Boston Globe: “The incessant din of beeping monitors can numb or distract hospital staff; the consequences can be deadly”

The February 13, 2011 Boston Globe has a disturbing report about how alarms can blend in with ambient background for healthcare workers. This really is where usability and quality assurance and medical informatics and medical IT all need to come together, no? But that would require money and training, and I can tell you as someone finishing a PhD focusing on medical cognitive science and medical informatics, these are in short supply. I have written previously about how a checklist evidently can lessen medical error, and sometimes there is (relatively) low-hanging fruit where a modest investment can yield impressive savings, but solving the problems written about here I think are more often not going to be cheap, quick, or easy. The devices themselves typically represent massive expense. What we would need is a holistic, integrated usability analysis of the sort that human-factors engineers perform for NASA or the cockpit of an aircraft. This isn’t cheap though.

“At Tobey Hospital in Wareham, nurses failed to heed a different type of warning on a September morning in 2008. An elderly man’s electrocardiogram displayed a “flat line’’ for more than two hours because the battery in his heart monitor had died. While nurses checked on him, no one changed the battery. The man suffered a heart attack and was found unresponsive and without a pulse.

These were just two of more than 200 hospital patients nation wide whose deaths between January 2005 and June 2010 were linked to problems with alarms on patient monitors that track heart function, breathing, and other vital signs, according to an investigation by The Boston Globe. As in these two instances, the problem typically wasn’t a broken device. In many cases it was because medical personnel didn’t react with urgency or didn’t notice the alarm.

They call it “alarm fatigue.’’ Monitors help save lives, by alerting doctors and nurses that a patient is — or soon could be — in trouble. But with the use of monitors rising, their beeps can become so relentless, and false alarms so numerous, that nurses become desensitized — sometimes leaving patients to die without anyone rushing to their bedside. On a 15-bed unit at Johns Hopkins Hospital in Baltimore, staff documented an average of 942 alarms per day — about 1 critical alarm every 90 seconds.

In some cases, busy nurses have not heard or ignored alarms warning of failing batteries or other problems not considered life-threatening. But even the highest-level crisis alarms, which are typically faster and higher-pitched, can go unheeded. At one undisclosed US hospital last year, manufacturer Philips Healthcare, based in Andover, found that one of its cardiac monitors blared at least 19 dangerous-arrhythmia alarms over nearly two hours but that staff, for unexplained reasons, temporarily silenced them at the central nursing station without “providing therapy warranted for this patient.’’ The patient died, according to Philips’s report to federal officials.

In other instances, staff have misprogrammed complicated monitors or forgotten to turn them on.

The Globe enlisted the ECRI Institute, a nonprofit health care research and consulting organization based in Pennsylvania, to help it analyze the Food and Drug Administration’s database of adverse events involving medical devices. The institute listed monitor alarms as the number-one health technology hazard for 2009. Its review found 216 deaths nationwide from 2005 to the middle of 2010 in which problems with monitor alarms occurred.

But ECRI, based on its work with hospitals, believes that the health care industry underreports these cases and that the number of deaths is far higher.”

EHR usability and quality assurance: do the Feds understand what is at stake?

So, 2011 is the year the checks for EHR get issued. The IT industry seems to me to be adopting a bit of a wait-and-see attitude about the Federal push to implement and integrate EHR, possibly because the standards for “meaningful use” are only now being rolled out. This is such heavily bureaucratized terrain; not every vendor wants to mess with it. A certain Zen-like patience is required for this market, what with business rules, such as they are, based on the sometimes inscrutable calculations of public-sector analysts and specialists who issue Federal guidelines. I used to work as an analyst for a Health IT company, tracking  state compliance to the Federal Medicare data transaction standards, and every time a bureaucrat put me on hold, one more little part of my youth expired, joylessly.

But after all the regulations and rules have been parsed, the rubber must hit the road. Whether doctors and nurses and admins can use the EHR systems being implemented remains the $100 Billion question, no?

From the January 18 PC World:

Dr. Tom Handler, a radiologist and analyst for the research firm Gartner, said one of the main barriers to adoption, “valid or not,” are concerns about the productivity and usability of EHR systems. Many physicians also believe that the data collected by the government through EHR reporting criteria will be used to decrease Medicare and Medicaid reimbursements, Handler said.

“Ultimately, what I hear doctors saying is, ‘Let me get this straight. You want me to spend money to put in a system that will be harder to use and slow me down, so I will earn less money, and that the end result is that someone else makes more money,” Handler said. “If you phrase it that way, it’s not illogical to see why they don’t want to do it.”

E-prescribing is another example. “Docs say, ‘I didn’t go to medical school to become a data entry clerk so Walgreens could hire one less pharmacy tech to enter the system.’”

Handler said current meaningful use criteria also doesn’t take aim with incentives that address what physicians consider some of the most critical reforms needed in healthcare today.

For example, Handler said, a computer-based patient record system can catch duplicate patient test orders, but the current meaningful use incentives don’t penalize physicians for ordering duplicate tests.

Ultimately, it’s the patient — the insurance company and then society — that pays for the duplicate test, and yet, its the physician who’ll have to foot the cost for the system that can prevent the duplicate tests, he said.

Dr. Harry Greenspun, chief medical information officer for Dell and a member of the Healthcare Information and Management Systems Society (HIMMSS), said resistance to EHR adoption can be as simple as a physician not wanting to add steps to a process that has worked for decades.

“It’s really easy to write a prescription; you just jot it down on note paper. On a computer screen it can take a lot longer,” he said. “If you go have to through a check list or a menu-driven program, it can be clunky, and a barrier to adoption.”

“On the other hand,” he continued, “If I can share [radiological] images, pull data from other systems, write a prescription all from one screen … and get valid prescription alerts and find out about public health threats, then the value is obvious.”

Everyone wants doctors and other medical professionals to interact with systems that are as intuitive as possible. The Feds know that usability is make-or-break, and they are developing appropriate usability and quality assurance standards…one hopes. But this is a non-trivial business folks, and there are issues lurking under the surface that give me pause. For instance, there is the crucial distinction between usability and learnability that Andrew Dillon highlights (scroll down to comments):

Distinguish between usability and learnability. Most usability tests are short run tests of people’s initial reactions to a technology. This privileges the earliest phases of human reactions, the making sense of something new. This is important but it is not the full story. I have shown repeatedly in my own work that people’s later reactions take time to emerge and often run counter to their initial ones.

Are your eyes glazing over with this inside-baseball arcana yet? Are you thinking, we pay good money so those nerds with advanced degrees in cognitive psychology or human factors have to worry about this kind of hair-splitting, not us. THAT’S THE WRONG ATTITUDE. Too-big-to-fail projects can fail, and with as much money is at stake with EHR, failure can mean the entire universe is sucked into a fiscal black hole.

Oh, and people can die if we don’t get it right.