North Bristol Hits Appointment Problems: Another "Our Lousy IT Systems Screwed Up, But Patient Safety Was Never Compromised" Story

At my Dec. 2011 post "IT Malpractice? Yet Another "Glitch" Affecting Thousands of Patients. Of Course, As Always, Patient Care Was "Not Compromised" referencing prior posts, I wrote:

... At my Nov. 2011 post "Lifespan (Rhode Island): Yet another health IT glitch affecting thousands - that, of course, caused no patient harm that they know of - yet" I wrote:

There's been yet another health IT "glitch" that, of course, caused no patients to be harmed. See other "glitches" here, here, here and at other posts which can be found by searching this blog on the banal term 'glitch'.

Another "our clinical IT crapped out , BUT ... patient care/safety was never compromised" story just arose:

North Bristol hits appointment problems
E-Health Insider
11 January 2012
Rebecca Todd

Clinicians working at North Bristol NHS Trust have expressed concern about disruption to patient care, which they say is caused by appointment problems following the go-live of a new Cerner Millennium electronic patient record system.

I would have entitled the article "North Bristol hit by IT-created appointment problems."

Reported problems include patients being booked into non-existent clinic appointments or not being told about scheduled operations, resulting in some operations being cancelled.

No patient care compromise possible there. Who, after all, needs a timely operation? It frees up a lot of money for IT golf tournaments to let those of no value to society (i.e., the old, and those who will not admit computers in healthcare with deterministically revolutionize medicine because, well, they're magic) simply die due to delayed or cancelled surgery...

Ehealth Insider understands that some of the problems relate to the way the trust configured the EPR system; including setting up dummy clinics for which appointment letters were subsequently sent out.

It's never the software or computer's fault.

As a matter of fact, I have not seen any official response to the work of Dr. Jon Patrick at U. Sydney on the many software engineering flaws of another product of the same company. His work is entitled "A study of an Enterprise Health information System" and is at this link: http://sydney.edu.au/engineering/it/~hitru/index.php?option=com_content&task=view&id=91&Itemid=146. Do they have Class Action lawsuits in Australia?

In a regional BBC news report, aired on Monday evening, anonymous hospital clinicians called the implementation a “complete shambles” and said it represented a “potential danger” to patients.

According to the BBC report, the problems meant patients were being booked for impossible appointment times, such as 12.05 am, and quoted correspondence saying staff and the system were both on the “verge of meltdown."

The clinician comments are anonymous since non-anonymous reporting would get the clinicians declared health IT apostates, and then excommunicated. Non-anonymous 'whistleblowers' could also fear being sued due to possible gag clauses - the kind of clause hospital executives sign in violation of their fiduciary responsibilities to their staff and to patients. (See my 2009 JAMA letter to the editor "Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards"at this link and the much-expanded essay on the same themes "Health Care Information Technology Vendors' Hold Harmless and Keep Defects Secret Clauses" at this link.)

Martin Bell, director of IM&T at the trust, confirmed to EHI that North Bristol had experienced some “unexpected problems” in the past few weeks with some of the outpatient appointments and theatre lists.

Bell stressed, however, that patient safety had not been compromised and that this continued to be the top priority.

There's that line again. Perhaps it's part of some hospital administrator JournoList-recommended catchphrase for describing how safety was not compromised during a major workflow disruption?

He said the problems were not down to the software itself, but due to “implementation and data migration difficulties in some clinics."

Right. Quite credible.

“Our information management and technology team, supported by our suppliers BT and Cerner, have been working very hard to sort out any initial issues as quickly as possible and we are already seeing improvements,” he said.

Congratulations are due. They are seeing "improvements" in dangerous clinical IT malfunctions that should never have to have been seen in the first place, if the statement is true.

“Many wards, our two minor injuries units and the Emergency Department, are successfully using the new system." The trust is one of the largest in the South of England, with more than 1,000 beds.

Just give them time.

EHI understands that as part of the Millennium implementation, dummy clinics were set up. Patients were then sent appointment letters for these clinics in error.

EHI also understands that some patients had also not turned up for scheduled operations because they had not been informed about the booking.

Bell apologised to patients who had been “inconvenienced during this transition period” and said staff had shown real dedication to continue to deliver patient care.

What if someone had been inconvenienced into their grave, or ends up there as a result of delays? On what wavelength will the apology be transmitted?

“We firmly believe that the new system, once fully implemented, will improve services for our patients and provide real value,” he said.

That seems to be the mantra, but delivery on such promises are rare. See "Pessimism, Computer Failure, and Information Systems Development in the Public Sector" as here, Public Administration Review 67;5:917-929, Sept/Oct. 2007, Shaun Goldfinch, University of Otago, New Zealand. The article is a cautionary article on IT that should be read by every healthcare executive documenting the widespread nature of IT difficulties and failure, the lack of attention to the issues responsible, and recommending much more critical attitudes towards IT.

A £69m contract for BT to deliver Cerner Millennium to three new, or ‘greenfield’ sites in the South of England was agreed in April 2010, under the auspices of the National Programme for IT in the NHS.

That would not be the failed National Programme for IT in the NHS, the NPfIT what went PfffT, would it?

North Bristol was the last of these three sites to go-live with the system in December last year.

It followed Oxford University Hospitals NHS Trust, which went live a week earlier, and Royal United Hospital Bath NHS Trust, which was the first to go-live in July.

Cerner said it was working closely with North Bristol and BT on the recent implementation of Millennium.

