June 22nd, 2010
I just got this sent to me by Ross Koppel, a medical sociologist at the University of Pennsylvania Medical School who is an expert in the unforeseen problems created by health care information technology (HIT). See his articles in JAMA Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors JAMA. 2005;293:1197-1203. http://jama.ama-assn.org/cgi/content/abstract/293/10/1197. Ross and I are currenty working on a book that will come out in the fall of 2011 on the blindspots in teh patient safety movement. One of those blind spots is total faith in the solution of HIT. So, now on top of Koppel’s other work and that of even more folks, comes this.
Rush to Electronic Health Records Could Cause More Liability Risk
Released: 6/21/2010 3:20 PM EDT
Source: Case Western Reserve University
Case Western Reserve Professors Sharona Hoffman and Andy Podgurski Write New Article Warning of Potential Health Information Technology Hazards
Newswise — Electronic health record systems likely will soon become a fixture in medical settings. Advocates claim they will reduce health care costs and improve medical outcomes, which could be critical since the new health care reform law increases access for millions of Americans. Although benefits of bringing information technology to health records can be substantial, EHR systems also give rise to increased liability risks for health care providers due to possible software or hardware problems or user errors.
Two Case Western Reserve University professors, in a scholarly article published in the Berkeley Technology Law Journal, shed light on liability concerns and electronic health records systems. Until now, such a linkage has received little attention in the legal literature.
Sharona Hoffman, professor of law and bioethics and co-director of Case Western Reserve’s Law-Medicine Center, and her husband, Andy Podgurski, professor of computer science at the university’s School of Engineering, have written “E-Health Hazards: Provider Liability and Electronic Health Record Systems,” which offers a comprehensive analysis of the liability risks associated with use of this complex and important technology.
Hoffman and Podgurski are well known for their research and findings documenting a national need for effective EHR regulation. They analyzed the need for federal regulation of electronic health record systems in the scholarly article “Finding a Cure: The Case for Regulation and Oversight of Electronic Health Record Systems” (Harvard Journal of Law and Technology, 2009). That paper came after two previous publications by the two on security and privacy issues of electronic health records.
“This new piece focuses on health care providers’ liability. Are they at greater risk for malpractice claims? Are they at greater risk for privacy breach claims? And I think the answer to all of that is yes,” Hoffman said in describing the thrust of the article.
“It’s very personal to health care providers,” she said. “It’s what everybody who sits at that computer and uses it to manage patient care needs to know.”
At first glance, a quick transition to digital heath records seems a normal, even overdue part of the wider flow of high-tech change. It may seem surprising that many health care professionals continue to jot down notes and prescriptions on paper.
Even so, many doctors might not be fully aware of the fresh liability risk, Podgurski said. Problems providing are can arise, for example, if an EHR system contains software bugs, if it is too complicated, or if training for users is insufficient.
“Whether or not there is a software bug, in the sense of a clear error that causes a wrong output, the usability of the system may be lacking, and that may lead a user to make mistakes that have safety implications,” he said.
The authors make a strong case that without thoughtful intervention and sound guidance from government and medical organizations, EHR technology may encumber rather than support clinicians and may hinder rather than promote health outcome improvements. Aiming to prevent potential problems, Hoffman and Podgurski propose a uniform process for developing authoritative clinical practice guidelines, and they explore how EHR technology can assist in determining best practices. They offer recommendations to address liability concerns.
Congress has made a $19 billion investment in promoting health information technology, provided through the American Recovery and Reinvestment Act of 2009. The U.S. Department of Health and Human Services seeks to achieve nationwide usage of electronic health records by 2014.
So now is the best time to consider pitfalls. While the new Hoffman-Podgurski article draws attention to concerns over how EHR technology can lead to problems with patient care, the authors also point out that EHR system purchasers may never know about product flaws, because no regulation requires such disclosure, and some vendor contracts even prohibit it.
“If a computer problem causes an error in somebody’s drug prescription, medication dosage or surgical procedure, that can be catastrophic,” Hoffman said.
