(Tangentially related podcast here)

Here’s the thing: all this talk about arrogance in medicine is a red herring. It’s distracting us from the real question that we should all be asking: how do we improve quality medical care?

The personality of individual physicians is important, but not very, just as the medical mistakes of individuals have limited significance. As medicine has become more science-based, we have learned some important lessons about how to prevent and treat disease, and while the physician-patient relationship will always be important, as will the relationship between physicians and other professionals (see this discussion), implementing what we know about how to improve health care (and have known for years), will render much of it irrelevant.

Take the Keystone program. This simple program, developed at Johns Hopkins and piloted in Michigan, as well as a few other places, uses mandatory checklists for certain hospital procedures, and has been shown to reduce complication rates of these procedures. Unfortunately, bureaucracy threatened to strangle this program in the cradle, but that particular storm has apparently passed.

Quality medical care depends on many things (not the least of which is access, but that’s a topic for another time). It should be made to depend on individual personalities as little as possible. Let’s look at two areas where we can improve medical care.

Medical Errors

There are two main types of medical errors: individual errors and systems errors. Human beings will always make mistakes. That is the idea behind, for example, cockpit checklists—the checklist helps to minimize any individual pilot’s ability to screw up.

In medicine, medication errors are common, and while it is easy to blame an individual, it is really a systems problem. As an example, let’s look at how drugs are given in a hospital, and potential errors at each step.

    1) A doctor write an order, often by hand: may or may not be correct, legible, and appropriate.
    2) A clerk delivers the order to the pharmacy: hopefully.
    3) A pharmacist or tech verifies the prescription, fills it, and delivers it to the floor: hopefully. Remember that any error that has occurred in previous steps may be magnified.
    4) A nurse receives both a valid order and a medication, then delivers the medication to the patient: That’s a tall order. What if the nurse picks up the wrong med, or sets it down and forgets it while someone is having chest pain?
    5) A patient take the medication: whose?

As anyone who has taken basic science lab courses knows, the more steps you put into a process, the more error will be introduced. It’s inevitable, unless the system itself is fixed. Here are some basic systems fixes:

    1) A doctor enters a drug order in an electronic prescribing system, which checks the patient’s other meds, allergies, kidney function, etc., and flags potential problems before the doctor can sign off on the order.
    2) When the order is signed, it pops up on the pharmacists screen, who verifies it, and dispenses individually wrapped meds barcoded with the patients identity.
    3) The medication is flagged for delivery on the nurses computer or handheld device. S/he is cued until the med is delivered.
    4) The patient’s wristband barcode and drug barcode are scanned. If they match, the med is given.

The second system doesn’t reduce the error rate to zero, but it significantly lowers the chance of avoidable mistakes. This type of analysis can be applied to many aspects of patient care. Electronic health records (EHRs) would go a long way to helping reduce errors and make continuity of care more, well, continuous. At this point, however, there are no national standards for EHRs, nothing that requires them to be able to understand each other, nothing that subsidizes the huge costs to physicians and institutions for installing and implementing them. As an example, my three doctor private practice is planning to get an EHR, but the cost is tens of thousands of dollars. It’s taken us years to be in a place where we can (almost) afford it.

Standards

EHRs can help implement standards of care. Diabetes is a very common illness, one we’ve made great strides in treating. Science-based medicine has shown that certain interventions can reduce the complications of this disease. For example, ACE inhibitors given to diabetics with kidney disease can slow progression to kidney failure. Keeping systolic blood pressure below 130 reduces the risk of stroke and heart attack. Regular eye exams help prevent blindness, and foot exams prevent amputations. I use a pre-printed sheet to track these and other parameters in my diabetics. I also belong to a local physicians’ group that requires me to fill out a separate form on diabetics to track some of the same data. And Medicare has a new program called “PQRI” which also requires tracking of some of these data points. None of these systems is integrated, there is no one standard to allow doctors to simply enter the data and have it all go to the groups who want it. This is a huge disincentive to participating.

If EHRs were made available to all medical practices and institutions, all of these systems could be integrated. My diabetic data could be zapped to each of the organizations who wants it with the stroke of a key. This would allow easy implementation of standards tracking and free up more time to spend with patients.
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We know how to deliver quality medical care. We have the data and we have the technology. We’ve simply decided as a nation not to do it. Quality care requires quality people, but personality is only one factor in medicine and becomes much less relevant once we use our knowledge to improve the system as a whole.

