The system crashed while my coworker was running a code (aka doing CPR) in the ER last night. Healthcare IT is so bad at baseline that we are somewhat prepared for an outage while resuscitating a critical patient.
if it works, there's a lot more to be done to get the patient to stable.
Different medications may be pushed (injected into the patient) to help stabilize them. These medications are recorded via a bar code and added to the patients chart in Epic. Epic is the source of truth for the current state of the patient. So if that is suddenly unavailable that is a big problem.
Technologically it seems doable. Big enough order brings down the costs.
https://soldered.com/product/soldered-inkplate-5-5-2%e2%80%b...
Of course the real backup plan should be designed based on the actual needs, perhaps the whole system needs an "offline mode" switch. I assume they already run things locally, in case the big cable seeker machine arrives in the neighborhood.
Some hospitals require you to input this in order to even get physical access to the medications.
Although a crash cart would normally have common things necessary to save someone in an emergency, so I would think that if someone was truly dying they could get them what they needed. But of course there are going to be exceptions and a system being down will only make the process harder.
Yep, the business continuity boxes are basically minimally connected PDF archives of patient records "printed" multiple times a day.
Anyone involved in designing and/or deploying a system where an application outage threatens life safety, should be charged with criminal negligence.
A receipt printer in every patient room seems like a reasonable investment.
The grandparent indicated that the problem was that when all tow computers went down, they couldn’t look up what had already been done for the patient. I suggested a simple solution for that - receipt printers.
After the computers fail you tape the receipt to the wall and fall pack to pen and paper until the computers come back up.
I completely understand the scale of the outage today. I am saying that it was a stupid decision and possibly criminally negligent to make a life critical process dependent on the availability of a distributed IT application not specifically designed for life critical availability. I strongly stand by that POV.
But they switched over to EMR because the advantages of Pyxis[1] in getting the right medications to the right patients at the right time- and documenting all of that- are so large that for patient safety reasons alone it wins out over paper. You can fall back to paper, it's just a giant pain in the ass to do it, and then you have to do the data entry to get it all back into EMR's. Like my wife, who was working last night when everyone else in her department got Crowdstrike'd, she created a document to track what she did so it could be transferred into EMR's once everything comes back up. And the document was over 70 pages long! Just for one employee for one shift.
1: Workflow: Doctor writes prescription in EMR. Pharmacist reviews charts in EMR, approves prescription. Nurse comes to Pyxis cabinet and scans patient barcode. Correct drawer opens in cabinet so the proper medication- and only the proper medication- is immediately available to nurse (technicians restock cabinet when necessary). Nurse takes medication to patient's room, scans patient barcode and medication barcode, administers drug. This system has dramatically lowered the rates of wrong-drug administration, because the computers are watching over things and catch humans getting confused on whether this medication is supposed to go to room 12 or room 21 in hour 11 of their shift. It is a great thing that has made hospitals safer. But it requires a huge amount of computers and networks to support.
Why would a Pyxis cabinet run Windows? I realize Windows isn't even necessarily at fault here, but why on earth would such a device run Windows? Is the 90s form of mass incompetence in the industry still a thing where lots of stuff is written for Windows for no reason?
Why does everything need the internet?
Why would you ever need to move a patient from one hospital room containing one set of airgapped computers into another, containing another set of airgapped computers?
Why would you ever need to get information about a patient (a chart, a prescription, a scan, a bill, an X-Ray) to a person who is not physically present in the same room (or in the same building) as the patient?
And sending data out can be done quite securely. Then replies could be highly sanitized or kept on specific machines outside the air gap.
And now you've added an army of people running around moving USB sticks, or worse, printouts and feeding them into other computers.
It's madness, and nobody wants to do it.
In my eyes, there is a technical solution therr that keeps friction low for hospital staff: network stuff, on an internet, but not The Internet...
Edit: I've since been reading the other many many comment threads on this HN post which show the reasons why so much stuff in healthcare is connected to each other via good old internet, and I can see there's way more nuance and technicality I am not privy to which makes "just connect LANs together!" less useful. I wasn't appreciating just how much of medicine is telemedicine.
Yes there will be some pain, but the alternative is what we have right now.
> nobody wants to do it.
Tough luck. There's lots of things I don't want to do.
Just so I understand what you are saying you are proposing that we drown our hospital rooms in paper receipt constantly. In the off chance the computers go down very rarely?
Do you see any possible drawbacks with your proposed solution?
> possibly criminally negligent to make a life critical process dependent on the availability of a distributed IT application
What process is not “life critical” in a hospital? Do you suggest that we don’t use IT at all?
