A Premature ‘Death’, Part 1: The Patient Safety Factor

Last month, Fortune Magazine published an article that purported to offer an insider’s view of the expensive, unholy mess of electronic health record (EHR) systems in the U.S. The article tells numerous stories of patients harmed, with hospitals and EHR vendors covering up and shifting blame. It describes several highly publicized lawsuits brought against vendors (although several of the cited cases did not yield findings of culpability).

The piece assails early federal efforts to stimulate meaningful adoption of health information technology as an “EHR conceit,” and decries how politicized it was, leading to non-sensical priorities that no engineer would adopt. It quotes former and current federal leaders of the initiative who candidly admit that the current reality does not match the initial vision.

The article also recounts what all readers here will know are common clinicians’ complaints:

• Some systems seem to be built more for billing than to support patient care.
• Clinicians do not have enough time to both relate to patients and documentation, and the latter makes them feel like data entry clerks.
• Clinicians can be overwhelmed by multiple open windows on screen, by “alert fatigue,” and by too many choices on drop-down lists.

Its tone is damning, and there surely will be many clinicians nodding along, because EHRs do have usability problems, there have been unintended consequences, and the historical staffing model has not necessarily transformed to accommodate this new method for capturing and interpreting and responding to information. And the inherent tension between the business and clinical aspects of delivering care is nothing new.

But as I read the article closely, and added some context and a few pieces of significant information, I came to the conclusion that with its accusatory tone, the article misses a major opportunity to inform.

First let’s talk about patient harm, and safety overall.

In 1999, years before EHRs were widespread, the Institute of Medicine issued “To Err is Human,” the first in a series of reports identifying and proposing solutions to the problem of poor healthcare quality. The executive summary opens the exact same way the Fortune article does: with horrific stories of patients harmed: A patient died from an overdose during chemotherapy. Another patient had the wrong leg amputated. An eight-year old died during minor surgery due to a drug mix-up.

These stories are remarkably similar to the stories that the Fortune article tells — except they had nothing to do with EHRs.

The IoM’s executive summary, however, continues in a way the Fortune article does not; by citing results from comprehensive peer-reviewed studies, estimating that “More people die in a given year as a result of medical errors than from motor vehicle accidents, breast cancer, or AIDs.” Recall that this is 1999, years before EHRs were introduced. Blaming EHRs for medical errors would only be justified by examining trends in error rates over time, and observing a non-random and sustained spike in error rate at the time that EHRs were introduced. The Fortune article doesn’t do that; it tells anecdotes instead, which are not dissimilar from the anecdotes told long before there were EHRs.

The Fortune piece also doesn’t tell the reader that the AHRQ and other federal agencies have been tracking safety issues related to EHRs, with recommendations for improvement. It doesn’t report findings and recommendations from review articles documenting EHR usability issues. The article quotes individuals who say that EHR systems reduced some types of errors but introduced others, which is nothing new, and makes sense. It does not, however, cite the ongoing work by several organizations to quantify these issues systemically, and to identify and act upon improvement opportunities.