GlassHospital

Demystifying Medicine One Week at a Time

Paging Dr. Dilbert

I always thought being a doctor I’d be free from cubicle life.

Not so.

Our medical center spent more than sixty million dollars over the last six years to upgrade the computer system we use.

It’s a system we use for just about everything.

With it, we can admit and discharge patients, write orders for the tests and medications they need while they’re in the hospital, and even do most of the documentation and charting for their stay. (Interestingly, though nurses, therapists, and virtually everyone else uses the computer for charting, we doctors still handwrite our progress notes and put them in a paper chart.)

I’m no Luddite, and generally I’ve been happy with the transformation of our systems.  The upgrade is in line with the federal government’s push to digitize all things medical to improve efficiency, safety, and ideally, lower health care costs. Medicine is finally moving (like most other industries before it) into the 21st century.

Be careful what you wish for.  Mandates bring all sorts of unintended consequences.

First, we’re now tethered to computer appliances.  To perform any basic hospital function, an order needs to be sent via the computer system.  This is good in that all doctor’s orders go through one standardized entry point, and eliminates issues with horrible physician penmanship.  This is bad because the computer can hamper communication amongst the care team.

For example, before our reliance on the computer, we would usually talk to our nurses about our care plan, or any updates or changes in the orders regarding a patient.  In this way, we knew that the nurses understood what we were doing and why we were doing it.  Now, we enter our plans in the computer, and the nurses receive them through the computer, but the communication piece is missing.

Sure, we can and sometimes do still talk.  Nurses are empowered to call us when there’s a lack of clarity.  But something elemental has been lost.

Being tethered to computers has other downsides.  There’s a much higher demand on the hardware side of things.  If the doctors need computers to enter orders, and the nurses and other staff need computers to read the orders, you can see how this can create bottleneck.  The medical center has to invest in hardware, maintain it and upgrade it constantly.

In one of the more ironic twists, to combat the hardware bottleneck around the various desktops on the wards or outside of patient’s rooms, hospitals have invested heavily in Computers On Wheels [COWS].  These portable workstations can be pushed along to patients’ rooms where the doctors can look at data, enter orders, etc. and/or nurses can enter data, read orders, reconcile medications, etc.

Many hospitals still call their units COWS.  My medical center correctly realized that patients might overhear this term and think: “Are they calling me a COW?”  We’ve therefore changed the name of our COWS to “R-2” units, a tribute to the little sidekick robot from the Star Wars series.  Sounds futuristic.  Sexy.  Cool.

“Hey R2, come here and figure out what’s wrong with this patient!”

“R2, save them!”

Wishful thinking, right?  But not too far off, perhaps, as computer simulations of patients for training purposes become more the norm at teaching hospitals.

One morning not too long ago, I walked down one of the hospital wards.  I saw half a dozen nurses sitting in the hallway at their R2 units, entering data and talking about their social lives and their schedules.

Where before they might have saved such chatter for the nurses’ station, they were now out in full force on the ward doing work at their “cubicles” and carrying on as if no one were listening.

A major downside of having computers everywhere is that there’s simply less contact with our patients.  Our tendency is to look at the computer for data before even embarking to the bedside to talk with or evaluate the patient.  And by this I mean doctors and nurses.  I don’t have data to prove this, but anecdotally I know that our increasing emphasis on informatics has made us more data-centric and less patient-centered.

Remember the term “pencil pusher,” and how in a world that values accomplishing things with smarts and brawn a pencil pusher was seen as a non-contributor?   I fear we’re becoming a profession of “keyboard krazies.”

10 Comments

  1. Sounds like the introduction of technology is having a bit of a novelty effect: the technology becomes the focus of activity because of its novelty. Patients are old news (and generally cranky), whereas R2 units are cool. This may be natural, but it isn’t inevitable, and it certainly doesn’t have to be permanent. After the splash caused by the introduction of the blackberry, rules of etiquette started to develop. Even as long ago as 2007, crackberry (a leading tech blog about blackberries) talked about it. http://crackberry.com/little-blackberry-etiquette.

    Why not propose (and start acting on) some basic rules of etiquette with regard to R2 units. No entering information in front of a patient. If you are talking to a patient, you are looking at the patient, not the screen. I don’t know whether it’s always necessary to talk directly with a nurse, but in cases where there is any doubt, commit to not entering instructions until AFTER verbally communicating with the nurse.

