Letters to the Editor

Dear Mr. Guerra:

As a vascular surgeon, I certainly want to share my best wishes to you and your father, because no one and no family dealing with a ruptured aneurysm can anticipate the stress of such a near-death experience.

Your impressions of the nurses and their role in the EHR environment is interesting, but you miss some big points. The nurses make a vital contribution, but the core function of the EHR is to have the key decision makers sharing information. Nurses are information providers, and they certainly give me, the clinician, important insights. Nevertheless, they do not have the whole, big picture about a patient, and their information is, of necessity, in the second echelon of importance. The primary information is generated and shared by the doctors, who are at the core of the process. Unfortunately, your industry has yet to figure out how to record, display, and collate physician evaluation and management information. Nurses work in a fixed, bedside environment. Doctors can be anywhere. I check on patients while on vacation through Web access, and I can enter data into the main hospital computer, where most of my patients are located from any computer with internet access at any time of the day. The problem is that my thoughts are entered by typing, which is inconvenient, even problematic for those who have no keyboarding skills. My thoughts are in a computer with a hierarchy of data that is cumbersome at best, and downright frustrating to query. Industry people for informatics seem to be clueless about what I need, how I think, and how I must communicate through a medical record. The fact is that the nurses need to document things and tell me what is going on, but they need systems that allow them to know what the docs are thinking and doing, and the current EHR systems fall flat on their faces on that task.

On another front, in the 11/08 issue, there is ongoing discussion of the impact and cost of ICD-10. Have you even looked at how it works? ICD-9 is simple, and physicians can do their own coding from cheat sheets or PDA's while on rounds. ICD-10 is slow and difficult because it demands types of data input that are unnecessary in -9, such as the intent of the procedure. I cannot deny that the problem with -9 is its lack of room for the future and lack of precision in the present. On the other hand, no one has shown me, as a clinician, how -10 will ultimately save the now financially stressed American citizen one cent for all the investment that will be necessary. Y2K costs will pale with the implementation of -10 because of the need for such a total overhaul of computers and expertise that will be required in the transition. Your journal has focused on support costs, but you have ignored the cost to retrain virtually every practicing physician on -10, because each of us MUST know how the coding works in order to give proper data for the system. Since we are in the worst financial meltdown since 1931, it seems to me that making the change to -10 in the time frame of 2012 is a horrid investment in human and financial capital. We have other dragons to slay…

Jeffrey L. Kaufman, M.D.

Baystate Vascular Services

Springfield, Mass.

p.s. I think your journal needs a column called: “best of the worst.” Your articles are always about how things work well and how much everyone saves and how happy people are with medical systems. How about discussing the skeletons in the closet, how things do not work. How about describing what physicians find unworkable in systems.

For example, in my hospital system, they decided to issue electronic warnings to get us to discontinue Foley catheters (urinary catheters). Great idea to control infection. However, I received nearly 50 warnings for one patient in a 24-hour period. This was a plague, a bit of computer stupidity that is intolerable. Why can't the industry beta test its products before torturing physicians with them????

Mr. Guerra,

Sorry for these comments coming so late, but I first saw “Biomed Joins the Party” a few days ago. I have been involved with interoperability standards efforts from the clinical engineering side of the business since the mid-1990s and feel compelled to comment that I find the article uninformed about if not condescending towards clinical engineering.

In the article's words, “There are a host of issues involved, from the governance level to the clinical, practical, and yes, technological.” Really? What about safety and regulatory issues? What about risk management and ISO 80001? What about unleashing the potential for Joan Ash's “unintended consequences” and even Charles Perrow's “normal accidents”? What about the recent JCAHO alert re: Technology-Related Health Care Errors?

Throughout my career I have considered “First do no harm” an overarching constraint to be intentionally applied throughout the technology life cycle. Providing engineering services to accomplish that is arguably the most valuable skills clinical engineering brings to the problem, but that barely gets mentioned in the article, which I find dangerously misleading by inferring that this effort is like any other systems problem. It is not. Many of the systems being integrated incorporate life critical equipment, the safety and safe use of which should never be placed at risk by the equipment with which it interoperates. This can only be ensured by intentional analysis and design involving all stakeholders.

As I recently wrote in “24x7”:

I've often cited the figure of 98,000 deaths attributable to error in … To Err Is Human. Recently, I realized that I overlooked another number, hidden in the very first sentence: “The knowledgeable health reporter for The Boston Globe, Betsy Lehman, died from an overdose during chemotherapy.” It's easy to miss it; the number is one. Ninety-eight thousand accidental deaths in this business occur one at a time. Lowering the number requires systems that enable each unnecessary death to be avoided. And that requires understanding the point of care…

With the convergence of medical equipment and IT, it's strategic for the clinical engineering voice to be present. Bringing IT to the point of care changes the point of care, and that change has to be understood as much as possible before making it…

As for parties, AAMI, ACCE, and HIMSS started one about a year ago called the CE-IT Collaboration. A good number of people from the clinical engineering community are already involved. One of the problems already facing the Collaboration is getting people from the IT world involved. Having been a member of all three organizations and attended AAMI and HIMSS meetings, I know HIMSS to have far more members. So why aren't their members at least as represented in this party, er, work, as AAMI's and ACCE's? Mr. Guerra, that is an important if not critical question. If the lack of involvement reflects a clinical IT establishment that undervalues or fails to grasp the nature of the safety and other engineering issues here, the risks associated with introducing this technology can only increase.

I hope I've have at least given you reason to ponder whether or not it is as important to bring the party to clinical engineering as it is to bring clinical engineering to the party.

Rick Schrenker

Systems Engineering Manager

Dept of Biomedical Engineering

Massachusetts General Hospital

Boston

Healthcare Informatics 2009 February;25(14):17-18