This much of patients state will be carried on their wrist. Maybe for complex cases you need two stickers. Have to be judicious in encoding data, maybe just last 48 hours.
Handheld qr readers, off line that read and display QR data strings.
I'm not even beyond two degrees of seperation here. I don't think a court'll have trouble navigating it.
Cloudstrike did not even have a duty of care to their customer, let alone their customer’s customer (speaking for my jurisdiction, of course).
Now, a tort is less of a stretch than a crime, but thank goodness I’m not a lawyer so I don’t have to figure out what circumstances apply and how much liability the TOS and EULAs are able to wash away.
If I go to Home Depot to buy rope for belaying at my rock climbing center and someone falls, breaks the rope and dies, then I am on the hook for manslaughter.
Not the rope manufacturer, who clearly labeled the packaging with "do not use in situations where safety can be endangered". Not the retailer, who left it in the packaging with the warning, and made no claim that it was suitable for a climbing safety line. But me, who used a product in a situation where it was unsuitable.
If I instead go to Sterling Rope and the same thing happens, fault is much more complicated, but if someone there was sufficiently negligent they could be liable for manslaughter.
In practice, to convict of manslaughter, you would need to show an individual was negligant. However, our entire industry is bad at our job, so no individual involved failed to perform their duties to a "reasonable" standard.
Software engineering is going to follow the path that all other disciplines of meatspace engineering did. We are going to kill a lot of people; and every so often, enough people will die that we add some basic rules for safety critical software, until eventually, this type of failure occuring without gross negligence becomes nearly unthinkable.
Then again, the management that put this in are probably also the same idiots that insist on a 7 day lead time CAB process to update a typo on a brochure ware website "because risk".
There are plenty of drugs that can only be given in certain quantities over a certain period of time, and if you go beyond that, it makes the patient worse not better. Similarly there are plenty of bad drug interactions where whether you take a given course of action now is directly dependent on which drugs that patient has already been given. And of course you need to monitor the patient's progress over time to know if the treatments have been working and how to adjust them, so if you suddenly lose the record of all dosages given and all records of their vital signs, you've lost all the information you need to treat them well. Imagine being dropped off in the middle of nowhere, randomly, without a GPS.
Will outages like this motivate a backup paper process? The automated process should save enough information on paper so a switch over to paper process at any time is feasible. Similar to elections.
there are backup paper processes, but they start fresh when the systems go down
If it was printing paper in case of downtime 24/7, it would be massive wasteage for the 99% of time system is up
Maybe a handheld device for scanning in drugs or entering procedure information that stores the data locally which can then be synced with a larger device with more storage somewhere that is also 100% local and immutable which then can sync to online systems if that is needed.
If medical data were synced to the cloud but also stored on the endpoint devices and local servers, you’d have more redundancy. Obviously much more complexity to it but that’s what it would take. Epic as single source of truth means everyone is screwed when it is down. This is the trade off that’s been made.
That's a recipe for a different kind of disaster. I actually used Google Keep some years ago for medical data at home — counted pills nightly, so mom could either ask me or check on her phone if she forgot to take one. Most of the time it worked fine, but the failure modes were fascinating. When it suddenly showed data from half a year ago, I gave up and switched to paper.
More seriously, we need better purpose build medical computing equipment, that runs on it's own OS, and only has outbound network connectivity for updating other systems.
I also think of things like the old school "check list boards" that used to be literally built into the yolk of the airplane they were made for.
That doesn't help when the system goes down and you lose the record of all medications administered prior to having to switch over to the Sharpie.
Reality is complex.
And that's in the OR, where vitals are automatically captured. There just aren't enough computers to do real-time electronic documentation, and even if there were there wouldn't be enough space.
Its easier, faster, and more accurate than writing in my experience. We have a page solely dedicated to codes and the most common interventions. Got IO? I press a button and its documented with timestamp. Pushing EPI, button press with timestamp. Dropping an I-Gel or Intubating, button press... you get the idea.
The details of the interventions can be documented later along with the narrative, but the bulk of the work was captured real-time. We can also sync with our monitors and show depth of compressions, rate of compressions and rhythms associated with the continuous chest compression style CPR we do for my agency.
Going back to paper for codes would be ludicrous for my department. The data would be shit for a start. Hand writing is often shit and made worse under the stress of screaming bystanders. Depending on whether we achieved ROSC or not would increase the likelihood of losing paper in the shuffle
This wisdom is echoed in some religious practices that avoid complete reliance on modern technology.
Okay, how does that monitor work? Genuinely curious.
Nurses hated it.
If they go and publish "According to hackernews user davycro ..." _then_ there's a problem.