“In complex and large deployments, especially when migrating from two different systems, it is always anticipated that it would take time for the new system to bed-in,” it said in a statement.

The patients are given full informed consent on this issue, right? Right?

“Across much of the trust, the deployment has worked well. However, this is a major change management project and there have been some difficulties with outpatient appointments.

“Although this is not a problem with the software, Cerner is working in partnership with BT and trust staff to resolve any issue as quickly as possible.”

Link: BBC News

Right. Perhaps this software and claim needs testing - in a court of law.

The only thing missing is the word "glitch", though I am including that term in this posting's index, since I consider it another story in the ever-growing health IT "glitch" series.

-- SS

Addendum:

A reader sent me this comment:

How can anyone claim the problems at N. Bristol are unexpected. they are EXACTLY the same problems encountered in Taunton five years ago.

The Somerset Trust had sixteen cancelled go live dates and when Cerner 'Millennium" (note: they never defined which Millennium...) was switched on the whole hospital went into slow-motion.

Appointments could not be made at out-patient reception desks while patients waited and therefore had to be posted on. Twenty-four whole time equivalent clerks had to be employed to manage the back-up of appointment requests. So much for enhanced efficiency and cost savings.

The only possible response to this news is again to remind people of Einstein's famous definition of insanity: "repeating the same thing again and again and expecting a different result."

As for other Trusts, why no news of transformed performance by Cerner's systems at other Cerner implemented sites, Berkshire, Newcastle, Kingston, Oxford etc. The only 'good' news we get is that the system has been switched on.

If any of this expensive activity had really produced data, efficiency or cost gains, we would be drowning in Cerner press releases, the silence can only mean one thing, that their system is performing as poorly at other sites as it has in the South West.

Contrast this with the output and data produced openly by Birmingham University Hospital from its in-house created IT system.

Unfortunately one can only draw one serious conclusion about the whole Cerner/ NHS debacle - to paraphrase Mr. Clinton - "It's the (imho substandard) software, stupid!

This story needs serious investigation ... Recently US news items have started to discount the supposed efficiency gains for e-Health implementations and started to emphasize data capture and patient safety as the imperative for switch on. Unfortunately for Cerner supporters (and other vendors) the US Institute of Medicine's recent report stated unequivocally that there was (to everyone's apparent surprise) no quality evidence that e-Health improved patient safety.

I would contend no drug, therapeutic equipment or operation would or could be implemented in secondary care in the absence of critical and peer reviewed evidence of benefit [emphasis mine - ed.] that has characterized the rush to switch-on substandard IT solutions in English NHS hospitals.

I note that critical, peer-reviewed evidence, especially based on prospective randomized clinical trials as opposed to anecdotal, weak retrospective observational studies, have been deemed unnecessary in health IT.

Yet serious case reports of risk and injury from credible sources are deemed the true "anecdotes" and discounted. As I've written before, the science of medicine is nearly entirely lacking in the domain of health IT.

To put it in the words of James Le Fanu (channeling Sherlock Holmes) in his very apropos essay entitled "The Case of the Missing Data: The Dog That Didn't Bark", details on contrary strands of evidence that could reasonably have been expected to appear in evidential text are absent.

-- SS

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IT Malpractice? Yet Another "Glitch" Affecting Thousands of Patients. Of Course, As Always, Patient Care Was "Not Compromised."

At my Nov. 2011 post "Lifespan (Rhode Island): Yet another health IT glitch affecting thousands - that, of course, caused no patient harm that they know of - yet" I wrote:

There's been yet another health IT "glitch" that, of course, caused no patients to be harmed. See other "glitches" here, here, here and at other posts which can be found by searching this blog on the banal term 'glitch'.

Add another case to the health IT glitch file, under the "do we feel lucky today?" patient risk category.
From the Pittsburgh Post-Gazette (I am quoted):

Computer outage at UPMC called 'rare' Systemwide disruption potentially dangerous, expert warns Saturday, December 24, 2011 By Jonathan D. Silver, Pittsburgh Post-Gazette

UPMC's electronic medical records system for inpatients went offline for more than 14 hours at nearly all its hospitals in the region, marking what the health system called a "rare" outage, but one that it claims did not harm patients.

First, as my aforementioned Nov. 2011 post and its contained links point out, these events are not as "rare" as they should be. (The asteroid colliding with Earth that caused the extinction of the dinosaurs - now that's a "rare" event.)

Second, as multiple posts on this blog have pointed out, the claims that "no patients were harmed" is both misleading and irrelevant:

Such claims of 'massive EHR outage benevolence' are misleading, in that medical errors due to electronic outages might not appear for days or weeks after the outage, depending on what information was corrupted/lost/misindentified/or otherwise mishandled after it is 'backloaded' once the system is up. All it takes is one med lost to cause misery and death. (I can speak about that from unfortunate personal experience.

Claims of 'massive EHR outage benevolence' are also irrelevant in that, even if there was no catastrophe directly coincident with the outage, their was greatly elevated risk. Sooner or later, such outages will maim and kill.

The outage affected a system designed by Cerner Corp., a global electronic records company, and customized by UPMC that doctors and nurses rely on for communication about patient records, medical orders and prescriptions.

It was unavailable from about 8:45 p.m. Thursday to 11 a.m. Friday at almost all of UPMC's hospitals except for Children's and UPMC Hamot in Erie, spokeswoman Wendy Zellner said.