Of course a system that doesn’t cover everyone is a disaster waiting to happen. If you could carry all of your medical data on a card or flash drive that was readable by any physician, that would be great. What if you were “off the health care grid”? If you showed up at a hospital unable to speak, the staff would have to do a lot more guesswork and errors related to your care would rise. Imagine the difference in a natural disaster if we had access to a centralized data base of patient medical information.

Quality care isn’t about mistakes made by and to individuals. It’s about creating a health care system based on evidence. It’s about making data available and using it correctly. It’s something we can choose to do. Or not.

Comments

  1. #1 Comrade PhysioProf
    December 14, 2008

    Thanks for the link, Pal. I am updating my post to link here.

    What you say makes a lot of sense, but I’m not sure I see how it’s going to have an effect on the particular type of error I talk about in my post. Effective medical care frequently requires communication of urgent information between participants in the system, like a nurse telling a physician, “Doctor, your patient is in big trouble! You better come check it out!”

    No system of checklists or standard operating procedures is going to ensure that the physician takes the nurse seriously. Only a change in attitude will. Korean Airlines cockpits had the same system of checklists and standard operating procedures as other airlines, and it didn’t help when the plane was heading for the side of a mountain and the second officer couldn’t communicate that fact to the captain.

    Quality care isn’t about mistakes made by and to individuals. It’s about creating a health care system based on evidence. It’s about making data available and using it correctly.

    It’s about both.

  2. #2 Yagotta B. Kidding
    December 14, 2008

    If you showed up at a hospital unable to speak, the staff would have to do a lot more guesswork and errors related to your care would rise. Imagine the difference in a natural disaster if we had access to a centralized data base of patient medical information.

    And if our medical records were that widely published, you can bet that you’d have a lot of people avoiding treatment for “sensitive” conditions: “I might be in an auto wreck [1], but Daddy will kill me [2] if word gets back to him about the abortion.”

    EHRs are not a simple problem, and if someone selling you technology promises that they have a solution that makes all the problems go away, you can bet the farm that they’re lying. The fundamental problems aren’t technological.

    [1] Yeah, like anyone under the age of 30 actually takes that idea seriously.
    [2] Don’t be so sure that this is rhetorical hyperbole.

  3. #3 Yagotta B. Kidding
    December 14, 2008

    Effective medical care frequently requires communication of urgent information between participants in the system, like a nurse telling a physician, “Doctor, your patient is in big trouble! You better come check it out!”

    Considering that blowing off a warning like that moves the subject much closer to criminal negligence, Dr. R. O. Gant of the example is deep in denial territory. If (as he believes) the risk of any adverse outcome is indistinguishable from zero then he’s beyond rational discussion; he’s inventing his own reality.

    No system of checklists or standard operating procedures is going to ensure that the physician takes the nurse seriously. Only a change in attitude will.

    The question is, “what means can reliably produce such a change of attitude?” The literature I’ve seen on similar subjects isn’t promising.

  4. #4 Jim
    December 14, 2008

    electronic health records do not have to be public. I worked for a company that created ehr software and there never was an issue of people not getting treated because it was electronic.

    Just a few advantages:
    1. If the FDA pulls a drug for efficacy or safety the Dr.’s office can quickly know what patients are currently on the drug. (paper records they have to rely on slow, expensive manual search)
    2. It is more difficult to lose the chart.
    3. You can have automated edit and interaction checks.
    4. You can track who looked at the chart. (actually more secure than paper records)
    5. You could have a drug formulary in the system. It is unreasonable for a Dr. to be aware of all the different formulary plans for all the insurance companies etc.
    6. Even if you print the prescriptions out instead of sending them electronically the writing is clearer. Less chance for error. (We did have one Dr.’s office that encountered a patient seeking drugs. They got a prescription for motion sickness. They scanned the form in and altered the prescription to vicadin. (state didn’t require Dr. prescription pads) It was caught because they used MS Word’s Time Roman font and they didn’t know how to enter the vicadin prescription properly – form and dose. Pharmacist caught it and called the Dr.)

