Time Capsule: Is Forcing Physicians to Use Computers a Flawed Paradigm? 3/25/11

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in January 2006.

Is Forcing Physicians to Use Computers a Flawed Paradigm?
By Mr. HIStalk

Welcome to my weekly column, which will appear every Thursday morning as part of the Inside Healthcare Computing Electronic Update. For those subscribers who don’t know me, I’m Mr. HIStalk. I’ve been writing the blog HIStalk under that keyboard name for almost three years now, cranking out nearly 500 long and detailed articles about the health care IT industry, interviewing CEOs, and providing sniggering, sophomoric humor to an industry that often takes itself too seriously.

I don’t use my real name because I’m a cynical blowhard who likes to speak his mind. I think I’m entitled to that privilege after many years in the HIT industry as a clinician, vendor peon, informatics practitioner, and IT director for a couple of large IDNs. On the other hand, getting vendors, member organizations, and industry notables riled up (especially those associated with the hospital from which my paycheck flows) is hardly a ticket to job security. So, let’s just leave it as Mr. HIStalk, if that’s OK with you. I still need that day job.

My writing here will be specific to one timely topic, different than the highly-condensed news and occasional editorial that I write for HIStalk. I have just one objective: to make you think. Like an aging hippie, I’m imploring you to question authority and don’t trust people who tell you what to believe (even me).

Let’s jump into what’s new. The online world has been abuzz about the Children’s Hospital of Pittsburgh article in the December issue of the journal Pediatrics, which suggests CPOE caused increased mortality in the hospital. I’ve put some of my thoughts about this on HIStalk, but let’s look at this story from another angle. Namely, is the paradigm of forcing physicians to use our computer systems personally and directly a flawed one?

Think of your most recent meeting with a local banker, attorney, real estate agent, dentist, or accountant. Did they place a computer monitor between themselves and you, making your conversation nearly inaudible over their furious keyboard tapping? Did you trust their advice even though they weren’t staring at the computer screen while awaiting an infusion of wisdom from faceless offshore programmers whom they’ll never meet personally? Did you think less of them because they listened and talked instead of typed?

I haven’t seen that. So why then do we expect doctors to be held to a different standard? It doesn’t make much sense, especially considering that they’re mostly self-employed and are as much a hospital customer as patients. Is it realistic to believe that their profession alone requires them to interact constantly with a computer to be effective, both providing information for use by others and receiving similar information in return?

Suppose you go into a restaurant and the waiter informs you that a new policy requires you to enter your order directly into a PDA, which will also provide recommendations and dietary warnings that someone has decided you should be forced to review. This will also solve the problem of illegible food orders and wastage due to poor waiter handwriting, along with incorrect tallying of your final bill (and maybe slyly pitching high-margin alcohol and desserts along the way). Maybe you’d see this as a good thing, maybe not. And if not, you’d go elsewhere.

As a customer, the only place that I see a lot of computers in use is in retail establishments, where the user is the lowest level of employee. Those folks aren’t rocket scientists. They didn’t have to go away for a week of training, nor do they have to tape reminders to their smocks or juggle 10 passwords. The systems they use were written with them in mind: simplified, optimized to their workflow, and nearly impossible to mess up. The part-time kid at McDonald’s can get your hamburger order right just as easily at Wendy’s, every time. Very smart minds dumbed down the systems to be as foolproof as the French fry cooker.

CPOE systems, on the other hand, are confusing, even to long-time users who have attended training. Just ask a nurse or pharmacist exactly what will happen when they change the schedule of a QID order and you’ll see what I mean. Hospitals that found their clinical systems too inconvenient for impatient nurses to use (turfing them off to unit secretaries) are now surprised at CPOE pushback from the docs. If their systems are so great, how come every nurse doesn’t already use them for medication barcoding, for entering nurses’ notes, for receiving point-of-care recommendations, and for shift scheduling based on expertise?

I’m not saying that CPOE is a bad concept. I’m saying that CPOE systems (and user implementations of them) need to be better to avoid harming patients, as the Pediatrics article’s authors described in Pittsburgh. If not, then please don’t install anything that makes the situation worse. And if those systems really do reduce unwanted outcomes and decrease costs as everyone believes (but few have proven), shouldn’t whoever benefits from that situation be willing to pay doctors for the indisputable extra time it takes to use the systems, possibly in the form of reduced malpractice insurance premiums or higher reimbursement?

Maybe what we should be pitching is electronic medical records — still a new concept to the hospitals that are chasing the sultry siren of CPOE instead of automating the basics first. Let’s worry less about who does the keyboarding and concentrate instead on making all existing information available in electronic form.

In the meantime, vendors can do a better job in designing CPOE that works for doctors, not programmers. And we in hospitals can rethink whether we’re using doctors optimally by having them interact with computers, doing the same things they did on paper, or whether new roles are needed for “information assistants.”