"This is rare. This kind of widespread, extensive downtime would be rare," Ms. Zellner said.

Doctors and nurses continued to have access to patients' electronic records through backup systems, she said. They also had to resort to using old-fashioned paper records for documentation and orders.

"These things happen. They have really well spelled-out procedures for what to do when something goes down," Ms. Zellner said.

She acknowledged that doctors and nurses faced some challenges.

Faced 'some challenges?' In other words, care was compromised by the outage and the 'challenges' were to avoid medical error (and, of course, to make sure billing was unaffected):

Compromised -

a. To expose or make liable to danger, suspicion, or disrepute

b. To reduce in quality, value, or degree; weaken or lower.

Thousands of patients were affected, again reinforcing my point about how IT can and does greatly amplify the risks of paper -- as in my Rhode Island post -- such as errors and confidentiality breaches.

I cannot, for example, think of a single instance where thousands of paper records went unavailable simultaneously (unless, that is, someone lost the key to the Medical Records department), were made available to identity thieves en masse, or where thousands of medical orders were scrambled or truncated in a relatively short period of time as in Rhode Island.

These amplified risks could wipe out any advantages of EHR's over paper in a microsecond.

A partial list of facilities apparently affected in this latest episode of EHR mayhem, from this list:

• Magee-Womens Hospital of UPMC
• UPMC Bedford Memorial
• UPMC East
• UPMC Horizon
• UPMC McKeesport
• UPMC Mercy
• UPMC Montefiore
• UPMC Northwest
• UPMC Passavant
• UPMC Presbyterian
• UPMC Shadyside
• UPMC St. Margaret
• Western Psychiatric Institute and Clinic of UPMC

That accounts for several thousand active patients, I am sure.

(12/28 Addendum: Bed counts of PA hospitals are here. Searching on "University of Pittsburgh Medical Center", it can be seen that thousands of beds were indeed involved.)

"Whenever people aren't working in their native system and workflow I have to believe that is more cumbersome for the clinicians, but these folks are well-trained in what to do when these things happen."

This seems at best an insensitive and perhaps even inhumane bit of P.R. More "cumbersome" for the clinicians? What about the poor patients? How would Ms. Zellner feel, I wonder, if it were her mother, child or significant other on the Operating Room table or having an acute MI when the EHR/CPOE systems went down?

Ms. Zellner said UPMC's public relations staff was unaware of the outage until contacted by a reporter.

It appears P.R. is not very high on the list for receiving information when a crisis arises. I may have known of the outage before they did.

The outage was caused by a "bug" or glitch in software designed by a vendor affiliated with Cerner, Ms. Zellner said. She refused to identify the company.

"We're not trying to point fingers at different vendors. It's a database bug, that's all I can tell you."

(That is, it's not our fault, it's the fault of the database vendor. Hospitals, I regret to inform you - you are responsible for unapproved medical devices used in your facilities, no matter what the source.)

And there's that word "glitch" again, accompanied by the equally banal "bug."

It's just a "bug." Cute little critter!

Me again in the Post-Gazette:

Scot M. Silverstein, a doctor and assistant professor Healthcare Informatics at Drexel University in Philadelphia, disagreed with the use of the terms "bug" and "glitch."

"What occurred here was a disruptive, potentially dangerous major malfunction of a life-critical enterprise medical device," he said.

Somehow, when a clinician makes a mistake, the terms "bug" and "glitch" are never used. In fact, when clinicians fail to meet accepted professional standards of healthcare practice, it is called "malpractice."

I think we can all agree that a major near-full-day outage of an enterprise EHR affecting multiple hospitals and thousands of patients does not meet accepted professionals standard of life-critical computing practice. Yet, all this merits is the word "glitch." It seems to me that if patients are harmed by, in reality, what is (on its face) IT malpractice during such events, not only the clinicians affected should be held liable.

Ms. Zellner said the problem was not a "crash" of the system because there were alternate methods used to cope that prevented patient care from being compromised.

The usual refrain. Let me repeat my definition of "compromised:"

Compromised -

a. To expose or make liable to danger, suspicion, or disrepute

b. To reduce in quality, value, or degree; weaken or lower.

A simple question - if extended EHR outages like this never seem to "compromise" care, then why not eliminate health IT entirely and spend the hundreds of millions saved on patient care?

"This is not a crash of Cerner either," Ms. Zellner said. "I think a crash is, 'Oh my God, the sky is falling,' nobody can get anything."

I leave it to the readers to ascertain the computer expertise levels and reasonableness of what Ms. Zellner thinks a "crash" is.

Technicians from UPMC, Cerner and the third company [the 'mystery' database company? - ed.] worked together on-site to identify and fix the problem. Ms. Zellner said she did not know why it took 14 hours to fix and the underlying cause was still unclear.

"They know what the problem is and I believe it's been fixed, but we really don't know what triggered it," Ms. Zellner said. "I think the next step would be some actual software upgrades."

They "don't know what triggered the 'problem'" - is a proper translation that they have no idea what went wrong?

In fact, regarding another Cerner EHR system which was extensively studied (see "A Study of an Enterprise Information System" at this link), Dr. Jon Patrick came to the conclusion that one of the sources of catastrophic failures is poor software engineering that has made the behavior of the studied system "non-deterministic." Further, software upgrades are not protected from incremental changes made by maintenance and customization staff, and may introduce even more instability.

A software upgrade without clearly understanding "what triggered the problem" is simply asking for more trouble. (My bet, however, is that they attempt it anyway.)

