This is wonderful!
It was Leslie Lamport quoted as saying: A distributed system is one in which the failure of a computer you didn’t even know existed can render your own computer unusable.
This truism has been highlighted over the last few years through often unforeseen incidents and consequences of failures in highly complex, loosely integrated systems, especially when running feeder systems through often distant, unrelated and often multiple applications. While the advantages of federated systems are substantial they are sadly often highly susceptible to failures in any one aspect of the network.
To manage such chaos, highly resilient systems and redundancy are essential, as the loss of both intended and unintended connections between systems can have serious impacts on patient care, resource allocation, workforce, data quality and collection as well as the inevitable political and media stressors. Even external agents can create chaos, as Sony is now so clearly aware. Health is just as, if not more, susceptible to attacks.
The solution is not simply good design and architecture (essential) but also expensive mirroring, security, cloud use, redundant storage systems and well planned paper backup solutions. Achieving 100%, 24×7 system availability should be the holy grail of ehealth systems but it is very, very expensive. Many non-clinical architects, analysts and developers downplay the need for such costs or support systems but as we find greater and greater integration into the day to day clinical management of patients these costs must be seriously considered and only rejected or watered down following thoughtful consideration of the tragic impacts that may follow.
As massive gains to clinical safety, effectiveness and efficiency are achieved by ehealth, these marginal gains start to decrease relative to the growing insidious and potential harm of major system failures.
Comedian Bill Murray said “Don’t think about your errors or failures; otherwise, you’ll never do a thing,” and while there is modicum of wisdom in his thoughts, it is critical that we understand and learn from our errors and failures when another’s health is at risk. Sadly if one looks at the last 20 years in ehealth we do learn but ever so slowly and only after the repetition of the same outcomes over and over – but fortunately we do learn!
As we move rather rapidly down the integration pathway, we should keep asking our clinicians to consider the impacts of sudden or silent failure and ensure solid, well practiced back up processes with auditing are in place and not left to the rushed search for a notebook and pen when the inevitable happens.
Isaac Asimov understood this when he said: “It is change, continuing change, inevitable change, that is the dominant factor in society today. No sensible decision can be made any longer without taking into account not only the world as it is, but the world as it will be.”
Our work continues!
Recently I sat through a Gartner talk on the EHR.
While many of the points below are valid issues and relate to an major EHR implementation there was little focus on the underlying knowledge management issues, such as cross system integration, standards in data sets and interoperability.
Issues around safe user interface design and new and innovative uses of telehealth and seamless patient movement around a nation have not been taken up. The USA model of the big vendor system (e.g. CERNER, EPIC, ISoft) misses the wonderful integration achieved by Australia in the last few years and while it is far from perfect in many ways it leaves the USA gasping in its wake.
As long as you never move between hospitals things will be fine and well integrated for those patients but change providers, move between jurisdictions and your EHR rapidly becomes hidden and of diminishing value.
The following points though are all valid and important but don’t for one minute think this is all you have to deal with.
There clearly needs to be consideration of planning, project management, vendor selection, change management and execution.
The following areas were highlighted as a main focus of complaints and concerns during and after implementations.
- Lack of clear executive clinical leadership
- Complex technical organizational regulatory, cultural challenges
- Lack of dedicated resources
- Poor project management
- Weak governance
- Poor change management
- Weak benefits realization process
- Poor communication
- Vendor inability to deliver to specification
- Clinical rejection of system
Many lessons therefore should be considered constantly both before, during and after implementation.
- Unrealistic timelines
- Failure to review clinical workflows / processes
- Failure to understand the technical requirements
- No clear vision as to why we are doing this
- Stakeholder conflict
- Scope creep
- Inadequate in-house support
- Lack of clarity on interface requirements
- Underestimating data conversion
The following cycle of issues may be of value to follow and review n a very dynamic manner and particularly as warning signs are developing.
- Develop a communication plan
- Review Total Cost Ownership
- Review EMR Lessons
- Review Procurement Model
- Review Readiness Assessment
- Review EMR Strategy
- Identify stakeholder Engagement model
- Review Governance
- Plan for Change Management
Other Factors to Consider
- Standardisation of medical practice and reducing variability and variance between practices
- Development of the CMIO role to assist in the redesign of clinical workflows
- Develop and review your engagement strategy as issues and tension develops.Some of the long term demanding issues will be sustainability and optimisation over time.
Gartner is pushing The Real Time Healthcare System
Telehealth has been alive and reasonably well in Australia for over a decade now. There are a multitude of services being provided across a wide range of specialties and professional groups.
While some innovative apps, home monitoring and consultation styles are being developed or in some cases are well entrenched and in place, there seems to be a gap and limited growth in the seamless electronic medical record with the non-virtual health world.
This is about to change with integrated repositories of patient data, a national infrastructure of providers and access, web based user interfaces for viewing and studying repository material.
As defined by the Britannica Concise Encyclopedia, safety defines activities that seek to minimize or to eliminate hazardous conditions that can cause bodily injury.
There are innumerable risks to human safety and the management of those risk to ensure a safe environment is a task that is imposed on every human being from the earliest age as a genetic imperative around which cultural taboos, social norms and engineering, in all its aspects, cocoons society and its members.
Risk Management is all about identifying safety risks and putting in place controls to minimise or eliminate those risks. Errors and mistakes are an inevitable part of human development be it as a child touching a hot surface, tripping over, ingesting inappropriate materials to their elders speeding, utilising infectious needles or simply loosing control with legal or illicit drugs.
Mistakes can often be as good a teacher as success, (Welch, Jack) if you survive. If you don’t of course that meets the genetic imperative. The Darwin Awards make light of some of those issues. Unfortunately one person’s mistake, sometimes remote from the final outcome, can lead to the deaths of many whose loss to humanity should never be underestimated.
What makes a computer application used in the health care industry safe?
Simple answer is we do!
All tools – cars, aeroplanes, hammers and chisel are extremely safe until a human decides to use them. Mind you an unused tool is not really a tool at all and a computer application that is not used is of no intrinsic value to anyone. It is only when the button is pressed, the icon released or the message sent that those relying on the accuracy of the underlying systems and the human input provided are in receipt of a benefit or harm as a consequence.
Many applications look fantastic, attractive and modern but are incredibly unsafe either in their own design, the systems they reside upon, the messages they send or the lack of skill of the human at the interface.
This site hopes to look at all aspects of creating safe health information systems and the issues the applications development.