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May 17, 2011 News 10 Comments

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5-17-2011 8-25-15 PM

image HHS’s Office of Inspector General spanks its fellow agency ONC for pushing interoperability without mandating security controls or encouraging standards. Examples of what it wants to see: requiring portable media to be encrypted, requiring two-factor authentication for remote access to PHI-containing systems, and mandating timely OS patch application and antivirus updates. OIG based this work on a previous project that looked at providers, in which it found unsecured wireless networks, lack of application vendor support for OS-level changes, poor antivirus practices, lack of event logging, allowing shared user accounts, and giving too many users administrative rights over their PCs.

ONC’s response to this report: (a) we turfed security work off to HITSP and incorporated some of its specs as HHS policy and in EHR certification requirements; (b) Stage 1 of Meaningful Use requires providers to fix their own security problems; (c) our job is to convince providers to use EHRs and we will worry about security later in the process; (d) our chief privacy officer is drafting a plan. It sounds to me like the typical external auditor’s report: their job is to find stuff to make sure you keep hiring them, while yours as the IT shop is to balance their sometimes ivory tower observations with your own realities. My only takeaway is that ONC should spend some of its billions to push security awareness, which you would think highly paid hospital and vendor IT people wouldn’t need, but apparently they do.


Reader Comments

image From Mia: “Re: CompuGroup. Big layoffs at Noteworthy Medical (last week, I think) and other of their companies. Will be interesting to see how many of the 420 ONC-ATCB certified EHR companies are around five years from now.” Unverified.

5-17-2011 8-35-00 PM

image From CPOE Zealot: “Re: medication error. Incidents such as these give CPOE a bad rap.” The parents of a five-week-old premature baby who died after being given 60 times the ordered dose of IV sodium chloride sue Advocate Lutheran General Hospital (IL) for wrongful death. Like most fatal medication errors, CPOE was a non-factor here: — most in-hospital medication error deaths are caused by incorrect IV preparation or administration. In addition, the doctor ordered stat labs and then a re-test after getting a high sodium level back, but nobody drew it, leaving the baby on the hyper-concentrated fluid for 20 hours. There is one good reason CPOE gets a bad rap in cases like these, though: vendors sell and hospitals buy the seemingly logical argument that CPOE prevents patient harm, when what it mostly does is prevent lots of errors that were being caught anyway (like poor handwriting, in which somebody just calls the doctor for clarification). The risk of harm doesn’t change much unless you work at the sharp end of the stick where EHRs fear to tread – medication preparation and administration. The best IT systems in existence (including bedside bar-code checking) couldn’t have saved this baby’s life when hospital employees, despite experience and best intentions, are just as prone to distraction and carelessness as the rest of us humans, especially when they are overwhelmed and tired (sometimes because their peers were laid off to help pay for CPOE systems).

image From Wireless Observer: “Re: Cerner. Word on the street is that Cerner is getting ready to announce some big organizational changes and these are not good kind of changes for the employees (may be good for Wall Street, however). This is supposed to hit the CareAware division pretty hard.” Unverified. CareAware is Cerner’s solution for connecting medical devices to EMRs (video above).


Acquisitions, Funding, Business, and Stock

FairWarning will hire 70 employees over the next 24 months.

5-17-2011 1-22-46 PM

Salt Lake City-based MediConnect Global announces plans to hire 100 employees across multiple departments.

5-17-2011 1-28-26 PM

Cerner names SenSage its “Accelerate Partner of the Year” for demonstrating speed to value for Cerner and its customers. SenSage also an expanded alliance with Cerner to offer a SaaS-based version of P2Sentinel, Cerner’s enterprise clinical system auditing program.

5-17-2011 1-35-08 PM

CareCloud partners with Xpress Technologies to launch a combined EMR/PM solution for urgent care facilities and hospital ERs.


Sales

Sharkey Issaquena Community Hospital (MS) selects Custom Software Systems ChartSmart EMR.

5-17-2011 3-32-09 PM

Onslow Memorial Hospital (FL) contracts with Language Access Network  to provide hospital video language interpretation services.


People

5-17-2011 6-38-04 AM  5-17-2011 6-39-43 AM

Awarepoint names Ralph Keiser (MedeAnalytics) EVP of sales and Jaime Ojeda (PCTS) EVP of marketing and business development.


Government and Politics

CMS announces plans to release applications for “mature ACOs” interested in participating in its new Pioneer ACO Model and taking part in shared savings. CMS is also seeking input on the idea of an Advance Payment ACO Model, which would give certain ACOs access to their shared savings up front so they could build the required infrastructure. For providers wanting to learn more about ACOs, CMS is offering four free Accelerated Development Learning Sessions beginning in June.


