links for 2005-12-25

EHR Interface May Contribute to Medical Errors

This article in the  throw-away "journal" Family Practice News caught my eye.

The article reports on a presentation given by Melonie Nance.  In one of the case reports:

 .. a patient was discharged in acute renal failure 30 minutes after the renal failure had been noted and documented by the critical care fellow. The fellow had entered the diagnosis into the electronic record at the end of a lengthy note but had not communicated the information to the otolaryngology resident who discharged the patient. The error was discovered quickly and the patient was readmitted 2 hours later.

The primary problem in this case was that data entry was mistaken for thorough communication. Critical patient information was hidden from the discharging physician and the record contained excessive information.

Information overload is common and preventable .. and of course, data entry is NEVER a substitute for picking up the phone and calling someone.

RHIOs: The Next Big Thing?

I've done a lot of reading this weekend about RHIOs.  RHIOs are Regional Health Infromation Organizations.

There are a number of reasons I've been doing my homework on this – and a primary one is that our region may have some opportunities to begin some collaborative work, and I think it's important that I understand as much as I can about some of the issues involved.   I've done some of this homework before – but there has been quite a bit written about this recently – so it was time to catch up.

Here's a short tour of some of the reading.  Let's start with some of the most recent information .. which is the transcript ( and video!) of the ONCHIT's most recent meeting:  November 29, 2005

Be sure to read the transcript.  It's very interesting .. and reveals some of the vision of the future of HIT.  Doug Henley shares an important point:

?about demographic data of a patient, registration data, and they walk into a hospital physician?s office and they want to rather than fill out the clipboard three different times, they say ?my data is available on www dot whatever? or it may be on a memory stick and ?here I give it to you or give you access to it?. So to reinforce my comments earlier about integration or interoperability, it is one thing to have the patient in this case in control of that information, which is great for updating purposes etc, but most places in the system now ? forget the HRs for moment ? have for want of a better word practice management systems in their electronic. What we don?t want to have happen is for that patient to show up with a memory stick with that data or a Web site and somebody to have to go to it and re-key it and re-enter that information. It has to be able to flow into other systems freely, interoperably, so that hands don?t have to touch it any more in terms of mistakes that could be made. That could be an EHR, it could be allergy information, it could be medication information, and we don?t want mistakes to be made so wherever the data is, it has to integrate across various sites of service and flow freely from point A to point B to point C."

Of course, this is self-evident.  But it's important that he says this – and that there seems to be concensus that this is what the government wants – and that the government will help to faciliate this vision. 

.. And here's an interesting little article on RHIO resistance.  CIOs – generally a cautious species – are not uniformly embracing RHIOs.

.. Ignacio Valdez recently wrote a rather thorough editorial on the topic:


"Does it bother anyone that for years, Health Information Technology (IT) successes implied by the news and even in casual conversation may largely be an illusion?"


I  don't always agree with him – but this time, Ignacio is right on target.  He points us to this old paper by Paul Starr:

Smart technology, stunted policy: developing health information networks — Starr 16 (3): 91 — Health Affairs

But some RHIOs are working well .. right?

Here's one physician's view of a RHIO that's in our backyard  – 50 miles South of Albany.

And of course the Massachusetts project has been quite successful.

So how can we make sure that our local efforts are successful?

Ther is ample guidance from the RHIOFederation -  which is a product of HIMSS

Nancy Lorenzi's excellent 2003 essay on strategies for creating successful local health information interface initiatives (LHII) .. reflects on some of the rare successful implementations in the last decade.  Some key points:

1. Building an LHII is more of a political process than a technology process.
2. Collaboration is achieved through consensus built on sharing and trust.
3. The LHII must be structured so that participation does not mean the loss of
power, control and/or status.
4. Being the champion for an LHII requires risk-taking behavior.
5. Participant acceptance comes in phases and requires knowledge of the
participants needs.
6. Creating an LHII will take time, both in the initial work and for the length of
time until it is the ?new? way of working.

Beginning with some shared principles would be a good first step.  Without clear principles – any project is a rudderless ship. 