A Cerner representative could not be reached for comment.

What's to say?

How about this:

Dr. Silverstein said based on what he was told about the computer outage, it means that hospital medical staff would have been unable to update patient charts and probably would not have been able to issue any orders through the system during the time it was off line.

He also questioned how up-to-date the hospital's redundant records were.

Repeating UMPC's statement from the article that appeared after I gave my quotes to the reporters: "Doctors and nurses continued to have access to patients' electronic records through backup systems, [the UPMC spokesperson] said. They also had to resort to using old-fashioned paper records for documentation and orders."

My stated fears of disruption and increased risk due to compromised care seem well-grounded.

In May, Allegheny General Hospital had to shut its electronic medical records computer system down because of problems with the vendor's hardware.

The hospital used backup procedures to continue care for patients, including using paper orders and record-keeping.

Wait ... I thought I'd heard these events were "rare." Two in the same city within six months?

---------------------------

Truth be told:

The primary rule in computing is:

Either you are in control of your information systems, or they are in control of you.

Clearly the latter was the case here.

The following questions arise:

• Was the software containing the "bug" properly vetted before being used on live patients? This is not just the vendor's obligation.
• If it was not vetted properly, why not?
• Was it an "upgrade" or patch? (If so, the same vetting rules apply.)

Further, the soft-selling of these incidents must end. The use of terms such as "bug" and "glitch" must also end. What occurred here, echoing my newspaper quote, was a disruptive, potentially catastrophic major malfunction of a life-critical enterprise medical device.

System-wide EHR crashes are not merely ‘glitches’ or ‘bugs.’ They need to be considered, as in medicine itself, as 'never events.' From AHRQ:

The term "Never Event" was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors (such as wrong-site surgery) that should never occur. Over time, the list has been expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable.

Further, re: "patient care was never compromised." How do they know that? In fact, this is 'spin' and word games on its face. By definition, if CPOE and chart updating was unavailable, patient care was compromised, where "compromised" means "increased levels of risk for error were created, requiring workarounds."

Further, as mentioned earlier, harms might not show up for some time. Lost orders, corrupted data, errors of omission or commission transcribing backup paper records into the computer ("backloading"), etc. can take their toll later. Post-outage vigilance is essential, putting even more stress on clinicians that increases likelihood of further error and that they certainly do not need. Clinicians are stressed enough already.

Finally:

IT personnel have not only deliberately inserted themselves into clinical affairs (e.g, via the HITECH Act of 2009), they have also done so with a stunning arrogance and unproven braggadocio about their systems "revolutionizing" medicine (whatever that means).

Indeed, they need to accept the medical responsibility and obligations this territorial intrusion entails.

On its face, this massive outage was the result of issues that did not meet accepted professional standards of IT practice for life-critical environments. Res ipsa loquitur.

Something was not vetted properly, there was a lack of redundancy, the IT personnel were NOT in control of their systems.

Just as when physicians don't provide care that meets accepted professional standards of healthcare, this incident and others like it are, by definition, a result of IT malpractice.

If patients are harmed, IT personnel and their management (often non-IT C-level officers) involved in this system need to be held accountable.

If they can't take the clinical heat (as clinicians do daily since the time they enter medical or nursing school), then they need to get out of the clinical kitchen.

-- SS

Note: see this take on these matters at the HIStalk blog:

UPMC’s Cerner systems go down for 14 hours at most campuses last Thursday and Friday, forcing them to go back to paper. The PR person blamed “a database bug,” which makes the above Oracle press release from this past summer a particularly fun read. Cerner and UPMC have an atypical vendor-customer relationship since they’ve invested big money together in innovation projects and UPMC runs a Cerner implementation business overseas.

Now we know who the unnamed "mystery database vendor" is...

-- SS

Dec. 29, 2011 Addendum:

Was UPMC acting as a "proving ground" for some Oracle-Cerner-UPMC experimental health IT technology that resulted in the crash? The claim of being an IT "proving ground" has been made in the past:

Pittsburgh Tribune
May 2, 2006UPMC partners with technology provider

The University of Pittsburgh Medical Center is taking another step in a quest to commercialize new medical technology.

UPMC on Monday signed a three-year deal with health care information technology provider Cerner Corp. to develop and market medicine-related technological advances. Both parties will contribute $10 million in cash, services and intellectual property to the effort.

The deal is a smaller version of an April 2005 deal between UPMC and information technology behemoth IBM.

As is the case in the IBM deal, UPMC will serve as a built-in proving ground for jointly developed technologies and products, with Cerner marketing the products and UPMC awarded a share of profits.

As I wrote at "Proving Ground for IT Tests On Children: Pioneers in Health IT, or Pioneers in Ignoring the Past?":

"A hospital and patients are not a learning lab for HIT vendors. The appropriate "proving ground" for new medical technology is the controlled clinical trial where participants (in this case, patients and healthcare professionals alike) have freedom of choice whether or not to participate, and a chance to give (or deny) consent after being fully informed of potential risk."This is a fundamental human rights issue.
-- SS

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Lifespan (Rhode Island): Yet another health IT "glitch" affecting thousands - that, of course, caused no patient harm that they know of - yet

There's been yet another health IT "glitch" that, of course, caused no patients to be harmed. See other "glitches" here, here, here and at other posts which can be found by searching this blog on the banal term 'glitch'.

I note that when a clinician makes a mistake, it's called "malpractice."

