Another experience at the ER

by Hans on 2008/11/18

Unfortunately, I had another experience with the health care system recently – well, not me, specifically, but my dad. He was taken to the ER and so I spent a few hours waiting with him.

The interesting thing was to see Credit Valley Hospital’s new ER. As always, they had the mobile computer stations, but what was fascinating was how little the nurses used them. The nurses spent most of their time documenting on coloured forms which were either stapled together or kept together via clipboard.

Some of the biomedical devices were fascinating too. There was a device that monitored the blood pressure (BP), heart rate (HR), and a few other clinical measures that I couldn’t make out. My dad had something connected to his index finger with some sort of light/laser that presumably measured blood sugar. What was most annoying was that some sort of alarm on the device kept going off every two minutes or so. I tried to make sense of the display, but to my untrained eye, many of the values weren’t very meaningful. I had a chance to watch a few nurses make adjustments to the device and it was very interesting to watch the nurses navigate through the multiple levels of menus using a dial. My friends and colleagues at the Centre for Global eHealth Innovation might be interested in some of the usability/human computer interaction issues. Nevertheless, the sad thing was that this biomedical device was a stand-alone device not connected to any other (as far as I could).

The staff were all very nice, but having worked in the ehealth area for quite some time, I wonder how we can get the indivudal clinicians involved with ehealth. One of the challenges that seem very apparent to me is that using technology is foreign to the daily work process of the clinical environment. Seems like there is much work to be done to get clinicians to adopt ehealth.

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{ 2 comments… read them below or add one }

Betsy November 20, 2008 at 3:23 pm

What has to be done to get clinicians to adopt ehealth is to have clinicians involved in developing the programs. And then to deveop programs that work. That can lessen the workload, not increase it. The program writers should be on the floor, shadowing the docs, nurses, social workers, therapists, etc, while they work with sick people, in all areas of care. Then they can create programs which flow with the clinical work, not against it. Where documenting in the e chart is easier than writing on the piece of paper. There is always the assumption that the clinical staff is rigid, hates change, just won’t cooperate with moving forward. This as opposed to the possibility that they are given a pep talk by people who have no idea how to do what they do, and then left alone to struggle with cumbersome, unintelligent programs that begin to feel like another ailing patient to be assessed, diagnosed, and treated.
I recently communicated with a clinician whose hospital’s new ‘echart’ was going to be read from oldest to newest. Anyone in healthcare knows that we have always had the most recent entries first-because in an emergency, that’s how we need to review the record for efficiency and accuracy. The person who decided to design the flow ‘backwards’ had never had to use a medical record for clinical care, I’m here to tell you!
We should be creating a record that is, first of all things, a clinical tool, and then make certain that the clinical tool incorporates all regulatory elements. There is always a clinical reason behind any regulation. Whether the legal department or the accreditation department or the IRB wrote the reg, there was a clinical situation that necessitated that reg. I hate hearing staff say: “oh, that’s just a document. That’s just paperwork for xyz.” And, I think it’s demoralizing for people who do such important work to feel that the extensive documenting and reporting they do is just wasted space. While people who love to heal, to be around people and interact with them in a therapeutic way may never fall in love with charting, I think we can teach clinicians how to make recording a vital part of what they do, to own it and see it’s worth (beyond I’ll get fired if I don’t…) even be made to feel as proud of their documentation as they are of their clinical work. In order for this miracle to occur, though, I think that the front-line clinicians, the ones who actually care for the patients, day in and day out must be a much greater part of designing the system we use. What if, for example, you could use the same documentation you created on mrs. X in rm 3455 to e-mail the order for her non-contrast MRI? What if you could auto-fill the discharge instructions? What if you could instant message the on-call doc, and so perform the communication and the documentation of the communication in one action? Then, when the Doc orders a new drug during that communication, you could email or efax the order to the pharmacy? And then, from the same computer, download and print out patient information leaflet on the medicine to help with teaching? These are the kinds of things that take so much of a nurses or therapists or social workers time. We have to go from one computer to another, close one program open another, then track down the paper chart to write it all down in…if you could see the 4 different e-record systems in my institution that we must work from simultaneously, you would cry. At the incredible redundancy, except for some very primary but very minimal types of data that can’t be gotten from one to another program. And how the incalulable potential for increasing utility-for research, for administration, for quality assurance-is completely dashed by the design of these systems. I know there has to be someone who can do it-who can design a truly elegant system that meets the needs of the staff using it and, ultimately, the patients whose care depends on it, while providing the regulators all the documentation they need to assure that the care is excellent. We have to aim higher, and we have to include the front-line staff in the process from the start-not just as a marketing afterthought, to hand to a couple of day-shift nurses to ‘try out’ for a week and then supply commentary. Or worse, fill out an evaluation questionnaire!

Hans January 16, 2009 at 11:33 am

Hi Betsy,
Thanks for the well thought out comment. Not much to say except that things need to get better, especially if the goal of an EHR in five years is to be realized (Obama/Bush).

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