Yesterday’s blog post showed how electronic medical record systems can divert, or “channelize,” a nurse’s attention away from the patient, causing harm to the patient – just as channelizing a pilot’s attention can cause an airplane crash.
Continuing the theme that information without attention is worthless, today’s blog shows two other ways that EMRs can crash patients like airplanes, based on recent experiences of a friend, named Alex.
Alex returned home from the hospital elated but exhausted. After a few days, with the exhaustion worsening and her usual internist unavailable, she was directed to see an internist new to her. Fearing lung blood clots, this internist ordered a CT scan of the chest. It showed no clots, but – completely unexpectedly – showed a large mass in the chest that the radiologist felt was cancer. The internist compassionately broke the shattering news, but Alex responded as most people would to a cancer diagnosis.
Two days later, a physician friend of limited experience, but who had detailed memories of Alex’s medical history, read the radiologist’s report and offered a different diagnosis: the mass in the chest was actually a greatly enlarged vein that had grown up following an unusual blood clot Alex had suffered years ago.
An agonizing week later, super-specialists at the university hospital reviewed the CT and confirmed the vein diagnosis, telling Alex she was cancer-free and needed no tests to prove it. Alex was overjoyed.
Besides bad doctoring, what happened here? And why must the electronic medical record (EMR) share responsibility for Alex’s psychological brutalization? The answer lies in two characteristics of the EMR.
First, EMRs reduce the mouth-to-ear conversations physicians have with each other, exactly as email reduces conversations in business offices. While this may increase efficiency with routine medical care, when a case has unusual elements, conversations become essential. In Alex’s case, the internist and radiologist should have talked to each other the day of the CT. The internist should have challenged the radiologist’s interpretation, and the radiologist should have pressed the internist for more information about Alex’s history. Between them, they would have had a chance to figure things out. Both, however, probably thought they had all relevant information from the EMR, making such an exchange “unnecessary.”
Second, the EMR mixed informational wheat with chaff. Alex’s extensive EMR record did indeed mention the old blood clot that led to the correct diagnosis, but both the internist and radiologist failed to find this historical nugget, not believing it worth their while to study the record, even for an unusual case. In other words, the friction of seeking and absorbing information in the EMR inhibited their search.
Reinforcing these points, a week later Alex visited a hospital clinic to discuss her medications with a pair of doctors. Reviewing her EMR record, the pair re-shattered Alex by declaring that cancer was still possible, and by recommending two tests. Fortunately, Alex resisted, saying that information in the EMR obviated these tests, and insisting that these doctors actually talk to the super-specialists. When this was done (three nerve-wracking days later) the doctor-pair relented, and pronounced Alex cancer-free. For the second time in two weeks, Alex felt the joy of a cancer cure.
These EMR problems have strong aviation parallels.
Regarding communication, all aircrew members receive extensive training in cockpit communication, to overcome cultural and other influences that tend to silence the exchange of observations and questions. In medicine, the EMR is inhibiting important mouth-to-ear conversations.
For wheat vs. chaff, in every aircraft’s thick technical manual, emergency procedures are printed in boldface font, and no one is allowed to fly the aircraft until they prove they have memorized the boldface. In medicine, each human’s “boldface” is unique, but EMRs contain so much chaff – courtesy of simple cutting and pasting, plus reimbursement-motivated templating – that doctors cannot reasonably find their patients’ boldface, as four different doctors proved to Alex.
Bad as these problems are, another exceeds them. After an airplane crash, aggressive and intrusive external investigators pinpoint causes and assign blame, aiming to propose system fixes that will prevent recurrences. Medicine, with its less fiery accidents, rarely conducts such investigations; certainly, none of the errors that befell Alex were officially recognized as such. And so, defective systems – whether software, organizational, or human – continue defective, and kill and maim.
Medicine’s need for a true aviation-style safety culture has long been recognized. But as the amount of physician-computer interaction increases, it becomes ever more vital to implement.