When health IT causes errors that can injure or kill, it's commonly referred with the banal, now-standard euphemism for computing malpractice:

Presenting the latest healthcare IT "glitch", affecting thousands:

Computer glitch led patients to receive wrong meds
Senator calls for review of Lifespan

WPRI.com (Providence, RI)
Updated: Thursday, 03 Nov 2011, 5:47 AM EDT
Published : Wednesday, 02 Nov 2011, 11:56 PM EDT
Reported by Steve Nielsen

PROVIDENCE, R.I. (WPRI) - Rhode Island State Senator Jamie Doyle says he is shocked to hear a Lifespan computer glitch caused thousands of patients to receive the wrong types of medication. [Appx. 2,000 across five Lifespan hospitals according to the Providence Journal, see below, and the WaPo - ed.]

Doyle is now calling for an independent review of all the hospitals Lifespan runs, and a review of the Rhode Island Department of Health.

The DOH is investigating after learning patients who were supposed to receive medications taken once a day instead received medications meant to be taken more than once per day.

Health IT, of course, is unregulated by FDA or anyone, and vetted for safety only so far as the seller wishes to spend money on such tasks - which cuts their margins.  Ultimately, debugging is on live patients.

[11/5/2011 note: As an anonymous commenter pointed out, the 2,000 or so errors at Lifespan should probably be multiplied by the number of organizations using the same software ---> "The entire country may have suffered 25,000-50,000 errors from this one glitch alone", the commenter astutely notes - ed.]

Of course, the customary "we did feel lucky today, and the gun was empty" disclaimer follows:

"Lifespan has not reported any adverse events or situations where patients required additional medications, but the information gathering and investigation is still ongoing," said DOH spokeswoman Annemarie Beardsworth.

In other words, there could have been adverse events, we just at the Dept. of Health don't know yet with certainty, because none have been reported yet.

In addition, some patients who were meant to get a medication with a coating did not receive a coating. The coating can help with stomach pains of other problems.

"I just don't feel comfortable right now with some of the things that are coming out of there," Doyle said, "I really don't want to point fingers in any direction. but what we need to do is we need answers." Senator Doyle wants to have the review started in the next two to three weeks.

Mr. Doyle, see my academic site on HIT failures here and an account of repercussions here from an EHR-related medication error.

Lifespan released the following statement Wednesday:

"Lifespan is actively contacting 2,000 patients affected by this issue to ensure they receive the correct form of their medications. So far, we have reached out to more than 90 percent of the patients, many of whom were already taking the correct medication."

Lifespan expects to finish contacting patients by Thursday.

It will be interesting to understand the nature of this particular "glitch" and who the software vendor is.

All it takes is a single "glitch" to seriously reduce a patient's lifespan.

Siemens software may be involved. See this mutually self promoting, marketing-style Siemens document "Newport Hospital - a Lifespan Partner - At the Forefront of EMR Adoption" (PDF), also cached here. (As an aside, one wonders if the hospital and/or its leadership received special financial or other "incentives" in allowing their name to be used in corporate promotions.)

Also, Siemens was a company that apparently did not listen to an internal informatics specialist physician's concerns that their health IT for critical care was endangering patients (link). They terminated the whistleblower.

Also see my Aug. 2009 post "Why Siemens Healthcare Fails" which I had emailed at the time to the Siemens Healthcare CEO Hermann Requardt.

-- SS

Nov. 4, 2011 addendum:

Felice Fryer of the Providence Journal sent me a link to the story of Nov. 3, 2011 she wrote with a few more details, here. Excerpts:

Flaw found in hospitals’ prescriptions

Some patients discharged from Lifespan hospitals got right drugs in wrong form due to software error

By FELICE J. FREYER JOURNAL MEDICAL WRITER

Some 2,000 patients of the Lifespan hospital group were discharged with incorrect prescriptions over the past 9 to 15 months because of a software glitch.

[It took a year or more to discover these mounting errors? This is beyond the "red flag" warning signs I used to write about. This is crossing the chasm into the territory of "asking for catastrophe" - ed.]

The prescriptions listed the right medications, but in the wrong form: people who were supposed to get time-release pills received prescriptions for short-acting ones.

The error affected dozens of generic medications for a variety of conditions. Lifespan discovered the problem on Oct. 25 and had fixed the software by Friday, according to Dr. Mary Reich Cooper, Lifespan’s senior vice president and chief quality officer.

The hospitals have placed calls to nearly all the affected patients, although not all have called back, Cooper said. Most patients reached had already obtained the correct medication because the error was noticed by someone at the hospital, or a pharmacist or doctor outside, she said. So far, Cooper said, there is no evidence that anyone was harmed.

But Dr. Michael D. Fine, state Health Department director, said that the incident is an example of how electronic medical records, which normally help reduce errors, can sometimes amplify them by quickly affecting large numbers of people. “It’s the flip side of what has otherwise been a process that has improved accuracy and reliability,” he said.

[I don't notice mention of a "flip side" to health IT in the aforementioned glossy hospital/IT company marketing brochure - ed.]

The Health Department is investigating the incident. Fine also plans to examine whether the department should regulate the safety of electronic systems in health care. [Readers of this blog know my opinion on that matter - ed.]

Asked whether he was worried there may be other as-yet-unrecognized software glitches, Fine said, “I’m reasonably concerned about the accuracy and integrity of electronic medical records.”... The software in question is not in use at other hospitals in Rhode Island, and the software vendor, Siemens, is notifying hospitals elsewhere in the country, according to Cooper.

