Healthcare Safety Lessons from the Inter-Tropical Convergence Zone
In the final edition of this particular blog, we will explore the last four HCIT CDS factors I developed that relate to the causes of the crash of Air France Flight 447. Let’s begin.
5. Real Time Management: The potential role of technologies, such as GPS and real time remote flight tracking, could have added much-needed clarity in the three minute, uncontrolled vertical decent of AF447. However, they were not implemented.
These technologies would have added to the amount of data that needed to be processed. And, it would have been data that needed to be processed more quickly than unaided human interpretation could possibly achieve. The resulting network could very well have shifted the “decision rights” out of the cockpit during a time of cascading, chaotic failure.
But isn’t the “pilot as the ultimate decision maker” (or doctor for that matter) an explicit design assumption that’s being called into question? The philosophy of more pilot and less automation is now evolving to less dependence on pilots. As illustrated by this crash, it may be impossible to staff a cockpit adequately to sort out the confluence of interacting complexity of subsystems. And as noted by Captain “Sully” Sullenberger, cockpits that bring together the pilot’s user experience and usability with analytics and related automation can have a huge impact on safety. Captain Sullenberger has suggested that the lack of all necessary data hurt the survivability of AF447.
This is exactly the argument for much richer support to review information and test hypotheses, the so called “Watson for Healthcare” that I’ve elaborated on in a previous blog. The fact is, at some point in time, this becomes the only way to review and analyze data within the required time constraints.
6. “Coffin Corner” Stakes: The physics, and metaphorically, the complexity of human physiology and pathology of disease.
The presence of a “Coffin Corner,” the point at which an aircraft’s stall speed rises with altitude, is a narrow operating airspeed band that must be maintained. It is also a technology-created hazard that cannot be avoided. Before we attempted to fly so high, flight management was easier.
The question becomes, with critically ill patients or simply considering genomic data, have we become more reliant on HCIT than we may be prepared to manage?
7. Safety Regulation: The U.S. has the National Transportation Safety Board, which has the budget and governance to independently investigate accidents in the public's interest.
It's argued that the French Bureau of Investigation and Analysis did not have the budget to do its job. Further, the French government has a financial interest in both Airbus, the manufacturer of AF447, and the airline, Air France. These factors could influence the nation’s judicial system, which is accountable to assign liability based on available data.
In healthcare, the economic interests and politics of our vendors, device manufacturers, hospitals, health systems, doctors, payers, and pharmaceutical companies would likely be similar to the Airbus and Air France situation, and similarly co-mingling with government interests.
My take is two-fold. First, we need an independent agency like the NTSB to produce unbiased reports. Second, we should expect and plan for something far more nuanced.
Instead of the rare, publically visible, simultaneous deaths of 200 people at one time in one location (AF447), the safety challenges to healthcare are far larger, far more common, and far less mature in terms of technologies in routine use. The current scale of these challenges has been called the equivalent of 20 Boeing 747 Airliners crashing per week. Therefore, improving healthcare delivery by even a small, measurable fraction is huge. That, of course, starts with significant advances in our current reporting systems, exploiting the relatively new Patient Safety Organization Framework and Common Formats.
8. Privacy and Individual Rights: Once the wreckage of AF447 was located, the question of whether to exhume the bodies was raised. The families of the victims had polar opposite feelings on what was appropriate. In healthcare, there is precedent to perform an autopsy to establish cause of death when it is unknown or where foul play is considered a possibility.
Take, for instance, the excerpt from a speech by Sorrel King describing her experience with her daughter, Josie King. After reading it, I think you’ll agree that it is rare for a patient or family member to place the common good ahead of their personal feelings. What Sorrel King did required tremendous strength of character, as well as forgoing the privacy that could have been evoked after a devastating event.
My wife and I once received some truly bad medical advice for our daughter’s care from multiple professionals. Had we followed one of these recommendations in particular, certain harm would have resulted. This was confirmed for me a half dozen times by experienced practitioners in the field in question. My point is that improving healthcare safety is often less black and white than an aviation crash in terms of reporting and learning.
Here are my conclusions. The HCIT challenges elaborated in the context of AF447 remain challenges for us all. They underscore the necessity to move forward: off of paper, off of systems relying on individual human brain power, off of unreliable communications of semantically inoperable health stories, and off of systems without clear databases, shared and common measurement frameworks, and disciplined processes based on solid problem lists.
The medical record, and therefore EMRs, cannot be separated from the safe and effective delivery of healthcare. This is not a new issue, as noted by Larry Weed in 1971. What we need to learn from the final crash report is that now is the time to put our focus on the eight areas highlighted by that crash as they impact the application of HCIT to the delivery of healthcare.
What do you think?
Joseph I Bormel, MD, MPH
CMO and Vice President