By TOM LANG, MD

Recent government incentives have gone a long way toward bringing digitization to healthcare, with  particular benefits seen in the PACS/ digital radiology areas and digitally archiving data for better access.  A 2016 AMA survey (1) has shown that the biggest desires for physicians from digital health are increasing patient safety and improving work efficiency.

I would like to propose that the most important aspects of patient safety are as follows:

• clinical workers (that is, doctors, nurses and other members of the caregiving team) need to maximize their time ‘at the bedside’
• clinical workers need to maximize their communication and interaction within the patient care team to optimize patient care

• clinical workers need to minimize distractions from the two activities above.

Health IT systems need a complete overhaul, guided by these principles, in order to optimize patient safety with its use. One way to look at health IT from a clinical perspective is to break it down into 2 pieces: data aggregation (that is, the ‘anytime, anywhere access’ to digitized health information) and data entry: the time and distraction from patient care that data entry tasks require for clinical workers.  The big wins so far with health IT has been with the former, the big problems with the latter.

Recent US government incentives have pushed healthcare systems and participants to buy and implement products that were already available in the marketplace.  Clinicians often feel that these systems were built primarily for administrative purposes, such as billing, coding, regulation, and malpractice concerns.   Furthermore,  current systems impose a crushing amount of data entry work upon clinical workers (i. e. doctors and nurses).  Also, mouse and keyboard data entry imparts a significant cognitive load, as opposed to, for example, completing a data entry task by jotting something down on a piece of paper on a clipboard.  The unintended consequences of this process is that clinical workers spend a very large amount of their time sitting in front of computer screens entering data, which is a big contributor to errors in patient care.  It’s not really an issue of paper vs computers, it’s just that current, poorly designed and ill-conceived systems that have been foisted upon clinical workers in the field are distracting and time wasting.

Personally, I have found that I make significantly more errors when using computers for data entry tasks such as ‘order entry’.  Here are important aspects of order entry (and execution) where I find myself making frequent errors:

1. Order entry should be done at the ‘point of care’ and ‘time of care’.  Clearly the safest and most efficient way to complete orders is at the time you are interacting with the patient.  Previously I would quickly record what I wanted to do while with the patient by circling or writing on a piece of paper on a clipboard.  Now, I leave the room, sit down in front of a computer and go through a multi-step process to do even the simplest order entry tasks.  In the meantime, I’m frequently interrupted, often a number of times, and forget important orders I had in mind.  Even if I have a mobile device, it is simply not practical to do order entry and the point and time of care ….. often I get frequently logged off the computer, and usually have too confusing, distracting, or time consuming processes to efficiently make this happen.
2. Clicking on the wrong patient.  Because of the distracting nature of a multi-step process of doing an order, it easy to miss the fact that you inadvertently clicked on the wrong patient.  Also, I work in 2 systems, both with  frequent screen ‘refreshes’ that are problematic.  Unfortunately, the patient list can shift at just the wrong time and it is impossible to notice that you clicked on the wrong patient at the time it happens.

3. Clicking on the wrong choice of medication.  I am frequently presented with very long and confusing choices of doses and forms of a medication that makes it very easy to click on the wrong choice.

4. Lack of discussion of a patient with the caregiving team. Communication of the caregiving team has diminished significantly with use of computers.  Previously, I would frequently discuss with the nurse a patient that both of us are caring for.  The nurse often had valuable insight which was an important determinant for the care plan and order writing.  Now, with doctors and nurses both spending an inordinate amount of time in front of computers, this critical communication has greatly diminished, which is very dangerous for patient care.

Let me give you one example at one hospital that I work at to illustrate a degradation of patient safety as the ED has been digitized.  This is a university hospital that has the typical mix of many chronically ill patients with long ‘problem lists’ and medication lists.  In my job as a locums emergency physician I have worked at this hospital on and off over a 5 year period during which time things have become significantly more digitized.  Previously, a staff member would assiduously compile a medication list on paper and do a quick ‘triage note’ (which included vital signs, allergies, chief complaint, and pertinent past history).  This information, which is absolutely critical to delivering safe care, was available to me on a clipboard which I carried to the bedside when I first went to see the patient.  I was constantly referring to this information as I talked to, examined the patient, and formulated my plan of care  Now, this process is theoretically completed in the computer; however, it is never done in a timely fashion because the process is too cumbersome and time consuming for the nurses to complete.  Even if it were there, I would still be lacking in the ability continuously refer to this information at the bedside.  So what happens is that I find a clipboard, get a piece of paper, and try to piece together enough info from the patient and/or family to make some decisions.  The folly of this is obvious.

One statement by an ER colleague was: ‘I used to be able to see 3 patients per hour, now I can only see 2.’  Even though data digitization can speed up and facilitate review of archival data, I believe a 30% loss of ‘productivity’ is a conservative estimate of loss of efficiency by doctors and nurses compared to previous paper based systems.  Even though this productivity loss is totally unacceptable, the really dangerous things it leads to are way worse.  We are forced to  cut corners on the really important aspects of patient care.     

The care processes in the ER are similar (basically, just faster) to those in most clinical care delivery settings, and these principles are largely the same across the enterprise.

