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No Sour Notes

October 1, 1998
by Alan Joch
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It’s not surprising that IS professionals and medical workers sometimes clash. Each comes from a distinct world, one built around computer code and circuits, the other around patients and medical procedures. Unfortunately, clashes between these two groups can sometimes bring a medical operation to a standstill. "I have seen nurses actively sabotage their hospital computer systems because of [IS] attitudes that portray disinterest and disrespect for nurses," explains Linda Goodwin, Phd, an RN and nursing informatics scientist at the Duke University Medical Center, Durham, N.C. Once in an emergency room she saw nurses pour Coke over a computer keyboard, an act of protest against a PC and a help desk staff that were both deemed unresponsive.

Talk about "what have you done for me lately." IS professionals at healthcare organizations can feel like they’re constantly fighting to keep sophisticated--and in some cases--faulty hardware and software working efficiently in the pressure-charged atmosphere of a hospital.

Doctors, nurses and medical support staff, on the other hand, expect reliable computer systems that are simple to use and don’t present roadblocks to the fundamental task: caring for patients. From the clinicians’ perspective, computers aren’t always in top shape and the IS staff--in fact or in perception--isn’t always ready to act on user complaints. "The most consistent complaint I have heard over the past two decades is that the IS department fails to provide responsive, adequate and timely support," Goodwin reports.

Sometimes the problem is real incompatibilities in software or breakdowns in hardware; other times, it’s because user expectations are beyond what hardware and software vendors are delivering--no fault of the IS department.

In the vortex of these opposing forces is the hospital help desk, the real-time thermometer of how well IS systems and medical personnel are getting along. "Users perceive all the efforts of IS through a 15-inch PC screen," says Robert Warren, senior manager for First Consulting Group, a Long Beach, Calif., systems integrator specializing in healthcare clients.

The key to portraying a world of harmony on those screens, according to consultants and IS managers, is breaking down divisions between technologists and end users. Here are some reasons why medicine and cyberspace don’t always work in concert, and five ways to hammer out harmony in a world of petulant PCs.

Clinical complaints
The complaints doctors and nurses have about hospital computer systems aren’t that different from what you’d hear in the average corporate office: Computers are arcane, unreliable and unintuitive. Worse, there’s the nagging fear that computers represent a new way of working, but ultimately don’t make us more efficient at our jobs. In short, the promise of PCs is appealing, but they haven’t yet become integrated into the workflow of healthcare. "It would thrill me to take vital signs and have a computer automatically collect the data," says Margaret Cox, nursing and clinical informatics coordinator at Children’s National Medical Center, Washington, D.C. "I hate having to type the results into the computer."

Worse still is redundant data entry some doctors and nurses cope with because clinical applications, like HIS and lab programs, often reside in separate systems that can’t share information. "In one of my previous lives, I worked with a team to build an allergy documentation application, and we found the nurses were supposed to manually enter the same patient allergy data on eight different forms," Goodwin says. An added insult is the fact that medical applications demand to receive data in specific formats but often can’t give it back in ways doctors and nurses need for medical reports.

In addition to wanting seamless integration of systems and applications, medical workers also bristle at having to sign on to multiple systems each day, according to Warren. "They want to enter their name and password once on one networked PC and be able to call up any data or application for which they have access privileges," he explains. "I can’t name one healthcare organization that has implemented a single sign-on system."

Add inconsistent computer interfaces to the list of complaints. "Nurses get annoyed when in one program they press F1 to open a screen, and in another program they have to hit a different key to do the same task. The lack of consistency is frustrating," Cox says. People would like to see computers make their jobs easier, not harder, she says. "That’s a challenge for the computer industry, which doesn’t have a great track record in healthcare."

Underlying problems
Fortunately, some healthcare and IS professionals understand that finger pointing won’t solve pesky technical problems. Getting a better understanding of each others’ responsibilities, however, can ameliorate some troubles.

Programmers, some clinicians charge, don’t understand medical workflow. "They need to understand that our schedules and assignments vary, so we’re not at the same desk using the same PC every day," Cox explains. "And we may work 12 hour shifts three days a week--not a traditional business day."

Goodwin adds that nursing knowledge and expertise are hard to define, measure and communicate. "There is a vast body of knowledge that expert nurses use to provide high-quality care to their patients. But extracting and representing that mostly embedded knowledge and structuring it for a computer system remains difficult," she says. Working toward systems that support what nurses know and providing decision support for what nurses do will remain a prime IS challenge for the next decade, she predicts.

On the other hand, clinicians, many of whom aren’t experienced computer users, may expect to go to any one workstation in a hospital, pose any question, and get the answer he or she is looking for without understanding what a technological feat that represents in today’s non-standardized, platform-segregated computer world. "Getting different systems to work together is extremely challenging from an IS point of view," Warren observes.

