To Err is Not Just Human

In the article How to Eliminate EHR-Based Medical Errors, presents a list of computer errors that affect patient care. While many tend to blame poor programming and software glitches, these developmental issues are only partially to blame. The ultimate culprit is a lack of standardization in EHR systems, in general. Sufficiently standardized systems would make it possible for a physician to enter data at one hospital, and when at a different one, use the very same methods.

 

Unfortunately absence of standardized interfaces is ubiquitous in our currently technological society.  For example, how often does one go to one store, say a grocery store, and when trying to pay for goods, has to deal with a card reading device that is entirely different from the adjacent store.  One has to figure each one out independently. If spending too much time shopping, one could easily run into ten different interfaces.  Quite maddening.  But that is the normal world, one would expect better of medicine and medical technology. Or is that expecting too much?

Some examples of the confusions encountered include:

1.  Data base/CPOE’s (computerized physician order entry systems)have inconsistent dosing for medications, or manages to switch the dosing between 2 medications
a.  Solution is national data base for CPOE. The data base can “live in the cloud” and be accessible to all

2.  Artificial intelligence that is artificial but not intelligent, such as incorrect weight adjustment for natural growth
a.  Solution –data base that is accurately age and weight adjusted and that catches irregularities and sends notification.

3.  Failure to inform clinician of critical lab information is a major problem.  The more clinicians are depending on technology, the more they naturally depend on them to flag problems.
a. Solution –warning system of critical lab results---coordinated through a national data base for national CPOE, mentioned above.

4.  Prescription with wrong decimal point for dangerous medications. Deadly !
a.  Solution—standardized CPOE/Pharmacy and automated safety testing.

5. Duplicate patient records.  How difficult is it when Patient Sam Q. Brown enters and registers as Sam Brown.  But the computer is thrown off by the absent Q…..and then a second record is created, one that does not have all the important information that Sam Q needs to have in place.
a. Database error created by expected variance in human nomenclature. The error should be trapped and the medical team prompted to sort it out and reconcile the records. Google does this, why can’t medicine.

6.  OUTPUT is “Gobblygook” at best. A combination of typing, cut and paste, macros, mini-macros, and  “computerize” that makes no sense. The inputs are all given the instruction to create text. There is no instruction set that can be made which will create automatic meaningful text.
a.  One solution may be greater use of voice recognition. For example, Voice Activated Technology (Dragon) allows a clinician to dictate several common sense sentences about what really happened during the encounter.  Siri does pretty well on this too.  Apple, Dragon do it, why not get medicine more fully on board?

7.  Scanned documents sent to wrong patient.
a.  No fail safe mechanism exists for stupidity or incompetence

8.  Action items never were seen or acted on by the clinician.
a.  Programming issues/inappropriately mild alerts can be blamed, often
b.  Often, it is difficult for a provider to comment on action taken because there is an inability to easily add addendum.  Developers should really try to make the systems at least better than paper in this regard.

The fundament problems are lack of standardization, easy navigation, appropriate warnings, and ______________ fill in the blank. Meaningful use money would have been better spent on a national data base and CPOE. Each vendor could then create their own system with built-in universal knowledge, integration, and interoperability as a baseline.

“Mama Don’t Let Your Babies Grow Up To Be Doctors”

This is Waylon Jennings' and Willie Nelson's 1978 cover of "Mamas, don't let your babies grow up to be cowboys". The song, originally performed by Ed Bruce, was number 1 on the charts for four weeks in the spring of 1978 and was released on the classic duet album "Waylon & Willie".

In the famous song by Willie Nelson and Waylon Jennings, they opine about the hardships of the “cowboy life”.

This song was Waylon Jennings' and Willie Nelson's 1978 cover of "Mamas, don't let your babies grow up to be cowboys". The song, originally performed by Ed Bruce, was number 1 on the charts for four weeks in the spring of 1978 and was released on the classic duet album "Waylon & Willie".

When asked the question of whether you would want your children or relatives to become physicians in the modern era, the answer is always “YES… but….”

Motivations for becoming a physician are multiple with multiple answers. They are generational in scope and multi-factorial. These include

1. Saving the world

2. Helping mankind

3. A means to an end.

4. Avoiding the draft and the Vietnam War

5. Family tradition

6. Economically motivated

7. Opening doors

8. Raising your social statue

9. Good at “School”

10. etc.

