Computers and Prostate Problems in Pennsylvania, East and West

At "Bungled Brachytherapy, Computer Interfaces and Other Mysteries At The Philadelphia Veterans Administration Hospital" at this link I reported on serious problems involving brachytherapy treatment of prostate cancer at the VA Medical Center in Philadelphia.

One of the issues involved computer problems, in the form of failure to network a key computer involved in treatment evaluation.

Now at the other end of the state, Pittsburgh, more prostate-related computer problems have occurred:

Prostate cancer test interpretation flawed
By Walter F. Roche Jr.
PITTSBURGH TRIBUNE-REVIEW
Friday, March 5, 2010

A computer programming error caused West Penn Allegheny Health System's laboratory to send physicians incorrect interpretations of prostate cancer tests for 288 patients over 15 months.

Hospital officials say physicians who ordered the tests were advised about the errors in recent weeks. They were sent revised, corrected interpretations, said Dr. Jan F. Silverman, chairman of the Department of Pathology and Laboratory Medicine.

One wonders how such a "programming error" can occur.

Silverman said actual test results were correct, and most physicians would rely on those and not interpretations. He said hospital officials found no evidence that incorrect test interpretations resulted in delayed or improper care ... The erroneous interpretations were provided on a test physicians use to assess whether patients need biopsies of their prostates. The test provides a comparison of total prostate specific antigen, or PSA, versus free or non-attached PSA.

That there was no apparent delayed or improper care was by happenstance. The purpose of health IT, however, is not to give physicians the opportunity to have a lucky day, or to have placed upon them the additional cognitive burden of deciding which is correct: the test results, or its interpretation.

This episode raises another question: in addition to whatever "programming error" caused this problem, was there no QC of the actual reports to ensure the "interpretation" matched the pathological, serological and other results and findings?

Dr. Ralph Miller, head of the Allegheny Prostate Cancer Center, said it was "theoretically possible, but very, very unlikely" that erroneous interpretations resulted in delayed or improper care.

[That may be true, but is it due to luck and/or the inconvenient fact that most physicians 'did not rely' (i.e., ignored) the computer-generated interpretations? Also, will luck run out the next time a "programming error" occurs, resulting in dead patients? - ed.]

Silverman said those interpretations were sent between Oct. 1, 2008 and January. Of 818 PSA tests the West Penn Allegheny Core Laboratory performed during that period, 412 included comparisons of the two PSA figures. Of those, 288 included incorrect interpretations of that ratio, Silverman said.

That's a very high percentage of error. Should that have occurred in a drug trial, the FDA would likely have been all over the responsible parties. However, health IT is unregulated, therefore all that's required is an "please excuse us, we'll do better the next time" from the involved parties.

The programming error was discovered recently when a physician questioned an interpretation, Silverman said.

I have written before on these electronic pages that physicians and clinical settings should not be the testing labs for IT personnel, with the clinicians using their clinical skills in locating programming bugs.

-- SS

VA / DoD EHR Interface Debacle: Will It Take the Luminosity Of A Dozen Supernovas To Shed Light On The Obvious About Healthcare IT?

(12/2010 note: I have observed a large number of "hits" on this post from multiple offices of the Mitre Corporation in the past several weeks. Dear Mitre, I ask that if you use my materials in your proposals or writings, that you please let me know. Thank you. My email address is in my profile under "Contributors." -- SS)

The VA and DoD have been working for a number of years on interfacing the VistA EHR system and the military's EHR, AHLTA (why anyone would want to interface to AHLTA in its present state is of concern to me, but...)

[Note: this is not to denigrate the military, and I am very thankful to all who serve and defend our country and freedoms. HIT problems seem unfortunately universal - ed.]

The interface attempt, likely done by the usual actors in the traditional "business IT" manner has resulted in the predictable:

Glitch prompts VA to shut e-health data exchange with Defense
NextGov.com
By Bob Brewin 03/04/2010

The Veterans Affairs Department closed off access to the Defense Department's huge electronic health record system on Monday because it found errors in some patients' medical data clinicians downloaded from the Defense network, according to a departmental patient safety alert, which Nextgov obtained.

Although no patient was injured, the errors shed light on how software glitches could affect the accuracy of electronic medical records and a planned national system that has been backed by the Bush and Obama administrations.

"Shed light on how software glitches could affect the accuracy of electronic medical records?"

