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Only Fools Rush In


 

Irecently bought an Apple computer. This is newsworthy because I am a lifelong PC user, and because I suffer from a genetic inability to adopt new technologies. In fact, I’m so old-school that only the graceless act of brandishing my credit card kept me from being unceremoniously escorted out of the store by Apple “specialists” for scaring off iPod-yearning tweens. Even then I wasn’t allowed to linger post-purchase.

After racing home, I eagerly slipped the 24 inches of iMac splendor out of its slick, mod-ish packaging and set it up on my desk. Thoughts of newfound cachet danced in my head as I peeled off my black “dad” socks and Tevas. It was clear to me that, as advertised, this sleek beauty was going to transform me from a doddering old Luddite into one of those trendy hipsters so keyed into the pulse of society. And it promised to be easier … and better.

What followed reminded me that the gospel of technology could sometimes preach a false god. It took but a few keystrokes to find myself grappling with a new operating system—it looked like Windows but felt like closed doors. Things that I can do effortlessly on my PC—navigate through files, open Web browsers, access my Outlook account, PowerPoint—seemed to take extra steps, new steps, or unknown steps.

I fully support automating healthcare as much as possible and sit on numerous committees at my institution charged with doing just that. Further, I believe it will be a salve to many of our efficiency, quality, and patient safety issues. However, I worry that in solving some problems, these new technological cure-alls will simply introduce other, unanticipated problems.

Eventually, I was able figure most of this out, but in the end I was left with the very un-sating realization that the Mac wasn’t really any better than my PC. It was cooler, that’s for sure—even my wife took a renewed interest in me. However, after that cool factor quickly chilled, I was left with the queasy feeling that I had just dropped thousands of dollars on a machine that didn’t really function any better than my old machine. And in some cases, it functioned worse.

Fool’s Gold?

Like my new iMac, electronic health records (EHR) are touted as the technological savior of healthcare—if you invest in the rhetoric coming out of Washington. As our legislators struggle to figure out ways to shoehorn 50 million more Americans into the “insured” category, stave off the growing epidemic of medical errors, and improve the general quality of care, digitizing our health records is a commonly noted panacea. And EHR, it’s promised, somehow will do all of this while conveniently reducing the skyrocketing costs of healthcare.

My hospital is on the verge of siphoning tens of millions of dollars of government stimulus funding and hospital capital into the purchase of a major EHR upgrade. This system aims to seamlessly integrate our inpatient and outpatient billing, documentation, lab, and ordering systems into one neatly packaged, computer-driven solution. I’m left wondering if my iMac experience is an augur of how this will play out on a grand stage.

In the spirit of full disclosure, I fully support automating healthcare as much as possible and sit on numerous committees at my institution charged with doing just that. Further, I believe it will be a salve to many of our efficiency, quality, and patient safety issues. However, I worry that in solving some problems, these new technological cure-alls will simply introduce other, unanticipated problems.

Several years ago, my hospital introduced several systems and technological applications aimed at improving quality, safety, and efficiency. One of these is called “rounds reports.” These very handy, printable documents are a terrific idea and a great example of simplified workflow. The doctor simply prints out a one-page summary of the patient’s 24-hour vital signs, medications, and labs, and uses that as the template for their daily note.

As promised, it’s a time-saver. The problem is that this new technology harbors insidious flaws that prey on the frailties of human nature by introducing new portals for error. For example, the report makes it simple to not reconcile medications daily. The time-honored and time-intensive manner of writing all the meds on a progress note is indeed cumbersome, but it has the added effect of forcing the provider to think about each medication—the utility, the dosage, the effects of the failing kidney on the dosage. Automation of this process removes this small but critical safety check. Sure, diligent providers can overcome this by paying close attention to the printout, but human nature dictates that we don’t always do it. In fact, we employed automation to save this type of time in the first place.

The rounds report also helpfully displays the vital signs and blood sugars for the past 24 hours, reducing the time the harried hospitalist has to spend looking these up and writing them down. However, the report doesn’t print out every vital sign and blood-sugar level; it provides a range. Again, it is possible to access these individual levels, but the post-EHR provider, lured by simplification, often doesn’t take the extra step to go to the separate program to gather these numbers. This shortcut enhances efficiency at the expense of having complete data, a scenario that can breed bad outcomes.

More Efficient Doesn’t Mean Better

Then there is the catch-22 of electronic imaging reports. It is impressive how quickly a chest X-ray gets read and reported electronically in my hospital. The downside, of course, is that today’s techno-doc can rely on the written report without reviewing the actual image. We’ve again, in not reviewing the films personally, removed an important safety check.

The point is that while mechanization offers great potential, it is easy to overlook the downside. Many physicians are not as tech-savvy as their kids and likely will struggle with these newfangled devices. For them, this will not simplify their workflow, but rather it will bog them down. These gizmos also are extremely expensive, and many small clinics and rural hospitals will struggle to afford these upgrades, even with taxpayer support. And let’s not overlook the myriad unforeseen hiccups these new systems will breed.

None of this is to say we shouldn’t embrace our “Jetsons”-like future. In fact, I’d counter that we must, and now is the opportune time. Still, I get nervous when I read stories of the endless EHR potential that omit or gloss over the probable limitations. The key will be to adopt these systems in ways that augment their strengths while mitigating their weaknesses. This must include achieving the delicate balance of usability, efficiency, and safety.

Otherwise, we might find that the technological apple will keep the doctors away. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

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