something they wreck it. Our health care used to be good here before Alberta Health Services took over.”

No comment.

At HealthWORX, office manager Carel Liebenberg said the office was doing what it could to reschedule people. One patient had driven three hours to be there for his appointment early Monday.

It's just a "glitch", sir or madam.  Stop complaining. (http://hcrenewal.blogspot.com/search/label/glitch)

At Health Matters Medical Clinic, staff confirmed they too were dealing with no access to patients’ records on TELUS’s Wolf system.

Originally to encourage physicians to move to electronic medical records, the government gave a monetary incentive. Alberta Health selected TELUS Health Solutions Wolf EMR after a request for proposals in 2008.

There was a requirement for the service to be available 99.9 per cent of the time between 6 a.m. and midnight with financial penalties for failure to do so.

“There is no longer any government support,” said Nunweiler. “We (Southlands Medical Clinic) pay $2,000 a month for this. Who is going to hold TELUS accountable now? The government has abandoned us. Cost and issues switching patient data, when systems are not compatible, prevents us from going somewhere else.”

Seems to be this TELUS:  https://www.telushealth.com/health-solutions/electronic-health-records-%28ehr%29.  Sounds like a monopoly to me.

On that page:

TELUS Electronic Health Records (EHR) provides a better way to share, access and consolidate information.

Without quick, secure access to complete and reliable information, healthcare provision can be inefficient, preventing patients from receiving the best care possible.

How ironic.

Liebenberg reached TELUS at 9 a.m. Monday.

“They said they had just become aware of the issue and that their data technicians were in a meeting discussing the problem,” said Liebenberg. “Last week the system was extremely slow, taking 15 minutes for a physician to simply renew a prescription.”

Data technicians were in a meeting?  Sounds like a fantastic way to respond to a Province-wide medical emergency.

Nunweiler said he’d made notes on paper as he struggled to manage the snail’s pace of the system last week. Monday he would be adding to those notes and envisaged several hours at night entering the data to make it current.

Paper never goes on strike.

Liebenberg said the need to re-schedule appointments reflects badly on the clinic and some patients don’t understand it’s a system failure beyond the clinic’s.

That's just great for patient-physician relations.

Dr. Franz Yonker said HealthWORX had been using JonokeMed but the government endorsed TELUS Wolf and physicians were encouraged to switch.

“I think this is really bad for a government-backed system,” said Yonker.

"Wolf" is a somewhat humorous name considering these problems.  As in, a predatory EHR ... one wonders just how much better the others are.

Becky Nelson arrived for her appointment to refill prescriptions and was concerned about how long it would take to get another appointment.

“The government needs to get this on track. We are suffering the consequences,” said Nelson.

I wonder if any patients will suffer the ultimate consequence.  (Hint to Canadians:  never become too dependent on the Government.  Stuff like this happens.)

Donna Schneider brought her mother Vernie Ferguson in for results of some tests. Ferguson said she was not at all well.

“There is nowhere else to go and get my test results,” said Ferguson.

Held medical hostage to bad health IT.  How horrible.

The News requested an interview with TELUS but there was no response on Monday afternoon.

The News requested information from Alberta Health but that was not available on Monday.

Perhaps they're busy, in meetings discussing how to fix the problem.

-- SS

The Return of PharmaLot

After an unfortunate hiatus (see this post), PharmaLot is back.  PharmaLot was one of the premier sources of incisive information on the pharmaceutical industry, is back.  PharmaLot was and now is run by Ed Silverman, and is known for publishing important, but sometimes unpleasant truths.

Ed Silverman provided unbiased, insightful reporting.  Notably for the Health Care Renewal audience, he was not afraid to report on the good, the bad, and the ugly. He was no friend of marketing and public relations smarm.  Often he was first to break stories involving legal settlements, guilty pleas, and miscellaneous misconduct, and in some cases was one of the few to document such stories.

For example, when PharmaLot last disappeared, I noted that it provided one of the few accounts of a $21 million fine imposed on Merck by French antitrust regulators (here is the brief Reuters version.)  PharmaLot reported on a judgement against Actelion for anti-competitive practices in support of its drug for pulmonary artery hypertension.  The only other media report on this was in the San Francisco Chronicle, and it was less detailed. 

