Texas Medical Association slams ONC Healthcare IT safety plan

The Texas Medical Association offers views similar to the views I have been writing about for a decade and a half on healthcare IT quality and patient care risks:

FierceHealth IT today

Texas Medical Association slams ONC safety plan

By Dan Bowman

The health IT safety action plan proposed by the Office of the National Coordinator for Health IT in December is not specific enough to succeed, according to recent comments made by the Texas Medical Association. In its letter to National Coordinator for Health IT Farzad Mostashari, TMA said that responsibility for the plan "lacks focus," and should be overseen by a "highly visible HIT Safety Czar. TMA also called setting mandatory deadlines and developing a "robust" reporting and learning system imperative to the success of the plan, saying that the plan's current reliance on voluntary reporting and funding represents a "fundamental weakness." "TMA believes that significant patient safety risks exist now, and new ones will emerge in the next one to two years as many [electronic health record] and other HIT vendors merge or go out of business," the letter said. Additionally, the group expressed doubts about a code of conduct proposed to keep vendors in line as far as ensuring cooperation with safety organizations for adverse event reporting. "TMA is concerned that this will not materially affect industry accountability and generate the changes that are needed," the letter said. "For example, what if a developer does not comply with said code of conduct? There is no penalty or impetus for change." The American Medical Association was a bit less harsh in its assessment of ONC's plan. It supports most of the ideas outlined in the plan, although it called for more research to be done on the impact of electronic health record use regarding patient safety in the ambulatory setting. "Physicians are concerned about potential liabilities from EHR system design and software flaws, as well as lack of interoperability among EHR systems that could result in incomplete or missing information, which may lead to errors in patient diagnosis and treatment," the AMA letter said. "In addition, the impact that EHRs have on physician practice workflows can lead to unintended consequences. Those impacts are the result of how the software is developed." HIMSS said in its letter to Mostashari that it wants to see more provider-vendor cooperation when it comes to investigation of patient safety events, as well as usability, while the AHA said in its letter that its stakeholders would like to see more of a focus on a single, national approach to matching patients with their records with a goal of patient safety. The College of Healthcare Information Management Executives, meanwhile, said that the plan needs to be facilitated by stakeholders not directly under government control. To learn more: - here's the TMA letter (.pdf) - read the AMA letter (.pdf) Related Articles:HIMSS, AHA support ONC's patient safety plan CHIME: ONC's role in health IT safety plan 'overstated' HHS issues health IT safety action plan

The TMA and AMA letters linked above are worth reading in their entirety.

I note, with little surprise, the "softer" stances (e.g., self-policing vs. government oversight) taken by industry-dominated bodies such as HIMSS and CHIME.

On the other hand, I find the AMA's "less harsh" views somewhat disappointing.  Their letter is welcome, and more research needs to be done as to risks in ambulatory settings (and inpatient settings as well).  However, the delays in action during the research are of concern.

Where patient safety is concerned, fast action is a top priority.  Patients, needless to say, have more rights than computers and their sellers.

-- SS

ATP, Thermogenesis and Leptin Man's Electrons

A little update on the adventures of a man we call Leptin Man here at The Asylum, Jack Kruse.  I skimmed his latest (6 page!) manifesto, and near as I can figure, his focus is on ATP stores.  His metabolic pathway du jour is the Pentose Phosphate Pathway (PPP).  Among many many words, he writes:

TRUTH BOMB:  This pathway has only a few major endpoints, but they are all massively important for human life.  It is designed to optimally restore RNA and DNA synthesis by providing maximum recycling of ATP;  and it allows for optimal formation of bio-energenic substrates to make replenish the mitochondria’s ability to increase total adenine nucleotides to re-establish optimal ATP stores from beta oxidation of fats.