The modern day physician is caught in the trap of the “fantasy” of the good old days and ever-changing landscape. The physician is no longer the perceived expert of their domain but a valued cog in the big picture.

Patients still love their personal physician but want input in all aspects of their care. The paternal system of “I’m The Doctor” no longer works.

The physician is also trapped in the electronic world of endless data capture that is rarely relevant to the individual patient in front of them. Click 18 more boxes and you might get paid. 17 boxes and you get a 50% reduction. Did the patient get better? Who knows?

The modern day physician has become a corporate employee with little autonomy unless you are a dinosaur from the past and cling to your “perceived” freedom. Once you accept Medicare and Medicaid payments, you are indirectly/directly an employee of the government.

Getting back to whether you would recommend it as a career. I would do it over again because of the positives definitely outweigh the negative. Every 10-15 years medicine has been shaken up for financial reasons and everyone survived. The burdens are different but with the proper understanding that early acceptors of change are always the winners.

Should Physicians Join the Union???

With the Brexit vote in the United Kingdom, endless global conflicts, and the 50-50 political dichotomy in the USA, it may be time for providers (physicians, Nurse Practitioners, and Physician Assistants to organize into an effective voting force.

 

In the interesting blog Physicians must unionize.  Here’s why, the author recommends that physicians create a union to protect their interests from governments, health systems, and the endless prevailing forces that the individual has no control over.

I would suggest reading the article as maybe the time has come for physicians to get organized and protect their substantial interests.

 

​​SLXThese interests include autonomy, financial security, work conditions, and protecting the greatest guild ever created. Physicians have reaped the benefits since the 1960’s thanks to a fee for service model and Medicare guaranteeing a financial floor to generate exceptional incomes for 30-40 year careers. Along with social status and respect, it is a great job.

However, practice and personal satisfaction has significantly decreased in the last decade. More government mandates (usually unfunded), hospitals employing physicians, and the destruction of the personal doctor-patient relationship has been steadily on the rise.

Physicians are generally organized if at all by specialty societies with varied interests. This diminishes the overall power and clout of all physicians. Critics would argue that doctors are overpaid compared to the world market and are chief offenders at driving up costs.

A similar argument can made against the National Football League Players Association (NFLPA). It has been called a joke because it represents rich football players. The football players do make great sums of money but their careers last 3-5 years with lifetime physical disabilities to follow.  Physicians can earn significant amounts of money over 30-35 years without similar threat to life or limb.

 

The union could  represent the physician body in the ongoing financial negotiations with CMS, insurance companies and hospitals, work rules, malpractice, contracts, Electronic Health Record implementations, ICD -10 implementation, and etc.

The individual has lost any clout to fight these forces or influence the decision making. A physicians’ union would put the “players” back in the discussion. And yet, there may be ethical and practical considerations that might keep some from wanting to join a union.  For example, would you cross a picket line to help the bleeding patient on the sidewalk?  Most would say yes, despite getting roughed up or jettisoned from the union.  And then, how many times have you seen a hundred or more physicians in a meeting (think union meeting) that agree on anything?  Younger physicians steer clear of medical entities, such as the AMA, which has a pre-union character to it.  Perhaps they realize that the results of joining could include an early retirement a la Jimmy Hoffa.  Lots to think about before unionizing.

Tai Chi for Health-care Practitioners

I recently started taking TAI CHI lessons to improve my balance, flexibility, and coordination.

It looks pretty easy on movies but does take a fair amount of training. People like myself, who cannot dance or suffer from right to left confusion will need to practice to gain muscle and brain memory.

​​SML

The article Tai Chi for Health-care Practitioners emphasizes the value for health care practitioners helping their patients. The programs includes  “applications for balance, geriatrics, stress and pain management, oncolcogy, PTSD,TBI, polytrauma, autoimmune diseases, women’s health. orthopedic, neurological, cardiovascular and respiratory rehabilitation".

           

Wikipedia states that “Tai Chi generally provides health benefits. In all the forms of Tai Chi there are movements that involve briefly standing on one leg, which may improve balance; circular movements of the shoulders and wrists which improve suppleness and circulation; learning the sequence of the set movements may improve cognitive function such as concentration; the social atmosphere can sometimes forge friendships and alleviate loneliness and anxiety; and the exercise itself can boost a person's mood and alleviate depression.[3][4]”

                       

My wife figured out at the first lesson that all the hand and feet movement should be considered preparations for striking and/or blocking an opponent. She’s right to have intuited the relationship between this originally Chinese practice, and the martial arts.  Many in the far east are skilled in both.  Not having 2 left feet will help with the movements. The individual motions are easy but the linkage and flow take practice, practice, and practice.