[In the interests of public health, I believe it incumbent on Siemens to make this "glitch" widely known not just to the hospitals but to the public in areas served by those hospitals, especially with the admission that "the (RI) hospitals have placed calls to nearly all the affected patients, although not all have called back." To not do so reflects negligence in my opinion - ed.]

... The errors arose from the process known as “medication reconciliation,” in which the physician compares the medications a patient was taking before hospitalization with those prescribed during hospitalization, and ensures that the patient goes home with a correct set of prescriptions. The Lifespan hospitals recently adopted an electronic system for this process.

Doctors were correctly prescribing medication, and the prescriptions looked right on the computer screen, Cooper explained. But when printing out the prescription list, the software was cutting off a two-letter abbreviation that indicated certain medications should be in long-acting form or coated to protect the stomach.

[As at Case 9 from FDA's MAUDE database at the post "Our Policy Is To Always Have Unabashed Faith In The Computer". Do these vendors robustly validate their products? The current errors, in fact, were only peripherally related to medication reconciliation. They were primarily related to computer errors impairing (sabotaging?) the clinicians. It would seem med recon now needs to include comparing what the doctor enters to what is output to the nurses and other healthcare personnel who provide written instructions to patients. Is such a task performable by healthcare personnel when the computer cannot be trusted? Further, do the doctrine of the "learned intermediary" and "hold vendor harmless" clauses seem appropriate here? - ed.]

... Cooper said the risk of harm from taking a short-acting medication instead of a long-acting one was “very, very minimal.”

[Cooper misses the point, and IMHO such nihilistic attitudes have no place in healthcare - ed.]

But Fine, the health director, said such mistakes “can be scary.” People taking medication for angina or high blood pressure would find their medication wearing off over the course of the day, putting them at risk of heart attack or stroke, he said.

Medical errors that might seem innocuous or minor to health IT amateurs can prove catastrophic.  I've seen it happen, leading to injury and death.

-- SS

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Hospital system has major computer breakdown with "resultant chaos"; patients not adversely affected (of course)

As mentioned on this blog numerous times. Healthcare IT outages never, but never, adversely affect patients in any manner whatsoever:

Traverse City Record-Eagle [Michigan - ed.]
June 30, 2011

Munson has 4-hour communications failure
By Bill O'Brien
bobrien@record-eagle.com
TRAVERSE CITY — Munson Healthcare officials are trying to figure out how to avoid a repeat of a four-plus-hour data systems crash and "resultant chaos" that gripped local hospitals and clinics this week.
A system failure Tuesday morning shut down computers, telephones, pagers and other telecommunications systems at Munson Medical Center and its Munson Healthcare affiliates in Frankfort and Kalkaska, an incident that administrators described as "unacceptable." [That sounds about right - ed.]

Munson officials still aren't sure why a back-up fiber optic circuit failed during a planned outage that started Tuesday at 7:30 a.m.

"You can rest assured we're looking very carefully at that," Munson Medical Center CEO Kathleen McManus said. "Of course, we need to know what happened."
McManus said no patients were adversely affected during the outage. Even with the "resultant chaos" that gripped the local hospitals and clinics, no patients were adversely affected.

Amazing. There must be a cybernetic angel department in heaven that prevents patients from harm - i.e., from missed or delayed treatments or treatment mistakes - during the "resultant chaos" of major systems outages.

I'm sure insurers and risk managers have full confidence in Providence when these mishaps occur.

-- SS

July 1, 2011 update:

The Traverse City Record Eagle has published a memo explaining the outage:

Munson Healthcare officials distributed a memo on Wednesday that explained Tuesday’s systems failure that affected Munson Medical Center, Paul Oliver Memorial Hospital and Kalkaska Memorial Health Center and various clinics. The following memo is attributed to Chris Podges, Munson’s vice president of information systems.

“As you are all aware, we experienced an unplanned network downtime (Tuesday) that had widespread operational and clinical implications. Briefly, here is what happened:

Munson’s data centers’ connectivity to the outside world runs primarily on two redundant high speed fiber optic circuits administered by Traverse City Light and Power. We were informed by them that they needed to take one of the circuits off-line in order for them to do maintenance.

This would leave us operating on one circuit for the duration of their planned, 12-hour downtime. This shouldn’t have been any problem for us and is precisely why we have parallel, redundant technology on our most important systems and infrastructure. We have frequently tested for an event like this (losing one of the circuits) by manually “switching off” a fiber circuit.

In our testing, the remaining circuit took on all the traffic, just as it was architected to do; no hiccups, no instability, no impact on users, no downtime. And that is what we fully expected yesterday morning when one of the circuits was taken off line.

In medicine, or in any complex domain, one must expect the unexpected...

Unfortunately, that isn’t what happened. The core switch of the remaining circuit became confused, couldn’t take over the role as the primary switch (a transition which is measured in milliseconds) and ultimately shut down. Once down, everything running on the network – applications, paging systems, wireless devices, IP phones, etc., went down with it.

(I hear Kate Winslet humming in the background...)

Anthropomorphism aside, it seems to me that switches and other inanimate objects don't become "confused." The engineers/programmers who designed them just didn't anticipate the event that sinks the Titanic.

But let's roll the technology out nationally, now, rush...rush...rush...before it's too late. Computer bits get stale after awhile, after all....

