Death by 1000 Clicks Redux

Back in the ‘stone ages’ when I (an MIT grad) was an intern, I was called at 4 AM to see someone else’s gravely ill patient because her IV had infiltrated. I started a new one and drew some blood work to check on her status. When the results came back (on paper) I (manually) calculated her anion gap. This is simple arithmetic but I had been up all night and didn’t do it right.

She died.

On morning rounds the attending assured me that there was nothing I could have done anyway but, of course, in other circumstances it could have made a difference and an EHR could have easily done this calculation and brought the problematic result to my attention. My passion for EHRs and FHIR apps to improve them really traces back to this patient episode I will never forget.

My criticism of the recent Kaiser Health News and Fortune article Death by 1000 Clicks is generally not about what it says but what it doesn’t say and its tone.

The article emphasizes the undeniable fact that EHRs cause new sources of medical error that can damage patients. It devotes a lot of ink to documenting some of these in dramatic terms. Yes, with hundreds of vendors out there, the quality of EHR software is highly variable. Among the major weaknesses of some EHRs are awkward user interfaces that can lead to errors. In fact, one of the highlights of my health informatics course is a demonstration of this by a physician whose patient died at least in part as a result of a poor EHR presentation of lab test results.

However, the article fails to pay equal attention to the ways EHRs can, if properly used, help prevent errors. It briefly mentions that around a 60% majority of physicians using EHRs feel that they improve quality. The reasons quality is improved deserved more attention. The article also fails to discuss some of the new, exciting technologies to improve EHR usability through innovative third party apps and he real progress being made in data sharing including patient access to their digital records.

The article acknowledges that “medical errors happened en masse in the age of paper medicine, when hospital staffers misinterpreted a physician’s scrawl or read the wrong chart to deadly consequence, for instance.” It misses the opportunity to quantify the awful scope of this problem as the Institute of Medicine (IOM) did in 1999 when it found, based on 1984 data from physician reviews of New York hospital patient medical records, that “as many as 98,000 people die in any given year from medical errors that occur in hospitals.” A 2013 Journal of Patient Safety article reviewing four studies done in 2008-11 indicated that things were actually worse: “a lower limit of 210,000 deaths per year was associated with preventable harm in hospitals”. There is controversy about the exact numbers but little doubt that they are significant. The two studies cited were, of course, well before most of the wide adoption of EHRs funded by the federal HITECH program to fund EHR adoption. Moreover, while the issue is far from settled, there are studies that suggest that hospitals “with automated notes and records, order entry, and clinical decision support had fewer complications, lower mortality rates, and lower costs.” Other studies suggest that EHRs improve physician-patient communications.