At one of many discussions, someone said, “I think we need to build just one more warning here.” I was terrified. “You can not see… “ I quite screamed. “The problem is we have too many warnings. Adding another just makes it worse! “
To address this, we have formed a committee to review all of our alerts, cutting them off one by one. This is the hard work, the digital equivalent of weeding, and even after two years we have successfully removed only about 30% of alerts from the system. Creating a larger dent in the warning problem will require more complex analysis that can signal, in real time, this Special warnings should not be triggered, because, in this particular situation, with this particular patient, it is most likely a false positive. We are not there yet. Epic, which sold us our electronic health record system – or anyone else, for that matter. But the need to resolve this issue is urgent.
We have also changed other things. Our computerized prescribing system will now block any attempt to prescribe more than nine pills in a single dose. Like so many other solutions, creating “hard stops” like this seems undeniable, but proven to be surprisingly complex. What if a patient is taking 20 mg of morphine and the pharmacy runs out of 10 mg, with only 2 mg left in stock? The solution of up to 9 pills – the only technically viable solution in Epic – will block the computer from dispensing ten 2 mg morphine tablets, possibly forcing the patient to wait in pain while the doctor or pharmacist Jump through bureaucracy to overwrite blocks.
But not every problem can be fixed in-house. Some problems can only be fixed by outside software engineers – in our case, people sitting at Epic’s grand headquarters in Verona, Wisconsin. Even then, the company only makes such revisions available to all of its customers during periodic software updates, perhaps once or twice a year. Because most medical IT systems are not cloud-based, they lack the ability to update quickly, as we all usually do on our smartphones and tablets.
There have been calls for the creation of a national payments agency for IT security and this seems to be a good idea to me. Such a clearing facility would at least offer the fighting chance that someone would identify a kind of computer-related error and the user and vendor would know about it. But such a central repository would need to have some teeth if it wanted to be efficient.
Tech fixes are important. But preventing the next Septra overdose will need efforts focused on problems that go far beyond technology itself, on top of other grades of Swiss cheese. For example, the pharmacist’s fault is, at least in part, due to the satellite pharmacy’s conditions, which include cramped spaces and often distraction. The satellite pharmacists are now working in a better space, and efforts have been made to protect pharmacists managing phone and door response alerts.
We also need to address another issue that isn’t just limited to the healthcare sector: overgrowth in technology. As Captain Sullenberger, the pilot “The Miracle on the Hudson Ship,” told me, aviation faces a similar need to balance trust in the machine and human instincts. The reality is that cockpit technology today is so reliable that pilots have a tendency to delay computers. But we need to be able to think critically, says Sully. “We need to do plausibility tests no matter what the situation is. You know, is there enough fuel for this flight? Was the plane really that heavy, or was it more or less? Are these takeoff speeds justified with the weight on these runways? Everything should make sense ”.