I'm amazed that city, county, state, and federal tech projects never want to clone best-of-show systems instead of starting from scratch. City needs a web site? Clone the best one you can find amongst the tens of thousands of cities already doing that. County jail needs tracking of inmate transports? Clone the best one you can find amongst the thousands of counties already doing that. State needs a sales tax system? Clone whatever other state system is the best. VA needs a system for hospital records? Don't develop from scratch, start by cloning the best system you can find amongst the thousands of existing hospital networks, and customize from there.
That's what they did. If you read the article, it discussed the whole program as being a change from an in house developed system, to an off the shelf system.
> The program launched in 2018 to replace the aging computer system used across VA’s health care network, which serves more than 9 million veterans, with an off-the-shelf product that could handle many of the same tasks: organizing important information including appointments, referrals, prescriptions and patient histories.
> David Shulkin, the secretary at the time, announced that VA would negotiate a contract to buy the records system from Cerner without competitive bidding.
VA leaders said they selected the program because the Pentagon already had purchased a similar Cerner system for the military’s more than 700 hospitals and clinics.
VistA is an old system, and it's definitely "aging." But the thing is that it actually works really, really well. For instance, it kills a remarkably low number of people, which is one of the benchmarks I personally value in an EHR.
One of the interesting things about this is that, from my perspective, VistA's sort of a mesh of servers rather than the hierarchy we might expect from a federal system. Perhaps that's because of the complex interplay between federal and state and local laws. But anyway, there's probably a "station" for VistA near you that serves your area, and that's very similar (though not identical) to the "station" in the next neighboring area/metropolis/state/whatever.
But weirdly it seemed like the plan to roll this out was to replace all of the functionality at a given VistA station, rather than to do a strangler fig sort of thing and work on supplanting VistA's functionality in a specific functional area (whether locally or nationally). I don't know if that's because of the aforementioned complexity of laws, or the complexity of how the system(s) is/are administered, or other reasons that would elude me.
A lot of government procurement is bound by strict "competitive bidding" laws that seek to give everyome and their grandmother a fair shake at the contract, in the name of avoiding graft, corruption, and bribery.
This has led to somewhat of an arms race where government workers desperately collaborate with contractors to find a way to sidestep or subvert the bid process and other contractors aggressively seek to inspect and enforce the process.
Developing in-house governmental talent, institutional knowledge, and capacity is of course strictly off the table, as it would reduce opportunities for private profit in basic government services.
I once flagged a bug in Epic, the big EHR system.
The system had somehow mixed up kilograms and pounds.
For example, a normal adult male weight of 150lbs would be ~68kg,
But accidentally save it without converting and get 150kg.
Convert back and it becomes 330lbs.
Suddenly our reasonably slim man becomes grossly obese.
It's not just wrong,
it's extremely dangerous.
In an emergency situations,
where morphine is commonly administered for extreme pain,
the dosage needed to relieve the pain of a 330lb man would kill a 150lb man.
Granted the responder at the patient's side would probably realize something is amiss,
but a pharmacist in another room filling an order wouldn't have the context,
and could make the error.
I wouldn't trust that a nurse or doctor that is bedside to flag that either, though. Hospitals are woefully understaffed, and while they will do there best, we are all just humans.
My wife's grandmother was killed by a second dose of metformin (well kidney failure after a second dose) because the attending that administered the first dose left the room, planning on coming back a moment later, when the next round nurse came in, they noticed the does hadn't been administered (wasn't in the chart), ordered another dose, and injected it.
There were multiple layers that should have prevented that. The prescription shouldn't have been filled for a second time without someone noticing. The first doctor should have filled in the chart before leaving. And the pharmacist should have noticed that it had already been requested.
Too many patients, too few doctors, and with Epic, too many button clicks.
I am very sad to hear that your grandmother died as a result of a medical error, but the details of the story as you remember them aren’t quite plausible.
