Contemporary Issues in Medical Informatics: Good Health IT, Bad Health IT, and Common Examples of Healthcare IT Difficulties
Serious clinical computing problems in the worst of places: an ICU

Serious clinical computing problems in the worst of places: an ICU

(Note:  This is a case account from several years ago when I was Director of Medical Informatics. It was one of the major experiences that led to the realization that clinical IT difficulties were not being adequately addressed anywhere, and that Director of Medical Informatics positions were poorly structured and inadequately empowered.)

In an East Coast USA tertiary hospital’s medical intensive care unit, an electronic patient record and physiologic monitoring system was desired by the medical and nursing staff to save time and improve care. The MIS department was put in charge of software and hardware selection and configuration.   The implementation of the ICU system was near complete upon the arrival of a medical informatics expert, hired as “Director of Medical Informatics” largely at the prompting of the Senior Vice President for Medical Affairs to resolve major clinical IT problems and political infighting in the hospital.

The MIS department by policy only used Compaq computers. Any other computer manufacturer's computer was deemed "risky." There were stories of a bug in a model of Macintosh causing packet storms and taking down a network. Other computer brands might also have compatibility problems and require special drivers (not that this was ever tested). Therefore, Compaq PC's were the "one shoe" that would "fit all" needs in the organization.

The ICU rooms were very small. In order to fit the standard-issue Compaq desktop computer into such rooms, along with a standard CRT monitor, custom (expensive) cages were designed and ordered so that the machines could be bolted to the ceiling of each room. Special custom poles and cabling harnesses were also designed, ordered and installed, custom-made to fit each room at great expense – over five thousand dollars per ICU room. On each pole was mounted a standard computer CRT monitor, keyboard and ordinary computer mouse.

Issues such as air filtration, maintenance, and contaminant circulation from the power supply fans of each machine, heat generation from the CRT's, dirt accumulating on the mouse and keyboard, and other ergonomic and medical issues were not considered.   The informaticist, asked to evaluate the system, was rather shocked by this, especially with the rapid rise of resistant strains of pathogenic bacteria in the United States (e.g., methicillin-resistant staphylococcus aureus or MRSA), and other airborne pathogens such as TB where resistant strains were also appearing. 

The informaticist was a physician who had excellent training in infectious disease (his chairs of postgraduate medical education were infectious disease experts, one of national standing), as well as a thorough understanding of electronic equipment.  He had a clerkship in biomedical engineering, was a microcomputer hardware expert, as well as a licensed radio telecommunications specialist by examination, the amateur extra class, the highest certification.   He had constructed complex electronic equipment from kits as well as from raw parts and blank circuit board stock, including an infrared sensing heart monitor, high powered shortwave transceivers, and computer equipment (when individual parts required soldering onto blank circuit boards), as examples.  This was known to the hospital staff.

His concern – a concern in his judgment not just possible but highly likely – was that the dust balls and dirt that accumulate in any actively fan-cooled electronic equipment operated in contaminated or dirty environments might serve as an excellent medium for colonization by pathogenic organisms, and that the organisms could be spread by the air circulated by the fan.  These concerns were ignored by MIS staff, the infectious disease department and the head of the ICU (and by rumor also ridiculed). 

The informaticist was shocked even more by an apparently cavalier attitude of the senior hospital management towards these concerns.  Even at his recommendations, industrial form factor computers (small, convection-cooled or low-air-circulation, and mountable to a wall), flat-screen LCD monitors (compact, low-power-consumption, low-heat-producing), easily-cleanable track pads, and other ergonomically better-suited solutions were dismissed with the refrain "we don't support them".   No such technology was purchased for evaluation. In fact, as it turned out, the MIS system architects had actually never before seen or even heard of a combination keyboard and track pad that had been available off-the-shelf for a number of years from nearby CompUSA outlets - for the grand sum of $50 retail.

Worse, the ICU system had ergonomic and technical problems. A clinician hit his head on one ceiling-mounted computer. A monitor nearly toppled and caused an injury. Redesign and relocation of the hardware mounting cages and poles had to be performed at more expense. The ICU room crowding and tight workstation ergonomics were not appreciated by busy ICU personnel. The informaticist noted the ergonomic problems and recommended solutions, but was resented since the technology being suggested (e.g., industrial/clinical computing form factors, track pads instead of mice, and flat screens from a number of non-Compaq vendors) were "not supported by I.S."   Recommendations to periodically culture the dirt and dust inside the ceiling mounted computers were also ignored.