At first, when I found myself making more errors, I thought ‘maybe it’s just me’ ….. but as I talked to co-workers, they agreed with me.  Trying to complete data entry tasks with current systems while with a patient is like trying to do a crossword puzzle while having a critical conversation about patient’s health and life….. that is, it just can’t be done safely and efficiently.  This leads to time sucking things such as ‘double charting’ (writing things down on paper to be entered into the computer later on.) which simply takes time and focus from patient care and care team communication.  This distraction and time loss from important patient care activity is also a major cause of the high degree of ‘burnout’ we are seeing in our doctors and nurses.  One recent analysis (5) found that first year internal medicine residents spend only 12% of their time with patients! This is shockingly unacceptable.  Another recent time/motion study in an emergency department (6) demonstrated that the physicians spent a full 44% of their time entering data into a computer; part of the title of this article is ‘4,000 clicks’, denoting the amount of mouse clicks in an average 10 hrs shift in this ER.

How did we get to this state of affairs?  The major contributor, of course is the HITECH government ‘carrot / stick’ program to push health IT onto  clinicians’ and hospitals’ desks. .  Perhaps another way to frame this is the lemming-like behavior of US physicians …… rather taking the ‘just say no’ approach that our physician and nurse compeers in the UK did when faced with the top down implementation of HIT in UK hospitals a few years back.  The UK program, a colossal failure (at greater than $15B US dollars {8}, the largest public project IT failure in world history) was cancelled in 2011 essentially because of a revolt of physicians and nurses: a quote (9) from the first head of ONC, Dr David Brailer, about the UK failure:

“The experience in Britain is a warning to us. The thing that brought them to their knees was the confrontation with doctors.”

To try to make sense of the disconnect that I see ‘in the field’ from current health IT and one of its major intended goals of patient safety, I find inspiration from writings of a number of folks (2, 3, 4, 7), most prominently Ross Koppel PhD and Robert Wears MD (an ER physican).  Dr Koppel writes frequently (2, 7) about the fact that HIT errors that are noted and reported are just the ‘tip of the iceberg’ of what is actually happening, and there are many forces that are muzzling further delineation and correction of errors.  One particularly concise and incisive paper (3) makes the point that current efforts to decrease errors and increase safety are drawn from traditional industrial efforts, and are not entirely applicable to HIT.  In this paper, Braithwaite, Wears, and Hollnagel refer to this effort as ‘Safety I’ (defined as retrospectively finding errors and stamping them out) which is insufficient by itself.  The authors propose a new approach for HIT, which they term ‘Safety II’.  In their words:   

” Safety-II: a concerted effort to enable things to go right more often. The key is to appreciate that healthcare is resilient to a large extent, and everyday performance succeeds much more often than it fails. Clinicians constantly adjust what they do to match the conditions. Facilitating work flexibility, and actively trying to increase the capacity of clinicians to deliver more care more effectively, is key to this new paradigm. “

… and further:

“All levels of healthcare need to accept that it is impossible to reduce the number of errors by increasing the bureaucracy imposed on clinicians. Instead of accelerating efforts to constrain performance, or mandating how work should be done, we should pay attention to how clinical care can be supported so that the number of intended and acceptable outcomes becomes as high as possible. ….. Safety-II defines safety as the ability to make things go right and not merely the absence of failures or adverse outcomes.”

Another concept I found particularly enlightening was Karsh et al’s (4) description of the ‘Messy Desk’ fallacy of HIT:

“Much of the motivation for HIT stems from the belief that something is fundamentally wrong with existing clinical work, that it is too messy and disorganized. It needs to be ‘rationalized’ into something that is nice, neat, and linear. However, as a complex sociotechnical system, many parts of healthcare delivery are messy and non-linear. That is not to say that waste does not exist nor does it mean that standardization is unwise. There exist processes within clinical care that require linearity and benefit from standardization. But, in many clinical settings, multiple patients are managed simultaneously, with clinicians repeatedly switching among sets of goals and tasks, continuously reprioritizing and replanning their work. In such settings, patient care is less an algorithmic sequence of choices and actions than an iterative process of sensing, probing, and reformulating intermediate goals negotiated among clinicians, patients, caregivers, and the clinical circumstances”

Where do we go from here?  It is clear to me that it is not a matter of ‘removing a few clicks’ from current systems, we need a major redo of the software we are provided, starting from square one ….  software that supports clinical work.  Perhaps, now that the HITECH money has been largely spent, there will be an opening to move things in the right direction.

1. https://www.ama-assn.org/sites/default/files/media-browser/specialty%20group/washington/ama-digital-health-report923.pdf (accessed 11-2-2016)

The health information technology safety framework: building great structures on vast voids; Koppel, R.;  BMJ Qual Saf doi:10.1136/bmjqs-2015004746

Resilient health care: turning patient safety on its head. Int J Qual Health Care 2015;27:418–20.

1. Health information technology: fallacies and sober realities. j am med inform assoc 2010;17:617–23.

In the Wake of the 2003 and 2011 Duty Hours Regulations, How Do Internal Medicine Interns Spend Their Time?; Journal of General Internal Medicine; August 2013, Volume 28, Issue 8, pp 1042-1047

4000 Clicks: a productivity analysis of electronic medical records in a community hospital ED; The American Journal of Emergency Medicine; Volume 31, Issue 11, November 2013, Pages 1591–1594

Role of Computerized Physician Order Entry Systems in Facilitating Medical Errors; Journal of the American Medical Association 293(10):1197-203 · March 2005

http://www.theguardian.com/society/2013/sep/18/nhs-records-system-10bn  (accessed 11-2-2016)

http://bits.blogs.nytimes.com/2011/09/27/lessons-from-britains-health-information-technology-fiasco/?_r=0  (accessed 11-2-2016)