Health Information Technology, Patient Safety and Anesthesia Practice


November 14, 2011

More than 750 companies offering some form of electronic health record solution have entered the market within the last few years, according to a report entitled "US Markets for Electronic Medical Records in 2012" by the Millennium Research Group.  Millennium predicts that the EHR industry will continue to grow at least twelve percent per year through 2016.  Other observers consider the market already saturated.

Neither scenario is propitious for providers or patients.  New firms entering the field may not have the experience or depth to support their technology and may not be viable for the longer term.  If, on the other hand, the EHR market is becoming saturated, the next phase will probably be a rush to the exit and consolidation of the survivors.  Many software products will cease to be supported at all.  One analyst has stated that “it’s not hard to imagine a 90 percent consolidation over the next two to five years.  This means nine out of 10 products will be gone, or on life support.”  (Rob Tholemeier, The EHR Business – End of the Line.  Health Data Management Blogs, November 7, 2011.)

One consequence of the rapid expansion of the EHR industry is concern over the safety of health information technology (HIT) in general. Designed and used properly, HIT should help improve professional performance, reduce operational and administrative costs and enhance patient safety. Some HIT products have begun to be associated with increased safety risks for patients. A new report from the Institute of Medicine (IOM) recommends ways to make patient care safer through HIT.

The IOM Report

The Office of the National Coordinator for Health Information Technology (ONC), a unit within the Department of Health and Human Services, asked the IOM to evaluate HIT safety concerns.  The IOM appointed a study committee, whose report Health IT and Patient Safety: Building Safer Systems for Better Care has just been published.  (Click here for a copy of the Report Brief.)

The study committee found that some HIT applications are clearly successful at enhancing medication safety. In contrast to soundly implemented computerized prescription order entry systems, evidence of the impact of EHRs and certain other products is equivocal.

Some HIT applications can create new hazards for patients. The committee noted several examples:

  • Dosing errors
  • Failure to detect life-threatening conditions
  • Delaying treatment because of “poor human-computer interactions”
  • Loss of data

Most of the IOM’s recommendations relate to greater transparency. Among them are the following:

  1. HHS should create a mechanism for vendors and users to report HIT-related deaths, serious injuries or unsafe conditions;
  2. HHS should recommend that Congress establish an independent federal entity, similar to the National Transportation Safety Board, to investigate adverse incidents;
  3. HHS should fund a new Health IT Safety Council within an existing voluntary standards organization to develop criteria for judging
    • the use of health IT to enhance safety, and
    • the safe use of health IT;
  4. ONC should discourage the use of confidentiality agreements in agreements between HIP users and vendors, as well as clauses that limit vendors’ liability; and
  5. ONC should work with the private sector to make comparative user experiences publicly available (think of Health Grades, for example).

Based on our own experience, we would add to the third item on the list another bullet: “safe integration of HIT applications across a facility or health system.” A first-rate EHR used to perfection by the anesthesia team cannot guarantee patient safety if it does not integrate properly with nursing information, for example.

Lastly, because of the private sector’s lack of any track record in fostering safety, the IOM committee recommends that HHS actively monitor the progress of health IT safety activities. If progress is insufficient, the Food and Drug Administration (FDA) should be given the charge and the resources to regulate HIT.

In response, the National Coordinator for HIT, Farzad Mostashari, MD announced on November 8th that “ONC will lead an HHS planning initiative to develop a comprehensive EHR safety action and surveillance well within the 12-month period recommended by IOM.”

The medical community may be less receptive to the IOM recommendations for new bureaucracies and a potential new role for the FDA than was ONC.  The FDA does not enjoy complete credibility and trust.  On July 29, 2011, in the wake of a number of well-publicized recalls of medical devices such as metal-on-metal artificial hips, no less an authority than the IOM itself published a report urging the FDA to scrap its existing system for regulating many “moderate risk” devices. The FDA should instead devise a new approval system that would for the first time evaluate safety and effectiveness prior to sale – which seems to us like a no-brainer.  Predictably, the medical technology lobby unleashed a major campaign to discredit the IOM report.  (Barry Meier, Study Faults Approval Process for Medical Devices.  New York Times, July 29, 2011).

A General IT Hazard in the OR

In the November issue of Anesthesiology News, Peter J. Papadakos, MD, professor of anesthesiology, surgery and neurosurgery at the University of Rochester published  commentary entitled “Electronic Distraction: An Unmeasured Variable in Modern Medicine.

Dr. Papadakos argues cogently that the ubiquity of web-connected devices in the operating room is placing patients at risk. He acknowledges that “we have almost no data on how electronic distraction affects worker productivity and dedication to repetitive tasks in health care.” A growing body of research has demonstrated that the addictive quality of smartphones, tablets and computers has increased traffic accidents, however. Dr. Papadakos notes that:

A study presented at the 2011 annual meeting of the American Society of Anesthesiologists found that nurse anesthetists and residents were distracted by something other than patient care in 54% of cases – even when they knew they were being watched! Most what took their time were pleasure cruises on the Internet (abstract 1726).

Contributing to the assumed problem, doctors and nurses now receive much of their information on their patients from a downloaded health history. There is less direct communication. “They do not speak to patients to get the subtle feeling for a disease in evolution or any new ‘minor’ change that has occurred since the patient was last seen.” Patients, writes Dr. Papadakos, “are no longer at the center of their care—their data are.”

He states that “technological changes and the accompanying societal shift have created an environment in which the health care worker constantly is tempted to surf the net, check social media and send emails” (where are you as you read this Alert? – Ed.) and concludes:

Anesthesiologists have led the way in the past with our introduction of monitoring and best-practice guidelines, which have been the keystone of patient safety. We must help train the next generation of health care providers to deal better with the ever-growing explosion of electronic devices that have become so common in our modern world.

The varied distractions of technology use in the OR have led hospitals and anesthesia groups to provide focused devices that limit the activities available in the perioperative areas. For example, some computers and tablets that are provided by the hospital restrict internet access as well as the ability to download or use non-sanctioned programs.

All of us are struggling to balance mountains of digital information with face-to-face or oral communications. In the OR context, this is one application of the principle of increased safety in the use of IT. We encourage you in the safe use of all HIT as we at ABC continue to enhance the accuracy, reliability, safety and ease of use of the various components of our OneSourceAnesthesia software suite.

With best wishes,

Tony Mira
President and CEO