Re: "Unplanned network downtimes." In the long running TV series Stargate SG-1 there's a character, Walter Harriman, who runs the command console. Just about the only line he gets to say over the base PA system over 10 seasons is ...

"UNSCHEDULED OFF-WORLD ACTIVATION!"

... when some person or alien attempts to come through from another Stargate somewhere in our galaxy or others nearby.

Perhaps hospitals can use him as a role model to announce "unscheduled down time"...

... During the downtime, we assembled a small army working on three objectives:

1. Make sure the hospitals and clinics could operate - especially as to the provision of patient care – on downtime procedures

2. Communicate as comprehensively and as often as we could

3. Fix the technical issues

Aside from the fact that these "objectives" are obvious, now hospitals need "small armies" to protect patients when a network switch gets "confused." Pen and paper offer no analogous bellicose hostilities.

While the reports are that all hospitals and clinics did a fantastic job surviving the down-time, we fully understand that it was very difficult to manage the resultant chaos and that downtimes like this are unacceptable.

But no patient was hurt (as they never are when the IT goes down).

Thursday morning at 2 a.m. we are going to re-introduce the second fiber optic circuit into our network architecture. While we expect no issues, we’re planning otherwise. This afternoon your organizations will receive specific instructions on how to prepare for the event of another network outage; What to print in advance of 2 a.m., what resources are available to you during the downtime, how to get needed clinical information without the use of computers, who to call for help, etc.

Thank god.

Again, we do not expect any downtime tomorrow morning, but we did re-learn some valuable lessons yesterday and the safety of our patients is the number one objective should the network experience another issue. We’ll be ready at 2 a.m. and we want your organizations to be ready, too.

Why do such "lessons" need to be "re-learned" - EVER?

We are working diligently to understand what happened yesterday and will share with you what we learn and our plans to remedy whatever may need attention.

In effect, they really don't understand what caused the outage.

This is similar to other cases of outages written about at Healthcare Renewal. There's never certainty, because these IT systems have become so complex and the support relatively diffused (via outsourcing, consultants, etc.)

This is a fertile ground for patient injury and death when luck runs out. As stories like "Failures in care alleged after premature birth - $1,000,000 Settlement" from the Virginia Lawyer's Weekly I referenced here imply, the cost of ownership of HIT will likely go way up once the multimillion dollar lawsuits start adding up.

Considering the track record of health IT as it is in 2011 regarding reliability, risk/benefit and security, spending hundreds of billions of dollars to put patients at risk of life and limb, and risk of potentially career-ending or bankrupting loss of privacy, en masse nationally, is increasingly brainsick.

-- SS

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Twelve Hour Health IT "Glitch" at Allegheny General Hospital - But Patients Unaffected, Of Course...

At "Transplant Team at Univ. of Pittsburgh Medical Center Missed Hepatitis Result" I wrote about a kidney transplant gone bad at UPMC that may have been due to a computer "glitch."

Now Allegheny General Hospital in Pittsburgh has suffered a "glitch" that shut down their entire health IT system for approximately 12 hours:

Allegheny General Hospital's records system back online

By Pittsburgh Tribune-Review
Wednesday, May 25, 2011
Last updated: 10:26 pm

Allegheny General Hospital's electronic medical records system was online Wednesday afternoon after a morning shutdown caused by a glitch in a vendor's computer software, a spokesman [Dan Laurent] said.

... The hospital's system underwent a routine upgrade during the weekend, Laurent said. Staff shut down the system about 5 a.m. Wednesday after noticing it was running too slow. New Jersey-based software vendor Allscripts made repairs, and the system was online by 5 p.m., he said.

One might think the vendors of mission critical hospital systems would check their upgrades better before roll out to hospitals teeming with real, live, sick patients.

Of course, patient care was unaffected. It never is when a "glitch" occurs, despite the massive inconvenience to doctors who actually have patients to care for, and the need for backloading paper data - with inherent opportunity for error - after the computer system is resuscitated.

At a Jan. 2011 post "Orderless in Seattle: Software glitch shuts down Swedish Medical Center's medical-records system" I observed:

There's that word "glitch" again that I see so frequently in the health IT sector when a system suffers a major crash that could harm patients. Why do we not call it a "glitch" when a doctor amputates the wrong body part, or kills someone? ... the shutdown likely affected about 600 providers, 2,500 staffers and perhaps up to 2,000 patients, but no safety problems were reported.

As I've noted at this blog before, it is peculiar how such "glitches" never seem to produce safety problems, or even acknowledgments of increased risk.

Same in this Allegheny General Hospital case:

... [spokesman] Dan Laurent said staffers took drug and lab orders on paper forms, and that patient care was not affected by the shutdown.

If patient care is never affected by shutdowns even as long as an entire working day, one wonders why the tens or hundreds of millions of dollars spent on these systems is needed in the first place...

I have a solution.

Cloud computing!

-- SS

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Orderless in Seattle: Software "glitch" shuts down Swedish Medical Center's medical-records system

A commenter yesterday commented that after 25 years in practice, they had one lost [paper] chart (as opposed to an IT systems crash, where every chart is lost temporarily).

As coincidence would have it, there's this story in the news:

Software glitch shuts down Swedish medical-records system
Tuesday, January 25, 2011
By Carol M. Ostrom
Seattle Times health reporter

Related

A four-hour shutdown of Swedish Medical Center's centralized electronic medical-records system Monday morning was caused by a glitch in another company's software, said Swedish chief information officer Janice Newell.