As we have noted endlessly, bad behavior by large health care organizations, including pharmaceutical and biotechnology companies and the various organizations with which they interact, like contract research organizations, medical education and communication companies (MECCs), etc has often been anechoic.  If one likes to get along by going along, it is not a good idea to make too much of a fuss about such issues and suppression and manipulation of clinical research, deception in  marketing, and perverse incentives including the creation of conflicts of interests, much less outright crime and corruption.  Ed Silverman was known to fuss about such issues.

So the return of his fearless reporting, and willingness to post controversial interviews and editorials, is a rare ray of light in the gloom. 

PharmaLot has just been added back to our blog roll.  Welcome back!

PS - It may be too much to hope that the back archives of older versions of PharmaLot can be restored to public view.  We wait with baited breath. 

Hat tips to 1BoringOldMan, Fear and Loathing in Bioethics

Another Sign The EHR Experiment is Producing Undesired (But Predictable) Results: ED EHRs Produce No Efficiency Gains

Adverse results that run counter to the industry meme of healthcare IT exceptionalism are coming fast and furious.  It's hard for me to keep up with it all.

In addition to my post today "EHR Exceptionalism Debunked: Care Quality Variances Among VA Hospitals Suggest the True Value of Health IT Has Been Grossly Exaggerated" (http://hcrenewal.blogspot.com/2014/06/ehr-exceptionalism-debunked-care.html), here's another.

I won't comment on this very much:

http://www.jwatch.org/na34646/2014/05/30/electronic-charting-less-efficient-paper-charting

May 30, 2014 

Is Electronic Charting Less Efficient Than Paper Charting?
Daniel J. Pallin, MD, MPH reviewing Ward MJ et al. Ann Emerg Med 2014 Jun.

Operational performance was similar before and after computerization at 23 community emergency departments.

The federal government has provided $17 billion in incentives to computerize healthcare. The potential benefits include improved error checking, decision support, better billing, and more data for research. However, some research has suggested that going paperless adversely affects productivity.

To further examine this issue, investigators measured operational efficiency 6 months before and 6 months after implementation of an electronic health record system at 23 community emergency departments. No significant differences between the two time points were found in all efficiency factors that were measured, including time to provider, lengths of stay, walkouts, patient satisfaction, patients seen per provider per hour, and significant return visits.

Citation(s):

Ward MJ et al. The effect of electronic health record implementation on community emergency department operational measures of performance. Ann Emerg Med 2014 Jun; 63:723. (http://dx.doi.org/10.1016/j.annemergmed.2013.12.019)

One might seek to get better results for their $17 billion than, at best, parity to paper.

Finally, the reader comments at that post suggest ED physicians are the ones helping foot the bill.  As one commenter put it:

"Most quality EM docs won't let a record slow their care up front--especially when quaility metrics are staring us down on time until seen or discharge. So we just chart later and go home later."

We as patients certainly should not find a development like that desirable.

Note that in my work as a hospital Chief Medical Informatics Officer (CMIO) I recommended simple document imaging solutions for risk-laden ED's (where charts are usually short) to capture and make the paper chart content available anywhere/anytime ... not full-blown digital electronic medical records systems.

-- SS

Most quality EM docs won't let a record slow their care up front--especially when quaility metrics are staring us down on time until seen or dischage. So we just chart later and go home later. - See more at: http://www.jwatch.org/na34646/2014/05/30/electronic-charting-less-efficient-paper-charting#sthash.WCiV8FQg.dpuf

Most quality EM docs won't let a record slow their care up front--especially when quaility metrics are staring us down on time until seen or dischage. So we just chart later and go home later. - See more at: http://www.jwatch.org/na34646/2014/05/30/electronic-charting-less-efficient-paper-charting#sthash.WCiV8FQg.dpuf

Most quality EM docs won't let a record slow their care up front--especially when quaility metrics are staring us down on time until seen or dischage. So we just chart later and go home later. - See more at: http://www.jwatch.org/na34646/2014/05/30/electronic-charting-less-efficient-paper-charting#sthash.WCiV8FQg.dpuf

Most quality EM docs won't let a record slow their care up front--especially when quaility metrics are staring us down on time until seen or dischage. So we just chart later and go home later. - See more at: http://www.jwatch.org/na34646/2014/05/30/electronic-charting-less-efficient-paper-charting#sthash.WCiV8FQg.dpuf"

Grand Jury: Ventura County, Calif., Mishandled Electronic Health Records Transition

In Ventura County, California, "the function of the Grand Jury is to act as a civil oversight of county and city government, special districts, governing boards, personnel commissions, school districts, and humane officers. It is their responsibility to insure that government is serving the best interests of Ventura County's citizens" (http://www.ventura.org/grand-jury).