Innovation and Research

image Of the 75 operational RHIOs in the US, only 13 meet the basic criteria for Meaningful Use (e-prescribing, clinical data exchange, quality reporting) according to Harvard researchers. I don’t have access to the study, but apparently the findings are based on data from 2009 (so old they use the term RHIOs, apparently). Surely there’s been some improvement since 2009. If you’ve seen the full report, please share your insights.

JAMA reports that the use of telemedicine in ICUs reduces mortality rates and length of stay.

5-17-2011 8-30-14 PM

image The New Zealand government awards a $252K grant to Vensa Health to conduct further research related to its mobile health reminder system. The company recites an impressive list of technology features, but like just about every mobile health vendor, they have no evidence showing that their product is effective in improving health. Like Bill Gates told me at lunch once (well, OK, me and a huge ballroom full of people at the mHealth Summit), reminders and education don’t necessarily work when it comes to wellness – plenty of fat people own bathroom scales.


Other

image I got another “urgent news” e-mail blast today from one of the rags that reinforces my argument that most industry publications either (a) can’t distinguish real news from press releases, or (b) don’t care as long as it draws readers and advertisers. Today’s hot news: a bond rating agency issued a press release claiming their study correlated use of advanced IT to hospital profitability and quality. I downloaded the “special report” from Fitch Ratings and it was, as I expected, not worth the excitement, being even less methodical (and therefore even less useful) than the Most Wired survey. Here’s a summary.

  • The bond ratings company looked at only the 291 hospitals that use its services. That’s out of maybe 6,000 US hospitals – a tiny, non-randomized, non-representative sample that excludes for-profit and government facilities.
  • They checked Leapfrog, Baldrige, and Healthgrades and found that 75 of their clients had won a quality award (all awards are created equal in drawing room studies like this that just match Readily Available Data Set A with Readily Available Data Set B).
  • They checked with HIMSS Analytics and found that 24 were at EMRAM Stages 6/7 (ignoring all other forms of IT except inpatient clinical).
  • Apparently disappointed to find that only 12 of the 24 EMRAM 6/7 hospitals had won quality awards, they invented an excuse related to “the evolution and maturation of how quality is measured.” (maybe that should have been the headline – that half the hospitals who reached IT Nirvana haven’t won even one major quality award as a result).
  • They found that richer hospitals won more quality awards and had more IT (neither of which necessarily has anything to do with patient outcomes).
  • They looked at utilization trends and concluded that higher IT hospitals (meaning richer ones) are improving, although they did not look at their absolute performance (meaning a hospital could still be terrible as long as it’s less terrible than before).
  • The bottom line: even if the bond ratings firm had conclusively proved any kind of relevant correlation (which they most definitely did not), that still wouldn’t have proved causation. The implicit message in running this yawner of a study as real news is that everybody now has the justification to buy more IT, which is an absurd conclusion for an industry that somewhere down deep is supposedly based on science.

image Speaking of questionable studies, here’s another one: do seven percent of doctors really use video chat in patient care? I’m not interested enough to buy the company’s report to evaluate its methodology, but I would have to bet that they surveyed a disproportionate number of telemedicine physicians or tele-ICU intensivists. Most docs won’t even e-mail patients, much less fire up a Skype session for a leisurely and probably unreimbursed Webcam chat.

Quality IT Partners, Inc. announces its Facebook launch featuring a dedication to the Scott Hamilton Cares Initiative, including a song and video written and produced by the company.