    One way the hospital can help move things along in a better direction is to make the technology less conspicuous. Why doesn’t the hospital give everyone an iPod touch or iPhone or other like handheld/smartphone that can wifi into the records database and that has a large enough screen to view images and also has a simple interface? As the crackberry site above indicates, people have already started to develop workplace etiquette when it comes to handling such technology around coworkers and clients. There’s no reason doctors should try and reinvent the wheel.

    • glasshospital

      February 22, 2010 at 4:22 pm

      RobH-

      thanks for the comment and the blog link. You’ve said it beautifully.

      I’d like to print out your comment and post it around the wards, in addition to sliding it under some administrators’ doors–hoping they’ll get on board with the handheld/iPhone idea–I’m still carrying the same type of old pager I was first issued 12 years ago!

  2. Interesting article. But do computers enhance doctors talking with each other, or are they only used to share common data? I am known to a number of U. of C. clinics. On two occasions doctors have had different explanations for a problem I was having. I don’t believe they ever talked with each other leaving me a bit miffed. Does the computer system allow doctor to doctor communication separate from using someone’s email?

    • glasshospital

      February 22, 2010 at 6:56 pm

      Our new system comes from EPIC in Madison, WI. EPIC is one of the largest vendors of electronic medical records (EMRs) in the business. There is in fact an email function in EPIC that allows doctors or nurses to flag results and forward them and comment to one another. It’s all internal.

      Yet, you’ve found examples of physicians in different specialties (I assume?) not really communicating about your health issues. Kind of ironic, no, that with this tool for increasing communication in some ways it may actually get more challenging–more streams of information and data all the time, I know I sometimes feel like there’s less time to actually just talk…

  3. My hospital utilizes EPIC as well and the COWS became WOWS – workstations on wheels

  4. I hear more and more anecdotal stories from families and friends who go to the doctor only to look at their back through most of the encounter, since the physician is typing the whole time. I’m not sure how avoidable having the actual machines is, but secondary needs are arising: inter-personal skills instruction side-by-side with the technology training, and feng shui exam room designers so the computer doesn’t require the physician to face the wall!

  5. Personally I do not want a doctor who does not understand the fantastic potential of EMR’s
    My wife and daughter are both RN’s and they also disliked and hospital computers. As a retired physicist with 20 years in computer control applications it was easy to ascertain why:

    1. inadequate training -in one case a new system with no training manuals, one training station and verbal instructions

    2. No computer support staff or technology manager means no strategic planning and installation of incompatible sub systems and wasted dollars and unhappy staff, labs, nurses and doctors

    3. On the flipside my daughter spent $8000 at Mayo Clinic were everything in sight was automated in an integrated database! Any team specialist could see the results of the other specialists’ test within hours. Conclusion: at the end of the tests, no definitive diagnosis. Fast forward 8 months: all Mayo Test were sent to another specialist.

    Specialist’s conclusion: Examined her medical records. My daughter had diabetes -it required two visits.

    Moral :in the final analysis there is no substitute for intelligence.

  6. Frank – The problem RN’s dislike generally about computer charting vs paper charting is the greater time spent to accomplish the same result. Bear in mind my opinion has nothing to do with accessing test results, reading history, ect. I love the convenience of having those details at my fingertips. I am only speaking here to the problem I have with charting assessments by computer vs. trifold paper forms.

    I work in an ICU with very critical patients, full assessments every 1-2 hours can take upwards of 15 minutes to actually complete, however charting that full assessment in the computer can take upwards of 30 minutes.

    The more critical the patient = more things to chart. This means I spend increasing amounts of time charting on the computer as a direct result to the increasing level of care the patient needs.

    This is the opposite of how it should be when taking care of a critical patient so what happens in real life is the charting waits until later in the shift to be completed instead so I can concentrate on the patient’s needs in the present. Administrators need ideas on how to make this part of the EMR more streamlined.

  7. Thank goodness electronic health records improve quality and clinical decision making… oh wait…

    http://archinte.ama-assn.org/cgi/content/abstract/archinternmed.2010.527v1

    Electronic Health Records and Clinical Decision Support Systems
    Impact on National Ambulatory Care Quality

    Max J. Romano, BA; Randall S. Stafford, MD, PhD
    Arch Intern Med. Published online January 24, 2011. doi:10.1001/archinternmed.2010.527

    […]

    Conclusions Our findings indicate no consistent association between EHRs and [clinical decision support] CDS and better quality. These results raise concerns about the ability of health information technology to fundamentally alter outpatient care quality.

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