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It's Not My Job!

January 12, 2009
by Neal Ganguly
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(Let the computer do it)

I recently visited a friend in the hospital on discharge day. Knowing a thing or two about the challenges that the discharge process poses, I struck up a conversation with the nurse and the physician about things worked in their facility. It was a lively discussion that ended up focusing on the medication reconciliation process, and the problems with obtaining accurate information on ‘at-home’ medications. As one might expect, the nurse and physician both disagreed on who should be responsible for the process. They each felt that the other should be responsible, but ultimately agreed it should be the pharmacy’s problem, since there was no pharmacist in our discussion.

As I listened to them go back and forth, it struck me. Why isn’t this the patient’s responsibility? Have we become so completely disconnected as a society that we do not even feel the need to know and understand the medicines we take to improve our lives? Sure, some people take a lot of medications. How hard is it to carry a list? In fact, my thoughts went beyond medication lists, to nursing documentation, order entry, etc. All areas where compliance is often an issue and technology is blamed.

I asked the debating clinicians this question, and then ask folks back at my hospital as well. They agreed that the patient should know, but also blamed technology by saying that arguing that the information existed in various computers – why should they have to enter it again? There should be an interface.

And there it was. The interface. It is the magic bullet for end-users everywhere, the technology that would solve all the problems and do all the work. It got me thinking about all of the interfaces that are running in hospitals, and the many more that are being requested. Managing the growing tangle of interfaces is increasingly nightmarish for hospitals. Without real standards, how can it improve? I ended up having the following one-sided conversation in my head:

“Of course, we want the information to flow seamlessly to all who may require it. Sure, we’d like to get the information with as little work as possible. We’re not really sure about standards, because, let’s face it, our needs are ‘different’ from the rest. Oh yes, and our system vendors have a problem with standards, because they want to be different from the other vendors….” You get the picture.

Overall, I came back to two words that are tightly related: Accountability and Responsibility. While we are waiting for the fully integrated, standards based future, shouldn’t patients know what medications they’re on? Shouldn’t nurses make sure the allergies have been keyed into the system? Shouldn’t doctors check their dictated reports for accuracy? Technology is not perfect, and could do more, but it does help and will continue to improve. I just wonder, while we wait, shouldn’t we take more responsibility. After all – this is a people business.

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Comments

Hi Neal. I concur with the notion that the patient has the ultimate responsibility for knowing what meds they will need, but the whole medication and med rec process is so cumbersome, that I think patients have to depend on the "experts" to help them navigate through the medication thicket.

Technology should play a role in this, but you rightly allude to the limits of it, to the extent that individual clinicians don't see it as their respective responsibilities to utilize it. The experts have to see it as their duty at all points in the process to ensure the information is captured and shared properly.

There is a higher expectation when it comes to information systems. We expect things to flow into every system. Yet with paper charts, we expected lab results, allergies and meds not to be fully recorded, or to be missing.
Here is the solution: SouthWest Airlines model. Every employee at every level is required to switch jobs for a few days a year. Can you imagine if a physician had to be a nurse for a few days? better yet, a provider had to be a patient. The CEO had to be a transporter...wow, the possibilities are endless...the results...priceless.

Pete - The concept of walking a mile in another's shoes makes sense. Sadly, I don't know many doctors who would be willing to walk in a nurse's shoes. Clearly, the folks at Southwest understood the need to improve everyone's understanding of the 'big picture issues' in order to really improved process.

Rich - The lack of accountability all around is a little scary. Patient's who have no idea, Doctors who feel the nurse should be responsible, nurses feeling the doctor should be... You're right about patient's needing expert guidance. But the complicated business model of healthcare doesn't necessarily lend itself to teamwork and accountability in the model with a voluntary medical staff. Even with the employed constituents, such as nurses and pharmacists - 'assigning' the responsibility can become a political battle - and monitoring compliance a nightmare. Somewhere, the patient's best interest seem to fall out of the central focus.

I am not, in any way, minimizing the fact that technology needs to assist in the process. Nor am I hiding from the fact that sometimes technology makes it unnecessarily complicated. A collaborative effort is needed between IT, Clinicians, and the patient but there needs to be that big picture understanding that will allow timely movement towards a common goal - not in-fighting and finger pointing.

Neal Ganguly

CIO, CentraState Healthcare System, Freehold, New Jersey

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