Sponsor Updates

  • Sonoma Valley Hospital (CA) picks ProVation Order Sets.
  • BridgeHead Software will exhibit at the 2011 International MUSE Conference May 31-June 3 in Nashville.
  • Emdeon introduces Emdeon Audit Advantage, which will provide real-time prescriber eligibility and patient coverage alerts to pharmacies. The company also wins a five-year GSA contract that allows it to offer products to  over 90 government entities.
  • Healthwise Patient Education EMR module earns ONC-ATCB certification.
  • Imprivata announces GA of OneSign Anywhere for authentication and single sign-on for remote and mobile users.
  • Delta Health Alliance, one of the country’s 17 Beacon Health communities, collaborates with Medicity to connect participating physicians and hospitals.
  • Daughters of Charity Health System (CA) expands its partnership with Passport Health Communications and adds three additional RCM solutions from Passport’s eCare Patient Access Suite.
  • McKesson medical director David K. Nace, MD is named first vice chairman of the board of directors of the Patient-Centered Primary Care Collaborative.
  • Practice Fusion says it has grown from a team of four in 2007 to 75 today. The company is expects to reach 150 employees by the end of the year and is seeking new office space.
  • MyHealthDirect assumes a silver-level sponsorship for the 19th Annual Medicaid Managed Care Congress this week in Baltimore. CEO Jay Mason will also participate in a panel discussion on ACOs and patient-centered medical homes.
  • API Healthcare publishes a whitepaper entitled Achieving Quality of Care and Controlling Costs, which includes best practices for workforce automation.
  • Concerro creates a Mac versus PC parody that compares healthcare scheduling solutions with paper-based systems.
  • The City of Philadelphia selects eClinicalWorks to provide an EHR/PM solution for the Department of Public Health, which includes 230 providers and 20 primary care and correctional clinics.
  • JEMS Technology announces a rental program that allows hospitals to provide smart phone video consultation capabilities (JEMS Consults) to their physicians starting at under $1,000 per month.

Contacts

Mr. H, Inga, Dr. Jayne, Dr. Gregg.

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Currently there are "10 comments" on this Article:

  1. Re: medication error. Incidents such as these give CPOE a bad rap”

    This incident reminds me of similar cases brought out by JAMA on March 2009 article reporting that CPOEs facilitate 22 specific types of medication errors, and that many of these types of errors occur frequently in the hospital setting. Sources of stress and actual prescribing errors were found and surprisingly most of the errors were identified as Human-machine interface flaws along with other Information errors.Information errors resulted from “fragmentation” of data and information, which can occur when a hospital fails to integrate information from its multiple systems with the CPOE bringing hell lot of confusion to the Ordering physicians. Failures in human-machine interface occur when a computerized process’ workflow doesn’t correspond to how medical staff works.

    No doubt CPOE deployments can offer “extraordinary advantages” in reducing many mistakes, but hospitals that deploy those systems “need vigilance and self-examination, otherwise it will have to bear negative repercussions. After all we should not forget that its a technology a “TOOL” that is be used to “SUBSTANTIATE” Ordering Processes not ” SUBSTITUTE them.

  2. RE: “CPOE was a non-factor here…”

    Wrong! If you read the article again (thanks for the read, BTW!), it clearly states that:

    “It was determined that a data entry error was made in the formulation of the IV solution.”

    So CPOE brought forth 2 errors:

    1) It was at least partly at fault by making an atmosphere where a wrong dosage was entered into the system,
    2) It’s main touted advantage, that it prevents errors, failed. It failed to catch the dataentry error.

    Clear case to me that CPOE was very much a cause of the error.

    Al

    [From Mr. H] I would bet that the data entry error was made in the pharmacy, most likely as a pharmacist or tech re-entered the physician’s CPOE order into either the pharmacy system or an IV compounder. Those systems are not often fully interfaced to CPOE, so the possibility of transcription and order entry error just moves downstream from CPOE to the next system in the food chain into which paper orders (CPOE printouts) are manually entered.

    [From Mr H again] My suspicions were correct. According to the Institute for Safe Medication Practices, the error occurred when the pharmacy technician was re-entering the CPOE order into the pharmacy’s IV compounder. The order was for parenteral nutrition that was CPOE-ordered to contain 982 mg of calcium and 14.7 mEq of sodium chloride and the tech manually entered the amounts backwards. The pharmacist didn’t catch the error. I’ve seen that exact same error in a hospital I worked at — the unfortunate outcome was identical. The solution at our place – create a little program that creates the compounder’s pump file record directly from the pharmacy system.

    The ISMP link:

    http://www.ismp.org/newsletters/acutecare/articles/20110421.asp

  3. The Advocate CPOE devices were not innocent bystanders. Was the system was having mini crashes in the months leading up to the system wide crash reported in the linked report, below. TPN is tediously difficult to order by CPOE devices. Such an error and delay in lab tests is par for the course. Hey, were the computers down in the hours leading up to the death casuing error?
    http://archive.chicagobreakingnews.com/2010/11/computer-crash-crash-affects-chicago-area-hospitals.html

    And I thought that CPOE and EHRs were to eliminate such deaths.

  4. I luv your thoughtful comments Mr. HIStalk and incorporate many of your ideas.

    However, one must consider the poor usability, inferior layouts, and small fonted screens laden with legible jabberwock (for billing) that enabled this error.by obfuscating the key information which visually distracted the pharmacy staff.

