My friends over at Government Executive magazine broke a story late yesterday afternoon about a problem in sharing medical data between the US Veterans Administration's (VA) VistA electronic health record (EHR) system and the Department of Defense's (DoD) AHLTA EHR system.
For those unfamiliar with these EHR systems, AHLTA is used by doctors treating active duty military personnel and their families, while VistA is used by doctors treating military veterans. The last few years there has been a lot of effort in making the medical information contained in AHLTA available to VistA, so that when active duty personnel retire or are discharged from the military, their medical records are easily accessible by the VA doctors.
Last February, a VA doctor accessed AHLTA to review the medical information of a female patient. The doctor noticed that the electronic record displayed showed that the patient was being prescribed an erectile dysfunction drug.
Suspecting something amiss, the doctor called the DoD medical facility that had supposedly prescribed the drug to find out what the heck was going on. A long story short, the electronic medical record was in fact displaying the prescription for another patient.
How did it happen?
Quoting from the Gov Exec story, "The errors occurred in the Bidirectional Health Information Exchange, a project started in 2004 that allows clinicians in VA and Defense to view health information in patient files. Older code in the system became stressed at peak periods when clinicians were making the most number of queries, said Roger Baker, chief information officer at VA. At these times, the system did not clear out a memory cache, resulting in memory leaks 'so that information from one patient is presented as it is from another,' he explained."
CIO Baker said that incorrect information occurred about once in a hundred times, and only when the VA doctors accessed the AHLTA system. However, the glitch affected not only pharmacy information, but also laboratory and radiology reports.
On Monday, the VA closed down access to AHLTA to fix the problem, and said that it will reopen the information exchange next Tuesday, March 9th. The VA says no one has been harmed, although that might not have been the case if something so obvious hadn't shown up, as the VA itself admits. If the drug prescription for the female patient had been more plausible, it might have had a different ending.
As the US provides strong monetary incentives to the installation of interoperable but many different vendors' EHR systems, the issue of data integrity is going to loom larger. One question will be when something like this happens in the national health information network - and it is almost inevitable - who is going to be responsible for fixing the error? I can foresee a lot of finger pointing among vendors.
Doctors are going to have to be even more sensitive to the old adage, "Trust, but verify," I think.
Robert N. Charette is a Contributing Editor to IEEE Spectrum and an acknowledged international authority on information technology and systems risk management. A self-described “risk ecologist,” he is interested in the intersections of business, political, technological, and societal risks. Charette is an award-winning author of multiple books and numerous articles on the subjects of risk management, project and program management, innovation, and entrepreneurship. A Life Senior Member of the IEEE, Charette was a recipient of the IEEE Computer Society’s Golden Core Award in 2008.
