Friday, March 28, 2014

Now Here Is The Practicalities Of Just How Bad Health IT Can Actually Contribute To A Patient Death.

This awful story appeared a little while ago.

UK Coroner Fingers NHS Computer System in Toddler’s Death

By Robert N. Charette
Posted 10 Mar 2014 | 20:36 GMT
The number of IT-related errors, ooftas, and deficiencies reported last week reverted back towards the mean from the previous week's overabundance. We start off this edition of IT Hiccups with a sad case of a child’s death in the UK. The tragedy is being attributed in part to the past effort to fully computerize the UK’s National Health Service.
According to the Bristol Post, a coroner in charge of the inquest into the death of Samuel Starr, aged three, indicated in a narrative verdict that, “Due to the failure of the [Royal United] hospital's outpatient booking system, there was a five month delay in Samuel being seen and receiving necessary treatment.”  It is very rare for a coroner to criticize a hospital IT system so directly.
Samuel Starr was born with “complex congenital heart disease” in 2009. His parents were told at the time of his birth that Samuel would need several operations before he was five, and in fact, Samuel underwent an operation when he was nine months old. The Post reported that he made a good recovery, and was due to have regular checkups and further treatment at the Pediatric Cardiac Clinic at the Royal United Hospital (RUH) in Bath. Samuel received a checkup in October 2010 and one in April 2011, at which time his parents were told by his doctor to schedule another in about nine months for a more extensive examination of his heart.
However, a new electronic health record system, called Cerner Millennium, was being installed in 2011 at the hospital as part of the NHS’s National Program for IT (NPfIT), which was shortly thereafter cancelled. Though the main program was cancelled, certain elements, such as its national Choose and Book system for patient scheduling, remained. (Hospitals, like at Royal United, that were already installing electronic health record systems were given the go-ahead to proceed if they wished).
According to the Daily Mirror, “glitches” in the Royal United patient booking system caused Samuel not to receive his scheduled appointment with heart specialists as required, despite pleas for an appointment by his parents and a primary care specialist. The Mirror stated that medical secretary for Samuel's doctor insisted that she had taken down the appointment details and forwarded them on to a dedicated appointments team, but they were apparently not logged in. “While Samuel's medical records had been created on the new Millennium computer program, no appointments had been transferred across [from the old scheduling system],” the Mirror explained.
By the time Samuel was eventually seen, his heart condition had taken a turn for the worse, and he required immediate surgery. Unfortunately, the child died after enduring a series of cardiac arrests a few weeks after his surgery.
The rest of the story is found here - along with some other mess-ups.
This is a sad story which shows just how there can be consequences if great care is not taken to ensure IT that is involved in patient care is not looked at a whole and that seamless end to end operation is assured. Also important is to carefully ensure that issues that emerge with respect to use of systems and IT are appropriately escalated and remedied.
This really feels like a glitch that should have been caught and it is sad that it apparently was not.


Grahame Grieve said...

David, if you read the fine details, it rather sounds as

(1) there was no arrangement to migrate the appointments from the old system ("no appointments had been transferred across" - if there was an arrangement, there was no QA on the process).

(2) no one did anything to fill the process gap due to appointments going missing

(3) there was no other clinical follow up for the child (review lists, progress prompts.. EHRs have them for a reason)

(4) the parents let it slide

So naturally, Cerner, as the vendor of the new system, gets the blame.

in real life, these things are always multi-factorial, and culture is the real problem. I see no evidence from the coroner's report that the apparent culture problems have been identified as the source.

p.s. I'm not blaming the parents, but the patient or their advocate is in the best position to ensure that plans don't lapse if the system fails to follow through

p.p.s All we have to go on is a flawed coroners report, reported by a (probably more) flawed journalist. So take everything I said at face value.

Anonymous said...

Culture is the real problem????? Get real. You've been hanging around those nehta bureaucrats too much!

Anonymous said...

If by culture you mean the culture that holds in technological driven organisations and companies, and that blinkers their eyes to seeing only software code and nothing but the code as the solution, then I agree.

The health IT industry has to take this on the chin - some of them are writing crap systems with crap interfaces chasing the dollar, and harming patients as they go.

Some of them are writing great software but have no clue about the universe within which it will be used, and their error is a lesser one - but still probably leads to much harm.

I have no idea why its so hard to say "we are writing code that affects the way healthcare is delivered, and if we do a bad job, then bad healthcare will result - so lets strive to be safety focussed - both in the way we design, build, and implement."

Grahame Grieve said...

"Culture is the real problem" - I do not think that this is an unsurprising conclusion in this or most safety cases, nor does hanging at NEHTA occasionally (I do work for NEHTA a little) have anything to do with this

From the story, there is no evidence that this problem had anything to do with a technological organisation. Though I'm not denying that such organisations can and have been the source of problems. And no would I deny that some companies have pursued the dollar at whatever cost.

However the vendors I have worked for or with have all taken safety as seriously as they know how, or they can afford to. From my perspective, I thought as much fault was with the purchasers, who procure systems that don't fit their culture, who don't put safety systems in place, who use IT to force process change without changing the culture, and who buy solutions without paying more for proven safety (not always, but far too often).

Still I agree that too many programmers writing code often have no clue about the way their code will be used - that's why I'm running clinical safety courses for application designers (or trying to - I'm not getting a lot of interest, in spite of enthusiastic support from several people, including David very kindly letting people know about them - thanks David)