Patient care is like a house of cards, a delicately constructed hierarchy. Without the proper foundation, the whole house collapses, just as one misstep – one clinical oversight during diagnosis – can often constitute the difference between obtaining a successful patient outcome and the mistreatment of a patient, or worse. Like a house of cards, the strength of our EHR depends on the sum of its parts; yet at the heart of any clinical system, there often lies a troublingly overlooked aspect of care that leaves both clinicians and patients vulnerable to error. The ability to positively identify both patients and users is an important first step in administering care. But without proper reinforcement, this simple but fundamental concept can sabotage the entire care process, like a single unstable card at the base of the house.
Patient identification has long been a point of contention for healthcare providers, but with the increased emphasis on Role-Based Access Controls (RBAC) in recent years, the clinician identification has become equally important. In the aims of maintaining a more secure care environment, clinical systems such as MetaCare Enterprise EHR™ have placed more rigorous authentication measures on users. These technologies are designed to increase attention and awareness during diagnosis, holding clinicians more accountable for their actions. Similar methods have been deployed for the identification of patient and clinician alike.
The most prominently used measures include biometric validation of users, barcoded identification and medication administration systems, Radio-Frequency Identification (RFID) technology for inventory and user validation, and encrypted passkey technology. Meta is capable of successfully integrating these and many other identification technologies, but those listed above rank as today’s most widely-used methods for the positive recognition of patients, clinicians, devices, and medications.
One of Meta’s longest-standing partners was instrumental in paving the way for identification technology usage among MetaCare users. In 2008, when the client had had already successfully completed the implementation of our EHR, we were contacted by hospital administrators and asked to identify a creative solution for the identification of users and patients beyond the typical user ID, password, and non-repudiation software security. After carefully examining the criteria given to them, our team determined that the most advantageous solution to the request was through the pairing of the eMAR system already in place, and dongle technology. Though the use of barcoded identification technology was not previously unheard of in health facilities, the introduction of the dongle provided an extra layer of protection to the hospital’s already formidable security system. The encrypted passkey technology contained within the dongle requires the physical insertion of the key into the system computer, acting as a barrier to restricted users attempting to access the system. This was then paired with proximity readers to trip locks on automated drug dispensing machines and medication cabinets to provide the site with a complete and efficient solution to their identity crisis.
The combination of these technologies continues to act as a model for Meta and our clients. The use of barcode scanners at the point of care enables users to positively identify patients, while the Dongle allows for increased security by mandating verification of the user with the use of an external passkey. Today, we have found the most success in patient and user identification through the pairing of these two methods; but that does not mean we limit ourselves to one approach. We work with administrators and clinicians to determine which identification technology would most suit their facility. By doing so, we continue to explore new innovative solutions to the identification needs of our clients
The widespread use of these types of technologies will only improve the overall security and safety during the administration of care. Facilities that implement this technology can expect to see a drastic reduction of errors and an increase in positive patient outcomes, most notably by helping prevent serious medication errors and adverse drug events. However, they are also capable of minimizing dosing, documentation, timing and transcription errors, preventing cases of fraud and identity theft, and eliminating duplicate medical records, overlay records, and patient mix-ups. Overall, these positive identification technologies can have quantifiable benefits for providers, regardless of protocol or departmental standards, allowing for a safer and more responsible care environment.
After the first case of Ebola in the United States was reported in Dallas back in September, many critics, including hospital staff of the same facility at which the patient was treated, were quick to chastise the EHR in place as having a critical system flaw. However, though contradictory reports hindered the genuine critical analysis warranted by a case of such paramount importance, most experts agreed that the oversight was not due solely to the EHR. Rather, it was a combination of factors that caused the diagnostic lapse, principle among them human error.
The case highlighted some of the biggest flaws that currently plague the United States health system, namely the inadequacies of the Meaningful Use incentives program. Though the federal government attempted to normalize electronic health information system usage, its efforts fell short of its goals. The “shopping list”-like nature of Stage One and Stage Two requirements was myopic in mandating and prioritizing certain EHR features for vendors and providers based on monetary incentives. Physicians were not consulted; this much was clear. The ensuing legislation inhibited the software from addressing the needs of those most affected by it. Clinicians remained vulnerable to many of the same problems they faced before implementation. They were still prone to error and unable to actualize the true potential of technology in healthcare.