1) Metformin is not available in an IV formulation
2) Metformin itself is not nephrotoxic
It certainly is believable that a medical error caused kidney failure but it is very unlikely to have been caused by an incorrect second IV dose of Metformin.
I expect GP mistook metformin-associated lactic acidosis in a patient with kidney disease as something metformin-caused. A separate but coincident IV misadministration could be an exacerbating factor. It would have been a rare case, but a plausible explanation for the misunderstanding.
Metformin is relatively kidney safe and not administered by IV. Thank you for clarifying that for anyone that may currently on or considering Metformin. It would be great if medical professionals were infallible communicators and had time to verify understanding, but they are human and we need more doctors and less time-pressure by profit extracting private equity.
Also even when medical professionals communicate flawlessly, they're communicating to non-professionals who will necessarily encode their understanding in an imperfect mental model that will likely degrade over time.
Oh absolutely, especially in an emergency. I mentioned the other scenario because when I've told this story before people have been skeptical that a bedside provider could make that kind of error.
Every user I’ve heard coming from a Cerner facility has said that Cerner is an unmitigated disaster.
It almost makes sense that the only way to get a customer was to essentially lobby and force your way into a government contract for it, and it’s still an unmitigated disaster.
My heart goes out to those that are going to get fucked over by this piss-poor deployment and be actually, physically harmed by bad EMR decisions and implementation choices.
Oracle acquired them. So, now you have the full power of Oracle standing behind them to convince customers to adopt it, and the same power to keep customers from migrating.
Meanwhile in Sweden:
> Scrapping the millennium: introduction of a health record in Sweden fails
> The introduction of a new, heavily criticized electronic journal system from Oracle in two Swedish health districts has failed spectacularly.
https://www.heise.de/en/news/Scrapping-the-millennium-introd...
https://archive.ph/4f6JE
I'm amazed that city, county, state, and federal tech projects never want to clone best-of-show systems instead of starting from scratch. City needs a web site? Clone the best one you can find amongst the tens of thousands of cities already doing that. County jail needs tracking of inmate transports? Clone the best one you can find amongst the thousands of counties already doing that. State needs a sales tax system? Clone whatever other state system is the best. VA needs a system for hospital records? Don't develop from scratch, start by cloning the best system you can find amongst the thousands of existing hospital networks, and customize from there.
That's what they did. If you read the article, it discussed the whole program as being a change from an in house developed system, to an off the shelf system.
> The program launched in 2018 to replace the aging computer system used across VA’s health care network, which serves more than 9 million veterans, with an off-the-shelf product that could handle many of the same tasks: organizing important information including appointments, referrals, prescriptions and patient histories.
> David Shulkin, the secretary at the time, announced that VA would negotiate a contract to buy the records system from Cerner without competitive bidding. VA leaders said they selected the program because the Pentagon already had purchased a similar Cerner system for the military’s more than 700 hospitals and clinics.
VistA is an old system, and it's definitely "aging." But the thing is that it actually works really, really well. For instance, it kills a remarkably low number of people, which is one of the benchmarks I personally value in an EHR.
One of the interesting things about this is that, from my perspective, VistA's sort of a mesh of servers rather than the hierarchy we might expect from a federal system. Perhaps that's because of the complex interplay between federal and state and local laws. But anyway, there's probably a "station" for VistA near you that serves your area, and that's very similar (though not identical) to the "station" in the next neighboring area/metropolis/state/whatever.
But weirdly it seemed like the plan to roll this out was to replace all of the functionality at a given VistA station, rather than to do a strangler fig sort of thing and work on supplanting VistA's functionality in a specific functional area (whether locally or nationally). I don't know if that's because of the aforementioned complexity of laws, or the complexity of how the system(s) is/are administered, or other reasons that would elude me.
It's, uh, it's a fun situation.
A lot of government procurement is bound by strict "competitive bidding" laws that seek to give everyome and their grandmother a fair shake at the contract, in the name of avoiding graft, corruption, and bribery.
