ePrescribing Increases Errors

A recent report in the open-access journal BMC Biomedical Informatics and Decision Making describes the experience of 3 large pharmacies in Sweeden. They found, as have others, that a sizable fraction of prescriptions need clarification before they can be dispensed. "Clarification" means the pharmacist cannot safely and reliably fill the order without contacting the prescriber. This is a good practical definition of "error" in this setting. These errors represent re-work for the prescriber, delay in care for the patient, and increased costs to the system. Some of them also represent potentially dangerous actions that put the patient at risk for illness, injury or death.

One of the main reasons to change from hand-written prescriptions to ePrescribing is to reduce the need for clarifications and the errors they represent. Unfortunately, the Sweedish team found that ePrescriptions were substantially more likely to need clarification than the old-fashioned ones. 2.0% for the electronic scripts vs. 1.2% for the older type.

Many of the errors could be traced to lack of standardization across ePrescribing systems. The authors also called for more training of users. However, anytime a system requires extensive training, that means it has too many inherent failure modes. For ePrescribing to truly save lives and money, the interfaces to the users need to be intuitive, easy-to-use, and supportive of the user's tasks. Until then, ePrescribing, like Computerized-Provider-Order-Entry, will just be another failure mode.

Confidentiality concerns may delay health IT investment

According to Robert Pear in today's New York Times, a wrangle over the confidentiality of health information could delay a $20 billion federal investment in Health IT. Some of the proposals seem pretty smart, like outlawing the sale of health records without the patient's permission.

Others strike me as seriously flawed, such as not allowing the routine transfer of electronic health information for care of the patient without specific permission. (Although HIPPA does not require this permission for care, the early proposals did. Even now, many folks still believe that they cannot transfer medical records to the patient's doctor without a specific permission - causing endless delays, confusion, and rework.) If interpreted too strictly, we could be in the position of knowing some information that could improve a patient's health or even save a life, but be constrained from acting on it. Public Health IT, in particular, could be seriously compromised - think tracking infectious diseases, but not being able to tell patients who might have been exposed.

A more difficult proposal is to allow patients to segregate some of their medical records as too embarrassing to allow out even with the confidentiality rules used for general medical information. I can certainly understand that information related to mental health, sexual behavior, paternity and a host of other issues needs to be handled with care. However, I believe that 1) all health care information deserves that level of care and 2) mental health, in particular, has suffered as medicine's step-child due to assumptions that it is somehow "different" or "special." Bringing these issues into the medical fold may be very benficial, as it was for cancer and diabetes, which are no longer "shameful."

The problems of data security and confidentiality that have been widely publicized (leaking health records to the press, for instance) do call for action. However, the best action would be serious enforcement of laws and standards that currently exist, rather than an extensive re-write.

New National Research Council Report on Health IT

The National Research Council just came out with a report on computers and health: Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions, that outlines a grand vision of what's wrong with HIT and what to do about it.

Here are their 9 principles to guide the use of HIT:

1. Focus on improvements in care —technology is secondary.
2. Seek incremental gain from incremental effort.
3. Record available data so that today’s biomedical knowledge can be used to interpret the data to drive care, process improvement, and research.
4. Design for human and organizational factors so that social and institutional processes will not pose barriers to appropriately taking advantage of technology.
5. Support the cognitive functions of all caregivers, including health professionals, patients, and their families.
6. Architect information and workflow systems to accommodate disruptive change.
7. Archive data for subsequent re-interpretation, that is, in anticipation of future advances in biomedical knowledge that may change today’s interpretation of data and advances in computer science that may provide new ways of extracting meaningful and useful knowledge from existing data stores.
8. Seek and develop technologies that identify and eliminate ineffective work processes.
9. Seek and develop technologies that clarify the context of data.

This is an important and welcome report by an experienced and wise team led by Bill Stead of Vanderbilt. The emphasis on achieving clinical results rather than achieving technology is, of course, an old lesson. But it warrants repeating. It is better to install a small system that you know will make one thing better than a giant system that you hope will make everything better. Such small systems need to be designed with integration in mind. But, if the system demands a wholesale change in behavior or a radical investment of financial, intellectual and human capital, watch out!

Happily, there are some approaches already available that meet the 9 principles. The Vermedx® Diabetes Information System meets all of them. It does it by having a narrow scope (just laboratory management for adults with diabetes in primary care). And, I would add another principle that Vermedx meets:

10. Demand rigorous evaluation

Morris F. Collen, M.D.

Congratulations to Morris F. Cullen, the pioneering physician informatacist at Kaiser Oakland. Dr. Cullen is writing his sixth book: "The History of Medical Informatics: The Clinical Support Systems." I, for one, am looking forward to it!

Maria L. La Ganga of the LA Times wrote a glowing profile of the nonagenarian physician with lots of great tid-bits. My favorite: his driver's license expires on his birth date on "11-12-13." Y2K lives!