Marion Ball, Ed.D., is a fellow at the IBM Research Center for Healthcare Management Research and a professor at the Johns Hopkins University School of Nursing (both based in Baltimore). She is also co-chair of the executive committee for the Technology Informatics Guiding Education Reform (TIGER) Initiative, which was created to develop a strategy for improving nursing practice, education, and the delivery of care through the use of health IT. Last year, Ball co-authored an article in Methods of Information in Medicine that examined why clinical information systems are failing. Recently, Associate Editor Kate Huvane Gamble spoke with Ball about the report's findings, particularly the importance of providing clinicians with the information they need at the point of care.
KG: Let's talk about the report. The basis seems to be that one of the key reasons why health IT adoption is so low has been the failure to provide healthcare professionals with effective health IT systems. Is that fairly accurate?
MB: Yes, but you have to be a little bit more precise in that they're not getting the information that they need at the point of care. In other words, we give them so much information that it's like they're being fed with a fire hose and everybody gets it from the same hose. The internists and obstetricians and psychiatrists all get the same template. If you're a gynecologist, you don't need to have the information that four years ago a patient broke her leg if she's there for an OB-GYN checkup. Instead of making their life easier, we're making their lives more difficult. So the whole idea is, how can we make them do less work and not more work.
KG: And a large part of that is not just providing the information a clinician needs about a specific patient, but also delivering it in a way that's tailored to their individual needs?
MB: That's right. In other words, the system must adapt to the user, and not the other way around. It needs to cater to what we need, and not be set up so that we're serving the computer. And we need a rapid adoption; it's got to be the iPhone of the future, where it's intuitive, where it really helps, and where people will embrace it.
Right now, we have to be adaptable to any of the vendors' healthcare systems, and that's not the way it should be. They need to be adaptable to the physician, the nurse and the pharmacist; not the other way around. And in product development, we need much more significant input from physicians and nurses who are in the line of fire, at the point of care, to say, ‘Look, this is what we need when were in the emergency room. This is what we need when we're in a doctor's office in the private practice.’
Why should they have to go to every terminal and put in a password 10 times and then change it every 90 days? It's more difficult to get into the system than to look at the patient. When you watch a nurse at the station, you can see that it is a major operation just to get to the lab results.
We've been at this for almost 40 years, and we still have, at the maximum, 18 percent physician and clinician adoption. That tells you something. It's not giving them what they want - that's the bottom line. So we need to find out what it is that we really need at the point of care.
KG: What are some of the technologies that you think have the potential to deliver that information to the clinicians?
MB: One wonderful example is the University of Pittsburgh Medical Center's smart room. It's a disruptive technology that tells the nurse or phlebotomist immediately when they walk in the room that a patient is, for example, latex intolerant. It comes up on the screen - it's not at the nursing station on a computer where they have to go through all of the dropdown menus and look up allergies to find this out. You walk in, the two badges between the provider and patient connect, and the screen says, this patient is latex intolerant. So when they take that patient's blood, they know immediately to take off their gloves, otherwise that patient is there for another two or three days.
Another scenario is, the dietician walks in with the patient's breakfast, and a light goes on in front of the screen that says, this patient is NPO (nothing by mouth). That means don't give them anything to eat because they're being operated on today. So the dietician can take the tray right out. First of all, you don't have to waste the food, and second of all, the patient doesn't have to stay another extra day because they were given breakfast on the day of surgery. These are all very simple things, but, as people will say, the devil is in the details.
We're also looking at cases where you can do charting or nursing documentation verbally while you're with the patient, and not have to take notes and go back to the nursing station and put it into the computer. We're looking at where it can be used well and where it shouldn't be used; if you can chart while you are with the patient using hands-free technology, then you can use your hands to soothe the patient or to straighten up the bed instead of being tied up in the room typing something into the laptop or the PC.
And nurses will tell you what they like. You've got Vocera and Vocollect, different companies that are starting to do that. But again, who is going to be developing these? It's got to be physicians, nurses and pharmacists, very much involved in the entire development, implementation and planning of these systems.
KG: And this is where initiatives like TIGER come into play.
MB: Right, I'm a big advocate of the TIGER Initiative for technology. We need to have trained healthcare professionals who can effectively communicate with the well-meaning IT people and vendors. New training methods are needed in nursing schools, pharmacy schools and dental schools, where the young people already know about enabling technologies and can learn how to apply them.
KG: Ultimately, what does TIGER hope to accomplish, and what message would you like to send out to hospital leaders about the initiative?
MB: You can't do anything unless you recognize the problem. So the first thing is to realize that the medium is not the message. It's not about technology; it's about how do we change behavior and processes and thought flow to be able to transform the way we practice, and then use the enabling technologies to transform healthcare. That's what it's all about.
We need to be able to get involved with changing legislation. There is very little research, money and support for nursing, and yet nurses are the ones who are taking care of all the sick people, and we're all going to need them when we get older.
KG: And the goal is for this to happen before all of the money starts flowing in from the stimulus package?
MB: Absolutely. There's a wonderful quote from Albert Einstein that says, the definition of insanity is doing the same thing and expecting different outcomes. For the last 40 years, we've had 18 percent clinician adoption. If we think that because we're going to pour the ARRA money into what we've been doing, that it's going to be more successful, that makes us insane. It's just going to speed up chaos.
These are the kinds of questions we should be asking. Is it going to make any difference if we put more money into what we've been doing, or do we need to look at a whole disruptive innovation to seeing how we can use different ways to skin the cat, so to speak. And one way is to address the issue of what the clinician needs at the point of care.
How are we going to use enabling technologies as we move into the medical home concepts, using primary care physicians, using nurse practitioners, looking at how do we provide care - not only in the emergency rooms, but at Wal-Mart and at drug stores. These are all disruptive innovations, each of which will also need the information component and some enablement by technology. But it's 90 percent transforming and change management, and 10 percent technology. Changing behavior is more difficult than anyone ever wants to admit.
KG: So it all comes back to the idea that technology needs to adapt to users and not the other way around?
MB: Yes. But also, the technology and the vision that we have needs to be platform-independent, it's got to be ubiquitous access. When you look at a clinician, that person is a mobile individual. He or she is not in one place for more than one minute. And the systems they use were designed by brilliant computer scientists and information scientists who are sitting at their desks.
So the problem is, how do I get the information I need on my Blackberry? How do I get it on my tablet? How do I get it in my office when I'm on my PC? I'm going to three hospitals and each hospital has a different system - one is Cerner, one is McKesson, one is Epic. I want to be able to have my Blackberry or iPhone give me the same information so that when I walk into the hospital, I don't have to put in 20 or 30 passwords. And that can be done. I want to know who my patients are, I want to know who is most sick, and I want to know what the latest lab results are. So the whole idea is, give me less, but give me what's relevant to my practice. And that, I can assure you, we are not doing.