My brain-injured mother was admitted to a suburban hospital (recently acquired by the "big hospital" where her EHR-related injuries of May 2010 had occurred) Saturday morning.
She was again in a confusional state (delirium) of unknown cause, probably recurrent infection.
Of note, almost every time I see their EHRs, I note a problem.
In my Jan. 2011 post on this issue at the same organization, "EHR Problems? No, They're Merely Anecodotal; the Truth Must Be That I Attract Bad Electrons and Stale Bits" I observed a nurse-stated "glitchy-ness" that day that manifested as unreliability in pulling up the patients' current med lists. I had to be the conduit of my mother's meds, despite having gone through them in detail for computer entry in the exact same ED just 24 hours prior after a fall:
This was not the "FirstNet" ED EHR by Cerner forensically analyzed by Dr. Jon Patrick (as I wrote about here), but another ED EHR, "Pulsecheck" by Picis -- a company whose ICU physiological monitoring system I once as CMIO struggled with due to repeated, unexplained crashing.
On this most recent ED visit/admission to the satellite just days ago, I noted another problem with the ED EHR system (the same one that started my mother's travails at the main facility in May 2010, and now in use at the satellite).
When the ED nurse brought up my mother's allergies, they were repeated over and over and over on the ED screen, in a long recurrent list dozens of lines long, as if they'd been cut-and-pasted multiple times at each visit. She apologized to me. See images of a printout I later demanded, below (names digitally redacted):
Allergy list, page 1 (printout of an on-screen continuous list). Click to enlarge.
Allergy list, page 2 (printout of an on-screen continuous list). Click to enlarge.
Allergy list, page 3 (printout of an on-screen continuous list). Click to enlarge.
Note that on-screen these appeared as one long, confusing list.
The repetition made the list near useless to the ED personnel (for example, they don't have time to look for the one crucial item that ISN'T a duplicate in the mess).
Legible gibberish indeed.
The ED RN just asked me about my mother's allergies. Fortunately, I'm a doctor and know them well.
The hospitalist then called me that night suggesting she would give my mother Levaquin, an antibiotic. For the umpteenth time I had to tell a doctor at these facilities my mother was allergic to Levaquin. This was in fact one of my complaints on my April 2010 warning letter to the hospital's CEO and CMO on EHR deficiencies I'd noted in my mother's care. This was just one month prior to her catastrophe, when a critical heart medication "disappeared" in the ED EHR, causing a cascade of medication continuity failure.
Yesterday I insisted the duplicate entries be removed.
It is, on first principles, inherently harmful to the public to have critical patient data stored in disarray in an Emergency Room electronic health record.
See the above images, and ask if this is what you'd want busy ED doctors to have to wade through to figure out if a drug they're about to administer might injure or kill you.
I note that "Pulsecheck" is an ironic name for this system, because the users may need to keep doing that to their patients - checking their pulse - repeatedly to stay out of medical and legal hot water.
In my Jan. 2011 post on this issue at the same organization, "EHR Problems? No, They're Merely Anecodotal; the Truth Must Be That I Attract Bad Electrons and Stale Bits" I observed a nurse-stated "glitchy-ness" that day that manifested as unreliability in pulling up the patients' current med lists. I had to be the conduit of my mother's meds, despite having gone through them in detail for computer entry in the exact same ED just 24 hours prior after a fall:
... My mother was having a repeat of the ischemia to the brain or "TIA" (transient ischemic attack, i.e., threatening to have a stroke), only this time the ED EHR itself was also having a TIA.
This was not the "FirstNet" ED EHR by Cerner forensically analyzed by Dr. Jon Patrick (as I wrote about here), but another ED EHR, "Pulsecheck" by Picis -- a company whose ICU physiological monitoring system I once as CMIO struggled with due to repeated, unexplained crashing.
On this most recent ED visit/admission to the satellite just days ago, I noted another problem with the ED EHR system (the same one that started my mother's travails at the main facility in May 2010, and now in use at the satellite).
When the ED nurse brought up my mother's allergies, they were repeated over and over and over on the ED screen, in a long recurrent list dozens of lines long, as if they'd been cut-and-pasted multiple times at each visit. She apologized to me. See images of a printout I later demanded, below (names digitally redacted):
Allergy list, page 1 (printout of an on-screen continuous list). Click to enlarge.
Allergy list, page 2 (printout of an on-screen continuous list). Click to enlarge.
Allergy list, page 3 (printout of an on-screen continuous list). Click to enlarge.Note that on-screen these appeared as one long, confusing list.
The repetition made the list near useless to the ED personnel (for example, they don't have time to look for the one crucial item that ISN'T a duplicate in the mess).
Legible gibberish indeed.
The ED RN just asked me about my mother's allergies. Fortunately, I'm a doctor and know them well.
The hospitalist then called me that night suggesting she would give my mother Levaquin, an antibiotic. For the umpteenth time I had to tell a doctor at these facilities my mother was allergic to Levaquin. This was in fact one of my complaints on my April 2010 warning letter to the hospital's CEO and CMO on EHR deficiencies I'd noted in my mother's care. This was just one month prior to her catastrophe, when a critical heart medication "disappeared" in the ED EHR, causing a cascade of medication continuity failure.
Yesterday I insisted the duplicate entries be removed.
It is, on first principles, inherently harmful to the public to have critical patient data stored in disarray in an Emergency Room electronic health record.
See the above images, and ask if this is what you'd want busy ED doctors to have to wade through to figure out if a drug they're about to administer might injure or kill you.
I note that "Pulsecheck" is an ironic name for this system, because the users may need to keep doing that to their patients - checking their pulse - repeatedly to stay out of medical and legal hot water.
-- SS
0 comments:
Post a Comment