  5. #5 The Perky Skeptic
    December 14, 2008

    I’m a big fan of the electronic records system, along with the bar-coded bracelets and the scanners. The first time I encountered that system was when I was giving birth. Every time I was given a pill to take, the bracelet got scanned, along with the pill label. It impressed me with the care expended on patient-care.

    Also, the babies were linked by bar code to the mother, and if a baby were improperly removed (kidnapped) from the hospital, alarms would have sounded, automatic floor lockdown would have ensued, and the dogs with bees in their mouths would have been released. Srsly, it went a long way to alleviating any shred of maternal anxiety I might have had!

  6. #6 Denice Walter
    December 14, 2008

    Ironically,using the word “arrogant” to describe MD’s is a favorite of those *maitres de woo* who often give medical advice without any actual or reality-based education/training.However, I do understand why they aren’t too concerned about human error, since they themselves obviously could *never* err in action, methodology, or judgment(Hey, you know, divine inspiration and all).

  7. #7 Sari Everna
    December 14, 2008

    At my doctor’s office they print off prescriptions, and I think this is very wise. Even if you have incredibly neat printing, my “faith” in human beings tells me someone could get it wrong. Plus, from what I’ve caught glimpses of, it looks like there’s a form they fill out to do this that also adds that to the chart, basically killing two birds with one stone. Now, if my old doctor’s office and my current one had been hooked up to the same network, I wouldn’t have even had to go through the process of moving the chart, which would have been wonderful. Even more so when you consider that, since this is university res, I do go home now and again(Like for Christmas!). If they could both always have access to the same information, I wouldn’t have to worry if something changes while I’m home for the summer.

    Not to mention being able to get quite accurate statistics, track progression of conditions more accurately, and other number crunching that could be done on a quite grand scale with this kind of system and of course help further in understanding certain conditions or common variables or what have you. Of course, that’s my geek (more than) half exploring the possibilities of a new toy, but that doesn’t change the fact that there are some very interesting alternate uses for this kind of thing.

  8. #8 Yagotta B. Kidding
    December 14, 2008

    electronic health records do not have to be public. I worked for a company that created ehr software and there never was an issue of people not getting treated because it was electronic.

    You can restrict access to EHRs to, for instance, only the patient. At which point many of the claimed advantages go away. One of the popular claimed advantages is “you’re in a distant city and are taken unconscious to the hospital …”

    If, indeed, X. Random Nurse in “distant city” can pull your records, they’re pretty damn public. That may be OK, but the use cases claiming privacy and those citing “distant city” are disjoint. There are purely human tradeoffs here that have nothing to do with the technology.

    4. You can track who looked at the chart. (actually more secure than paper records)

    This is the kind of sales BS that I mean. Unless you’re doing a direct-to-brain transfer with encryption the whole way, it’s blatantly bogus to claim that you can track who shoulder-surfed Nurse Random while she had your chart open — and once she does have your chart decrypted, it’s there to be copied.

    If you think otherwise, have a talk with the MPAA.

  9. #9 a lurker
    December 14, 2008

    You can restrict access to EHRs to, for instance, only the patient. At which point many of the claimed advantages go away. One of the popular claimed advantages is “you’re in a distant city and are taken unconscious to the hospital …”

    If they are electronic records they should include full identities of those who access them. That would include doctor name, affiliation, username, IP number used to access, time of access, etc. The those wanting access must either sign off they have explicated written permission to access the information or that the patient is in emergency medical care. It would be illegal for provide the information to any third party not directly taking part in the patient’s care. And manufacturing and marketing are not part of care. Patients have the right to there medical information including access information. Anyone would buys or sells that info would be subject criminal and civil action including the patient being entitled to getting twice the purchase price from both buyer and seller plus court and lawyer costs.

    Some system for court orders would have to be in play as well. I would say that those to must become part of the record include the name of the Judge that authorized it.

    And how often and for how many people any doctor or institution uses the system should become public. That way if someone requests info on more people than they have under their care, it can be noticed.

    Obviously the possibility of hacking exists. But that to some degree exists in almost everything that is done today.

  10. #10 dave
    December 14, 2008

    “Obviously the possibility of hacking exists. But that to some degree exists in almost everything that is done today.”