           

In general, TAI CHI is another worthwhile avenue to explore as we have a tendency to live longer and become quite immobile. You may learn how to dance. And if not, you may be able to defend yourself better.

Cost of the Click!

In the article The Hidden Cost of a Click, the author states, “A bad user interface can turn an EMR/EHR into a minefield of medical errors and inefficiency.”

At the present time, the number of clicks necessary to fill out a chart is endlessly time consuming and non-productive.  The cost per click is now being calculated and quantified.  The work flow is slowed down and there is a real-not imagined- price to pay.

One solution is to create an auto-flow sequence that is tunable by site or provider and that comfortably guides the clinician from one area of the chart to another in a logical-customary- sequence.  If an out of sequence entry is desired, this should be easily accomplished.  A system with automatic guidance will eliminate the need to figure out where one should go next, especially if one is interrupted.  When it is acknowledged that one area is complete, it then moves to the next area when documentation is continued or resumed.  Once the area is completed, the list shrinks.  Your favorite click might be auto-sequenced.

An example sequence could be...

• Vital signs
• Triage sheet
•  Past medical history
•  Nursing notes
• History and PE in logical order
• Medical decision making
• CPOE
• Lab and x-ray results
• Clinical course
• Final diagnosis
• Disposition
• e-Prescribing
• Patient education
• Follow-up
• Review nursing notes
• Sign the chart

Navigation would be significantly simplified.  The provider can always go to any area directly and in any order.  Nursing notes might be reviewed, if easily accessible.  Training would be simplified and hopefully stress-reduced.

Clicking Your Way to Burnout

The Mayo Clinic published the article Electronic medical practice environment can lead to physician burnout that “shows the use of electronic health records and computerized physician order entry leads to lower physician satisfaction and higher rates of professional burnout.”

It states that the negative effects of decreased efficiency, massive clerical burden, and provider burnout counterbalance the positive potential for quality medical care using an Electronic Health Record. These negative forces seem obvious to any practicing provider but are generally lost on administrators, insurance companies, vendors, and governmental agencies.

Logical reasoning would indicate, however, that when providers, including nurses, are “happy,” productivity, motivation, and commitment are increased, leading to higher quality and greater safety in health care.

The authors conclude that:  "Burnout has been shown to erode quality of care, increase risk of medical errors, and lead physicians to reduce clinical work hours, suggesting that the net effect of these electronic tools on quality of care for the U.S. health care system is less clear."

What is the solution? Some have been mentioned multiple times in previous blogs. But here is a list of EHR functionalities that have great potential to impact quality of care:

1.    User-friendly, site specific, specialty specific documentation

2.    Easy navigation with intuitive, user-friendly interfaces 99.9% consistent every day, every site.

3.    Changes, should be made gradually, to avoid having to relearn the program every outing

4.    Uniform CPOE (computerized physician order entry) that is the same in every system

5.    Institution of a national database to encourage real-time interoperability

6.    Voice activated technology built-in

7.    Bringing back the “Ward Clerk” – that is, let the doc do doctoring, the nurse nursing.

8.    Decreasing the work burden-eliminate unnecessary machine time, as well as homework

9.    “Alert” controls.  Too many alerts are ineffective, become “white-noise.”

10.  Ability to see what other people are documenting without making lots of clicks

11.   Every click should be counted to help design a better interface, with minimized clicks.

12.  Keep clinical interaction IT separate from bookkeeping and billing IT.

13.  Artificial intelligence that provides an “instant second opinion”

Hopefully, the future will brighter. Bean-counters should remember that clicks have financial and psychological costs. And the wrong click could cost thousands of beans.

The Medical Errors Debate

A recent article published in the BMJ has caused a furor in the medical community claiming that medical error is the third leading cause of death in the US.  In the article Sensationalization of Medical Errors: Breaking Down the Data In Order to Improve Patient, the author makes a careful analysis of the data used to come to these conclusions. The methodology of the data collection makes the claims of the study grossly overstated, but does deliver an important message to the medical-industrial complex. 