This has led to somewhat of an arms race where government workers desperately collaborate with contractors to find a way to sidestep or subvert the bid process and other contractors aggressively seek to inspect and enforce the process.
Developing in-house governmental talent, institutional knowledge, and capacity is of course strictly off the table, as it would reduce opportunities for private profit in basic government services.
I once flagged a bug in Epic, the big EHR system. The system had somehow mixed up kilograms and pounds. For example, a normal adult male weight of 150lbs would be ~68kg, But accidentally save it without converting and get 150kg. Convert back and it becomes 330lbs. Suddenly our reasonably slim man becomes grossly obese.
It's not just wrong, it's extremely dangerous. In an emergency situations, where morphine is commonly administered for extreme pain, the dosage needed to relieve the pain of a 330lb man would kill a 150lb man. Granted the responder at the patient's side would probably realize something is amiss, but a pharmacist in another room filling an order wouldn't have the context, and could make the error.
I wouldn't trust that a nurse or doctor that is bedside to flag that either, though. Hospitals are woefully understaffed, and while they will do there best, we are all just humans.
My wife's grandmother was killed by a second dose of metformin (well kidney failure after a second dose) because the attending that administered the first dose left the room, planning on coming back a moment later, when the next round nurse came in, they noticed the does hadn't been administered (wasn't in the chart), ordered another dose, and injected it.
There were multiple layers that should have prevented that. The prescription shouldn't have been filled for a second time without someone noticing. The first doctor should have filled in the chart before leaving. And the pharmacist should have noticed that it had already been requested.
Too many patients, too few doctors, and with Epic, too many button clicks.
I am very sad to hear that your grandmother died as a result of a medical error, but the details of the story as you remember them aren’t quite plausible.
1) Metformin is not available in an IV formulation 2) Metformin itself is not nephrotoxic
It certainly is believable that a medical error caused kidney failure but it is very unlikely to have been caused by an incorrect second IV dose of Metformin.
I expect GP mistook metformin-associated lactic acidosis in a patient with kidney disease as something metformin-caused. A separate but coincident IV misadministration could be an exacerbating factor. It would have been a rare case, but a plausible explanation for the misunderstanding.
Metformin is relatively kidney safe and not administered by IV. Thank you for clarifying that for anyone that may currently on or considering Metformin. It would be great if medical professionals were infallible communicators and had time to verify understanding, but they are human and we need more doctors and less time-pressure by profit extracting private equity.
Disclaimer: I am not a doctor.
Also even when medical professionals communicate flawlessly, they're communicating to non-professionals who will necessarily encode their understanding in an imperfect mental model that will likely degrade over time.
Damn, sorry to hear that a nurse killed your grandma :(
Oh absolutely, especially in an emergency. I mentioned the other scenario because when I've told this story before people have been skeptical that a bedside provider could make that kind of error.
Opiates are not weight based dosed for adults. Typically pain protocols start at fixed doses based on prior opioid use and titrate up for effect.
Also was this a bug in Epic proper or a site specific customization?
Wired covered the story twelve years ago of an Epic implementation failure that led to a child’s overdose (and recovery), of note:
https://www.wired.com/2015/03/how-technology-led-a-hospital-... https://archive.is/1QPmK
Every user I’ve heard coming from a Cerner facility has said that Cerner is an unmitigated disaster.
It almost makes sense that the only way to get a customer was to essentially lobby and force your way into a government contract for it, and it’s still an unmitigated disaster.
My heart goes out to those that are going to get fucked over by this piss-poor deployment and be actually, physically harmed by bad EMR decisions and implementation choices.
Every single time I've heard about an org onboarding Cerner, it was a disaster. One wonders how they can possibly still be in business.
Oracle acquired them. So, now you have the full power of Oracle standing behind them to convince customers to adopt it, and the same power to keep customers from migrating.
Nobody got fired from buying Oracle