As my early medical mentor, Hahnemann cardiothoracic surgery pioneer Victor P. Satinsky would have said about purveyors of such wisdom: they are Masters of the Obvious.

I ask:

Why do we keep needing to "shed light" on the blatantly obvious, in your face, computer science 101 reality about electronic information systems? The light was shed when the first stored-program computers were developed in the late 1940's.

Exactly how much light do we need to shed before IT personnel "get it" about the need for the most extreme diligence in IT-based medical records?

Perhaps the light of a dozen supernovas?

Is this the amount of light it will take before the IT world "gets it" about the need for the utmost engineering rigor in healthcare IT? (click image to play video).

It's fortunate the error was found in a somewhat less than life-threatening manner:

VA first discovered the problem in late February, when one of its doctors accessed the Defense health records system, called AHLTA, to review the prescription information of a female patient. The data showed a Defense physician had prescribed her an erectile dysfunction drug. The VA doctor suspected the system displayed erroneous information [although females have been known to use these drugs- ed.] and a check with the Defense medical facility that supposedly prescribed the drug informed VA that the data was wrong and the VA query had returned information for another patient.

... When doctors queried the Defense system for patient information, they received no data, a portion of the data, incorrect information, or the complete, correct data for the patient, according to the alert.

[Where have I seen these types of patient data errors mentioned recently? Perhaps at my recent post "FDA on Health IT Adverse Consequences: 44 Reported Injuries And 6 Deaths In Two Years, Probably Just Tip of Iceberg" ? - ed.]

The glitch did not cause harm to any patient, but "the potential exists for decisions regarding patient care to be made using incorrect or incomplete data," said Jean Scott, director of the Veterans Health Administration's Information Technology Patient Safety Office, in the alert issued on Wednesday.

Indeed.

"The VA clinician may see the patient's data during one session, but another session may not display the data previously seen," the alert noted. "This problem occurs intermittently and has been reported when querying DoD laboratory, pharmacy and radiology reports."

I would add that "intermittent errors" are by definition unpredictable. This is the most dangerous type of IT malfunction of all.

Until those systems are reactivated, VA doctors will have to obtain a patients' health information from their paper medical files, faxes or PDF attachments that are e-mailed to the physicians, Scott said.

What? That old-fashioned, unreliable 5,000 year old artifact upon which the foundations of modern medicine were built, and favored by Luddites?

The errors occurred in the Bidirectional Health Information Exchange, a project started in 2004 that allows clinicians in VA and Defense to view health information in patient files. Older code in the system became stressed at peak periods when clinicians were making the most number of queries, said Roger Baker, chief information officer at VA. At these times, the system did not clear out a memory cache, resulting in memory leaks "so that information from one patient is presented as it is from another," he explained.

Good software and information architecture engineering practices call exactly for testing under stress. Failure to clear caches, memory leaks, etc. are fundamental flaws that should never be permitted to see the light of day in clinical settings. That is what acceptance testing is designed to do. That's what mission critical software undergoes in other sectors. That is what drug and device clinical trials are designed to do.

At this link, for example, is NASA's Certification Processes for Safety-Critical and Mission- Critical Aerospace Software from 2003 (PDF). From that document:

... Since safety-critical aerospace software is prevalent and important to human life, what is the rationale behind certification of such software? In other words, how do engineers know when a new software product works properly and is safe to fly? In the United States, software must undergo a certification process described in various standards by various regulatory bodies including NASA and the Requirements and Technical Concepts for Aviation (RTCA) which is enforced by the Federal Aviation Administration (FAA).

There are no analogous requirements or enforcement in the healthcare IT sector. None.

In fact, the VA, of all places, should have been exceptionally wary of these types of malfunctions and exercised the highest levels of engineering rigor.

Why?

See "IT Vulnerabilities Highlighted by Errors, Malfunctions at Veterans Medical Centers" at this link. From that posting, reflecting a March 4, 2009 JAMA article by the same title by Bridget M. Kuehn (JAMA 2009;301(9):919-920):

... After a software update of the electronic medical records system at VA hospitals in August [2008], health care workers at these facilities began to report that as they moved from the records of one patient to those of a second patient, they would sometimes see the first patient's information displayed under the second patient's name. [If not for the diligence of the users then, that type of error could have led to dead patients -ed.]

