Vol. 41 March 7, 2011 “Hey, PC Guys, Get Over It!”

March 7, 2011

Physicians are buying and using iPads and iPhones just like the rest of the world because EITHER:

“The iPad is intuitive, easy to use, reasonably priced, easy to carry around, and has a lot of apps that have been developed for the platform. People — not just doctors — love the experience of using an iPad.”
“Apple has developed a very appealing hardware platform in the iPad. Recognizing the market strength and lock-in to their walled garden they are creating with consumers, Apple is targeting key market segments to create new revenue streams and business models. Health care is the next target for Apple’s aggressive smarts.”

This “coincidence vs. conspiracy” theory was advanced in a recent Health Care Blog.

The Apple II that I bought for my middle school son decades ago looked like a typewriter and had mostly empty air inside its case. Granted it needed a fan and lots of air around it to keep cool, but I suspect that Apple knew that we would be much more comfortable buying something that looked and worked like a typewriter to replace our typewriter. Apple continues to appeal to our comfort zone. “Hey, PC guys, get over it!”

During my years as a hospital administrator a decade or so ago the weekly mantra from the hospital’s Chief Information Officer seemed to be, “The critical step for implementing EMR is to get over the hurdle of the physician/computer interface.” He was talking about the proprietary computerized information system in our hospital. At the same time, some cardiologists in our hospital were asking when would they be able to review lab results and write orders from their Blackberrys (then) and  (now) iPads and iPhones.  Then, the initial single, desk top computers at the nurse’s stations were quickly overwhelmed with people trying to use them. Clunky computers on mobile stands began to appear to decompress the nurses’ station, and the competition with IV poles, wheelchairs, and other medical devices for noisy “banging rights” began. Now, a physician standing quietly in the hall between patients can review office schedules, review an EKG record from his office, check for on-call nights next month, answer patients’ emails, and maybe review some labs. Of course, the physician could also be checking a stock portfolio, scanning the movie directory, or sextexting the new ER nurse she met last month. Who cares?  The physician wants to write orders, dictate a note, and review a discharge summary while standing there. “Hey, PC guys, get over it.”

A banker spending a day shadowing two physicians in an educational program sponsored by our local medical society summed up his impression of the day with, “The physician’s job is a day-long quest for credible data.” That quest can extend from home to office to hospital to lab to x-ray to nursing home to other’s offices, etc. Much of that time that physician will be on his/her feet literally moving around. Why do they like a light, thin, easy to read, easy to navigate, hand-held computer? “Hey PC guys, get over it.”

James Gleick, author of “The Information”, states that it is neither the media nor the type of technology that transforms human societies. It is the information, and the way in which people communicate with each other. “Hey PC guys, get over it.”

By the way, the future is here. My three-year-old grandson was shown how to swipe his father’s iPhone and touch an icon so that he could pick out his favorite music to listen to. (He is, of course, “above average” in both reading and music appreciation. All of my grandchildren are, of course, “above average” in something.) Soon after his iPhone lesson he went next door to play, saw that their TV was on, and swiped the screen a few times with no result. He turned and announced, “TV broke.”
OK, he could use a little help with sentence structure, but I’m sure “there’s an app for it”.

[This post is a week early because I will be on vacation and off the grid for a while, and I didn’t want to expose my sensitive iPhone to any salt spray.]

Vol. 27 August 15, 2010 No One Is Perfect, Not Even Computers.

August 10, 2010

My last post described how a precisely regimented dosage of intravenous medication delivered to me over six hours by a state-of-the art computer actually depended on the existence (and the survival for 6 hours) of a handwritten yellow Stickie hanging on my IV pole. I write this post as a recipient, certainly not a victim, since no harm occurred, of a “care error” caused by a computer.

After my first infusion I grumbled to my physician that it had taken 6 hours, and that the package stuffer the nurse gave me recommended about a 2 hour infusion for someone my weight and age. He was surprised but responded, “Those nurses are really good. They probably have more information about the drug. I would go with what they say.” So I called the Head Nurse in the Infusion Center. She told me that the infusion rates come from the computer. “How does the computer know them?”, I asked.  She responded, “The Hospital Pharmacy Committee puts them in.” I called the Chief Pharmacist, noted the difference between the package insert and the computer recommendations, and asked him to review the information because I would sure like to spend just 2 hours off my boat rather than 6 for the next treatment. He contacted me a couple of days later to tell me that that medication infusion rate had been entered into the computer several years ago and was based on data from the one manufacturer of the medication. “There are now three manufacturers and two different concentrations. Each one has different infusion rates. Yours could go in over 2 hours. I will take care of updating the computer’s recommendations for your medication before the next treatment.”

The Institute of Medicine describes a medical error as “following a wrong plan of care or not completing a correct plan of care”. My computer-associated medical error was caused by “failure to update reference information”.

Do computers cause errors? The FDA maintains a data-base that categorizes voluntarily submitted adverse events associated with thousands of medical devices. Only five of the categories have the word “computer” in it. The Huffington Post made a considerable effort to analyze the most recent year’s findings in this data base and found 237 incidents that were related to health information technology. (1)

Six deaths were associated with computer adverse events. Except for two hospital-wide computer system crashes which delayed medications (both in 2006 in Cerner installations) the events included well recognized causes of NON-computer medical errors: delay in sending an x-ray image to another facility, a physician missed reading a significant “addendum note” on another physician’s progress note, an incorrect patient identification on an xray film, and an incorrect mixing of a chemotherapy solution.