There's that word "glitch" again that I see so frequently in the health IT sector when a system suffers a major crash that could harm patients. Why do we not call it a "glitch" when a doctor amputates the wrong body part, or kills someone?

The system, made by Epic Systems, a Wisconsin-based electronic medical-records vendor, turned itself off because it noticed an error in the add-on software, Newell said, and Swedish was forced to go to its highest level of backup operation.

Turned itself off? Back we go to the old Unix adage that "either you're in control of your information system, or it's in control of you."
To prove that point, note that "the highest level of backup operation" had a bit of a problem:

That allowed medical providers to see patient records but not to add or change information, such as medication orders.

I'm sure sick and unstable patients such as in the ICU's, as well as their physicians and nurses, appreciated this minor "glitch." Look, Ma, no orders!
(Do events like this ever happen in the middle of a Joint Commission inspection?)
The "glitch" didn't just affect a few charts:

The outage affected all of Swedish's campuses, including First Hill, Cherry Hill, Ballard and its Issaquah emergency facility, as well as Swedish's clinics and affiliated groups such as the Polyclinic.

I cannot imagine a paper-based "glitch" that could affect so many, so suddenly, other than a wide-scale catastrophe.

During the outage, new information was put on paper records [that 5,000 year old, obsolete papyrus-based technology that's simply ruining healthcare, according to the IT pundits - ed.] and transferred into patient records in the Epic system after the system went back up in the afternoon. [By whom? Busy doctors? - ed.] Epic, Newell said, is "really good at fail-safe activity," and if it detects something awry that could corrupt data, it shuts itself off, which it did Monday at about 10 a.m.

Which means that interfaced systems need to undergo the highest levels of scrutiny in real world use, if they can in effect shut down an entire enterprise clinical system.
I note the identity of the "other company's software" that brought the whole system to a grinding halt was not identified, nor was the nature of the "other vendor's" software "glitch" itself. Was the problem truly caused by "another vendor" via a bug in their product, via a faulty upgrade, or an internal staff error related to the "other vendor's" software?
It seems we now have yet another defense for HIT "glitches" other than "blame the users": it's not OUR fault; blame the other vendors.

Newell said the shutdown likely affected about 600 providers, 2,500 staffers and perhaps up to 2,000 patients, but no safety problems were reported.

As I've noted at this blog before, it is peculiar how such "glitches" never seem to produce safety problems, or even acknowledgments of increased risk.

Staff members were notified of the shutdown via error messages, e-mails, intranet, a hospital overhead paging system and personal pagers.

"Warning! Warning! EHR and CPOE down! Grab your pencils!" Just what busy doctors and nurses want to hear when they arrive for a harrowing day of patient care.
I wonder if the alert was expressed in a manner not understandable to patients, i.e., "Code 1100011" (99 in binary!) or something similar as in a medical emergency.

Newell said she was "99.9 percent sure" other hospitals have had similar shutdowns [that's certainly reassuring about health IT - ed.], because software, hardware and even power systems are not perfect. [That's why we have resilience engineering, redundancy, etc. - ed.]
"Anybody who hasn't had this happen has not been up on an electronic medical record very long," Newell said. "I would bet a year's pay on that."

A logical fallacy to justify some action or situation can take the form of an appeal to common practice. Is what I am seeing here what might be called an appeal to common malpractice?
Or is the fallacy simply a manifestation of the adage "misery loves company?"

Newell said this is not the first shutdown of Epic, which was fully installed in Swedish facilities in 2009 after a nearly two-year process. But it was the longest-running one, she acknowledged.

Gevalt.

Swedish is exploring creating "more sophisticated levels of backup" with other hospitals, Newell said, locating a giant server in a different geographic area to protect against various disasters such as earthquakes or floods.

Maybe they should have done that after the aforementioned other "glitches."

I repeat the adage:

"Either you're in control of your information system, or it's in control of you."

Indeed, if the information system is mission-critical, and you cannot control it, you literally have no business disrupting clinicians en masse and putting patients at risk by letting it control you.

Finally, on the topic of 'cybernetic extremophiles', I note that we have several Mars Rovers and very distant space probes such as Voyager 1 whose onboard computers (in the case of Voyager, built long ago with much less advanced technology than today's IT) have been working flawlessly in environments far more hostile than a hospital data center, and long beyond their stated life expectancies.

The Voyager 1 spacecraft is a 722-kilogram (1,592 lb) robotic space probe launched by NASA on September 5, 1977 to study the outer Solar System and eventually interstellar space. Operating for 33 years, 4 months, and 22 days, the spacecraft receives routine commands and transmits data back to the Deep Space Network. Currently in extended mission, the spacecraft is tasked with locating and studying the boundaries of the Solar System, including the Kuiper belt, the heliosphere and interstellar space. The primary mission ended November 20, 1980, after encountering the Jovian system in 1979 and the Saturnian system in 1980.^[2] It was the first probe to provide detailed images of the two largest planets and their moons.

As of January 23, 2011, Voyager 1 was about 115.963 AU (17.242 billion km, or 10.8 billion miles) or about 0.00183 of a light-year from the Sun. Radio signals traveling at the speed of light between Voyager 1 and Earth take more than 16 hours to cross the distance between the two.

While these are exceptional case examples of resilience in IT systems far less complex than hospital IT, I believe healthcare can do better in terms of computer "glitches" affecting mission critical systems that are a bit closer than 10 billion miles away.

-- SS

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