This records-scrambling problem was reported at 41 of the 153 VA medical centers, said Gail Graham, deputy chief officer of Health Information Management at Veterans Health Administration Headquarters in Washington, DC. Graham explained that the jumbling of records was an uncommon occurrence that only occurred after a particular sequence of events.

... Health care workers at the VA medical centers were notified about this potential problem in October, and on December 20, the centers received a software "patch" to fix the problem.

Nine VA medical centers reported another type of problem related to their electronic records system: physician orders to stop medication were missed, causing some patients to receive intravenous medications longer than necessary. The problem occurred because after the software upgrade, physician orders to discontinue such medications, which had previously appeared at the top of the screen, were not displayed.

In 3 cases, patients received infusions of drugs such as heparin for up to 11 hours after their physician had ordered the drug to be discontinued. Graham said the affected patients were not notified because they had not been harmed by the oversights. This software problem was corrected on December 8.

As I noted in that post: "... if this type of error occurs once too often, your patient's dead."

Back to the current VA / DoD interface "glitch":

... The VA has fixed the [current] bug and plans to bring the BHIE back online on March 9. Baker emphasized the bug's effect on the medical records of patients that VA and Defense clinicians share was sporadic and occurred in one out of 100 queries. The glitch caused errors only in the records that VA clinicians accessed. Defense doctors still have access to records Veterans Affairs stores.

"Only" 1 out of 100? ... that's only 10,000 errors per million EHR queries. Not too bad at all ... how many soldiers are in a military division?

Baker said the department's response to the glitch showed VA's overall health system worked "because there is always a doctor in the loop" who checks the accuracy of a patient's health data in combination with a well established patient safety organization that quickly alerts clinicians to any errors.

The "system worked" because luck prevailed that fallible, busy human clinicians were not deceived by erroneous information provided by a computer? I fall back on first principles of IT:

A computer can free professionals from tedious, repetitive work which does not require judgment. It can provide facts and figures with lightning speed, giving domain experts more time to exercise their judgment thoughtfully

The system is not working when computers add to the tedium, and having to expend precious cognitive capacity in ferreting out computer errors is certainly in that category. This excuse reminds me of a recent quote from our Homeland Security secretary about how the "system worked" when an airplane nearly was blown out of the sky.

These failure excuses, possibly written by a public relations 'spin doctor' in an effort at damage control, remind me of a humorous sign I bought in a novelty store once, for placing on the wall: "Our policy is to always blame the computer."

Perhaps clinicians need to stand up for this motto: No more alpha and beta software rollouts in healthcare.

Robert Charette, a risk management consultant and president of the ITABHI Corp. in Fredericksburg, Va., which consults with Defense, said VA was lucky it discovered an error as obvious as prescribing an erectile dysfunction drug for a female patient. He wondered if VA would have detected the error if it were for drugs with similar names, adding that despite the low error rate, "it's the one out of 100 that can bite you."

It's also the one out of fifty thousand that can bite you, for instance as Merck recently discovered.

Baker said the complexity of medical records systems like BHIE would make regulating such networks [by agencies such as FDA - ed.] a daunting task.

I thought we were just at the point of transforming health with one thunderous click of a mouse after another per our prior HHS secretary at the 2005 HIMSS summit. Perhaps not...

Dave deBronkart, a patient advocate in Nashua, N.H., who spoke at last week's Health IT Policy Committee meeting, said in an interview with Nextgov that the glitch paralleled the problems he encountered last year when he tried to transfer information from his hospital medical record to Google Health, an online electronic health record database the search giant launched in 2008.

I wrote about that at "Should Google Seek the Resignations of Those Responsible for This Healthcare IT Debacle?" here.

If the United States wants to develop a national health electronic record system, it needs to make sure heath information exchanges work correctly, said deBronkart, who added VA should be commended for reacting quickly to the software problem and issuing the patient safety alert.

I believe this is not possible under the current leadership, organizational and regulatory structures found in the healthcare IT sector. As I've written before, healthcare cannot be 'reformed' or even improved by IT, until IT and its culture are themselves reformed.

For more on these issues, see my site below.

-- SS

For more on HIT challenges see "Contemporary Issues in Medical Informatics: Common Examples of Healthcare Information Technology Difficulties" - http://www.ischool.drexel.edu/faculty/ssilverstein/cases/

FDA Criminal Division to Increase Prosecutions

In many posts on this blog, Roy Poses has lamented the fact that there are no personal repercussions for healthcare executives embroiled in malfeasance and scandals.

