In my last post I wrote about the communication difficulties caused by electronic medical records systems. The response on Twitter ranged from sentiments including everything from “right on, sister” to “greedy doctors are only complaining about EMRs because of their price tag.” The disconnect between policy wonk’s (and EMR vendor’s) belief in the transformative power of EMRs and exasperated clinician users of these products is jaw-dropping. Physicians are often labeled as obstinate dinosaurs, blocking progress, while policy wonks are considered by physicians to be living in an alternate reality where a mobile phone app could fix all that is wrong with the healthcare system.
Being on the dinosaur side, I thought I’d try a quick experiment/analogy to demonstrate that EMR dissatisfaction is not a mere cost artifact. To show what happens when a digital intermediary runs medical information through a translator, I selected a random paragraph about the epidemiology of aphasias from an article in Medscape. I copied and pasted it into Google translator and then ran it backwards and forwards a few times in different languages. In the end, the original paragraph (exhibit A) became the second paragraph (exhibit B):
“Not enough data are available to evaluate differences in the incidence and clinical features of aphasia in men and women. Some studies suggest a lower incidence of aphasia in women because they may have more bilaterality of language function. Differences may also exist in aphasia type, with more women than men developing Wernicke aphasia.”
“Prevalence and characteristics of men and women are expected to afasia is not enough information available. If afasia some studies, women work more, not less, because they show that the spoken language. There may be differences in the type of OST, women and men to develop more of a vernikke afasia, more.”
Although the B paragraph bears some resemblance to A, it is nearly impossible to determine its original meaning. This is similar to what happens to medical notes in most current EMRs (except the paragraph would be broken up with lab values and vital signs from the past week or two). If your job were to read hundreds of pages of B-type paragraphs all day, what do you think would happen? Would you enthusiastically adopt this new technology? Or would you give up reading the notes completely? Would you need to spend hours of your day finding “work-arounds” to correct the paragraphs?
And what would you say if the government mandated that you use this new technology or face decreased reimbursement for treating patients? What if you needed to demonstrate “meaningful use” or dependency and integration of the translator into your daily workflow in order to keep your business afloat? What if the scope of the technology were continually expanded to include more and more written information so that everything from lab orders to medication lists to hospital discharges, nursing summaries, and physical therapy notes, etc. were legally required to go through the translator first? And if you pointed out that this was not improving communication but rather introducing new errors, harming patients, and stealing countless hours from direct clinical care, you would be called “change resistant” or “lazy.”
And what if 68,000 new medical codes were added to the translator, so that you couldn’t advance from paragraph to paragraph without selecting the correct code for a disease (such as gout) without reviewing 150 sub-type versions of the code. And then what if you were denied payment for treating a patient with gout because you did not select the correct code within the 150 subtypes? And then multiply that problem by every condition of every patient you ever see.
Clearly, the cost of the EMR is the main reason why physicians are not willing to adopt them without complaint. Good riddance to the 50% of doctors who say they’re going to quit, retire, or reduce their work hours within the next three years. Without physicians to slow down the process of EMR adoption, we could really solve this healthcare crisis. Just add on a few mobile health apps and presto: we will finally have the quality, affordable, healthcare that Americans deserve.
An ICU Bed False Exit Alarm
I just spent the last 8 days in the hospital, at the bedside of a loved one. Although I squirmed the whole way through a tenuous ICU course and brief stop-over in a step-down unit, it was good for me to be reminded of what it feels like to be a patient – or at least the family member of one – in the hospital. The good news is that the staff were (by and large) excellent, and no major medical errors occurred. The bad news is that the experience was fairly horrific, mostly because of preventable design and process flaws. Having worked in a number of hospitals over the years, I recognized that these flaws were commonplace. So I’ve decided to tilt at this great hospital design “windmill” on my blog – with the hope that someone somewhere will make their hospital a friendlier place because of it.
Most of these design and process flaws have one thing in common: they prevent the patient from sleeping. In some circles, sleep deprivation is an organized form of torture reserved only for the most dangerous of terrorists. In other circles, it is hospital policy. And so, without further ado, here is my top 10 list of annoying hospital design flaws:
#1: False Alarms. Every piece of hospital equipment seems to be designed to beep for a complex list of reasons, many of which are either irrelevant or unhelpful. I snapped a photo of a particularly amusing (to me anyway) alarm (see above). This was a bed alert, signaling the “patient exit” of an intubated and sedated gentleman in the ICU. Not only was the location of the alert sign curious (if you could get close enough to the alert screen to read the text, you would surely already have noticed that the patient was AWOL) but it was triggered by mattress pressure changes that occurred when the patient was repositioned every 2 hours (as per ICU pressure ulcer prevention protocol).
The I.V. drip machines are probably one of the worst noise pollution offenders, beeping aggressively when an I.V. *might* need to be changed or when the patient coughs (this triggers the backflow pressure alarm, leading it to believe that a tube is blocked). Of course, I also thoroughly enjoyed the vitals monitor that beeped every time my loved one registered atrial fibrillation on the EKG strip – a rhythm he has been in and out of for years of his life.