Case Western Reserve University is among the nation’s leading research institutions. Founded in 1826 and shaped by the unique merger of the Case Institute of Technology and Western Reserve University, Case Western Reserve is distinguished by its strengths in education, research, service, and experiential learning. Located in Cleveland, Case Western Reserve offers nationally recognized programs in the Arts and Sciences, Dental Medicine, Engineering, Law, Management, Medicine, Nursing, and Social Work. http://www.case.edu.
This follows a big article in the New York Times about a week ago relating the death of another silver bullet — the human genome project. Remember the promises around that one. We would find a cure to everything by finding the genetic clues to all diseases. We would even be able to individualize treatments and pills. You wouldn’t be taking just any antibiotic or medication, you would be taking one specifically tailored to your genetic make up. Well, know we learn, some tens years later, that the genome project has uncovered lots about genes but very little of it can be used to “fight” disease. It used to be, to quote George Bush, “bring em on,” and now it’s, well gee…there’s not much we can do. I want to write more about this in another post. But for now, the issue is that of making huge promises, and spending huge amounts of money — money that could be spent on more nurses, more primary care docs, more home health aides, but that we don’t have, because we’re so busy trying to scale Everest that we forget that we live life here on the the ground.
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June 16th, 2010
Has anybody out there seen the new documentary on Medicins Sans Frontieres called “Living in Emergency: Stories of Doctors Without Borders.?” If you haven’t, do and then write a letter to MSF as well as to the producers. The film is both impressive, depressing and appalling. To spotlight the work of what is an incredible organization, it focuses on four physicians — three men and one woman. All have gone on tours to truly agonizing places to Liberia and the Congo at the height of their wars. All are overwhelmed by the level of suffering, grief, lack of health care services, poverty and violence. And so are we, as viewers. Choices in these countries and outposts have to be made between procuring anti-biotics and surgical gloves. You choose the latter and the patient dies of an infection. You choose the former and the patient gets an infection. The doctors have a terrible time because they were all trained in high tech medical systems — trained to use the latest gizzmos and there are no gizzmos where they are. Not even enough paid meds, or basic supplies. For them, care is a constant triaging and for each patient they rescue hundreds — no thousands — go untended. The film eloquently captures their anguishing daily dilemmas.
That is the good part of the film What is truly astoudning is that the film and film makers, and by extension MSF itself, depicts this organization and the effort to help deliver medicine to war torn countries as a doctors only enterprise. The majority of MSF volunteers are in fact not doctors but nurses and statisticians and others. There is not a single depiction of a nurse or other health care professional in the film. We see people working with the surgeons who probably are nurses, but who knows. What is even worse is that the relationships of the physicians in the film and at least to the local professionals and staff who are stuck in these terrible places is almost entirely disdainful. Do MSF doctors get any training in dealing with local people? You wouldn’t know it by watching this movie. They berate the locals, speak scornfully of their work and there are no local people who play a prominent role in the film — except as objects of derision. I was really shocked watching the movie.
The film has serious implications for health care. We now know that health care must be delivered in a team, with decent team relationships and team commuication, if it is to be safe and effective. But the media consistently depicts health care — medical treatment — as a doctors only affair. This film is a perfect — quintessential –example. Any young person wanted to do good in medicine who watches it will get the impression that its the heroic doctor who counts — now sometimes a female — but always flying solo. Anyone becoming a doctor, who could potentially understand the value of real teamwork, will learn all the wrong things seeing this film. They will never learn to ask the right questions about health care delivery or how to improve their practice and communication as doctors by watching material like this.
When will the media get it. When will doctors get it? When, will MSF get it. Okay — so its called Medicins San Frontieres, not Medicine Sans Frontiere (Doctors Without Borders not Medicine without Borders) that doesn’t mean the organization should legitimize as it does here the total exclusion of other non-physician members of the team. See the film. Write to MSF.
As I sat in that darkened movie theatre, in Berkeley,California, watching the film with all the progressive Berkeleyites in the cinema with me, I wanted to shout out — hey guys, this is not how it is either out there, or back home here. It takes a village to deliver this kind of care –whether high tech, or low tech, in war zones or back here at home. And that village is a complex entity, in which lots of people who are not physicians do a lot of important and mindful work. When are we going to learn about them?
