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Digital records safer than paper, but still not perfect
“Paper kills,” goes the mantra that was popular among health IT advocates a couple years back.
The point, of course, is that the risk of adverse patients events is greater with paper records than with digital records. However true the contention may be, a recent story highlights the fact that not all risk is going to disappear as providers increasingly shift to new health IT.
On the contrary, as this recent Wall Street Journal piece shows, error and risk are probably never going to be completely eradicated from the record-keeping landscape. The story describes the plight of Philips Healthcare, which recently “recalled a defective patient data exchange system after finding it could transmit incomplete reports on heart tests, which the company said could lead to ‘misdiagnosis’ and ‘incorrect treatment decisions.’”
The prospect of misdiagnosing heart conditions is disturbing enough, but for our purposes what’s just as disturbing is how simple, and thus how easily overlooked, the problem seems to be.
To wit: “hitting the ‘enter’ button, to start a new paragraph, in the summary field of heart test reports, sometimes caused the text entered below that point to be stripped from the report as it was transmitted into the patient’s electronic health record. And doctors later reviewing the patient’s electronic health record would not necessarily know they had received only part of the report, which could lead them to make ‘incorrect treatment decisions,’ Philips said in a letter to hospitals.”
One researcher interviewed suggested “the best chance of hospitals preventing life threatening errors, as systems are adopted, is to create a permanent, full-time observation team watching how doctors are using the systems. The team, which could have four members for a large institution, should staff both IT experts and clinicians.”
Something tells us an idea like that isn’t going to get much traction, particularly at a time when providers are under significant pressure to control costs in all departments, including staff.
Still, assuming the risk of potentially life-threatening glitches isn’t going to go away soon, providers and other stakeholders may want to give more serious thought to how those glitches can be detected, and their potential errors avoided.
Photo courtesy of zigazou76, via Creative Commons
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