Forty-three injuries associated with computer adverse events were reported. Many of these involved incorrect manufacturing of intravenous solutions rather than incorrect computer-directed delivery as well as incorrect dates, patient identification, or study type in radiology filing systems (PACs). These radiology “errors” became “injuries” when the errors were not perceived by human readers using multiple display screens, multiple screens,  screen short-cuts, etc.

Studies to date of computer errors in clinical care have by and large identified the computer/human interface as the most frequent cause of error: transcription errors, misreading of displays, mis-navigation among screens,  ignoring alerts, overriding warnings or alerts, failing to update reference and resource information. It is comforting to know that very few of these have led to harm because most of these are recognized as errors by trained clinicians before harm occurs. There is little data currently to suggest that we are just seeing the “tip of a gigantic iceberg.” Even the harshest critic of UK’s attempt to implement a nationwide EHR has been focussed on the business plans, difficulties of implementation, and cost. (2)

Several years ago a banker spent a day shadowing both an internist and a surgeon at our hospital as part of a Doctor-For-A-Day program and summed up his impression as: “A doctor’s  job seems to be a day-long search for credible data.” As long as we have well-trained clinicians providing our care, the help that computers will give them, and us as patients, in finding credible data will far out weigh any of the “new-found errors” (3) that will surely emerge as the new technology is implemented. The greatest threat to medical safety from computers will come from our trust in them, thinking that they are always right. A vigilant, skeptical clinician, and patient, is still the best defense against any subsequent harm from “computer error”.


1. The Health Care Blog, “Do EHRs Kill People”, June 11, 2010, Margalit Gur-Arie
2. http://hcrenewal.blogspot.com/ – Health Care Renewal – a blog “addressing threats to health care’s core values, especially those stemming from        concentration and abuse of power”.
3.National Research Council, January 2009

Vol. 26 August 1, 2010 The YELLOW STICKIE Ain’t Dead Yet.

August 1, 2010

I’m sure that many of us “old timers” can remember the early days of computer implementation in our hospitals. At that time you couldn’t help but notice the dozens (or more) yellow Stickies plastering the nurses’ station computers, usually around the monitor’s edges, filled with keywords, short cuts, new jargon, and other information helpful to them as they strived to give up their dependence on paper. Well, thirty years later, the yellow Stickie ain’t gone just yet.

I had to go into my hospital last week to get an intravenous infusion to help me with the effects of a neuropathy. The receiving desk at the IV Infusion Center had three computer monitors with two people sitting at them. My physician’s orders were already printed out and were attached to my computer printout encounter form. After receiving my computer generated ID bracelet with bar code, I was lead into a room with four chairs, each one next to a computerized infusion pump with blinking lights and various sounds to convey different messages to the nurses caring for me. Each pump had  touch-screen data entry and a multiple color display combined, was capable of at least three distinct alert sounds, and was neatly packaged to fit on a standard IV pole. The combination of four such poles, two automatic blood pressure machines with their display screens and alert sounds, the usual wall of oxygen, suction, electrical outlets, and signal lights, a R2D2-size  mobile air conditioning unit standing in the middle of the floor with its coiled, white PVC exhaust duct winding to the wall, and four brand new baby blue Barca Loungers made me think that this is what a passenger cabin on a space ship would look like.

I was to receive intravenous medication following a protocol of precisely increasing amounts over several hours, so I lay back, opened my book, and relaxed while surrounded by all this reassuring technology.

And then I saw it. There stuck to the top of my chart…right there next to my chair… hardly noticeable…seemingly insignificant in the midst of all this electronic wizardry…nicely framed by electric wires and IV tubing…was a small piece of yellow paper.


On it was written the settings for the proscribed stepwise increase of my medication.The physician’s orders were computerized. The pharmacy’s filling of that order was computerized. My registration and ID bracelet were computerized. My clinical record for the day was computerized. The correct step-wise increase of medication for my weight had been calculated and displayed by the computer at the nurse’s desk. …But, that computer couldn’t “talk to” the infusion pump computer, so the actual entry of correct information into that infusion pump by a nurse for each of 10 stepwise increases depended on that yellow Stickie.

When my chart got covered by a discarded newspaper the yellow Stickie was temporarily “lost” which caused a brief flurry of nurse concern. It was moved to the blue plastic of the infusion pump which repelled the yellow Stickie in a few minutes. It was next moved to the center of the IV pole itself, and there it stood, prominently and proudly revealing its data for the nurse as she entered the numbers every half-hour or so on the touch screen below. …That is, until the Stickie became unstuck while I was in the bathroom and fluttered silently to the floor, just missing the toilet bowl. An extra piece of scotch tape solved the problem of a Stickie not being sticky enough.

The medication was delivered as on the protocol, so all is well that ends well. My next post in two weeks will review some of the new data on clinical errors associated with computer use. I may title it, “THERE  AIN’T NO FREE LUNCH.”

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