He recently wrote:

So, here we go again ... To repeat, seemingly ad infinitum, these are just the latest in a now long parade of settlements and guilty pleas and criminal convictions, sometimes involving charges like bribery, fraud, or kickbacks, that serve as reminders of poor behavior by myriad health care organizations. As we have previously noted, these settlements seem to have little deterrent effect on future bad behavior. (Note that many large health care organizations have settled or plead guilty in several major cases since we started commenting on such settlements.) Usually, the companies involved only need to pay fines, and no individual who performed, directed or approved unethical or illegal acts will suffer any negative consequences. I submit once again that such fines are viewed merely as costs of doing business by the affected companies, and do not deter future bad behavior. Until the people who approve, direct, and perform unethical or illegal acts pay some penalties, expect such acts to continue. I again suggest that to truly reform health care, we need rigorous regulation of health care organizations that has the power to deter unethical behavior that may risk patients' health.

The companies of the bad actors are fined; the fine is considered a "cost of doing business"; but personal actions against the responsible executives engaged in malfeasance do not usually occur. Dr. Poses feels healthcare reform cannot occur under these conditions, and I agree.

Apparently, so do others at high levels:

FDA Criminal Division to Increase Prosecutions
Wall Street Journal
March 4, 2010

By ALICIA MUNDY

WASHINGTON—The Food and Drug Administration plans to increase prosecutions of pharmaceutical and food industry executives as part of an effort to refocus its criminal division, which has been under attack in Congress and is criticized in a new government report.

In a letter to Sen. Chuck Grassley (R., Iowa), the FDA says an internal committee has recommended that the FDA and its Office of Criminal Investigations "increase the appropriate use of misdemeanor prosecutions, which allows responsible corporate officials to be held accountable and is a valuable enforcement tool."

Misdemeanor prosecutions are a start; however, some of the behaviors seem to my uninformed legal mind to perhaps be more felonious in nature...

An FDA official said the agency has the authority to prosecute corporate executives for criminal actions within their companies under a provision called "strict liability." He said the government doesn't have to show intent to defraud in order to get a conviction. He added that the provision is an important tool that hasn't been used much in recent years.

As has been noted repeatedly on this blog.

A report set to be released Thursday by the Government Accountability Office, Congress's watchdog arm, says the Office of Criminal Investigations has operated autonomously for years with little or no accountability to top FDA officials

... The report said the FDA "has relied largely on the OCI director to determine which aspects of OCI's operations and investigations are made known to FDA's top management."

The GAO also said the FDA's criminal unit has fallen short compared with other agencies in developing performance standards.

This clearly must be corrected.

The FDA officials largely agreed with the assessment and in the letter said the agency is "developing meaningful performance measures" for the criminal office as part of an initiative begun in August. The FDA said it wants the criminal office to share information with FDA leaders regularly, and to do a better job picking cases.

I know where they can look to find cases ... here, for example.

... In 2008, Rep. Joe Barton (R., Texas) criticized the Office of Criminal Investigations, saying its budget had increased while its workload stagnated.

I think the many posts on healthcare corruption here and elsewhere suggest that the workload of the Office of Criminal Investigations needs to pick up quite substantially, if the behaviors are to be discouraged and the actors shown that the penalties are not just a "cost of doing business" (unless one is willing to acquire a criminal record or go to jail for one's company as a "cost of doing business", that is).

It is my hope that one day this increased vigilance will be extended to the healthcare IT industry.

-- SS

On the Wickedness Of Healthcare IT (And Is CPOE Just a "Typewriter For Orders?")

Large-scale implementation of comprehensive healthcare IT, especially if meaningful ROI on the hundreds of billions of dollars spent is to be attained, is more of a wicked problem than a tractable one, as I have written on this site and in a number of presentations (such as this one on HIT challenges and perils - PDF).

A "wicked problem" describes a problem that is difficult or impossible to solve because of incomplete, contradictory, and changing requirements that are often difficult to recognize. Moreover, because of complex interdependencies, the effort to solve one aspect of a wicked problem may reveal or create other problems.

In the current environment of irrational exuberance, healthcare IT has been presented as a ready-for-prime-time, "mouse click away from great healthcare", put-it-in-and-reap-the rewards technology. An example of this 'HIsTeria':

“We have the capacity to transform health with one thunderous click of a mouse after another,” said (former) HHS Secretary Michael Leavitt - 2005 HIMSS Summit

"Transform" healthcare via "one thunderous mouse click after another?" On an irrational hyper-ebullience having taken over in healthcare IT, I rest my case.