Wikipedia states a medical error is an error that is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment.

This is where the complications arise. Medical errors are and can be dangerously detrimental to certain patients but whether this is a cause and effect relationship can be very difficult to prove. Medical errors are contributory factors.

Medical errors run the gamut of poor communication, failure to diagnose in a timely manner (a complicated legal question), improper medications, not accessing the right data at the right time (a failure of interoperability of the modern Electronic Health Records, multiple intellectual and emotional biases of the providers, system errors (most common) and etc.

Whether a medical error directly cause a death, was contributory to what degree, and/or irrelevant would have to be carefully ascertained on a case by case basis. Making generalizations on death certificates where the data is frequently incorrect leads to suspect conclusions. 

The bottom line is that the medical community should take this article as a warning shot that there are significant problems in the system. Crying foul is not a solution. Moreover, the use of the word “cause” with respect to medical error is totally inappropriate.  We well know, too well, that “proximate cause” without significant other “contributory” factors, is necessary in a tort case. It is no different here.  When the disease is the underlying etiology, and the healthcare system does its best, but fails, as it naturally does now and then, what is the underlying cause?

Certainly minimizing what are termed “errors,” but should more properly be termed “imprecisions” or “flaws” is a goal to which all strive.  But as imperfect beings, subject to many flaws, a perfect medical world is not going to happen. Preventable means zero margin for the humanity under which we all labor. All we can do is our best to keep the imperfections minimized.

Fixing the present Electronic Health Record Systems to give accurate, clinically specific data would go a long way in solving some of the problems. Artificial intelligence giving specific warnings would give the provider an immediate second opinion that may help guide the proper course. Finally society has to come with grips that medical art and science is not perfect and never will be.

The Rise and Potential Consequences of Using Advanced Practice Providers

Utilization of APPs (advanced practice providers) or MLPs (mid-level providers) such as nurse practitioners and physician assistants, has increased geometrically all across the medical field. The APPs have filled huge gaps in medical care and have performed quite well. However, with growth comes the concerns and responsibilities of supervision, training, continuing education, and liability.

The recent article Medical Supervision of Mid-Level Providers written by a malpractice insurance company contains an extensive list of concerns. They are:
·         Ensuring proper credentials.
·         Delineating scope of practice.
·         Being sure a MLP’s clinical activities do no exceed the supervising physician’s Clinical privileges.
·         Teaching sufficient communication skills to the MLP.
·         Conducting regular and periodic reviews of the MLP’s activities and clinical responsibilities.
·         Encouraging each MLP to seek supervising physician oversight as needed; encouraging questions.
·         Require MLP badge identification to make credentials clear and avoid misunderstanding.
·         Provide patients a mechanism to access the supervising physician, if they choose or request.
·         Be familiar with local laws related to the scope of practice and supervision requirements for MLPs.
·         Be sure each physician who oversees MLP activities is authorized/approved to provide supervision.
·         Ensure that the MLP is properly trained for the nuances of your individual practice setting.
·         At least yearly, review/update MLP job descriptions, policy statements, practice protocols, collaborative and employment agreements.
·         Keep a copy of the collaborative agreement on file in each practice location where the MLP works.
·         Develop and approve guidelines concerning prescriptive practices. At minimum, the guidelines should:
o    Identify the supervising/collaborating physician(s);
o    Identify the types of medications to be prescribed as well as limitations;
o    Define provisions for managing emergencies; and
o    Specify the frequency of reviewing prescriptions written for controlled substances.
·         Regularly review and update protocols for frequently encountered clinical problem(s).
·         Plan scheduled meetings with each MLP at least monthly for the first six months and at least quarterly thereafter or as often as otherwise required by state-specific requirements.
·         Document any clinical problems discussed and a plan for improvement.
·         Be sure that professional liability insurance includes coverage for MLPs.
·         Contact your malpractice carrier immediately whenever adding MLPs.
 
While this may seem to be quite an extensive list, it is actually the same general conditions under which most physician providers function. Additional suggestions are:

1.    Make sure that the chain of responsibility of the supervising physician is specifically spelled-out, and understood by all.