What might be some of these beginning principles?  

  • The RHIO will enhance the quality and efficiency of patient care
  • The RHIO will provide adequate security to protect against inappropriate access to PHI
  • The RHIO will be managed and coordinated transparently – so that trust and collaboration is fostered.

Hmm .. I've worked on this for a while .. time to post .. but I expect I'll add more to this.  Please use comments to make suggestions for changes or enhancements.

E-prescribing errors

In this month's issue of Prescriber's Letter is a brief article summarizing what I'll call "medication errors version 2.0" (since everything's 2.0 these days .. and 2.0 is ALWAYS better than 1.0) ..

  • Selection error. It'll be easy to click the wrong drug, dose, or dosage form from a list where they all look similar. Topamax is just a slip of the pointer away from Toprol.  It'll also be easy to click on the wrong patient.
  • Assumed dose. Often the doses listed do NOT reflect minimum or maximum doses…just the dose the pharmacy stocks…or the formulary allows. For example, metoprolol is available in 25, 50, and 100 mg strengths…many pharmacies stock only the 50 mg tabs.
  • Alert overload. E-prescribing systems alert you to allergies, interactions, and therapeutic duplication. But not all are significant. When the computer cries wolf too many times, alerts get ignored.
  • Failure to discontinue. Attempting to change a dose sometimes results in a patient getting BOTH the new dose and old dose.

I agree that all of the above is not only possible – but likely.  I've seen every one of the above errors occur with our EMR.  I'll beat the "usability" drum again and suggest that bad design ==> bad medicine. 

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Time spent in face-to-care patient care

Time Spent in Face-to-Face Patient Care and Work Outside the Examination Room — Gottschalk and Flocke 3 (6): 488 — Annals of Family Medicine

The Annals of Family Medicine is becoming one of my favorite journals.  I been very impressed with the quality of the papers published their and as soon as they get RSS feeds (I lobbied Kurt las month about this) we will be all set.

The article about time that physicians spend with their patients is interesting to me because it seems that most physicians spend rather little time with their patients even though the paper suggests that the results revealed that physicians actually spend more time with patients than was previously thought.

I'm certain that I spend much more than 50% of my day in the exam room .. and my day is certainly longer than 8.6 hours

Another very interesting article in this issue looks at the time that physicians spend outside of the examining room.

The average office day was 8 hours 8 minutes. On average, 20.1 patients were seen and physicians spent 17.5 minutes per patient in direct contact time. Office-based time outside of the examination room averaged 3 hours 8 minutes or 39% of the office practice day; 61% of that time was spent in activities related to medical care. Charting (32.9 minutes per day) and dictating (23.4 minutes per day) were the most common medical activities. Physicians overestimated the time they spent in direct patient care and medical activities. None of the participating practices had electronic medical records

It would be interesting to see how things looked for practice with electronic medical records. I think that Paul Chang did some work on this subject in the late 1980s.  Until we get to the sort of usability improvements that we really need, I expect the electronic medical records will improve efficiency only marginally.

Finally, our old friend Brian Alper (who has finally been able to get his life work, Dynamed – into the mainstream) has a very good paper that reviews the clinical utility of such a resource.  I understand that Brian has improved the usability of Dynamed quite a bit recently.  the information indicted that is quite good and Brian keeps it up to date almost single-handedly.  He's been doing this since he was a third year medical student and his resource is certainly competitive with other products that cost much more.  Ideally, a resource such as Dynamed would become integrated within the electronic health record. 

But that's "web 2.0" whining all over again. a promise.  No more today.

Bioethics weblog

My wife  who is wicked smart and recovering from shoulder surgery made a remarkable one-handed weblog entry over at  It's her first weblog entry ever – so now she can't tease me and say the weblogs are stupid.   She writes about a case in Massachusetts involving the child with brain injuries and a rather challenging medical, ethical and legal situation involving the disposition of life-sustaining interventions such as a ventilator and feeding tube.

When's the Bioethics Podcast ?

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