Nevertheless, successes can occur when the two sides work together. For example, a stressful JCAHO review became even more perilous at Duke when some needed perinatal data was temporarily missing. In the end, a nurse analyst for Women’s and Children’s Services was able to dial up from her home and send the reports to the hospital. "Several different disciplines worked together to provide data for our JCAHO visit, and with favorable outcomes. It helps if all parties are working toward a common goal," Goodwin says.

Real-world solutions
How are healthcare organizations working to get medical and technical staffs focused on common goals? Experts say healthcare organizations can move in the right direction by taking a handful of basic steps.

1. Establish a technology facilitator Some pioneering hospitals have created formal jobs for informatics specialists, people experienced in technology and able to talk with developers but who are recruited from the clinical ranks. Both Goodwin and Cox fill this role at their respective organizations. Goodwin says she has the opportunity to practice "real-world informatics," by spending a third of her time as clinical team leader for seven nurses in Duke’s information services department. The team meets weekly to review nurse analysts’ projects, prioritize new user requests and resolve any problems. She devotes another third of her time to teaching a distance-based program in nursing informatics. She spends her remaining hours researching data-mining techniques for a National Library of Medicine project working to improve methods for identifying women at risk for delivering preterm babies.

"Many organizations get bogged down in turf battles between clinical providers and information systems personnel," she says. "Healthcare executives are learning that it is much easier to train a competent clinical person to become technology literate, than it is to train a programmer, for example, about complex clinical knowledge. So it is not surprising, to me, that we are seeing an increase in the numbers of clinical experts doing information systems work. The organizations where both clinical and IS people have learned to work well together and build on their different strengths are those organizations that are now setting the pace and designing the next generation of healthcare information systems."

Cox held a variety of nursing positions during her 17-year hospital career. Today, she works for the IS department, but still draws on her clinical understanding. "You can’t be out of either world totally," she says. "You have to understand where each group is coming from and try to satisfy both parties. Over the years you build alliances that make it easier to communicate."

2. Don’t skimp on training Experts agree that clinical people need to better understand computers and electronic systems like healthcare information systems and enterprisewide scheduling. The training responsibility rests both with clinicians themselves and with the organizations they work for. Formal education, such as outside courses or in-house classes run by professional trainers, give doctors and nurses hands-on skills in general topics, like basic PC and Windows usage, as well as more sophisticated tasks, like working with computer-based patient records. "As long as nurses with little clinical experience and two years of education are placed in nursing informatics positions, we will continue to deal with obstacles and hurdles that impede the advancement of nursing informatics," Goodwin believes.

On the other hand, physicians and nurses also need to take responsibility for self-education, says Dr. Charles Okstein, pediatric emergency room physician at the Maricopa Medical Center, Phoenix, and chief medical officer for HBOC’s CyCare Business Group. He believes clinicians should do more reading and talking to knowledgeable colleagues. More formally, they can organize informatics committees at hospitals that invite vendors in to provide product demos.

3. Set realistic timetables Users obviously become impatient if they take more time to do a task--like filling out a patient record--using a new computer application than doing the job manually. However, well-designed computer applications may require a learning period before users begin to see productivity gains. Make clear the long-term gains of suffering through temporary productivity set-backs. "I once built an OR documentation application system for nurses who complained about time factors in the beginning, but mastered the application within a few months and discovered they could document [procedures] more thoroughly and more quickly," Goodwin recalls.

IS people also should be alert to making changes in a new program to increase productivity. For example, Goodwin retrofitted her OR application with default information for certain pediatric procedures that allowed nurses to complete surgical documentation often in less than 10 minutes.

In addition, emphasize that even at their best, some computer programs may not help medical professionals work faster, but may deliver other benefits. "Many people believe that technology increases your speed, but we’ve found that’s not really true," says Cox. "Computers can help you improve your outcomes, provide an audit trail, help make your documentation more thorough, and help you avoid the handwritten scribbles that make patient charts unreadable. But they don’t necessarily help you work faster."

4. Implement computer triage By prioritizing computer support requests, the help desk can aid doctors and nurses in better understanding why an individual IS complaint may not receive immediate attention. "Triage is a model medical people really understand," says Warren. He suggests giving the highest priority to a PC that crashes in a clinical area over, say, a PC in an administrative office that’s running low on memory, or someone in accounting who is having trouble transferring data between two different applications. "We come to the clinical staff and say this is the level of service we can offer. There’s no tech-talk, no hocus pocus. Just a clear and simple priority scheme," Warren explains.

5. Computers aren’t silver bullets According to Goodwin, many healthcare workers assume there’s a computer application to solve every problem that nurses and physicians face, but "we just don’t have it. I’m not alone in a belief that there is no single-vendor solution on the market that will meet all the needs of healthcare providers doing direct patient care," she says.

In the end, better communications, key managers with an understanding of healthcare and IS issues, and realistic technology expectations can go a long way to helping IS people deliver what clinicians need from computers. At the least, these techniques may mean fewer keyboards forced to take a cola shower.

Alan Joch, formerly a senior editor at BYTE, is a contributing editor to Healthcare Informatics.

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