After the case was made public, an article began to circulate entitled “Ebola US Patient Zero: lessons on misdiagnosis and effective use of electronic health records.” The article, authored by Dr. Hardeep Singh (Chief of the health policy, quality, and informatics program at the Veterans Affairs Center for Innovations in Quality, Effectiveness, and Safety) and his research team, addressed some of the most important issues of “diagnostic decision-making in EHR-enabled health care” in light of the case in Dallas. The conclusions that Dr. Singh and his team determined were astounding: among them, they exposed the flawed nature of “pre-defined symptom options” standard in many EHRs; criticized the tendency of physicians to ignore nursing notes; and advocated policy and practice reform to address error in the developing field of electronic healthcare.
As a solution, they called for a refocusing of national efforts to encourage collaboration be-tween software developers and clinical users. The team criticized existing policies that promote complacency and inaccuracy in patient diagnoses, and determined that a balance between developer and provider was the only viable means for the development of a safer and more efficient software solution:
Physicians and health care organizations ultimately need to own the responsibility for addressing diagnostic errors, but several national-level initiatives can help, including working with software developers to improve EHR usability… [D]iagnostic errors are largely ignored by policy-makers, industry, and health care institutions in part due to their complexity and measurement challenges. Within the many initiatives attempting to improve patient safety and value-based purchasing being promoted… virtually none relate to accuracy and timeliness of diagnosis. Outpatient reimbursement policies do not reward diagnostic decision-making, teamwork, or quality time spent with the patient in making a diagnosis. 
The first case of Ebola in the United States prompted national attention (and rightly so) on several very important issues concerning US healthcare, chief among them clinician misdiagnosis and EHR misusage. But while the threat of a major outbreak should have been enough to catalyze reform, reform was not forthcoming. The responsibility lands at the feet of federal agencies, the ONC, the CDC, and others, to promote EHR usage that transcends the prominent “one-size-fits-all” mentality; but even in light of the Ebola threat, no developments have surfaced to improve overall functionality, interoperability, and effectiveness of these systems.
So the question remains: why have we put our faith in complacent requirements, circulated by complacent governmental agencies? Rolling requirements and monetary incentives are not the solution to maximizing EHR potential; rather it is fair and honest business practices that encourage the partnership of developers and clinicians, and competition among EHR vendors. We must learn from our past shortcomings and adopt a new strategy that is dynamic as the problem we are facing. For as the research team concluded their report, though “Diagnostic errors typically have affected only one patient at a time… Patient Zero reminds us that in certain cases, a single misdiagnosis can have widespread and costly implications for public health.”
 Hardeep Singh, et al. “Ebola US Patient Zero: Lessons on Misdiagnosis and Effective Use of Electronic Health Records.” October 23, 2014.
Transitioning into ICD-10 seems to be the only responsible option available to healthcare providers. The upgraded classification system is the most elaborate coding available to monitor and diagnosis disease, and a compulsory component in the evolution of American healthcare. But the switch, which has in reality been in the works for more than thirty years, was delayed yet again.
Though the problem is complex in nature, it is one that requires attention. The current system, ICD-9, lacks the processing capabilities necessary to confront the particular needs of today’s healthcare professionals (notably, there is not even an existing code for Ebola). ICD-10 will be able to provide a more comprehensive and inclusive coding system for specific patient conditions, symptoms, and diagnoses. The ability to code, group, and analyze data on a scale this large will make our healthcare professionals smarter, more responsible, and more prepared to treat their patients.
The switch from ICD-9 to ICD-10 was set for Oct. 1, 2013. Across the country accommodations were made by healthcare providers: systems were upgraded; EHRs were improved; clinical documentation was reinforced; training programs were begun; funds were dedicated. And though the HHS and CMS repeatedly reaffirmed healthcare providers that the deadlines would not change, the date was ultimately delayed and set for Oct. 1, 2015.
The progress that came with the certainty of the initial deadline was replaced by perpetual doubt and stagnancy. Facilities that had allotted resources to reach the 2013 deadline had to deal with the blowback: resources, time, and personnel that had been dedicated to a fruitless initiative could no longer be regained to support more worthwhile programs. But many providers, often smaller facilities, simply lacked the capital and resources to prepare themselves for the initial date. Without help from organizations such as the HHS and CMS, these providers were unable to meet the requirements within the allotted timeframe. They were effectively abandoned by the same governmental agencies conceived to assist and regulate in times like these; and as a result these undermanned facilities, through no fault of their own, forced American healthcare to remain retrograde and obsolescent.
