QUALITY/TECH: Bob Wachter on patient safety

Bob Wachter is probably the leading expert in the nation on medical errors and a great speaker.

He’s worried about the lack of budget for training, and that IT = Patient safety. But he does think that the IT/EMR movement is now tipping, especially as the disconnect between patient’s perception of being high-tech and what’s happening in the health care system is not tenable, and docs saying that they can’t do it is not credible even for the older docs

He talks a little bit about computer induced errors and problems. There’s a new literature replacing the Bates stuff about how great the Brigham’s system was, and now it’s all about how it’s going wrong.  It’s not a mistake to computerize but you need to go in with your eyes open. You need to think about the process improvements…including the easy ability to cut and paste H&T and continuing on mistakes. What happened when the computer goes down? As at Beth Israel Deaconess. And then in the example for Childrens’ Pittsburgh, does CPOE kill people? Well the chaos still goes on and CPOE clearly gets in the way in ICUs. The critiques of this study are that they "didn’t do it right" but that’s what an implementation looks like. Plus what looks good in the demo doesn’t work per se in your local community hospital. Or the experience of the Brigham is not transferable …unless your hospital also has a 1,300 strong IT department.

The Cedars Sinai story: They built their own and they built in some decision support. But the medical staff revolted. Too many alarms, reminders, too many screens, etc, etc. But not just that, also a story about control over medical care.  Cedars was exerting central control.

So the question is, who exerts control. He quotes Spiderman. "With great power comes great responsibility"  Now there are institutions that are going to have to wrestle with this problem, and if you push too hard the backlash is very tough.  get it implemented first, and do the control later…one little thing at a time.  It’s like the Right Stuff which changed the test pilot from being a cowboy pilot like Chuck Yeager to being a goody two shoes Astronaut like John Glenn….it got more boring, but mortality rates fell dramatically. So this shift is coming too, and will be a huge shift.

Add to this the emergency dislocation of medicine, such as late-night radiology reading in Bangalore. This means that the world gets wired and we start to figure out how to provide care very differently. eICU from VISICU is another reason, seeing a real time data stream and facilitating the care remotely. One of the most profound affect is going to de-tether the assay from its interpretation.

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  1. The most dangerous and expensive problem of our medical system is the amount of freedom doctors have to do whatever they want. To the extent that IT embraces that paradigm, it is likely to fail. To the extent that IT creates a new pradigm where EBM actually is practiced and systems are put in place when a treatment plan is going wrong or may be improved, it is likely to succeed. Unfortunately, the first type of system is one the most powerful stakeholders tend to favor.