From The Ergoweb® Learning Center

Blumenthal to Lead Electronic Patient Records Challenge

President Barak Obama sees an interoperable electronic system for patient records as the foundation for healthcare reform. On March 20, he tapped David Blumenthal, a Harvard University professor who is director of the Institute for Health Policy at Massachusetts General Hospital, to realize the vision. The president argued shortly before he took office that the system will “cut waste, eliminate red tape, and reduce the need to repeat expensive medical tests … [and] save lives by reducing the deadly but preventable medical errors that pervade our health care system."

Blumenthal faces a formidable challenge. In his role as national coordinator for health information technology, the professor will have nearly $20 billion to meet it. An Associated Press article notes that some experts worry the funding could pay for making paper records electronic, without giving doctors and hospitals much greater ability to connect.

Closing the gap between the vision and its realization will require countless ergonomic solutions to individual challenges.  Dr. Blumenthal referred to one of the biggest – coaxing hundreds of thousands of doctors to quit using paper files and join the digital age – in an article he wrote with Jonathan Glaser, Chief Information Officer at Partners HealthCare, for the New England Journal of Medicine in 2007. According to the Wall Street Journal, Blumenthal and Glaser pointed out that for doctors, particularly those in solo or small practices, computerization conjures an image of “a waiting room full to bursting, a crashed computer, and a frantic clinician on hold with IT support in Bangalore.”

In a January 21 paper this year called “Digital Health Record System an Elusive Goal,” The Ergonomics Report®, a publication for subscribers with a professional interest in ergonomics, cited other articles in which experts explored individual challenges.
Luis Castillo, senior vice president of Siemens Healthcare, a company that designs health care technology, told CNN Money, that the experts will have the extremely difficult task of designing a system that "thinks like a physician." Doctors cannot spend hours and hours learning a new system," he said. "It needs to be a ubiquitous, ‘anytime, anywhere’ solution that has easily accessible data in a simple-to-use Web-based application." The doctors have to learn how to interact naturally with their patients, even as they are entering data into their PCs.

Robert. N. Charette’s overview of the project in the October 2008 issue of IEEE Spectrum, the journal of the Institute of Electrical and Electronics Engingeers, Inc., explained that if the system is to be realized, it will mean getting every hospital, every nursing home, every pharmacy, and every one of the hundreds of thousands of physicians who belong to solo or small group practices to participate.

He noted that figuring out how to integrate the many types of information that could be included in a patient’s record—doctor’s notes, test results, billing data, not to mention the dozens of sources of information—is an enormous challenge. Among the unanswered questions, he said, are how the hundreds of thousands of electronic medical record systems will interconnect; how they will they exchange data; how the privacy and security of hundreds of millions of personal files be maintained; and who will pay. He notes that the biggest question of all is whether the network, once installed, will work.

Computerized provider order entry issues and unintended adverse consequences are so common in e-health system research that they have earned their own acronyms—CPOEs and UACs, respectively. The sheer number of research papers on the problems suggests an almost bottomless demand for ergonomics and human factors solutions.

In a 2005 issue of JAMA, the American Medical Association publication, Ross Koppel, Ph.D., and colleagues worked to identify and quantify the role of CPOE in facilitating prescription error risks. Published studies report that CPOE reduces medication errors up to 81 percent, they noted, but few researchers have focused on the existence or types of medication errors facilitated by CPOE. He listed many examples of this kind of error. 

After a near miss involving a diabetic patient and bar coding, researcher Clement J. McDonald, MD, concluded in the 4 April 2006 issue of Annals of Internal Medicine that “computer systems may have the pernicious effect of weakening human vigilance, removing an important safety protection.”

The effort to build patient privacy into a network that is national in scale presents both human factors challenges and technical headaches. Charette asks how it will be possible to ensure that various healthcare workers see only what they need to see. 

Several articles cite concerns about hackers and system failures. As reported in the Charette article, Britain’s experiences to date offer a foretaste of issues that will have to be confronted on this side of the Atlantic. One hospital in Oxford reported patients’ digital records disappearing from its database. A recent study found security systems that were so poorly constructed medical staff routinely bypassed them when accessing Britain’s National Health Service computer systems. The study documented 70,000 cases in a single month of people at one medical trust gaining inappropriate access. Some doctors have refused to enter any patient data into the system, for fear of making errors or compromising their patients’ privacy. In some surveys, support for the project among doctors has fallen by almost half over the past two years.

The experts are not arguing for for killing the project to develop an interoperable e-system for patient records. They present their concerns as a way of alerting the system’s designers to issues that must be addressed.

The example of the Moon landing suggests United States expertise is equal to the task – if the political will to achieve the goal is sustained. 

Sources: Wall Street Journal; The Ergonomics Report®;  IEEE Spectrum, CNN Money; JAMA; Annals of Internal Medicine