Thunderous computing! Oh my!

Unfortunately, realizing the capabilities of healthcare IT is not simple. It is in fact devilishly complex. For instance, is CPOE a "typewriter for orders", as it's sometimes represented in this industry to de-emphasize its potential hazards?

Far from it.

In recent testimony submitted at the HIT Policy Committee, Adoption/Certification Workgroup of HHS on February 25, 2010, a meeting on HIT safety, Geisinger medical informaticist/CMIO James Walker, MD wrote (PDF) the following (emphases and red comments mine):

... In 2005, Geisinger was preparing for its first inpatient EHR implementation. Several months into the project, the project director informed the CIO and me that the EHR team’s business analysts were unable to map safe and effective workflows between the new order-entry system and our existing pharmacy system (provided by another vendor).

[As an aside, one might question why "business analysts" were attempting a clinical mapping such as this - ed.]

They and the project director believed that the only safe approach was to de-install the existing pharmacy system and replace it with the pharmacy system provided by the order-entry vendor—at a cost of several hundred thousand dollars and a nine months’ delay in the project.

Pharmacy’s management was pained by the need to remove what was indisputably the best pharmacy system on the market [yet, even so, it needed to be removed and replaced with something that may, or may not, be equivalent in safety, ease of use, customizability, lifecycle maintenance, etc. - ed.] (which they had used very effectively to improve safety and efficiency). Nevertheless, they agreed with the workflow analysis and supported the change. Executive leadership approved the change and we proceeded.

Two years later (2007), when I reported this experience to an EHR-safety conference, David Classen noted that the results of the Leapfrog CPOE test in 62 carefully studied hospitals confirmed that this hazard ... appears to be present regardless of which vendors’ products are used. (Classen, in press).

[The effects of the disruptions at those 62 carefully studied hospitals might likely increment the "tip of the iceberg" HIT-related injury/death figures cited at the same meeting by FDA official Dr. Jeffrey Shuren- ed.]

In other words, any organization that implements a CPOE system needs to throw away whatever IT system is being used in pharmacy, with all of the familiarity and experience of pharmacy staff, and safety improvements that software might have provided because interfacing the systems is (allegedly) impossible and/or impractical. Then, after a learning curve characterized by disruptions in service, it is hoped the new pharmacy system will provide similar benefits to the old, and that the CPOE itself will work well (and not do this).

This disruption, caused by software dependencies in a complex biomedical setting and perhaps other reasons (see below), certainly represents a complex interdependency, the "solution" to which creates new problems, such as:

• What if the new CPOE vendor-sourced pharmacy system is inferior to the old?
  
• What does the organization due if the single-source vendor folds, now causing orphaned software over two, not one, critical functions?
• What other software-to-software interdependencies and bottlenecks exist that are not easily remedied by interfaces? CPOE-diagnostic imaging (radiology)? CPOE-laboratory? CPOE-O.R.? CPOE-dietary? CPOE-bed control? And so forth for CPOE and other systems to be installed.
  
• What happens if the CPOE fails (as here)?
  

As to causation of the allegedly irremediable incompatibility between CPOE's and Pharmacy IT, Dr. Walker submitted the following testimony:

... hazards arise due to failures in health IT design, implementation, and maintenance. (While many of these failures are due to a lack of skill or vigilance, many more are due to the interactions of complex healthcare processes and the necessary complexity of IT systems capable of supporting those processes.)

While I await the aforementioned Classen in-press paper on 62 hospitals, I take a more saturnine view and would argue that most of the interfacing problems probably have more to do with "lack of skill and vigilance" as opposed to some "organic" problem in interfacing these systems.

My view is based on experience in the IT backwater of hospitals and HIT, where bureaucrats and IT personnel largely are working far outside their core competencies; where straightforward software adaptations in complex subspecialties can be completely and repeatedly bungled until appropriate expertise is leveraged; where expert advice may simply be ignored and worse; and other pathologies. (See more on ONC Director Blumenthal's call for correction of the healthcare IT skills problem at "ONC Defines a Strategy of Robust HIT Leadership".)