    …and that’s exactly the problem. Medical records are one of those things where that kind of risk is a lot less acceptable than in most other areas.
    Keeping electronic records has a lot of benefits, but I for one would not want to trust my medical records to what passes for “security” in most of the computer industry. At least with paper, the inefficiency built into the system limits the rate at which damage can be done.

  11. #11 Max Kennerly
    December 14, 2008

    Problem is, the more automated a system becomes, the harder and less likely it is to be overseen properly, and the greater the damage that can be caused by a single malfunctioning actor.

    Like a recent trial I had where a resident, after consultation with the pharmacist (and not the attending), verbally ordered a preoperative antibiotic with a high likelihood of cross-reactivity instead of an alternative preoperative antibiotic with no likelihood of cross-reactivity. (Adding insult to injury, the attending surgeon actually preferred the latter, non-reactive antibiotic).

    None of that occurred on paper, despite hospital protocols requiring all orders be documented and all resident orders by co-signed by the attending. Not at all surprising — every week I review cases where a nurse or doctor just plain didn’t follow protocol, despite all kinds of checklists and automatic warnings.

    Don’t get me wrong: I’m a big fan of using appropriate checklists like the Keystone program and using electronic health records. But increased automation is not a solution by itself — you still need to encourage the same type of regimented-but-open discourse that, e.g., military units and athletic teams use to control and to react to dynamic situations.

  12. #12 Anonymous
    December 14, 2008

    Clearly Yagotta B. Kidding is technologically ignorant. There are plenty of methods of keeping the information secure without preventing those who need to know it from getting it. Not only that but there are very strict Federal laws regarding medical information. (HIPAA) Could someone print the information out and copy it? Sure, they can do that with a paper chart today. Should we get rid of paper records too because people can copy those? (no) (At least with the electronic copy the user has to log in and has to be a recognized user in the system, paper copy you have no chance of knowing that. You could even use biometrics at login further identifying the user. (eg a thumb print. you don’t allow web access.) We knew of one medical practice who washed and cleaned the Dr.’s cars every Friday so they could get the paper charts out of their cars. (they didn’t tell the Dr.’s that)

    You have to consider both sides. If you so restrict access to the medical records that the medical professional can’t use the information to better the patient you potentially hurt the patient. Should security be an important consideration in the design of the system? Absolutely.

  13. #13 Yagotta B. Kidding
    December 14, 2008

    Clearly Yagotta B. Kidding is technologically ignorant.

    If you say so. I wonder what your opinion of Bruce Schneier is.

    There are plenty of methods of keeping the information secure without preventing those who need to know it from getting it.

    And they all start with physical security. Those that can’t manage physical security have a short list of authorized accessors. Tell me again how many medical-system workers there are in the USA.

    When you have an “authorized access list” counting into the millions, you don’t have access controls any more.

    Not only that but there are very strict Federal laws regarding medical information.

    There are very strict laws against decoding DVDs and against fileswapping. How’s that workin’ for ya?

    Could someone print the information out and copy it? Sure, they can do that with a paper chart today. Should we get rid of paper records too because people can copy those?

    Paper charts aren’t broadcast to millions of people.

    (At least with the electronic copy the user has to log in and has to be a recognized user in the system, paper copy you have no chance of knowing that.

    With a paper copy you have to have physical access. With the electronic copy, it’s out on the net. Remember, the “unresponsive patient in a strange city” use case requires that those records be accessible from anywhere in the United States (or potentially anywhere in the world) without patient authorization.

    You could even use biometrics at login further identifying the user.

    And you’re thinking that with millions of authorized users, this is going to All Just Work? Biometrics (in case nobody told you) can be copied like any other bits — they’re just a password that you have a hard time losing.

    We knew of one medical practice who washed and cleaned the Dr.’s cars every Friday so they could get the paper charts out of their cars. (they didn’t tell the Dr.’s that)

    Well, with electronic records that won’t be possible. The lovely thing about bits is that they’re so marvelously copyable.

    You have to consider both sides. If you so restrict access to the medical records that the medical professional can’t use the information to better the patient you potentially hurt the patient.

    I believe my making that very point was what led you to declare me “technologically ignorant.”

  14. #14 MartinB
    December 15, 2008

    “There are plenty of methods of keeping the information secure without preventing those who need to know it from getting it”

    Sure. And we see how well this works out – data lost in the UK from government computers, in Germany a newspaper was able to buy a CD with tens of thousands of bank account data on it (including PINs).

