To err is all too human

March 6, 2006

Many people, probably too many, have stories about medical practice gone bad: the cancer that was missed, the medication that shouldn’t have been prescribed, the follow-up that wasn’t done.

Many people, probably too many, have stories about medical practice gone bad: the cancer that was missed, the medication that shouldn't have been prescribed, the follow-up that wasn't done.

In 2000, the National Academy of Sciences published a report, entitled To err is human. To make its point, the authors cited studies attributing annual deaths in the U.S. due to medical error as ranging between 44,000 and 98,000 - more than motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516).

The report has become a call to arms for advocates of healthcare IT, one that has attained a life of its own. Almost six years after the report's publication, its findings served as fodder for formal presentations and hallway discussions at the annual meeting of the Health Information and Management Systems Society.

Somewhere along the line, I think, the intended message has gotten lost.

Each of the references I heard was uttered to support the development and adoption of information technology. No one spoke of the other recurring themes in this book, the need to align medical values, culture, and priorities with a reduction of errors.

Rather than struggling with the problems underlying medical error, we look instead to technology to solve our problems. This kind of thinking and the solutions it breeds are ubiquitous: the diet pill that burns fat, the hair dye that washes away age. In medicine, it is IT. Install an electronic health record and link the "ologies." But what good will it do if the information is not used wisely?

Would an IT system have saved Boston Globe health reporter Betsy Lehman, who died from an overdose during chemotherapy? Would it have kept Willie King from having the wrong leg amputated? Would eight-year-old Ben Kolb, who died during "minor" surgery due to a drug mix-up, be alive today? These three cases, cited in the NAS report to humanize the tragedy of medical errors, barely hint at the complexity of making medical care safer and more effective in this country.

To make the right decisions requires not only having the right information in hand but also the right interpretation of that information. And that may be what we should be looking to get from technology. Here, technology can help by guiding medical practice, by backing up decision makers, ensuring that proper procedures are followed and the right tests are ordered.

Siemens' Soarian IT employs algorithms that synchronize workflow across the enterprise, anticipating needs and simplifying tasks, using embedded analytics to monitor, measure, and act on incoming data. Soarian is designed to merge with the various medical domains within an enterprise, integrating, for example, modules for imaging and workflow.

Cerner's Discern Advisor clinical decision support engine is being enhanced with guidelines, developed by Medicalis, that are intended to reduce unnecessary imaging procedures and ensure that patients receive the right test first. The context-specific rules that will support this engine take advantage of patient data to ensure that information presented is relevant to the clinical situation.

By driving informed decisions, technologies like these might make a difference. But they will not be enough.

Only people make mistakes, and only people can stop making them.