A day or so ago I posted a blog on
the risks associated with errors in the data held in your medical record.
Here is the link:
I had this commentary on a personal experience from an
alert observer sent to me a day later.
To quote:
“A few years ago I
attended one of Melbourne's leading tertiary hospitals for a wider excision of
a Melanoma which fortunately was diagnosed very early by me and had not had an
opportunity to invade or spread. When I was clerked in for the excision I was
asked to sign the consent form 'here' which most patients probably would have
done, but being a nosy parker I turned it over and asked the nurse "Why am
I signing a consent to have my finger amputated?" The melanoma, which had
been excised for pathology diagnosis by my GP, was on my flank! Oh, said the
nurse, that consent form is for someone else, it must have been put into the
wrong record! We fixed that problem.
When I returned 2
weeks later for review the receptionist had difficulty finding my record on the
hospital computer system. As it transpired, in the short time that I had been
attending the hospital I had been given TWO slightly different surnames and TWO
medical (UR) numbers. We fixed that problem.
The discharge
procedures then came into play and I was formally discharged back to the care
of my GP. For the next 3 weeks I received 3 follow-up letters from the hospital
asking me to please attend for post-op review and discharge which I had already
done. We fixed that problem.
During my second
visit for post-op review with the consultant dermatologist, being a nosy
parker, I looked at my hospital A4 record with the consultant and we were both
surprised to find that it did not contain the histopathology report which was
also not available in my electronic hospital record. We followed up with
pathology and obtained a hard copy. We fixed that problem.
On leaving the
hospital I was curious to know why I had encountered so many 'issues' with what
should have been a relatively simple process - admit, treat, manage, discharge,
all the while recording information along the way. Being very familiar with
hospitals and with information technology, on the way out of the hospital I
wandered down to the basement and asked to speak with the health record
librarian or health informatician as she was then called. We had a delightful
and informative chat. She took me on a tour of her department and showed me the
pile of documents waiting to be imaged into various patient's hospital computer
records. I was stunned to see the size of the pile of documents and to learn
how far behind (more than 2 weeks) the department was in imaging the documents
into the hospital's computer system.
We discussed the
problem. In particular we discussed how dangerous the entire system had become
with some information being held in the hospital's manual A4 records and some
being held on the computer system and no one reliable source of truth to which
doctors and other hospital staff could refer. We couldn't fix that problem.”
And that is just one
patient’s experience of confusion and near catastrophe!
All I can say is to
point out to be very alert and alarmed while in Hospital and triple check
everything. As they used to say “it’s dangerous out there!”. And so it is in Hospital!
David.
9 comments:
It is very dangerous out there, and not getting any better because of totally inept management and a total lack of governance by the government bodies. In reality it is a disgrace and is a huge threat to patient safety and privacy and there is no sign of any appreciation that data quality and good PKI is vital for safety.
The government powers that be just seem to run to anything new without actually doing anything to fix any existing issues and sector wide implementation of something new is a pipe dream unless they have a huge pot of money to pay every existing player to drop what they are doing and spend a year implementing something totally new to a high, tested level. That is just never going to happen and there is no working infrastructure wrt things like even basic PKI. There are security holes you could drive a bus through with existing PKI infrastructure and when we report they they just say, Oh well we are moving to something new soon so we are not going to fix it!!!! This is actually a major security flaw that was reported to them last week.
They start projects and then after the first meeting demand an outcome within weeks before anything has even been discussed, which is similar to the scatterbrain idea of "Tiger Teams" a few years ago. The whole eHealth branch needs to be disbanded before they completely destroy eHealth in Australia and make us the laughing stock of the world.
Andrew I completely agree they have become dangerous. I hear they are unable to make a change and generate a specification anymore, no one knows how to use the tools or the tooling is no long working.
Automating systems does not make them safer. Human error is always a problem.
Emphasis has on digitalisation of health records and integration of previously disparate health systems has taken the most qualified health information managers 'away from the coalface' and into 'special projects'. Many vital and strategic positions vital leadership and data quality roles are now undertaken by staff with limited or nil qualifications in this subject area. They attend strategic meetings and/or send an equally unqualified proxy proxy 'the blind leading the blind' springs to mind and so the hole just gets deeper as these people are unable to grasp the complexity and importance of data quality and the ramifi
cations to patient safety and grossly under resource the appropriate areas and services with suitably qualified staff who might be able to make a difference
Automating systems does not make them safer. Human error is always a problem.
Emphasis has on digitalisation of health records and integration of previously disparate health systems has taken the most qualified health information managers 'away from the coalface' and into 'special projects'. Many vital and strategic positions vital leadership and data quality roles are now undertaken by staff with limited or nil qualifications in this subject area. They attend strategic meetings and/or send an equally unqualified proxy proxy 'the blind leading the blind' springs to mind and so the hole just gets deeper as these people are unable to grasp the complexity and importance of data quality and the ramifi
cations to patient safety and grossly under resource the appropriate areas and services with suitably qualified staff who might be able to make a difference
On Friday afternoon last week, just before parliament rose for the year, the Health Minister tabled a hard copy of the My Health Record business case he had been asked for two weeks earlier by Dr Kerryn Phelps.
https://aushealthit.blogspot.com/2018/11/the-adha-is-on-warpath-again-against.html?showComment=1543480622446#c6222195040199427346
It is three pages long and contains little more than unsubstantiated claims of benefits.
The difference between manual systems and automated systems is that you can tell a person that if they come across something unexpected, to call for help. With an automated system you need to predict and allow for all exceptions.
Simply automating a manual system will just make thing go wrong faster and be worse.
An example is unauthorised access to health records. Hack one GP's system and a few people are put at risk. Hack myhr and a large number of people will be impacted and the government will have a crisis on its hands.
ADHA knows little about information systems, and even less about automation. WCGW?
@ 11:24 AM "It is three pages long and contains little more than unsubstantiated claims of benefits."
Is there a copy publicly available?
It's been tabled in parliament so one should emerge soon.
Seriously 3 pages? Are they numbered M, H, and R.
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