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Readers Write: Help Us, Atul Gawande, You’re Our Only Hope

November 15, 2013 Readers Write 7 Comments

Help Us, Atul Gawande, You’re Our Only Hope
By John Gobron

11-15-2013 7-32-39 PM

I recently had the pleasure of reading Atul Gawande’s essay, "Slow Ideas," published in The New Yorker. In it, Gawande discusses two innovations from healthcare’s past that profoundly and forever improved the delivery of patient care: anesthesia and antiseptics. Both advances provided obvious and impactful benefits to patients. One (anesthesia) was immediately and universally adopted, while the other (antiseptics) took a generation to become commonplace.

Why did the use of ether to numb pain "spread like a contagion?" Gawande argues it was because, while the patient was clearly better off in not suffering the agony of the surgeon’s knife, the surgeon himself benefited as well. After all, cutting someone open to practice painful, invasive surgery back then was, in fact, a risky business. Compare that to infection control. Back in 1875, antiseptic efforts were practiced by spraying everything and everybody with carbolic acid.  As the gentle reader might imagine, this wasn’t exactly a welcome or pleasurable experience for physicians.

As I read on, I kept waiting for what seemed to me to be the inevitable extension of the essay to address healthcare IT, where the adoption of the electronic health record promises to forever improve the entire healthcare ecosystem. After completing the article, I asked myself the sad question, "Are EMRs the carbolic acid of our generation?"

It is difficult to argue against the current and future benefit of the electronic medical record. Fourteen years ago, the Institute of Medicine estimated that as many as 98,000 patients per year die as a result of preventable medical errors, many of which were rooted in problems related to paper-based documentation and communications. Four years ago, the US government established a "pay then punish" wealth redistribution system for funding the adoption and actual use of EMRs. Outside of our healthcare biosphere, other industries accomplished similar computerization initiatives years ago. Yet despite the benefits, incentives, and examples, EMR adoption is mired in the 50 percent range. Why?

This really is the $23 billion dollar question, isn’t it? If there is a simple answer, it is that the physician does not benefit enough. Does this make them bad actors? Yes in the case of Travis Stork, but no for most everyone else. No other industry asks its highest-level knowledge workers to document the transactional activity found in most EMR data entry fields. CEOs don’t take minutes at board meetings, CFOs don’t tally balance sheets, lawyers don’t do stenography, and Congressmen don’t … well, I’ll leave this one alone, but hopefully you get the point.

Much has been written, especially here on HIStalk, about usability and design and other factors that go in to the actual EMR technologies. But the simple fact remains that for most physicians who practiced medicine in the paper age, paper was and remains better than anything that appears on a glass screen – for them, that is. Physically writing information down in a paper chart or even on a 3×5 card is much faster and more intimate than using a clunky PC or even a sexy tablet. Faster yet, is just telling someone else what to write down or enter into said computer or Appley gadget.

Let’s face it: physicians become physicians to treat patients and to participate in the miraculous science of medicine. Under that paradigm, paper is really good for the physician workflow and computers are really good for research. A physician can physically maintain her focus on the patient infinitely better when writing than when looking back and forth at a keyboard and screen.

In his summary thoughts on adoption, Gawande notes, "To create new norms, you have to understand people’s existing norms and barriers to change. You have to understand what’s getting in their way." What is getting in the physician’s way? Time, first and foremost. With today’s clinical computing workflow, it simply takes too much time and proves too distracting to document within the requirements and constraints set out by IOM, Joint Commission, HITECH, HIPAA, Meaningful Use, etc.

Much like adopting the use of sterile instruments and working conditions, adopting the use of an electronic health record adds burden to the physicians. As Gawande notes, “although both [anesthesia and antiseptics] made life better for patients, only one made life better for doctors.” Today, for some reason we are asking these same doctors to do what amounts to data entry. Therein I think is our lesson for anyone engaged in the mission of better adoption of EMRs — make life better for doctors. It’s not really as complicated a task when you look at it that way.

Think about all of the unlucky people who died from infection between 1875-1905 while healthcare waited a full generation to adopt an enormously beneficial change. Are we to see the similar fate of 98,000 people per year for the next 30 years to achieve the same outcome? Can the dead teach the living, and 138 years later, make it better this time around?

As I see it, we have three choices:

  1. Send a holographic message to Atul Gawande asking him to figure this out for us (Inga has volunteered to send this message, btw).
  2. Sit back and wait a generation until our digital native teenagers mature to replace today’s clinical computing-averse physicians.
  3. Redesign and bind the disparate processes of clinical workflow, clinical computing, and reimbursement together so that the benefits of healthcare as an electronic medium align with the efforts needed to achieve clinical computing adoption.