From this chain of events it is difficult to discern the correct course of action. Many detractors argue that this new date is not to be trusted, that we are better off looking forward to ICD-11, and that as a whole the ICD-10 initiative was a failure. However, the fact of the matter is that, regardless of one’s opinion, the only responsible response is preparedness. Even if the governing bodies delay the switch once again, there are certain steps that healthcare providers and facilities must take, regardless of ICD-10 qualifications, to improve quality of care. These include reassessing reimbursement procedures and diagnoses codes, increasing coder training, placing increased emphasis on clinical documentation, implementing fiscally responsible business practices to increase revenue, and upgrading existing clinical information and EHR systems to ensure improved enterprise-wide patient care.
The end result of all of this, however, is doubt and distrust in regards to the federal government’s attempts at healthcare reform. They have proven their ineptitude in the healthcare field time and time again: the ICD-10 saga and the Meaningful Use incentive program are prime examples. However the reality of the situation is that the world has entered a new era of data processing and handling. By implementing practices like those mentioned above, along with others that may be facility-specific, providers can help improve the quality of care, regardless of the verdict made on the ICD-10; but if healthcare professionals feel they cannot rely on the federal government for guidance, they must take the initiative themselves. The rules in medicine have changed immensely in a matter of just a few years, and in the game today, the only way to keep up is to not fall behind.
With all of the recent developments regarding the Ebola outbreak, experts have begun proposing radical changes in regards to the functionality of EHRs and Population Health Management. Not surprisingly this “buzz word” has begun to creep into the vernacular among clinicians as hospitals and healthcare facilities immerse themselves in a new modus operandi.
The health of an entire population is becoming more and more dependent on the implementation of these technologies in healthcare facilities, evidence of which can be seen in the case of the Texas man who recently died of Ebola after traveling to West Africa. The first patient to die of Ebola in the United States was released by doctors from Texas Presbyterian Hospital in Dallas, Texas after the EHR in place failed to highlight the patient’s travel history.
PHM concerns itself with the improvement of the physical wellbeing of a designated population, classified based on demographics, geographic location, or other important determining factors, by focusing on and addressing the disease-specific exigencies of said population. The goal of these practices is to “improve morbidity patterns (i.e. the illness and injury burden) and the health care use behavior of defined populations,” and in turn, the overall outcomes of patients. Facilities across the spectrum, from large university hospitals to small, rural CAHs, have begun to recognize the importance of PHM, not only for its ability to improve patient care, but also to prevent the spread of disease.
Certain provisions included in the Stage 2 Meaningful Use attestation criteria reflect the growing importance of PHM, testifying to the direct correlation between EHR implementation and PHM improvement. Included in the stipulations for EHs and CAHs are four core objectives that have played a crucial role in the current population management metanoia:
9. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreac
13. Capability to submit electronic data to immunization registries or immunization information systems except where prohibited, and in accordance with applicable law and practice.
14. Capability to submit electronic reportable laboratory results to public health agencies, where except where prohibited, and in accordance with applicable law and practice.
15. Capability to submit electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice.
By simplifying data collection and distribution and creating specified patient lists, care facilities are able to play their part in preventing epidemics and outbreaks. Smaller facilities, such as CAHs, are especially benefitted, as many would not otherwise have the resources to realize such an undertaking. The automation of this process also allows for a seamless flow of information between providers and Public Health Agencies (PHAs), decreasing the burden on clinicians and reducing the risk of misreporting or documenting errors.
The key word here, however, is syndromic surveillance – the ability to analyze medical data on a large scale to detect and prevent outbreaks of disease and epidemics. As part of the movement to prevent emerging infectious outbreaks, hospitals and healthcare facilities are being called on to play an enhanced role in surveying public health. According to the Centers for Disease Control, “The fundamental objective of syndromic surveillance is to identify illness clusters early… and to mobilize a rapid response, thereby reducing morbidity and mortality.”
Though many of the details are still unsure in this particular case, whether it was the way in which the EHR was utilized or the technology itself, either procedural or technical improvements can certainly be made to avoid future incidences such as the one that led to the first death of an American Ebola patient. We can only hope that from this episode, clinicians, programmers and government officials learn to collaborate effectively on a solution to the looming problem posed by the Ebola outbreak. The prudent implementation of EHR technology forms an integral part of a solution that can save lives today, and prevent new outbreaks in the future.
 Bleiberg, Joshua and West, Darrell M. (October14, 2014) Could Better Electronic Health Records Have Prevented the First American Ebola Case? http://www.brookings.edu/blogs/techtank/posts/2014/10/14-electronic-health-records-event
 Hillman, Michael. (2002) Testimony before the Subcommittee on Health of the House Committee on Ways and Means, hearing on promoting disease management in Medicare.
 Chapman, LS. (1997). HEALTH MANAGEMENT: Optimal Approaches for Managing the Health of Defined Populations. Summex Corporation. Seattle, WA.
