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    Sunday, February 18, 2007

    Birth Pangs: There aren't too many hosannas being sung to electronic medical records at Kaiser these days:

    Kaiser Permanente's $4-billion effort to computerize the medical records of its 8.6 million members has encountered repeated technical problems, leading to potentially dangerous incidents such as patients listed in the wrong beds, according to Kaiser documents and current and former employees.

    At times, doctors and medical staff at the nation's largest nonprofit health maintenance organization haven't had access to crucial patient information, and system outages have led to delays in emergency room care, the documents show.

    .....By far, the biggest challenge occurred over several weeks in April and May, when much of the system was repeatedly unavailable, including once for nearly a day and another time for more than two days.

    The main problem originated at Kaiser's primary data center in Corona, which houses Health Connect servers and backup power supplies. Poor design of the system's technology infrastructure and power problems led to a series of crises, according to documents and interviews with Kaiser employees.

    It was during this time that a rash of potentially risky events occurred, documents and Kaiser medical staff say. A problem report during that time listed two events. In one, patients at an unnamed Southern California hospital were listed in the wrong beds, potentially not getting the treatment they needed and possibly "receiving the incorrect medications." In another case, staff at the Baldwin Park Medical Center reported lab workers may have missed crucial patient requests from doctors.

    ......."We were told this would be a panacea, but it's not that," said Justen Deal, a Los Angeles Kaiser project supervisor who worked on the new system. He was placed on leave in November, after sending a critical e-mail about the project to most of the organization's 153,000 employees.

    "The truth is there are a lot of people inside the company who are worried the project is costing too much and is putting patients at risk," Deal said.

    Adrienne Clements, a nurse at South Sacramento Medical Center, said parts of the new system work better than older paper records. But she worries about several recent problems, including malfunctioning bedside scanners.

    "We were told this would be a panacea." Yes, we are constantly told that. So much so, that when the problems with electronic medical record systems are pointed out , the true believers shout them down and refuse to take the matter seriously. That electronic records are good and paper records/systems are bad has become dogma.

    There's also the cost, which puts a strain on the business side of medicine, even for big business like Kaiser. Of course advocates say that the systems will save money:

    Computer-linked health systems also may help reveal the forces pushing up costs, make it easier to analyze the risks and benefits of prescription drugs and improve the understanding of dramatic variations in medical care and access to it.

    They could reduce the nation's $1.9-trillion healthcare bill by as much as $81 billion a year, according to a Rand Corp. report. The question is how easily and safely providers can make the technological transition.

    That's a big "could." So far, Kaiser hasn't seen any of that $81 billion/year savings:

    .....Health Connect also is costing a lot more than anticipated. Its current price tag is more than double its original $1.8-billion estimate, calculated in February 2003. Halverson said costs rose in part because Kaiser decided to add electronic medical records in all its hospitals later that year. The board approved a $3.2-billion budget in September 2003. But officials can't fully explain why the budget figure they cite now is $800 million higher.

    Critics will say they just chose the wrong system, but no system is perfect and since this is all very new, no system has been tested in big systems like Kaiser's. We may be jumping onto this electronic record bandwagon faster than we should be.

    posted by Sydney on 2/18/2007 07:32:00 AM 3 comments


    Mr. Deal's credentials have been inflated by the newspaper reporter: he's a 25 year-old trainer (i.e. teaches people how to use Epic) who thinks he's got the technical and managerial background to hold KP's leadership accountable for reality. He sounds to me like an idealistic young man who has finally seen for the first time the implementation of a business system in real-life instead of a classroom case-study. Instead of being repelled by the classroom case-study, he's repelled by real-life. Here's a link to his ill-advised manifesto.

    To address in part the substance of what he and Syd have said...

    All this is true: electronic systems will not solve every problem of medical records. It is true they are expensive, and that those expenses are painfully visible. It is true that they suffer failure modes that paper records don't suffer. It is true that "Big Bang" implementations are risky for a number of reasons, including managerial ignorance of existing business processes. It is true that health system managers by-and-large don't adequately plan for system outages. It is true that health system managers fail to enlist support from physicians and nurses and medical reords staff. And evidently their IT staff as well.

    It is true also that paper records are expensive. Paper records systems fail. Paper records systems put patients at risk of many well-documented things that go unnoticed the way we don't usually notice air. And it is true the IOM report has shown us the risks of all this.

    To jump headlong into electronic medical record systems in 1980 might have been premature. Not to have seriously begun by 1990 might have been excusable. To label recent industry-wide attempts to address the problems of disjoint, incomplete, incorrect, illegible, and unavailable medical records a "bandwagon" and to say a quarter-centruy past techincal feasibility is still too soon strikes me as some combination of silly and irresponsible.


    By Anonymous Tom Leith, at 2:18 PM  

    That's all very well said, but going without ANY RECORDS AT ALL for two days is really terrible. The computer solution may be more expensive than expected, but it sounds like not nearly enough was spent on duplicate equipment to avoid rare, disatrous shutdowns.

    I'd like computer solutions to work, because I've seen what happens when a doctor looks at my paper file. I've gone to the same medical center for 35 years, I'm healthy but there's a lot of paper in my file, and it's not in chronological (or any other ) order. Doctors just riffle it for a second and set it aside unread.
    - tobias robison
    princeton, nj usa

    By Blogger The Blogger, at 5:10 PM  

    Electronic medical records do not save money in their current configuration, and should not be touted as doing so. They will never save time for the physician and some other providers, though it might for business functions. In our hospital, the ICU and L&D are not required to use the current EMR system because there is too much data to enter and the patients are too acute to allow attention to be diverted from the bedside to the computer. It'll be interesting to see how the new $2mil system works in those areas.

    The only benefit that all EMR systems should have is improving patient care. Otherwise, there clearly is no point in having one. I think that it's possible, because the NHS has done a great job with it, and clearly it must be saving them money, or they wouldn't have bought the system in the first place. It's a mystery why Kaiser couldn't do it as well.

    The other thing the NHS has is the availability for each patient to carry their own records on a memory stick. I wonder if Kaiser patients have the same option. It would sure help when the system is down, as systems sometimes are....

    By Anonymous danie, at 12:11 PM  

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