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Better Care Through HCIT 101: Part Four, Reliable and Timely Care

May 5, 2009
by Joe Bormel
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Better Care Through HCIT 101: Part Four, Reliable and Timely Care

If you need to cross over a body of water when driving a car, there had better be a bridge, tunnel or ferry of some sort.Occasionally, you can drive around it, or drive your 4x4 SUV straight through it. My point is, however, the practical solution is not to redesign the car so that it's amphibious!

In a wide variety of ways, this issue keeps rearing its head: What's our goal here with HCIT? Drive adoption of EMRs in the inpatient and outpatient world, or something subtly or dramatically different? Like our amphibious car analogy, we're not going to get reliable, timely, and cost-effective care by improving the EMR. Not through certification.Not through getting the definition of "meaningful use of an EMR" correct. And not through performance measures obtained through requiring amphibious cars, aka EMRs, being asked to cross gaps in our processes, gaps where we need to start at the total trip view. Moving from task thinking to process thinking provides that total trip view.Dr. Jim Walker at Geisinger describes how that's really working today, in two links in the conclusion section.

We've read Adrift in PolicyLand, where Anthony shared his family's experience receiving care; it left mom and dad sure that the care processes were not reliable and timely.

I've previously shared, in Relativity and Reality, my experience that the reliability and timelines of gettingcare for my daughter was horrible. The recommended care for the same problem at four institutions was radically different. Different diagnostic processes and different therapeutic recommendations were presented. Could they all be correct?

And this past weekend, a close friend took her son to the ED for what was determined to be a urinary tract infection. She and her son were sent home after testing, diagnosis and administration of a potent antibiotic, with instruction to follow-up the urine culture results. When she followed up, she was told that, somehow, they lost the urine culture, either the order or the specimen.Reliable care? Would an EMR have changed the reliability? Is putting in an EMR the solution (rhetorical; we don't have enough information)? Does the ED have control charts on the reliability of getting a "resulted urine culture on all applicable UTI visits?" Should that sort of thing come before installing an EMR?

Okay, you say, "Thanks Joe, but isn't that all a bit anecdotal, no offense?" Right! Great point. Okay, it's only a good point. For it to be a great point, I would need to have a previously prepared PowerPoint or blog post prepared to address it. I do, however, have exemplary data that is scientific:

In a multi-province Canadian study Olivotto et al, Canadian Medical Assocaition Journal 165, no. 3 (2001):277-283), 14,000 women were studied for the reliability and timeliness of follow-up from breast cancer screening. One group of women had 2.6 weeks test diagnosis (median) times; for other groups described in the article, it was weeks or longer, generally more than two months. A third group fell through the cracks completely, never receiving or documenting follow-up. This example comes from Walker and Carayon's Health Affairs article, and is offered with a solutions framework — design for processes, not simply tasks. Or in amphibious car language, plan for the whole trip, instead of solving for a ferry, when you really need a ferry, bridge, or aircraft.

Conclusion and Lessons?
To quote Anthony Guerra, there is broad concensus that "Electronic medical records, while critical, do not constitute a silver bullet." I think Walker and Carayon have it rightThere's a different mindset that occurs when the focus is moved to reliability and timeliness.It's the mindset of redesign around value-added processes of care. Paraphrasing a bit (sorry Jim and Pascale):

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Thanks for the comment, Anthony.

There's another trade-off that's as big as the one you offered. Should we increase the use of checklists, and the number of things on them, or, move in the opposite direction. That is, redesign care with less reminders and alerts, focusing on process completion and performance, with virtual checklist being invisibly completed as a by-product of the services being delivered correctly.

More concretely, do you remind a doctor to check for drug interactions, or, more simply, make it easy to pick the pre-checked, safe and appropriate drug, that factors in allergies, co-morbidity and proposes the right dose to boot.

I find myself more often, however, hearing new proposals for amphibious cars. And hearing "it's too late to do it right."

Great post Joe. I'm always pleased to see members of the medical community who understand the importance of incorporating human factors engineering principles to enhance the safety, performance, and satisfaction of health care services delivery.

BTW, I've recently started posting on the top of health care and human factors at my blog, The Human Factor Advocate (http://www.thehumanfactorblog.com/). Please feel free to check it out and email if you have questions and/or comments.

Exactly right. I've met a few physician executives who worked on patient-centered inpatient models in the 1980s. The unintended consequence of eliminating the nursing station, was that the care team communication was very negatively impacted.  Social networking and social behaviors of knowledge work need to be explicitly recognized and invested in.  (Drucker talked about this 50+ years ago.)

Jim Walker's article and video go into some depth on their experience, increasing the team communication, throughout the redesign and solution.

There are a lot of innovations in the 'Tasks to Processes' article. Another one, related to your observation, is the importance and commonness of unstructured encounters.

Great post Joe. Are we slowly, reluctantly, moving toward a scary conclusion that the country's focus on forcing in electronic systems is, at best, being done prematurely (a step out of order) and, at worst, totally misplaced?

What I hear more and more is that for whatever you gain with an EMR, you lose something by the reduction in human-to-human contact. There is some value in the discussion between doctor and nurse that envelops the communication of an order, there is some back-and-forth that allows the order receiver to clarify the request, to offer more context on the patient condition, perhaps even to relay the family's state of mind. ("Perhaps you could have a word with the son, he's very upset.")

My point is that we should make sure we're not losing more than we're getting.

Here's another apparently positive change which, taken to its logical conclusion, may not be so positive after all. I moderated a Webinar yesterday on the convergence of evidence-based design and healthcare IT as they relate, especially, to new facility construction. I wondered: what could be done to reduce noise levels in patient rooms? Perhaps the incessant alerts and alarms on biomedical devices could be silenced. Perhaps if those devices where "networked up," the alarms could only go off at nursing stations and on their handhelds, leaving the patient in relative peace and quiet.

But alas, I reflected on my time attending to a sick family member and thought of all the instances when I heard the alarm and notified a nurse. Nurses are incredibly busy, running around non-stop for more than 12 hours. There are many times when NO ONE is at the nursing station and they are deeply engaged in other, all-consuming, tasks. Would we exchange that extra layer of "alert" for improved patient rest?

Perhaps so, perhaps not, but no matter what trade offs we decide to make, it's critical WE KNOW WE ARE MAKING THEM.

First, do no harm.

Eric,
Thanks for the recognition.
I found your post (http://www.thehumanfactorblog.com/2009/04/29/human-factors-can-assist-wi...) to be very comprehensive. Thanks for your note here.

Can you point me to HFE literature on the use and abuse of Checklists? The health/medical literature has some nice positive examples (Atul Gawande on Peter Provonost's work, and by extension, guidelines as checklists.) I'm interested in David Allen (a la GTD)'s work, where there is a more dynamic thought, factoring in end user experience. Has this topic been elaborated in the HFE world?

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Joe Bormel

Healthcare IT Consutant

Joe Bormel

@jbormel

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