The incident that perhaps most fully impressed the potential dangers of electronic health records (EHRs) on hospitalist pioneer Robert Wachter, MD, MHM, came two years ago. It started, innocently and well-intentioned enough, years earlier with the installation of EHR systems at the University of California at San Francisco (UCSF). Flash-forward to 2013 and a 16-year-old boy’s admission to UCSF’s Benioff Children’s Hospital for a routine colonoscopy related to his NEMO deficiency syndrome, a rare genetic disease that affects the bowels. For his nightly medications that evening, the boy was supposed to take a single dose of Septra, a common antibiotic that hospitalists and internists across the nation routinely prescribe for urinary and skin infections.
But this boy took 38.5 doses, one pill at a time.
How could that possibly happen? Hospitalists might rightly ask.
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Because the EHR told everyone involved that’s what the dose should be. So every physician, pharmacist, and nurse involved in the boy’s treatment carried out the order to a T, discovering the error only when the teenager later complained of anxiety, mild confusion, and tingling so acute he felt “numb all over.”
In an era when EHR is king, an adverse event such as a 39-fold overdose is just another example of the unintended consequences technology has foisted upon hospitalists and other providers in America’s massive healthcare system. It is the unfortunate underbelly of healthcare’s rapid-fire introduction to EHR, thanks to a flood of federal funding over the past 10 years, Dr. Wachter says.
Dr. Wachter
“Most fields that go digital do so over the course of 10 or 20 years in a very organic way, with the early adopters, the rank and file, and then the laggards,” Dr. Wachter said at SHM’s 2015 annual meeting in Washington, D.C., where he recounted the UCSF overdose in a keynote address. “In that kind of organic adoption curve, you see problems arise, and people begin to deal with them and understand them and mitigate them. What the federal intervention did was essentially turbocharge the digitization of healthcare.”
And with the relative speed of digitization comes unintended consequences, including:
- Unfriendly user interfaces that stymie and frustrate physicians accustomed to comparatively intuitive smartphones and tablets;
- Limited applicability of EHRs to quality improvement (QI) projects, as the systems are, in essence, first constructed as billing and coding constructs;
- Alert fatigue tied to EHRs and such medical devices as ventilators, blood pressure monitors, and electrocardiograms desensitize physicians to true concerns; and
- The “cut-and-paste” phenomenon of transferring daily notes or other orders that’s only growing as EHRs become more ubiquitous (see “CTRL-C + CTRL-V = DANGER”).
“Health IT [HIT] is not the panacea that many have touted it as, and it’s really a question of a reassessment of where exactly we are right now compared with where we thought we would be,” says Kendall Rogers, MD, CPE, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque and chair of SHM’s Information Technology Committee. “I think our endpoint—that we’re going to get to—this is all going to result in better care. But we’re in that middle period of extreme danger right now where we could actually be doing harm to our patients but certainly are frustrating our providers.”
Funding Failure?
HIT’s rapid evolution starts with the creation of the Office of the National Coordinator for Health Information Technology (ONC) in 2004, which began receiving funding in 2009 to the tune of $30 billion to improve health information exchanges between physicians and institutions.