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Guest post by Dr. Jon Patrick, U. of Sydney: On the ECRI Institute's recommendations following a "deep-dive" study of HIT-related events

At my Feb. 9, 2013 post "ECRI Institute PSO Uncovers Health Information Technology-Related Events in Deep Dive Analysis", I wrote about an ECRI Institute study of well-defined client data submitted over a 9-week period (a "deep dive" study) on EHR problems.  Risk-creating events at a level that should be a significant concern to patients and clinicians fell into the following categories: 

• inadequate data transfer from one HIT system to another 
• data entry in the wrong patient record
• incorrect data entry in the patient record
• failure of the HIT system to function as intended 
• configuration of the system in a way that can lead to mistakes

Dr. Jon Patrick at U. Sydney, a scientist and medical informatician who sees the issues from a number of unique perspectives (link to bio), has offered the following critique of the key recommendations made by the ECRI Institute as a result of this study of health IT events (see aforementioned post for the text of those recommendations). 

One caveat is that neither he nor I have the full report as of this writing in part due to expense:

The ECRI has produced a report on HIT errors. I was concerned about the manner in which the Key Recommendations minimised, generalised or failed to concretise important issues that I offer these comments.

On ECRI Key Recommendations:

1. Enlist leaders’ commitment and support for the organization’s health IT projects.

JP: This is clearly a comment from one level of  management to those levels above it. It doesn't seem to be a comment about the nature of the HIT itself but more about the internal processes to getting it established. There is really not much to say here because if upper management don't want to do anything about the introduction of HIT then engaging in the task is probably futile, hence it was difficult to understand why it was included.

2. Involve health IT users in system planning, design, and selection.

JP: yes, this is crucial to successful solutions.

3. Conduct a review of workflow and processes to determine how they must be modified.

JP: the missing clause at the end of this sentence is "to fit the introduced HIT system". This is putting the cart before the horse. The notion that a piece of software designed by engineers should have priority over the team of clinicians who are experts in their business is highly naive. Also this statement is in contradiction to point 2 above.

The privileging of the functioning of  the IT system as the expert over that of the clinical team, AND making a recommendation in contradiction to an earlier recommendation is absurd enough by itself  to undermine the credibility of  the report.

4. Evaluate the ability of existing IT systems within the organization to reliably exchange data with any health IT system under consideration.

JP: And after the evaluation what should be done. This is hardly an informative recommendation. It is of the form "Do Something, it doesn't matter what you do, just do something."  A more compelling statement that would have enhanced the credibility of the authors and demonstrate their knowledge of the industry would have been: " Establish unambiguously and conclusively that any health IT system under consideration has the ability to reliably exchange data with existing IT systems within the organization". Note the focus needs to be on the incoming system being the object of conformity not the incumbent systems.

5. Conduct extensive tests before full implementation to ensure that the health IT system operates as expected.

JP: this is a clearly a desirable goal and applies to point 4 above as well as all other aspects of the system functions.

6. Provide user training and ongoing support; educate users about the capabilities and limitations of the system.

JP: This is a motherhood statement that does nothing to contribute to the nub of training issues in the use of HIT. Training is an ongoing issue for two reasons: staff change and new staff come on to the roster and need to be trained, and, these systems are complex and expert advice and skill needs to be available to staff as an ongoing service so that work is not delayed due to confusion on how to use the IT. An alternative proposal to reduce training costs and investment would be to design the system so that it matches current best practice of the clinical team so that learning the system is minimised because it fits seamlessly into their work processes.

Surely the issue of educating users about the capabilities and limitations of the system is independent of the training topic. The users will discover on their own bat the limitations of the system as they try to use it.

7. Closely monitor the system’s ease of use and promptly address problems encountered by users.

JP:This is a quite inadequate description of the action that needs to be taken. The real consideration is for them to have an effective avenue for expressing the limitations in a manner that is acceptable and they are NOT chastised as malcontents [or Luddites or technophobes - ed.] AND that the unnecessary or dangerous limitations are addressed promptly.

8. Introduce alterations to a health IT system in a controlled manner.

JP: It is hard to understand what is meant by this statement. Firstly I would have said "introduce alterations to the clinical processes  in a controlled manner". Secondly, alterations to the HIT system need to be done promptly  when it is defective. Once again, as in point 3 above the technology is being preferenced over the clinical processes which I argue is back-to-front.