2.    Be careful of having different malpractice vendors for MLPs and supervising physicians. This can generate adversarial situations when a case appears.  
3.    Have clear, specific policies regarding when the MLP should ask for an immediate consultation.
4.    Make sure APPs do not identify themselves as doctors, even if one has a PHD. Juries are sensitive to potential misrepresentation.
5.    Send your APP to specific courses for the care setting in which you work. Remember how practical knowledge comes with time, but is not innate.
6.    Understand your malpractice coverage. A consultant may help make sure everyone is adequately covered. The APP needs to be named on the policy.
7.    Have a cordial and professional relationship with your APP.
8.    Avoid allegations of fraud by following CMS billing guidelines; your degree of clinical involvement in any case should never be overstated.

Times are changing and it is important to adapt to the new realities. The Advanced Practice Provider is the political answer to lack of access to health care for the near future.

The Beach Boys - I Get Around - Workarounds

In the recent article Targeting EHR Workarounds, the author makes the following comments: Workarounds, depending on the system and the user, might be harmless in some cases but potentially dangerous in others.

 

Whatis.com states the definition: A workaround is a method, sometimes used temporarily, for achieving a task or goal when the usual or planned method isn't working. In information technology, a workaround is often used to overcome hardware, programming, or communication problems.

The fundamental problem is that these workarounds may solve problems, but may inadvertently create hidden/unknown downstream issues.

1.      Potentially created by a non-authorized user, circumventing safeguards
2.      Putting the facility, the user, and the supervising hierarchy at liability risk
3.      Affecting data collection
4.      Missing financial credit for the documentation
5.      Missing data qualifying for “meaningful use” credit
6.      Potentially using macros with cut and paste that obscure the individuality of the encounter
7.      Potential fraud issues as to what discussions and acts were actually performed.
8.      Very important: avoiding definitive resolution of the issue. That is, by taking the workaround short-cut, and not communicating with the vendor about the problem (sometimes easier said than done), it will continue to appear for everyone.
9.      Customization may be creative but cost-prohibitive.
10.  ETC.

Many workarounds are designed to avoid alert fatigue. These may do the job most (99%) of the time but can be disastrous if key information happens to be ignored at a crucial time. See our prior blog on “Alert Fatigue”.  For example, scanning-in of relevant documents (say, a medication list) may make life apparently simpler, but if physician eyes do not see a key item (e.g. warfarin) the EH R and its decision support mechanisms will be missing critical data (so, the patient may bleed to death if sent to surgery without anticoagulant reversal).

 

Workarounds are most often created by the most innovative and intelligent clinicians among us (and the ED seems to have it share of them), trying to overcome tedious workflow issues in their E H R.  Many are guilty of discovering and using them. No names will be given. Unfortunately, however, the problems noted above can (and have) come back to haunt the provider and the facility. The best solution is find an EHR designed specifically for your area of work and engage the vendor in a continuous process of making the product more user-friendly. In that way, workarounds can quickly become a principle source of EHR and workflow improvement. “Workaround types” would enjoy listening to the Beach Boys classic –I Get Around.

Which is Worse? Malpractice Case or Medical Board Investigation

The Black Cloud of a Medical Board Investigation is a must read for practicing professionals. The title speaks for itself. A referral to the medical board of your state can turn into a complex nightmare scenario in which you can be viewed as guilty until proven innocent.

To limit damages, targeted providers are forced to hire lawyers at their own expense to hopefully limit damages. Even though most cases are resolved quickly, even these can easily cost $20,000 and up in legal fees. In our experience, medical board actions have been as costly, as high a career risk, and as stressful as a malpractice suit.

The cases that go “south” can lead to summary suspension of license, difficulty in obtaining malpractice insurance, getting on certain insurance plans, dismissal from a hospital staff, and getting a “strike” in a 3 strike (3 strikes and your out) state like Florida.

Unfortunately, complaints are easy to file. The accessibility of filing by everyday individuals has made these actions much more common than malpractice suits. To make matters worse, accusations can morph over time and can be resubmitted multiple times if a patient or family does not get their desired result.

Medical boards receive many different kinds of complaints. Some are extremely serious (see below) but it has been found that most board actions are a result of poor communication and poor interpersonal relationships.

The most serious kind are designated sentinel events. According to the Joint Commission, a sentinel event is “and unexpected occurrence involving death or serious physical or psychological injury, or risk thereof.”  They are called sentinel because “they signal the need for immediate investigation and response. 