 Centers For Medicare & Medicaid Services (Cms). Stage 2 Eligible Hospital and Critical Access Hospital (CAH) Meaningful Use Core and Menu Objectives (n.d.): n. pag. Www.cms.gov. CMS. Web. <http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_ MeaningfulUseSpecSheet_TableContents_EligibleHospitals_CAHs.pdf>.
 Henning, Kelly J. “Overview of Syndromic Surveillance What Is Syndromic Surveillance?” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, n.d. Web. 04 Aug. 2014. <http://www.cdc.gov/mmwr/preview/mmwrhtml/su5301a3.htm>.
Where has the summer gone? That seemed to be the consensus at my “Last Summer Barbeque of the Year” barbeque last week. It was a strange summer in central NY as we had either heat/no rain or rain and no heat. We did have some great sweet corn from one of my fields but overall the summer went by way too quickly for most of us.
The neighbors found time to talk about the latest local gossip. On this occasion, our local hospital was the subject. Recently, newspapers were filled with articles concerning a lawsuit about a near-fatal drug mishap. It is alleged that a nurse accidentally administered the wrong drug. Most of the comments approximated “How stupid could they be?” and “How could that happen?”
As always I started to enumerate the many causes of medication errors. I explained to these folks that errors can occur for many types of procedures or issues, from seemingly simple to very complex. Then my non-clinician friends began to speculate “How hard can it be to give a drug?” I quickly pointed out the various ways that things can go wrong. I told them about the look-alike sound-alike scenario. Then I explained to the group that a simple mispronunciation of a word, a missed allergy, an unreported drug a patient is taking at home, even a practice or protocol bypassed entirely can all lead to a serious if not fatal medical misadventure.
I went on to explain that “Some drugs are just very toxic and need special handling to mix, make or administer. Many of these agents are rarely used and special handling instructions can get ignored or go unnoticed. All these nuances of error can cause serious problems, especially if you are not accustomed to using them. In a busy pharmacy environment it is likely that the pharmacist gets distracted or interrupted when filling them. All it takes is a moment of diverted attention. With these classes of drugs, such as neoplastic agents, the more reminders a pharmacist has on how to handle them, available on-demand, is the best way to prevent errors. To ensure that the staff stops, looks and knows what to do, is the best way to avoid any medicinal mishap.
I continued on, “There are likely more ways to cause an error than to prevent one. Errors can happen anywhere in the order process, from inception to administration. Each step in the process (prescribing, verification, dispensing/compounding, storing and finally administration) is a new and different stage in the medication process for the error to occur. One of the best ways to stop these types of errors is to make a proactive risk assessment and have in place protocols and procedures that determine how drugs are to be used before the problem arises.
After all, if you are aware of the step where a potential problem can or has happened then that is the place where the appropriate prophylactic measures must be implemented. An electronic system that alerts users at the appropriate point, can go a long way in preventing any issue from arising at any given stage in the process.
It’s been my experience that every hospital has problem drug or two that are vulnerable to errors. When you identify those drugs you need to make sure that those drugs are handled with an extra amount of care. The best part about a good electronic medication software is the ability to customize your warnings. In this way, we can take our ideas and tailor them to be more proactive about resolving medication errors before they happen.
An effective EHR can allow users to identify and isolate those special, problematic drugs and give them clear and concise instructions as to how they want the drug handled. Flexibility and customization can help everyone be aware that this drug needs special attention. The best part is the software can then notify the user where in the chain of events the issue happens.
For problems such as a “look alike, sound alike” users can put their special warning at time of order entry (for the prescriber and for the verifier) so the drug is entered properly. They can do this again at the time of drug fill – so they can take that extra second to check it, making sure they have the correct drug or yet again at the time of compounding with warnings such as “after mixing, check for particulars. If present discard and redo”. And lastly when the nurse goes to administer the drug a special warning or note can be tailored to appear explaining just what needs to be checked prior to administering it to the patient. The availability of drug images in conjunction with bar code scanning can reinforce and enhance 5 rights checking.
A comprehensive EHR that allows for customization can identify and require certain drugs to have a second person check and verify that the drug is correct as well. By having the additional clinician enter their password into the system before the drug is delivered or administered.
Taking a user out of their comfort zone for a few seconds by requiring their special attention is one of the best ways to prevent any error. With electronic health record software you can tailor warnings to the prescriber, pharmacist, technician or administering personnel, ensuring that each receives enough information that is vital to helping prevent a medical misadventure. Sometimes it’s the little help that these pop-ups give you make all the difference between safety and disaster.