Healthcare delivery organizations, if you want to finally realize the benefits of improved outcomes, patient engagement, and ultimately preventative care, make the required workflow and infrastructure easy and economically advantageous for physicians to use-without needing to be bribed by the government.

I believe today’s healthcare executives are in the enviable position of being able to write their names in the history books as the alchemists who transformed their foaming beakers of physician-burning carbolic acid into the clinical computing manifestation of nitrous oxide. In addition to smiling, your doctors, your health system, your nation’s economy, and your patients will thank you when you pull this off.

I close with Atul Gawande’s simple instructions. “Use the force, Luke”, (sorry, I couldn’t resist)  What Dr. Gawande actually said was, "We yearn for frictionless, technological solutions. But people talking to people is still the way that norms and standards change."

John Gobron is president and CEO of AventuraHQ.

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7 Responses to “Readers Write: Help Us, Atul Gawande, You’re Our Only Hope”

  1. 1
    Frank Poggio Says:

    John,
    Very good points…and hopefully Atul has a simple solution, (like another checklist?) but your key point is on target. If there is little in it for them, then change will be slooooow.
    I wrote a similar piece, published several years ago in HIS Talk, entitled “CPOE and the Doc Dilemma”
    http://www.kelzongroup.com/CPOE_Doc_Dilemma.html

  2. 2
    Anydoc Says:

    This is so true and thank you for being the kid who said “the emperror has no clothes”.
    It seems that the HIT industry is acting like the parents who threw a birthday party for their kid only to have the kid babysit the other adults children while the adults are having a blast. Forgot what the party was about in the first place.

  3. 3
    Fourth Hanson Brother Says:

    What doctors have to accept is that while they may be the highest level educated people in the clinic, they are also hands on, getting dirty, working hard professionals. And while CEOs don’t take minutes at meetings, these days they do type their own emails. In the rest of the world, they may be one administrative assistant for every 50 people, with those people being masters and doctorate level folks. I don’t think even lawyers do steno anymore anyway.

  4. 4
    Robert D. Lafsky, M.D. Says:

    You listed 3 options toward the end. You want #3. What you will get is #2. The Gordian knot cannot be cut, it just has to weaken and fall apart with age.
    As for Atul Gawande, good New Yorker writer. Which means very good writing that sometimes gives you the added bonus of being true. I’ll respect him more when he writes an honest account about how much a surgeon like him makes from his practice and how me makes it.

  5. 5
    Michael Rothman, PhD Says:

    Adoption will follow function.
    We’ve digitized the data in a paper chart, at great initial and ongoing expense, and we’ve used the paper chart as the model for the computer interface.
    There are some immediate advantages to the computerization of the medical record: legibility is no longer a problem and you can’t physically lose a chart.
    But on the other hand, physicians have reported that it’s harder to understand the patient’s history now that the information is on the computer.
    And paper is a great tool. It’s easy to carry around, easy to consult, easy to flip through, easy to change…
    As long as these factors are the only factors… plus/minus for paper, plus/minus for the computer, we won’t get the adoption we want.
    More importantly, we won’t get the change in outcomes we want.

    However, what the government has encouraged and many hospitals have invested in, the digitization of medical information, has provided the infrastructure to change hospital care. When we start using the digitized data to do things that cannot be done on paper, adoption will follow.
    It probably will not be the EMR companies who create these new functions, but rather it will be many small companies, each with expertise in a well-defined area, who will create important applications which use this data to do things that have never been done before.
    The EMR of the future will be a platform upon which these “apps” operate. Think iPhone… it’s just a platform where a million apps live… some of which change your life.

    Adoption will follow when there is a reason to adopt.
    And at that point, the EMR will become essential.
    Older and younger physicians will use it because they will not be able to not use it and practice the best medicine.

  6. 6
    Deborah Kohn Says:

    I believe, as does M.Rothman, PhD, above, that future electronic patient records (health, medical, financial) will be platforms, where “apps” operate. However, difficulties, differences of opinion, etc., managing these platforms, as described in my Readers Write, above, still will remain. (In the case of my Readers Write, I discuss “consumer-grade” platforms, such as Google Drive, MS SharePoint, Box….). The good news is job security, as even platforms will evolve into ????

  7. 7
    Lanie Frame Says:

    Well-written article, John. I’ve noticed that the younger the physician, the more apt he is to use his computer rather than his pen. But, as you point out, waiting a generation is not the answer. The acceptance and success of innovations designed for medical practitioners are generally due to four factors: profitability, creativity, efficiency and effectiveness. If a physician is not convinced of the immediate benefits to himself and his practice, he can easily choose to ignore the new and coast along with the familar.

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