The CPOE interface difficulties may also be in part due to vendor strategies of closed and overly complex software and information architectures, and vendor unwillingness to assist in interfacing to "alien" pharmacy IT products through ominous cost structures and halfhearted attempts. These matters could be strategic business decisions in a highly competitive market. (The supposed incompatibilities might actually be another argument supporting open source in healthcare...)

-------

In either case regarding interface difficulties, i.e., human-based vs. "organic" IT issues, however, one can see that health IT is no easy "plug and play" affair.

There is no predetermined benefit nor ROI. The complexities and "wicked problem" nature of HIT argue that benefits and ROI will not come short term - and never if the technology and its mass implementation are treated as easily tractable, not experimental and "wicked."

Finally, CPOE a typewriter for orders? Perhaps, if this is the kind of typewriter being referred to:

Typewriter for Japanese language

-- SS

For more on HIT challenges see "Contemporary Issues in Medical Informatics: Common Examples of Healthcare Information Technology Difficulties" - http://www.tinyurl.com/healthITfailure

Sacks Medical, KV Pharmaceutical Plead Guilty, Mariner Health Care, SavaSeniorCare Settle

The march of legal settlements and guilty pleas by health care organizations just keeps going.  The most recent participants were:

Sacks Medical Corp

The Pittsburgh Tribune-Review reported:

A Butler County drug company pleaded guilty in federal court in Pittsburgh to international money laundering and violating federal drug laws in an investigation that involved the now-defunct Monsour Medical Center Research Institute.

Sacks Medical Corp. of Evans City was fined $500,000 and ordered to forfeit an additional $500,00 by U.S. District Court Judge Gustave Diamond on Monday. The firm was placed on one year's probation.

The research institute was not charged in the investigation.

According to federal prosecutors, Sacks in 2004 obtained pharmaceutical drugs at discount prices, which were then resold to other drug wholesalers in violation of the Prescription Drug Marketing Act.

Sacks persuaded officials at the Monsour Medical Center in Jeannette to create the research institute, which was nothing more than a shell company, according to the charges.

The institute joined two group purchasing organizations and began buying large amounts of medical supplies that should have been designated only for the hospital's use and not resold, according to the charges.

Purchases were made from major drug companies, AmerisourceBergen of Valley Forge and McKesson Corp. San Francisco. Monsour then sold the medications to Millenia Hope Healthcare Inc., which was located at Monsour.

Millenia then sold the drugs directly to Sacks or to San Med Development Group, which is owned by Sacks, according to prosecutors.

Sacks supplied Monsour with the money to buy the discounted drugs. The company then tried to disguise the transaction by wiring the money to a Canadian bank, which in turn wired the money back to Monsour, according to the plea agreement.

The novel element here seems to be the charge of international money laundering.

KV Pharmaceutical

Bloomberg reported:

KV Pharmaceutical Co. agreed to pay a $25.8 million fine and forfeit $1.8 million to resolve a U.S. Justice Department investigation of its generic pharmaceutical marketing and distribution unit, which will cease operations.

That unit, Ethex Corp., will also enter a plea of guilty to criminal charges arising from its actions in 2008, according to a statement issued today by St. Louis-based KV. The agreement requires court approval, the company said.

Under the terms of the accord, Ethex will plead guilty to two felony counts stemming from its failure to make and submit to the U.S. Food and Drug Administration a report on its discovery of undistributed pills that 'failed to meet product specifications,' KV said separately in a filing today with the U.S. Securities and Exchange Commission.

Note that these first two cases both involved guilty pleas to criminal charges, felonies in the latter case.  Further note, however, that in the latter case, the felony pleas were made by a subsidiary of the corporation, which will then be dissolved, leaving the parent corporation intact.  Although in both cases organizations pleaded guilty to criminal charges, there were no reports that any individuals who worked for or were otherwise involved in these organizations pleaded guilty to any charges.
Mariner Health Care, SavaSeniorCare (and Omnicare)

Again, from a report by Bloomberg:

The U.S. reached a $14 million settlement with nursing home chains Mariner Health Care Inc. and SavaSeniorCare Administrative Services LLC over allegations of kickbacks from a supplier of drugs to nursing home patients.

The accord resolves claims that the companies and their principals, Leonard Grunstein, Murray Forman and Rubin Schron, solicited kickbacks from Omnicare Inc., the U.S. Justice Department said in an e-mailed statement.