The informaticist sensed a motivation of the MIS department might be to protect the investment they’d made for the custom installation of desktop computers on the ceilings of ICU rooms, requiring the Rube Goldberg-style mounting cage, swivel pole, interconnecting cables, and other hardware that had been acquired at great expense to “force-fit” inappropriate computers into the ICU rooms for the convenience of the MIS department.  The informaticist also sensed a motivation of MIS to meet remaining project deadlines and budgets, perhaps related to bonuses or to advance their careers – at the expense of proper due diligence regarding seriously ill ICU patients.  Unbelievable, thought the informaticist.  The MIS culture - and the culture of indifference to that culture by clinical leadership – might be endangering patients, and his advice was being ignored and marginalized.

As an engineering specialist later commented when reading this story:

If there is a specific application (example: a PC requirement for an ICU room), then the specifications for what should be in the room should be established first. If the requirements are that the equipment be compact (small, out of the way somehow), this should be part of the specification. MIS personnel and the users (clinicians who operate in the room) should define what is required, including any "hardening" requirements (CPU shielding from magnetics or radiation), ventilation requirements, and display requirements (touch sensitive LCD screens?).

Obviously, there needs to be consideration as to how to engineer this system (I'm still thinking get the CPU out of the room, wire in, that way there's only the monitor and input device/keyboard/mouse), but the system should be designed and not just slapped in as the same CPU as what's in the accountants office. More importantly, if the MIS group insists on a standard CPU (Compaq, HP, IBM), then they are responsible (and in my view liable) for guaranteeing that the system meets the standards required.

In pharmaceutical plants, there are areas which are designed to be low or no particulate generating (Class 100 areas) where product might be exposed to the environment. In these areas, all the equipment is required to be of clean room design (low generation, no aerosols, etc.). When equipment such as computers are required for the area, the engineer MUST find a way to keep the system from putting material in the area. This means either locating the CPU (with its fan and heat generating components) outside of the room (with sealed cables coming into the room) or putting the CPU under an exhaust hood which removes the exhaust air from the room. Either way, the system must be designed to the needs of the area.

The system was also repeatedly crashing.  The informaticist noted portable x-ray machines in frequent use in patient rooms, as happens in ICUs, and realized x-ray scatter could be a cause of PC crashes. MIS personnel, on the other hand, thought insufficient RAM might be causing the crashes (empirically - there was no actual evidence for this) and were set to spend a large amount of money to upgrade each machine.

When the informaticist inquired if the computers used parity-checked RAM as a precaution against memory errors caused by x-ray radiation or other factors (a reasonable question for an ICU setting), it became apparent to him that the MIS personnel, including the MIS director, did not know if the computers were so-equipped, and worse, did not know what parity checking memory was or why it might be needed in such a setting.

After this basic question and a lack of response, the informaticist reported the potential problem to the head of the ICU. The response of the MIS personnel was to shun the informaticist and say non-complimentary things to administration about the informaticist's role and beliefs. The MIS personnel assured administration that all computers had the parity feature, and that is was not very important anyway since only "satellites in Earth orbit" needed protection from x-rays.

The informaticist pulled a memory module from a machine and found it was an 8 bit, not a 9 bit, module and therefore did not support parity checking. However, administration did not believe the informaticist's concerns about ergonomics or technical issues such as this, after the assurances and spin from MIS.

It later turned out that neither x-ray scatter nor memory quantity was causing these particular crashes. In fact, a vendor software design deficiency was found to be causing the crashes. The vendor had apparently designed the system so that each individual client workstation was responsible for initiating printing of periodic reports on the patient in its room, rather than centralizing this function at the server. This introduced a manifold increase in potential points of failure and was found to be the major source of the trouble. Significant modifications to make the reporting function server-based solved the problem.

This was a design deficiency that the informaticist, who had developed significant software in the past, would have recognized quickly as suboptimal for a critical care setting such as an ICU in the first place. Also, the informaticist still recommended parity memory for any critical care setting as a relatively inexpensive legal due diligence. This advice was not heeded.

The informaticist's credibility with administration had been tarnished by MIS. The informaticist's concerns about the technical abilities of the MIS department to support equipment so closely involved in this critical patient care setting were also resented by administration.  Regarding organizational changes recommended by the informaticist on clinical IT leadership, the chief medical officer seemed more concerned with the possible effects on IT personnel’s careers than with the effects of faulty computing on patient well being.  The informaticist found such priorities simply stunning.

