Thanh Tran, CEO of Zoeticx Inc.
Donald M. Voltz, MD, Autman hospital – Ohio.
It is preventable medical error due to miscommunication! Recent Ebola outbreak has highlighted some healthcare challenges. Finger pointing has started very quickly, first to the EHR system as it fails to highlight the previous recorded data about the patient recent travel history. Failure to bring such information to the emergency physician leads to a discharge of patient Eric Duncan. Recent article by Jeff Higgins has correctly pointed out that it is miscommunications among care providers and not an EHR system problem (in this case, Epic). It should be classified as a preventable medical error due to miscommunication, omissions. Not long ago, we had similar case in New York – Rory Staunton (2012), a 12-year old boy, has died because of another preventable medical error due to miscommunication. Rory was sent home with a diagnosis of upset stomach and dehydration while the missing signals about a septic shock recorded with his increased fever and lab test results – all recorded in the EMR system, but again, not brought to the attention of the physician – timely enough to remedy the situation. There is one yet-to-be-published case in Ohio where a patient dies from a simple hernia operation. The case is quite similar to the above, where an EKG was ordered prep and was posted up to the EHR about 10 minutes before a patient was taken to the operation room. No one read the EKG as the patient has just a normal EKG a few days ago as part of a prep screen. There is another EKG taken right before the surgery showed acute ischemia. The patient died in the recovery room. Again, all data are recorded in the EMR system but fail to communicate to the physician, timely enough to prevent the medical errors. Patient care quality has many guidelines but there is one most simple, critical guideline missing: Showing the actual reduction of medical errors due to miscommunication, omissions. These preventable medical errors may appear under different forms, different cases, different healthcare institutes, and different impacts but there is one common denominator – miscommunication or omission of critical patient medical information to care providers. The video ‘Life almost lost’ by Zoeticx summarizes the missing components in healthcare – communication, collaboration among care providers. Jeff Higgins has correctly pointed out that it is the miscommunication leading to the discharge of patient Eric Duncan and not an EHR system problem. It is true as an EHR system is a recording system, where care providers must be looking and searching the relevant patient medical data for their patient diagnosis. Misdiagnosis in this case is not about missing data but the fact that the data fails to present to physicians for the correct diagnosis outcome. Would this particular case different from Rory Staunton, the recent Ohio case or the theoretical case of Billy White presented in Zoeticx – A life almost lost video? EHR system – Recording patient medical data The issue is about recognizing that any current EHR is a passive database component. As any other passive database components – in any other vertical industries (finance, manufacturing), they do not address the challenge on presenting information to the decision making, let alone being timely. The issue is about understanding that there must be applications – designed in healthcare, to bring those information forwarded to physicians in order to prevent such medical errors. And none of the EHR systems perform that task because it is a passive database component. Most of the tasks to bring such information to physicians have been put on the ‘customized solutions’ built specifically for each healthcare institute, addressing some of the basic needs for physicians. What everyone is falling into is that the expectation that EHR systems, once deployed, would address all the needs by care providers. The flaw in our healthcare system is to accept that assumption, also incorrectly supported by EHR vendors. The reality is that US healthcare needs to inspire a next set of innovative solutions, focusing on supporting care providers in Improving Patient Outcome®. In order to achieve such inspiration, healthcare must figure out how to address EHR interoperability and EHR agnostics to free up independent developers from draining their resources in addressing the infrastructure challenges, created by EHR vendors. Healthcare challenges – how to Improve Patient Outcome®! Both Eric Duncan and Rory Staunton have the same outcome from the same characteristics of preventable medical errors. Both cases raise the attention of our nation – then, soon forgotten when the media switches its focus on other news. The difference is Eric Duncan case is an epidemic one and Rory Staunton is an individual patient outcome. However, from the standpoint of patient outcome, both are preventable medical errors claiming 400,000 US lives per year. It is time to get the innovation going in healthcare, starting with addressing EHR interoperability / EHR agnostics and the acceptance that EHR systems are simple a data component on the whole equation. Stop blaming EHR systems; Start recognizing that the journey ahead needs more than EHR systems!