The defendants conspired to have Omnicare pay $50 million in exchange for agreeing to use the supplier for 15 years, the government said last March in a complaint in Boston. The alleged kickback scheme involved Omnicare’s paying $40 million to buy a Mariner unit whose only assets were less than $3 million in accounts receivable, according to the complaint.

Note that we discussed another settlement involving Omnicare and kickback allegations here.  It appears, however, that Omnicare paid any additional penalty in this case, despite allegations that it provided the kickbacks.

Summary

Again, another week, another series of colorful legal settlements and/or guilty pleas and/or convictions involving health care organizations.  Again, although organizations settled or pleaded guilty, no individuals seemed to be held accountable for authorizing, directing, or implementing the actions that lead to these pleas and settlements.

So, here we go again ... To repeat, seemingly ad infinitum, these are just the latest in a now long parade of settlements and guilty pleas and criminal convictions, sometimes involving charges like bribery, fraud, or kickbacks,  that serve as reminders of poor behavior by myriad health care organizations. As we have previously noted, these settlements seem to have little deterrent effect on future bad behavior. (Note that many large health care organizations have settled or plead guilty in several major cases since we started commenting on such settlements.) Usually, the companies involved only need to pay fines, and no individual who performed, directed or approved unethical or illegal acts will suffer any negative consequences. I submit once again that such fines are viewed merely as costs of doing business by the affected companies, and do not deter future bad behavior. Until the people who approve, direct, and perform unethical or illegal acts pay some penalties, expect such acts to continue. I again suggest that to truly reform health care, we need rigorous regulation of health care organizations that has the power to deter unethical behavior that may risk patients' health.

FDA on Health IT Adverse Consequences: 44 Reported Injuries And 6 Deaths In Two Years, Probably Just 'Tip of Iceberg'

The Office of the National Coordinator for Health IT held a meeting of the HIT Policy Committee, Adoption/Certification Workgroup on February 25, 2010. The topic was "HIT safety." The agenda, presenters and presentations are available at this link.

At this meeting FDA testimony was given by Jeffrey Shuren, Director of FDA’s Center for Devices and Radiological Health. Dr. Shuren noted several categories of health IT-induced adverse consequences known by FDA. This information was striking:

He wrote:

... In the past two years, we have received 260 reports of HIT-related malfunctions with the potential for patient harm – including 44 reported injuries and 6 reported deaths. Because these reports are purely voluntary, they may represent only the tip of the iceberg in terms of the HIT-related problems that exist.

[I'd call that a likely understatement - ed.]

Even within this limited sample, several serious safety concerns have come to light. The reported adverse events have largely fallen into four major categories: (1) errors of commission, such as accessing the wrong patient’s record or overwriting one patient’s information with another’s; (2) errors of omission or transmission, such as the loss or corruption of vital patient data; (3) errors in data analysis, including medication dosing errors of several orders of magnitude; and (4) incompatibility between multi-vendor software applications and systems, which can lead to any of the above.

This is a technology almost universally touted as inherently beneficial, right up to our most senior elected leaders, who are now pushing this unproven technology under threat of penalty for non-adopters - certainly a precedent, especially in a supposedly democratic country. I have given examples on this blog about how this belief about the universal goodness of healthcare computing is itself inherently idealistic - and unrealistic.

Now, here are some very striking, discrete examples of HIT-related adverse consequences, the tip of a larger iceberg, size unknown but quite possibly very large (where's Kate Winslet when you need her?):


(1) Errors of Commission

Example 1: An error occurred in software used to view and document patient activities. When the user documented activities in the task list for one patient and used the “previous” or “next” arrows to select another patient chart, the first patient’s task list displayed for the second patient.

Example 2: A nuclear medicine study was saved in the wrong patient’s file. Investigation suggested that this was due to a software error.

Example 3: A sleep lab’s workstation software had a confusing user interface, which led to the overwriting and replacement of one patient’s data with another patient’s study.

[I covered other examples of confusing or "mission hostile" interfaces at an eight part series here - ed.]

(2) Errors of Omission or Transmission

Example 1: An EMR system was connected to a patient monitoring system to chart vital signs. The system required a hospital staff member to download the vital signs, verify them, and electronically post them in the patient’s chart. Hospital staff reported that, several times, vital signs have been downloaded, viewed, and approved, and have subsequently disappeared from the system.