Meanwhile, the system proved more costly to support than MIS had predicted, requiring extensive development and customization (over and above the inflated costs of the fancy mounting accouterments), since it was immature, not entirely reliable, and user-unfriendly. One very valuable system feature, the severity scoring system, was never enabled. That feature might have allowed patients to be transferred out of the ICU earlier, saving a significant amount of money.

The system struggled with proving a return on investment, was nearly canceled after a year, and was given a "try-it-for-one-more-year-but-prove-the-ROI" reprieve only after a large degree of pleading and politicking by key personnel (including the informaticist). Its future became uncertain, plans to spread the technology to other ICU's in the organization were canceled, and administration had been needlessly "turned off" to this type of technology.

On the whole, the principal actors in the case described above were petty, small-minded, self-serving, and narcissistic at the expense of patient safety.  The dysfunction in this malignant hospital environment (madness, actually) was one factor in the informaticist later resigning this role and taking a position in industry. 

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Addendum:  the informaticist’s fears have since been well-confirmed.  It would have been helpful to patients if the hospital had actually taken a scientific approach and investigated the concerns of its own expert. 

Dirty PCs fuel hospital super bugs

Hospital Computer Keyboards May Spread Danger

Computer equipment could help MRSA spread

The informaticist can only wonder if the iatrogenic infection, morbidity, and mortality rates had increased in patients who’d spent time in MICU when the computerized physiologic monitoring system that is the subject of this story was in operation.

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It is worth reviewing the first linked story above, from The Register, a UK newspaper:

Dirty PCs fuel hospital super bugs

by Peter Warren, The Register

Published Thursday 26th May 2005 10:23 GMT

Scientists in the US have linked the spread of the hospital super bug MRSA to a sharp increase in the use of technology in hospitals.

Researchers working in hospitals have found that the deadly bacteria clings to the keys of the computer keyboards used to update patient records and therefore can re-infect the hands of staff even after they had washed their hands.

There were 55 deaths from MRSA in UK hospitals in 1993, but fatalities have increased every year since and by 2003 were running at nearly a 1,000 annually, according to the National Office of Statistics.

The US findings, which were presented to the Society for Healthcare Epidemiology of America earlier this month, found that just touching a keyboard is enough to pick up the bacteria and pass it onto a patient.

The researchers also found that cleaning IT equipment with soap and water was not enough to remove the bacteria.

The only way to clear the infection from the keyboards, according to Dr Gary Norskin from the Northwestern Memorial Hospital in Chicago who carried out the study, was to rinse the keyboard with disinfectant.

"A computer keyboard is like any other surface in a hospital and has to be sterilised," said Norskin, Northwestern Hospital's director of healthcare.

The Chicago study is part of a new trend in the US which is now taking a long hard look at how the introduction of computer equipment into hospitals can often represent a health risk.

Computers quickly become magnets for airborne dust and bacteria-harbouring dirt, which builds up on their internal cooling fans.  The fans represent a further health hazard because of their potential to blow that same dust around a ward.  "Anything that can put bacteria into the air is a risk," said Norskin. "If you bang into a computer and disturb that dust you can effectively create a dust cloud."

Doctors at the Oklahoma Heart Hospital have already started to address the problem.

"We have computers everywhere because our goal it to have a paperless hospital and to have computers everywhere a patient goes,” said Jeff Jones, Oklahoma Hospital's lead system specialist.

"Computers harbouring bacteria is a very big concern of ours because we have computers only three feet away from patients in our operating rooms and we can't have dirt in places like that," he said, adding that tuberculosis is another potential risk from technology as it is the world's number one airborne disease.

"We did experiment with waterproof keyboards that you can wipe clean but found out that they were generating a lot of keystroke errors that could have been just as dangerous for patients," said Jones.

A spokesman for the UK’s National Health Service confirmed that the department's computer specialists were looking into the concerns and that the agency responsible, NHS Connecting for Health, was conducting a study into the issue at University College London to find the risks.

Dr Paul Grime, the British Medical Association's spokesman on MRSA commented: "If computers and keyboards are going to be next to people's beds then this is something that we have to be aware of because this equipment is no different from any other hard surface in a hospital but the key to this is hand hygiene and staff have to get used to washing their hands before and after touching a patient.”

Such health risks have not gone unnoticed by the computer industry which has moved quickly to respond to the threat created by technology in hospital.

 

 

 

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