9. Monitor the system’s effectiveness with metrics established by the organization.

JP: This is definitely something that should be done but it also needs a more directed purpose. It is easy to say to assess patient safety but most systems don't readily capture relevant data or supply analytical devises to easily draw a picture of patient  safety. However there is an equally important factor in care that is often overlooked and that is staff productivity and by implication morale. There is a need to understand better ways of assessing staff productivity in positive ways and the effect a CIS has on staff morale.  Typical comments about CISs is that they cost staff  up to 20% more time to maintain the patient record. Staff wouldn't mind giving up that time if it was returned in some other form, but it isn't, so they feel the time is stolen from them or from their patients.

10. Require reporting of health IT- related events and near misses.

JP: This is poorly stated and is probably meant to read "health IT - related adverse events". This is a positive recommendation but does not go far enough. A more comprehensive statement would be "Install a process and technology for reporting adverse events and establish methods for evaluating the reports and recommending changes to clinical practice, or technology functionality and implementing them.

11. Conduct thorough event analysis and investigation to identify corrective measures.

JP: This  goes some way to dealing with my point in item 10 above. Its weakness is in not identifying the types of problems and taking a firm stance on completing the correct action.

SOME of the Items that have been OVERLOOKED

1. The system needs to be alterable at any time by the clinical leadership so as to immediately emplace revised work practices when they are approved.

2. The system needs to have native analytics so that the clinical leadership can monitor the activities of their teams and provide evidenced based feedback to support continuous process improvement.

3. The system needs highly accurate natural language processing so that the search for required content though the clinical record can be fast, efficient and reliable.

Professor Jon Patrick
Chair of Language Technology
School of Information Technologies
Faculty of Engineering
University of Sydney
Health Information Technologies Research Laboratory

http://www.it.usyd.edu.au/~hitru

This is excellent advice coming from perhaps the only computing expert in the world who's conducted a forensic analysis of a major commercial EHR product, one intended for high-risk ED's.  His analysis of that product, intended for government-mandated rollout in public hospitals in Dr. Patrick's Australian state of New South Wales, is at this link.

This work has largely been ignored by the health IT industry and the academic Medical Informatics community.  However, I can assure the industry and the academic community that the report will not be ignored by those in the legal community if (perhaps I should say when) patients are injured or killed by the system's deficiencies.

-- SS

How a β-cell Works

In the next day or few, I'm going to be discussing diabetes. What it is, and what the science says causes it -- at least to the current state of knowledge and understanding.  This will serve as a prelude to  a larger discussion on hyperinsulinemia and insulin resistance in the pathogenesis of Type 2 diabetes.   Diabetes is β-cell dysfunction. Period. This does not mean that other organs and the organism as a whole are not involved in this dysfunction developing, but diabetes is, ultimately, an insulin deficiency syndrome.   If that sounds "off" because of the hyperinsulinemia associated with T2, stay tuned!

So I'm going to cobble together a few sources to introduce (or reintroduce) some terminology and basics of  β-cell function that will be used in future posts on this.  

Molecular Formation of Insulin

On a molecular level, the final product, insulin, starts out as preproinsulin, is converted to proinsulin and then finally to the insulin.  This is shown schematically below:

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Wow! Xperia Z dapat Memotret 999 Kali Hanya dalam 68 Detik

Limit Komputer | Wow! Xperia Z dapat Memotret 999 Kali Hanya dalam 68 Detik - Setelah beberapa hari yang lalu Blackberry 10 telah resmi dirilis, kali ini Sony Xperia Z juga ikut ambil bagian dalam menyemaraki pasar Smartphone dunia.

Tidak jauh berbeda dari Smartphone canggih lainnya, Sony Xperia Z juga akan hadir dengan berbagai fitur-fitur canggih baik dari sisi Software maupun Hardware. Xperia Z juga digadang-gadang merupakan  salah satu smartphone yang paling ditunggu-tunggu di tahun 2013 !

Ketangguhannya pun juga ikut diperlihatkan Sony dengan mengupload video yang berdurasi 1:26 detik di youtube. isi dalam video tersebut menggambarkan fitur utama yang dimiliki Xperia Z seperti: Video, Kamera, dan desain yang sangat elegan yang tidak terpengaruh oleh debu bahkan air sekalipun!.

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