Safety is always cited as a reason to involve government in medicine. But those of us on the front lines, those of us actually seeing patients, realize that government cannot insure your safety – and generally makes things worse.
Recently we and every other hospital and clinic which accepts Medicare payment has implemented electronic medical records. Electronic medical records were forced on us as part of Medicare and Obamacare, purportedly to help avoid redundancy of testing, to make past medical history more available and to make it easier to monitor the disease processes both individually and in aggregate.
Trust me, it does none of these things, but it does make you, the patient, at more risk of gross medical error.
I don’t know any non-university physician who likes electronic medical records. The issues I raise should not be seen as isolated to my facility, nor to my particular brand of EMR (electronic medical records).
In a busy orthopaedic clinic, in order to see patients efficiently, records may be dictated after the patient has left. It is not uncommon to make an error in recording the location of an injury or lesion, mistaking left for right either through dictation error, thinking backwards or transcription error. For example, I see a patient with a broken arm, and accidentally dictate right when it is the left arm that is broken. Thankfully, there are multiple layers of checks and balances to catch such mistakes. With a paper chart, this can easily be corrected on the note so that there is no evidence of the wrong side being recorded – we simply retype the note. Or the error can be crossed out, so the error is still visible, but clearly has been corrected.
Not so with EMR. Once the note is signed off for 24 hours, it cannot be changed. The best that can be done (at least in some systems) is that an addendum can be put in the chart. This little correcting note, for example, “Regarding Mrs. Jones wrist fracture, the injury occurred on the left, not the right as previously noted,” may or may not be stored next to the note with the error. It may or may not be obvious to anyone needing information about the patient. In other words, a physician seeing the patient in the future who is not familiar with the case may read the note, but not the addendum, because he does not know to look for it. It is obvious to any physician, but apparently not to the people who write these programs, that this is a major safety hazard.
The risk of medical error is compounded by the new digital X-ray systems. For decades, ever since X-rays have been used in operating rooms, there has been an industry standard. The X-ray was put up on the view box with left on left, and right on right. As a resident, it was my job to insure that the X-rays were correctly hung. So if I am operating on a left sided lumbar disc, the X-ray picture on the wall mirrors the reality with the ruptured disc on the left.
But in the new digital world, the industry standard is left on right. In other words, in the operating room the new standard for displaying images is backwards from historical precedent and from reality. Now, with a brain lesion, kidney mass, ruptured disc, or fracture on the left, the digital X-ray shows it to the right of the screen.
This came about because radiologists, not surgeons, developed the systems for digital X-ray, and their standard is to view the patient from the feet up, i.e. bottom to top, so the patient’s right is on the radiologist’s left. But the purpose of X-rays is not for radiologists to read them and get paid, but rather for surgeons and other physicians to use the X-rays for patient care.
I love my radiologist friends, but to adopt the radiologists’ standard over the operating surgeons’ is nightmarish. It is like setting airplane controls, not for the pilot, but to the standard of the repair crews. And although the young surgeons growing up with this may adapt to some degree, for those of us with over 20 years in the operating room, it is one more reason to retire early. Backwards X-rays add one more more level of uncertainty to an already complex situation.
Lets put this all together. Suppose there is a patient – a non verbal elderly man who is being taken to the operating room to have a right-sided brain tumor removed. In clinic the note was recorded in EMR erroneously by the resident physician as a left sided lesion. He recognized the error later and typed an addendum. But in the new world of medicine, where doctors are shift workers, he is not the one who prepares the patient for surgery. The next resident prepares the operative consent and paperwork for surgery, and he doesn’t find the addendum. So, he schedules the patient for a left-sided tumor removal. The patient – who cannot speak – cannot confirm verbally to the preoperative nurse that the procedure is on the right, a final check in most patients. And the surgeon, in the OR, who is used to having X-rays reflect the lesion as it really is in respect to left and right, sees the MRI of the tumor on the left of the screen, reads the notes and proceeds to explore the left side of the brain. Unfortunately, the tumor is on the right.
This happened very rarely in the old system. But, I expect an increase in frequency. Imagine if suddenly the auto industry changed the standard for steering wheels and now, when you turn the wheel to the right the car goes left. You may be OK most of the time, but when you are tired, anxious or just have a momentary lapse – boom. You revert to the old habits. It is human nature.
I would love to say that physicians are perfect, but we are human. As private individuals, physicians developed a system of medical practice over years that worked to prevent such errors, and overnight, the federal government replaced it with a top-down experimental system that has never been used or even tried.
Safety is everyone’s concern, but can only be practiced by those actually doing the patient care. And no one has more interest in your safety than your doctor. Instead of helping us, government mandates have made it harder and harder to be safe. In my hospital recently, an incident report was made after a patient did get to the Operating Room with a history that recorded the problem on the wrong side. Fortunately the correct operation was done.
More tragically, in Massachusetts, a patient received a kidney transplant from a patient who was Hepatitis C positive. Six physicians reviewed the donor’s chart and missed the fact that the donor was positive for the virus. In doing a so called “root cause analysis,” you have to either believe that six well-trained, seasoned specialists suddenly became carelessly incompetent, that the information was not readily available or that the information was presented in an unusable format. Although the uninitiated may think EMR makes everything readily available, the opposite is true. Electronic records present data in an impossible laundry list with no prioritizing and poor labeling.
We as an industry are an accident waiting to happen, in spite of pleas from physicians. It is no coincidence that the world-famous Barrows Neurologic Institute was one of the last hospitals to adopt an electronic X-ray system, or that surgical specialists have drug their feet on EMR in general.
Before I undergo any surgery on my own body, I will make sure to write “no” on the uninvolved side, and I carry a one-page medical summary of my diagnoses and medications wherever I go. With the government smart guys in charge, it is more critical than ever for patients to take an active role in safeguarding their own health.