Example 2: An operating room management software application frequently “locked up” during surgery, with no obvious indication that a “lock-up” was occurring. Operative data were lost and had to be re-entered manually, in some cases from the nurse’s recollection. [I experienced similar problems: a decade ago - ed.]

Example 3: An improper database configuration caused manual patient allergy data entries to be overwritten during automatic updates of patient data from the hospital information system.

(3) Errors in Data Analysis

Example 1: In one system, intravenous fluid rates of greater than 1,000 mL/hr were printed as 1 mL/hr on the label that went to the nursing / drug administration area.

Example 2: A clinical decision support software application for checking a patient’s profile for drug allergies failed to display the allergy information properly. Investigation by the vendor determined that the error was caused by a missing codeset.

Example 3: Mean pressure values displayed on a patient’s physiological monitors did not match the mean pressures computed by the EMR system after systolic and diastolic values were entered.

(4) Incompatibility between Multi-Vendor Software Applications or Systems

Example 1: An Emergency Department management software package interfaces with the hospital’s core information system and the laboratory’s laboratory information system; all three systems are from different vendors. When lab results were ordered through the ED management software package for one patient, another patient’s results were returned.

Example 2: Images produced by a CT scanner from one vendor were presented as a mirror image by another vendor’s picture archiving and communication system (PACS) web software. The PACS software vendor stipulates that something in the interface between the two products causes some images to be randomly “flipped” when displayed.

The above is from FDA and by their own admission under-represents the problems, perhaps massively. Most of these errors are inexcusable from an engineering and quality perspective.

Unfortunately, there actually is no comprehensive data on the true magnitude of the problems.

44 injuries and 6 deaths: tip of the iceberg?

Merely writing about this scarcity can bring opposition. For instance, a recent paper I wrote about lack of data on unintended adverse consequences of HIT and remediation of the data paucity was rejected. (The paucity itself might be considered an 'unintended consequence' of HIT, since secrecy about pros/cons of HIT was not the intention of the medical informatics pioneers.)

One of the reasons given by an anonymous reviewer justifying rejection of the paper was itself striking:

The paper "adds little that is new or that goes beyond what a reader might find in a major city newspaper", the reviewer wrote.

Little that is new to whom, exactly? Where are the extant papers on the scarcity of such data?

I am also highly uncertain as to which "major city newspapers" the reviewer was referring to, as I've rarely if ever read articles in newspapers about the paucity of data on adverse consequences of HIT or the remediation of the paucity.

One reason for writing the paper was due to the fact the "major newspapers" - and the medical and medical informatics journals - largely avoid such issues entirely.

(The scarcity was noted by organizations such as the Joint Commission, however, in their 2009 Sentinel Events Alert on HIT - "There is a dearth of data on the incidence of adverse events directly caused by HIT overall.")

This reviewer continued with the frivolous comment that "proposing a classification of sources of unintended consequence and analysis of reasons for undereporting of each type in the resulting classification could be a useful addition to the field."

Ironically, I actually devoted an entire section of the paper to reasons for under-reporting and scarcity of unintended consequences, broadly speaking, although that this wasn't the paper's main purpose. Its purpose was to point out the dangers inherent in such an information scarcity. It is also hard to granularly classify variants of a phenomenon on which there is scarce data to begin with.

Rather than revise the paper, I may simply put it in the public domain and send it to my elected representatives involved in healthcare IT policy. I'd done this with another paper I'd written in 2007 on EMR's and postmarketing drug surveillance that had received a mysteriously similar "could have read this in any newspaper" critique.

In summary, the light is starting to shine on HIT dangers. It is also increasingly recognized by regulators such as FDA that "data scarcity" is a problem of major significance ("tip of the iceberg"), although there are those in this sector who would prefer to keep physicians and patients in the dark on this issue and keep such data scarce.

Finally, while Shuren presented a number of options regarding FDA involvement in HIT regulation, he wrote that "in light of the safety issues that have been reported to us, we believe that a framework of federal oversight of HIT needs to assure patient safety." This itself represents a major change in the culture of HIT.

Addendum: the Huffington Post Investigative Fund wrote about this meeting in an article entitled "Experts: Safety Oversight Needed as Patient Records Go Digital" here.

-- SS

For more on HIT challenges see "Contemporary Issues in Medical Informatics: Common Examples of Healthcare Information Technology Difficulties" - http://www.ischool.drexel.edu/faculty/ssilverstein/cases/