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May 30th, 2010
A few weeks ago, I talked with a friend who was about to have a hip replacement operation. She has been in severe pain for quite some time and as we chatted she said, “you know Suzanne, the insidious thing about pain, is that, unlike other conditions, it is impossible to see. For example, here we are, and can you tell that right now, I am in so much pain I could scream?” Indeed, I could not. As we sat chatting, she looked great, almost luminous. And yet, she was in agony. If she had had cancer, God forbid, or some other disease, she would have been rail thin, pale, sweaty, fainting. You could see it and feel for it. But she seemed in perfect form and yet,was in an agony as profound as anyone with a major, life threatening illness.
As I talked to her I was reminded that I have been remiss in not writing about an incredible new book our series on The Culture and Politics of Health Care Works published in the fall. The book is called Inside Chronic Pain: An Intimate and Critical Account. It is written by Lous Heshusius and is Commentary by Scott Fishman, M.D. who is a pain specialist. http://www.cornellpress.cornell.edu/cup_detail.taf?ti_id=5454 The author writes of her experiences — a long and unrelenting journey — into the world of chronic pain that began after she had a car accident that did irreparable damage to her neck. Her life has been dominated by pain ever since. She talks about how friends, relatives, colleagues, and most importantly, health care personnel, have reacted to her endless struggle to deal with her ever-present companion. The book is amazingly well written, which has little to do with the fact that I was its editor and everything to do with the skill of its author.
People may not want to read this compelling account. In a way, I think people fear listening to people who are in pain because unlike other illnesses, pain is something that it may seem impossible to prevent. You can try to eat your way free of diabetes, unsalt your way free of hypertension, anti-oxidant your way out of cancer, and exercise your way out of heart disease. At least, that’s the American fantasy. But pain? Heshusius’ anguished memoire reminds us that you can survive a car crash and medicine can rescue you — but then…what?
One of the most beautiful and important things about this book — aside from its writing– is that it asks us to come to grips with a very human problem — what do you do when confronted with suffering we can’t fix? Doctors and nurses, and physical therapists work on Heshusius with some success, sometimes. But her pain just won’t go away. And the temptation is to suggest that she is getting secondary gain from it. This concept is really insidious because illness does something to your brain chemistry and we do indeed become involved in a search for a cure, or for relief. And that means we become dependent on doctors, healers, chiropractors, PTs, you name it. But is our relentless search for relief really a sign of weakness or pathology? Or is it a sign of our desperation and, finally, of our ability to hope? Heshusius also talks about people who claim her pain is somehow in her head –not her neck. But how could pain not affect your emotions? Which is something Scott Fishman discusses with great eloquence in his commentary.
I have to use the trite phrase that Inside Chronic Pain is a “must read.” It’s not only that, it is an enlightening, and humanizing read. She doesn’t only challenge medical professionals, it challenges us all. As friends and family members, we all have to deal with pain — not just physical pain like her’s, but emotional pain. We are always confronted by people who suffer and who don’t get better. There’s the friend the pathological horder who can’t bear to throw anything out and seems to be limiting many options because of a lifetime’s love affair with needless stuff. There’s the friend or relative who won’t leave an abusive relationship, the one who can’t ask anything for himself. There’s the person who doesn’t — or so it may seem to us — recover quickly enough from the death of a loved one, or take our good advice about what to do with their kids. We stand helpless in the face of our own and other people’s seemingly intractable hold on what we think they should let go. And, of course, we always think we are exempt from this kind of denial and resistance, or would be in the face of the same situation.
Read this book. Put it at the top of your list if you are a doctor, nurse, PT or involved in any way with health care. Read it if you are in pain or have suffered from chronic pain. But mostly read it because you are a human being and because what it asks us to confront are the challenges — and joys of life itself. Along with its commentaries, I think its one of the best books ever written about a subject we reflect on too little and often too late.