Ordinarily, these types of incidents get reported to the Medical Board by the critical incident committee of the hospital.  Although relatively minor events can qualify as sentinel, more frequently they are about major events and wind up being appropriately referred from the hospital to the board.  A significant proportion of these complaints are initiated by unhappy families who want “whatever they perceive has happened to their relative never to happen again”. Those who work with such cases know that perception and reality are not always identical in many situations.

While most providers are understandably paranoid about malpractice and/or liability issues, they nevertheless need to educate themselves about medical board practices in their states.  The potential adverse effects of a board investigation are not to be taken lightly. Both type of incidents, malpractice allegation and medical board referrals, are serious events that can be life-changing. Hire appropriate experienced counsel to help you survive the process.

Good patient communication, positive interpersonal relationship, and excellent documentation will help prevent both malpractice claims and board referrals. Good documentation does not have to lengthy, but when it is goal specific and captures the essence of clinical interactions, it can be life-saving (and career-saving) if confronted with either type of incident.

Why Do Certain Electronic Health Record Installations Fail?

The article Denver Health CIO, COO quit, blame pricey Epic EHR installation, says Denver Health Medical Center (where Dr. Kamens and I trained during our early EM careers) our alma mater had considerable financial and personnel problems during their Electronic Health Record installation. As one might expect, the vendor and the hospital had different versions of what actually happened. Lots of finger-pointing ensued.

Implementation problems of this type may be caused by locally specific factors, but are not unusual throughout the EHR industry, and appear in diverse locations. Finding out (and revealing!) what those fundamental issues were would be a great help to other institutions and vendors.  Unfortunately scenarios of installation blunders are only rarely shared outside the vendor’s office, and we are left doomed to repeat history from which all could have learned.

In the old days (circa 1970’s-80’s) it was common to attend a hospital educational programs called M & M conferences. The New England Journal weekly case discussion at Mass General was a paradigm for many through which medical prowess could be advanced.  M & M stood for Morbidity and mortality. Wikipedia notes:

“M&M conferences “are traditional, recurring conferences held by medical services at academic medical centers, most large private medical and surgical practices, and other medical centers. They are usually peer reviews of mistakes occurring during the care of patients. The objectives of a well-run M&M conference are to learn from complications and errors, to modify behavior and judgment based on previous experiences, and to prevent repetition of errors leading to complications.^[1] Conferences are non-punitive and focus on the goal of improved patient care. The proceedings are generally kept confidential by law.^[2]M&M conferences occur with regular frequency, often weekly, biweekly or monthly, and highlight recent cases and identify areas of improvement for clinicians involved in the case. They are also important for identifying systems issues (e.g., outdated policies, changes in patient identification procedures, arithmetic errors, etc.) which affect patient care.^{[1][3]  “}

In the purely clinical realm, perhaps due to present liability issues, M & M’s may not be as forthright as in the past. For certain, every intern and resident dreaded to be on the podium at one of these events.  “And what were you thinking at that point, Dr. Ausgiblinken?  Today, it is likely that the extent of dread probably includes most staff, physicians, attending, and others. After all someone has to take the blame when things go south.

Knowing an implementation is coming up is a common cause for major anxiety too. Can we do anything about the fact that many doctors, nurses, other providers, and administrators shake in their boots when a new installation is on the calendar? Wouldn’t it be nice if they could be at least as relaxed and as confident as when about to have a colonoscopy? That should not be such a distant dream.  Really.  Nobody puts the clinical, IT, and administrative teams into Sims or Trendelenburg. But to look at their faces the week before the new system arrives, you wouldn’t know it. 

Could we have M & M conferences for EHR implementations, sharing analyses of the good as well as the bad?  Publically available, they could vastly improve implementations, avoid common failures, and create an important knowledge base. Such M and M reviews would be welcome tools from which to learn about what really happened and what problems could have been avoided.

One might discern whether problems encountered were:

1. Systemic
2. Caused by individuals, particular departments, or departmental relationship
3. Resulted from lack of buy-in by the providers
4. A result of insufficient training
5. Caused by Hardware and/or software issues
6. Plagued by Usability issues
7. Due to an absence of effective leadership
8. Arose from a combination of two or more of the above
9. Etc.

Data gleaned from such open discussion would certainly help all institutions and vendors. Become more effective at EH R implantation, for the overall benefit of patients, and healthcare delivery.