#2: Intercom Systems. Apparently, some hospital intercom systems are wired into every patient room and permanently set at “full volume.” This way, every resting patient can enjoy the bleating cries for housekeeping, tray pickup, incoming nurse phone calls,physician pages, and transport requests for the entire floor full of individuals undergoing the sleep deprivation protocol.
#3: The Same Questions Ad Nauseum. Over-specialization is never more apparent than in the inpatient setting. There is a different team of doctors, nurses, PAs, and techs for every organ system – and sometimes one organ can have four teams of specialists. Take the heart for example – its electrical system has the cardiac electrophysiology team, the plumbing has the cardiothoracic surgery team, the cardiologists are the “minimally invasive” plumbers, and the intensivists take care of the heart in the ICU. Not only is a patient assigned all these individual micro-managing teams, but they work in groups – where they rotate vacations and on-call coverage with one another. This virtually insures that the sleep-deprived patient will be asked the same questions relentlessly by people who are seeing him for the very first time at 20 minute intervals throughout the day.
#4: Inopportune Intrusions. There are certain bodily functions that benefit from privacy. I was beginning to suspect that the plastic urinal was attached to the staff call bell after the fifth time that someone summarily entered my loved one’s room mid-stream. Enough said.
#5: Poorly Designed Tubing. Oxygen-carrying nasal cannulas seem to be designed to maintain a slight diagonal force on the face at all times. This results in the slow slide of the prongs from the nostrils towards the eye. Since the human eye is less efficient at absorbing oxygen than the lungs, one can guess what might happen to oxygen saturation levels to the average, sleep-deprived patient, and the resulting flurry of nursing disturbance that occurs at regular intervals throughout the night (and day). My loved one particularly enjoyed the flow of air pointed directly into his left eye as he attempted to rest.
#6: The Upside Down Call Bell. In an age of wireless technology, where almost every American has a cell phone and/or a flat screen television, it is odd that the light, TV, and nurse call bell control system must be tethered to a short cord positioned just outside of the patient’s reach. The controller is also designed so that the cord comes out of the box’s farthest point, causing it to remain upside down in the hands of anyone lucky enough to reach it from a chair or bed.
#7: Excessive Hospital Bands. In addition to multiple rotating IV access points, my loved one’s wrists and ankles were tagged with not one but four hospital band identifiers, including one neon yellow band sporting the ominous warning: “Fall risk.” If that little band is the only way that a staff member can ascertain a patient’s risk for falling down unassisted, then one is left to wonder about their powers of perception. In a moment of rare good humor, my loved one looked down at his assorted IV tubes and three plastic wrist bands and concluded, “I’m one stripe away from Admiral.”
#8: The Blank White Board. Sleep-deprivation-induced delirium can be rather disorienting. To help patients keep track of their core care team names, most hospital rooms have been outfitted with white boards. Ideally they are to be filled out each shift change so that the patient knows which activities are scheduled and the names of the staff that will be performing them. Filling out these boards is tiresome for staff members (not to mention that the dry erase markers are usually missing) and so they remain blank most of the time. This has an anxiety producing effect on patients, as the boards boldly proclaim that no nurse is taking care of them, and no activities are scheduled. I also noted that the size of the board lettering was a fraction smaller than a person with 20/20 vision could make out from the distance of the bed.
#9: The Slightly-Too-Tight Pulse Oximeter. Because being tethered to a bed with IV tubing, telemetry cords, and a nasal cannula is not quite irritating enough, hospital staff have devised a way to keep one unhappy finger in a constant, mild vice grip. This device monitors oxygenation status and helps to trigger alarms when nasal cannulas achieve their usual peri-ocular destination every 30 minutes or so.
#10: The Ticking And Creaking IV Drip. During the few rare moments of quiet, we did not enjoy any sort of blissful silence, but rather the incessant ticking of the I.V. drip machine. My loved one remarked that he felt as if he were trapped in an endless recording loop of the first 5 seconds of the TV show “Sixty Minutes.” And so if the alarms, tethering, interruptions, PA announcements, tubing, or white boards didn’t drive you mad, the auditory reinforcement of a ticking time bomb next to your head could bring you close to tears.
And so, because of all these nuisances (not to mention the ill-fitting hospital gowns, inedible food, and floors covered with various forms of “seepage” that penetrated patient socks on hallway ambulation attempts) we had one of the most unpleasant experiences in recent memory. All this, and no dissatisfaction with the surgical team or the primary procedure performed during the hospital stay. In the end, it’s the little things that can drive you crazy – or make you well.
Bill Gates once said:
Success is a lousy teacher. It seduces smart people into thinking they can’t lose.
It’s clever, and it seems right. Now there is science to prove it.
In a study published last week, scientists studied special imaging scans of doctors’ brains as they made simulated medical decisions. Those doctors who paid attention to their mistakes made better decisions than those who were more interested in their successes: Read more »
*This blog post was originally published at BestDoctors.com: See First Blog*