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May 2nd, 2010
For over a decade now, nurses in Massachusetts and other states have been lobbying for legislation that would mandate safe nurse to patient staffing ratios for hospitalized patients. For these nurses the kind of safe staffing ratios enacted in California in 1999 and implemented in 2004 has been the benchmark. Industry groups like the Massachusetts Hospital Association (MHA) have insisted the California law has not helped patients and that the public should not support staffing bills in other states. Their message to patients and the public is “ trust us and we’ll look out for you.” In spite of dozens of studies documenting that contemporary hospital staffing patterns are linked to patient mortality and preventable complications – hospitals continue to insist that there is no need for either government mandated nursing workloads.
Well just in time for this year’s Nurses’ Week, a major research study has documented the direct connection between California’s staffing ratios and reductions in patient deaths and complications.
The study in question is entitled “Implications of the California Nurse Staffing Mandate for Other States” and appeared in Health Services Research – a prestigious scientific journal. www.nursing.upenn.edu/chopr/…/Aiken.2010.CaliforniaStaffingRatios.pdf
Its authors include a rock star like line-up of the most prominent nursing workforce researchers in the world – like Principal Investigator Linda Aiken and co-investigators Sean Clarke, Joanne Spetz, Douglas Sloane and Linda Flynn. These highly respected academics are by no means mindless boosters of either ratios or the unions that have promoted them as a solution to widespread hospital understaffing. Yet these academics conclude that ratios save lives.
This conclusion is the result of a comparison of nursing workloads and patient outcomes in California and New Jersey, and Pennsylvania – states that have no limits on the nursing workload. California legislation mandates a one to five RN to patient load -on medical surgical floors and 1-4 on specialty floors like oncology. In fact, researchers found that many California hospitals actually had better nurse to patient ratios than were mandated by law. With California as the benchmark researchers collected data on the nursing workload and patient mortality in New Jersey and Pennsylvania. While 88% of medical-surgical nurses in California cared for five patients or less on their last shift, that was only true of 19 and 33 percent of medical-surgical nurses in New Jersey and Pennsylvania respectively.
In those states nurses, on average, care for one or two more patients per shift. Turns out that just one extra patient makes a very big difference. With California style ratios in force, the researchers concluded, there would have been 10.6 percent fewer surgical deaths in Pennsylvania and 13.9 percent fewer in New Jersey. Even managers and chief nurses in California agree that staffing ratios positively impact patient outcomes as well as nurse retention. Which is why the authors argue that “outcomes are better for nurses and patients in hospitals that meet a benchmark based on California nurse staffing mandates whether the hospitals are located in California.”
This research comes out at a particularly critical time for nurses and patient care. Because of the lingering recession, more RNs who left thr workforce because of exhausting patient loads have been forced back into active duty and hospitals been able to declare that the “nursing shortage” is over.. In reality, there’s still a problem because many institutions – like Boston Medical Center and Tufts –are using the economy as an excuse to lay off nurses.
Four years from now, just as RN baby boomers begin to retire in greater numbers, the Patient Protection and Affordability Act of 2010 will kick in. When it does, 31 million Americans who’ve gone without primary care and preventive services will suddenly get health insurance and many of them will end up in the hospital. Laying off nurses and increasing their workloads, –which hospitals are free to do in the absence of legally mandated staffing ratios– is no way to pave the way for this huge influx of patients. As hospitals administrators function more like bankers on Wall Street hedge fund managers, can we afford to let them go unregulated. What we also can’t afford is the persistent myth that ratios are not in effect today. In fact, hospitals already operate on the ratio system. It’s the get-away-with-whatever-you-can ratio system. Hospitals staff according to ratios now. These ratios, however, are determined neither by what the patient needs, or scientific evidence on the connection between nurse staffing and patient care and the ignorance of many in the so-called C-suite (CEOs, CFOs and COO’s) of the importance of nursing care.
The people who now determine how many patients a nurse cares for are the kind of people a nurse manager recently told me about. She was fighting for an appropriate budget for her nursing staff and wanted to staff with an appropriate nurse-to-patient ratio. Many of her nurses had been there more than five years. In her budget meeting, the CFO of the hospital, she said, insisted that ” a nurse is a nurse, is a nurse, is a nurse. A nurse who’s been in practice for more than five years brings no more added value than a new nurse, he insisted. With this kind of disinformation passing as fact it’s no wonder we’re in the situation we are in in health care and nursing.
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