    I think you have to live in a fantasy world if you believe that making sucha system fool-proof is going to be easy…

  15. #15 D. C. Sessions
    December 15, 2008

    Stepping away from the charming topic of Clarke’s Third Law, I’ll instead suggest that medicine is overdue for some application of well-established process engineering. (My own mathematical metaphor is Shannon’s Theorem, by the way.)

    There’s been a lot of industrial engineering (often mathematically formal) applied to the question of how to get arbitrarily low error rates from a process with error-prone steps. Trying to drive the individual error rates to zero is not the best way, but that’s the approach that has been traditional in most professional fields.

    Medicine and engineering have some noteworthy exceptions [1], and one might hope that the future will include more. If nothing else, error correction is generally more cost-effective than trying to drive initial error rate down by another order of magnitude.

    [1] Sponge counts in surgery, for one. Checking beats counting on never overlooking one in the first place.

  16. #16 ArtK
    December 15, 2008

    @Anonymous:

    Clearly Yagotta B. Kidding is technologically ignorant. There are plenty of methods of keeping the information secure without preventing those who need to know it from getting it.

    In a word: No. As others have pointed out in this thread, these methods only work up to a point. Every method has a weak point, or ten, where it can be attacked. Those of us who actually work in information management are painfully aware of the shortcomings of the technology. (I’m a senior architect in information management for one of the largest hardware/software companies in the world — and part of my work is with the health care sector.)

    Besides the possibility of simple human mistake (i.e. leaving a screen open where someone who isn’t authorized can see it), as security technology becomes more powerful, it also becomes more difficult to use. At some point, there’s a bend in the cost-benefit curve that makes the technology too expensive.

    Part of the problem, too, is that there is no bright line between proper accessibility and proper security. There will always be a gray area between the two. We’ve got to apply a risk-benefit analysis to decide if giving access to group ‘A’ will also make us vulnerable to group ‘B’. Administering permissions at an individual level, even for a couple of hundred employees, is a logistical nightmare. It becomes worse as the control becomes more fine-grained. Fifty different access permissions in one system isn’t unheard of. Multiply that by 200 employees and you’ve got 10000 separate permissions to keep straight. With staff turnover in hospitals (e.g, traveling nurses changing jobs every 3 or six months), that means updating hundreds of permissions per month.

    Case in point: My SO is a manager in the OR for a major hospital — they just implemented an EHR system for the OR. She told me the following just this morning: They wanted to give someone very limited access to some of the records. The administrator ended up giving her full update access because finding the exact permission and assigning it to her is very difficult. Here we have both the human factor, as well as a technological failure. The design of the system doesn’t facilitate this kind of operation — making it do so is a cost to the developer, which gets passed on to the hospital.

    The points of this long-winded comment are these: 1) The technology is not nearly as strong as Anonymous would like to believe; and 2) The stronger technologies bear increased costs both financial and non-.

  17. #17 Anonymous
    December 16, 2008

    All systems have weaknesses. This is really more of the devil you know against the one you don’t issue.
    It’ a matter of what people are more afraid of, death from preventable mistakes or new ways of records breach, becuase bloody hell paper records are notmore secure you just don’t hear about it. I’ll take privacy risks if it improves my survival odds.

  18. #18 MDH
    December 17, 2008

    Nothing is foolproof. You can always make an argument for either side dependant on your point of view. Clearly it should be the Person choice. It�s their health, record and decision. Personally, given the chance to have access to my records when and where I might need them transcends some security questions for me. Everyone should look at both the pros and cons and think about. Not the place to make snap decisions.

  19. #19 Allo V Psycho
    December 30, 2008

    “all this talk about arrogance in medicine is misleading”

    Would it be OK to rephrase this as “some of this talk” or even “much of this talk”, rather than “all of this talk…”?

    Otherwise it might come across as medical arrogance….

    The article linked in the opening sentence does raise relevant issues. Mind you, I have also heard many ‘doctor’ stories of difficult, disruptive or wrong headed nurses, so I don’t think this just a doctor issue. However, stories often improve with time, in the sense that the issues become clearer, and the story teller becomes more and more perfectly vindicated. As for how to make health care teams more effective communicators, well that’s my day job, and I wish I knew if I was doing it well!