    The pharmacist made a cardinal error when using CPOE systems…that is, the pharmacist had blind faith in the devices he was using to be accurate.

    I, for one, can not trust the care administered when run by CPOE and other HIT instruments.

    This gets back to the issue of who is actually performing after market surveillance, recording the defects and associated deaths from these devices.

    My understanding is tha there ain’t any after market surveillance.

    [From Mr H] As I explained, this error had nothing to do with CPOE. The IV compounder is in fact FDA regulated, and assuming Lutheran uses Baxa’s (not specified, but theirs is the most common). Obviously FDA oversight is not a magic bullet when users make mistakes. In addition, one might question whether unlicensed pharmacy technicians should be transcribing orders into a medical device. Not to mention that perhaps Lutheran should have pursued (or pressured its pharmacy system vendor to deliver) an interface between its pharmacy system and the compounder since that’s a slam dunk compared to CPOE implementation. And, whether it had set up the compounder to check doses and concentrations, which at least in Baxa’s case, is readily availability functionality. Of all the things gone wrong at Lutheran in this case, CPOE wasn’t one of them.

  5. You see how many people are quick to blame CPOE? The pharmacist has a license for a reason. That is why all RX tech work is checked by the Pharmacist. This is a very sad situation and on top of that the basic Pharmacy process broke down. Mr. H is correct – CPOE did not cause this error. Next time the integration vs interfacing argument comes up during vendor negotiation, remember this story. The integration/interfacing functionality is one of the most important pieces. Thanks Mr. H for bringing us the facts.

  6. CPOE’s like a garden.

    It turns people into vegetables.

    I have to endure my own mother’s nightly agitated deliriums of late thanks to the miracles of CPOE.

    — SS

  7. It’s disturbing that the TPN compounding software allowed the entry of a potentially (and in this case actual) lethal amount of sodium into the compounder, implying that the hospital did not build concentration limits or alerts into the system. It’s even more disturbing that this was either not checked by a pharmacist or that the pharmacist would let such an obvious error get by. We manually transcribe TPN orders into a compounder program at our hospital, but the transcription is done by a pharmacist – not a technician – and the program has built-in concentration limits. The final product is checked by a different pharmacist.

  8. Re;HHS’s Office of Inspector General spanks its fellow agency ONC for pushing interoperability without mandating security controls or encouraging standards…

    Stage 2 criteria didn’t have much change in it for Priv & Security…but this could really change that. They were talking about doing Stage 2a, then 2b…guess we’ll see 2c…and …if we’re lucky Stage LEFT!

  9. I agree that it sounds like in this one case, CPOE itself was not at fault. The main cause was human error. The FDA-regulated TPN system is also a major player in the equation — perhaps an actual system fault, or the fault of the humans who built it at the hospital and did not build in dose range checking capabilities (assuming the TPN system has such capabilities — which it better!!)

    Yet to be explained is also the lack of executing the physician’s order regarding the elevated levels. That could be the fault of CPOE, Lab system, humans, or a combination.

    Wherever the fault lies, it is a very sad and tragic incident, and all of us working in Healthcare and HIT should always do what we can to eliminate, as much as possible, the opportunity for things like this to occur. And we should also avoid creating new ways for such incidents to occur.

    [[From Mr. H] Good comment. As far as the repeat blood test goes, I wonder if lack of CPOE wasn’t the problem. It almost sounded like the doctor did a verbal order or some kind of comment instead of just entering the order directly into CPOE, where there is little chance that it would have been ignored.

  10. The problems, sources of ADEs are multifactorial and multidisciplinary we all know that. Its about getting beyond Blame, punishment, and getting into strategies to avoid probable ADEs and find out means to stop it.
    I came across this interesting analogy in “the Swiss cheese model” , proposed by patient safety expert James Reason, who suggests that a system is analogous to a stack of Swiss cheese slices; each slice represents a part of the system that defends against errors. A hole in one slice of cheese, or system, may allow an error to get through a single layer, but in the subsequent layers, if the holes are not aligned correctly, the error may be stopped. For an adverse event to occur, the holes need to align perfectly for the error to get through the many layers of the system.
    http://www.springerlink.com/content/b18186462032n186/fulltext.pdf

    What I beleive is that there is a need of collaboration among different disciplines to implement safe practices and simply follow the principle of Non-Malfeasance , which says” All persons have a duty to prevent harm to other persons insofar as it lies within their power to do so without undue harm to themselves”.







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