Even under such a grand jury, the need for true Health IT experts (instead of amateurs) seems to have gone unnoticed.

A 2013-2014 Ventura County Grand Jury conducted an investigation in response to information received regarding the implementation of a new Electronic Health Records system by the Ventura County Health Care Agency (VCHCA).

Ventura County Grand Jury Final Report "Healthcare Records Processes and Procedures" (full PDF at http://vcportal.ventura.org/GDJ/docs/reports/2013-14/Healthcare_Records-05.29.14.pdf)

From the May 29, 2014 Ventura County Grand Jury Final Report "Healthcare Records Processes and Procedures" (full PDF at http://vcportal.ventura.org/GDJ/docs/reports/2013-14/Healthcare_Records-05.29.14.pdf).  Read the full report.  Any reader of this blog or my Drexel HIT site at http://cci.drexel.edu/faculty/ssilverstein/cases/ will recognize very familiar patterns.

Here are some highlights:

In April 2012, VCHCA hired an independent Information Technology (IT) consultant to oversee the EHR implementation; however, he was not authorized to be project manager.

An "independent IT consultant" who had no formal Medical Informatics expertise is a likely explanation for all that followed.  (Even if he did, his relegation to "internal consultant" was an attempt to seduce failure into rearing her ugly head.)

The Grand Jury found that, beginning with the authorization of the Cerner contract in October 2011, there was a lack of a dedicated and experienced project manager to oversee, track, and report all tasks related to the EHR implementation. The absence of a recognized standard project plan, as shown in the Project Management Institute’s A Guide to the Project Management Body of Knowledge (PMBOK® Guide), contributed to staff being inadequately prepared for using the new system and to a problematic EHR system implementation by VCHCA.

Lack of a "recognized standard project plan" was likely the least of the problems.

The Grand Jury found hiring of “contract staff” did not support project needs. The Ventura County Board of Supervisors’ (BOS) approval of additional funds allowed for the hiring of deployment staff. Hiring did not commence until August 2012, and continued after the VCHCA system “go-live” date of July 1, 2013. This indicated a lack of planning and diligence in pursuing the necessary qualified staff.

Lack of enough "contract IT staff" was likely the least of the problems.

The Grand Jury found that staff training on the new equipment was insufficient, leading to a lack of experience and knowledge with all components of the EHR system. There was a period of inefficient and delayed patient care.

Billing processes were significantly impacted, requiring manual intervention, taking additional time.

These are symptoms of what was likely truly lacking.

The Grand Jury found that VCHCA ordered the user hardware in May and June 2013, too late to allow proper time for configuring of computers, hardware testing, and user familiarization.
 
The Grand Jury found that VCHCA had until the end of December 2014 to implement the new EHR system to avoid federal penalties.

The Grand Jury found that VCHCA had to be on the EHR system for 90 days prior to September 30, 2013, to qualify for full Meaningful Use funding, therefore July 1, 2013 was selected as its go-live date.

It was all about money.  Still, that was not the likely problem.

The problem was likely leadership by healthcare IT amateurs**, lacking formal cross-disciplinary expertise in medicine and clinical computing.

Without that expertise, empowered in top leadership roles, these projects will fail or will be seriously impaired, at great cost.

If you don't believe me, believe the NIH (http://hcrenewal.blogspot.com/2009/12/onc-defines-taxonomy-of-health-it.html).

While the 'Grand Jury' investigation of a failed health IT project may be a first, and is not a bad development in my mind, perhaps the members of the Grand Jury need to read a bit more.

-- SS

** I am a radio amateur, a formal FCC designation for those licensed to use radio and who have some knowledge, but who are not formal radio telecommunications engineers (unless they have the required formal education, training and experience, of course).