Bob Brewin writes today in NextGov that the VA discovered a glitch in a system interface that could display the wrong patient’s information under peak load circumstances. The VA handled it in an exemplary fashion: they immediately issued a safety alert and shut down the connection; the bug (a memory leak) has reportedly been fixed and the link will be live again Tuesday.

The glitch came to light when a doctor noticed that a female veteran had a prescription for erectile dysfunction. Hm.

I spoke with the writer today about data quality in health IT. Only a few of my words made it into the article, but an eerie parallel came to mind:

I’m class secretary for my college class, so I occasionally go into the alumni database. This week I clicked the link to update my profile, and lo, somebody else’s came to the screen!

I was seeing (and editing) the data for the next person alphabetically, not my own.

Here’s the thing: this is MIT’s alumni database. Yeah, the geek school. Accidentally letting me edit somebody else’s info.

Reality: data doesn’t flow automatically to the right place. You gotta engineer the workflow carefully, and it’s a good idea to build in safety checks.

This doesn’t change my belief that good quality data, well managed can improve things. (I didn’t say “solve everything,” I said “improve.”) Airlines got it figured out (you never pull up the wrong person’s reservation), banks got it figured out (long ago you might get the wrong person’s statement, but no more), etc etc.

As we work on health IT, let’s:

  1. Build reliability into the workflow. (Methods exist. Use them.)
  2. Check frequently for glitches
  3. Don’t be shocked when one appears. Tell people, and fix it.

p.s. I notified the Alumni Association and it was fixed within a day.

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