Calgary’s e-health glitch: What went wrong

The Calgary Health Region is rolling out a patient identification system across its eight health care facilities that will help staff instantly spot a duplication or error in a patient’s health care record.

The system

builds on a technology that the CHR has been using for the past three years to scan all of its databases to locate duplicate patient records. Any time a health-care worker types in a person’s name into the computer, for example, it goes to a master patient index and sorts through all the records that have that person’s name on it.

The implementation of this new system comes on the heels of a computer error that mixed up 2,000 results from blood and urine tests, forcing the region to shut down the database on July 6. Problems with the Internet database have not affected any of the test results, according to officials at CHR. The region is currently investigating the situation and has contacted all 378 physicians and other health care workers that viewed the incorrect lab reports.

The glitch, which began on May 1 during an upgrade of a Calgary Laboratory Services’ computer program, wasn’t discovered until earlier this month. The problem occurred in one of the 25 interfaces where the lab data gets sent. One of the database fields that contains numbers that correspond with a particular kind of test was switched, rendering the numbers meaningless.

“Prior to the change, each of the digits had meaning,” said CHR vice-president of advanced technology Bill Trafford in an interview with Thursday. “The software that looks at that number to figure out which person’s results belongs to them incorrectly interpreted the numbers.”

Trafford added this number would only cause a problem one in 20,000 times — an error rate far lower than paper-based systems. The lab system, which produces 400,000 results monthly, has been in place for 10 years without incident, he said.

“The challenge is there’s a different expectation between what you see on paper and what you see in electronic format,” said Trafford. “Generally the error rates that you could have in paper are acceptable in much higher rates than you could have electronically.”

Trafford estimates that anywhere between two to four per cent of records in databases containing patient information are incorrect. This includes wrong addresses or misspelling of names, for example.

The current system is still largely paper-based as physicians and other health-care workers continue to receive test results via phone, fax and mail. Eighteen months ago, the region implemented a repository so that those clinicians that didn’t have access to lab results electronically could get access. The CHR is also rolling out a new system called Sunrise Clinical Manager from Eclipsys Corp. to all acute hospitals in Calgary that will allow physicians like Michael Giuffre to electronically order lab test and electronically get their results back.

Giuffre, president of the Calgary Regional Medical Staff Association (CRMSA), said while receiving results electronically has tremendous benefits, the majority of physicians and health-care workers still rely on paper-based communications. The computer error, said Giuffre, highlights the need for health-care organizations to review their policies – especially with an increasing number of processes being automated.

“It was a setback for those that put it forth but at the same time it can’t happen again,” said Giuffre. “Each of those policies are being reviewed and reinforced in terms of making sure everyone knows exactly what to do.”

Khaled El Emam, associate professor, faculty of medicine, University of Ottawa, points out that most software contracts or licenses that health-care organizations sign protect the vendor.

“The vendor is not responsible for any errors or any consequences of these errors,” said El Emam, who advises institutions to select mature vendors, which generally tend to have fewer problems with their software.

Montreal-based lawyer Gordon Kugler at Kugler Kandestin said the hospital or health-care facility would be at fault in a case like this because they are ultimately responsible for medical mishaps.

“If a computer error in the record says that a person must have your left leg amputated for a condition that he did not have because it should have been in the record of another patient, clearly he’s suffered serious damage as a result,” said Kuger. “The originating mistake would have been the error in the medical record.”

Likewise, El Emam said it’s more difficult for a patient to go after a vendor than a hospital.

“It’s harder to go after the developer themselves,” he said. “It’s the provider that would have to take the brunt of the consequences.”

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