Bob,
I've been in Public Health (as a Laboratory Director) now have my own company writing for Public Health LIMS. We've presented information to lab clients and they insist on paper and prefer 8x11 reports. The answer is quite simple. You can stick multiple reports in a folder and the attending physician can flip through reports from multiple labs/sections in the time it would take to log onto a computer screen.
There is no need to convert data from one system to another, since they are all optmized for the same (paper) system.
A quick scan and you have all the current information, much faster then opening multiple windows and trying to find the connections between report.
Next time you are at the doctor's office, watch them flip through the pages to build a synoposis in their head.
This doesn't mean that the data does not need to be in the hospital computer, but many decisions are done viewing the paper trail.
I make my living with a computer, but paper will always be the best media for physicians.
Bob

Interesting timing, my wife is a Nurse Practitioner and is going through an automation process as we speak. She's not opposed to it (mostly because their office is drowning in paper charts), but I wouldn't say it is going smoothly either.

A number of problems exist that I can see:
1) Medical practitioners use bizarre abbrivations that no one else uses and don't keyboard well. p with a line over it equals "with" for some reason. How do you type that?
2) Equipment needs to be easy to clean and not cumbersome. A laptop is not ideal for a provider to carry around. A tablet is probably better, but can be expensive and most practices don't really make that much money (obscure specialties and surgeons excepted).
3) Time is money. If something goes wrong, your patients get angry and don't come back. Paper never fails.
4) Like the above poster mentioned, paper charts are much better for scanning a lot of information quickly than a computer screen.

Finally, I don't think the typical medical professional understands computers all that well. Maybe people's brains are wired for either dealing with people or machines but not both. That can lead to a lot of frustration.

I'd like to expand on the "rock star" syndrome you mentioned.

I read an article a few years ago about a medical diagnosis program that was being tested. The premise was that given an accurate description of the symptoms, the system could recommend specific tests to conduct to either confirm or rule out various maladies. The greatest advantage of the system was that it is constantly updated with the latest information. It could present a list of possible diagnoses with relative likelihood, relative risk, and options for further diagnostic tests.

But even after it was demonstrated that the system was at least as good as human practitioners at diagnosing common ailments, and better at catching rare conditions, doctors didn't want to use it. They believed the system couldn't possibly make as good a diagnosis, despite evidence to the contrary.

The other major problem was related to cost. The fear was that doctors would now have to order all the suggested tests to confirm something they already believed they knew. If they didn't, and the patient had one of the conditions the system had mentioned, the doctor could be exposed to a lawsuit.

Basically, since doctors couldn't ignore any suggestion from the "expert system" no matter how remote the possibility, they preferred not to know about those possibilities. You can defend against a malpractice suit by claiming ignorance of a rare condition. How do you defend a decision to not order expensive tests to rule it out?

I do software development in a hospital, and here's my take on the situation.
Computers do really poorly on incomplete information. Few people remember the dates of all of their operations. Heck, women from some Muslim countries over a certain age don't even know their own birthdays.
There are multiple tests that measure the same things. There are also multiple standards that look like they mean the same thing, but don't. It's really complicated, and has resisted easy automation.
What has worked for us is computerizing the mundane things. We have a system that lets people get patient information (X-Rays, scanned documents, dictation, lab results) with minimal fuss, and the staff seems to like it pretty well.

Read your question again: Hospital > healthcare > doctors > nurses. Sounds like the OP is imagining one system that should suffice for all players. Would you ask your factory floor to run on the A/P software? Most doctors are independent business people. Nurses have collective bargaining agreements. Hospitals are one entity.
And I'm the patient, and I get to bounce around to all of them. At will. BCBS seems to be able to track me pretty well.
Just observed one MD doing voice recognition dictation. Radiologist won't email my MRIs because the files are too big--sneaker net works better.

The OP is asking the wrong question.

WRT one of the comments: EVERY field uses bizarre abbreviations. Deal with it.

I'm the Data Manager at an Alzheimers research center, and I agree about paper being better for some things. We actually looked at online forms, but the problem is that paper doesn't change formats, is easy to copy, can be written on, doesn't distract you from the patients or subjects you're interviewing or examining, and doesn't scare off people.

So don't blame doctors for wanting patients to open up to them and think they're human - that's their job, after all.

I aman independant continuous data protection consultant, and I agree 100% with your "rock star" observation. From it some major problems occur.

First is that the users (doctors, nurses) refuse to participate with IT in the process because, of course, if you aren't a doctor or a nurse, then you are only fit to change bedpans. Why would they want to participate with IT as an equal?

Secondly, many medical organizations recruit IT staff poorly. The ads are not under "Help Wanted IT" but hidden in "Help Wanted Medical". They go on and on about the world class doctors, professional nursing staff and only toward the end ... perhaps as an afterthought ... say that they need some network admins or a AD guru.

Worse yet are the display ads that have a laundry list of medical specialties (with the attendant bonus packages) and lowly IT is at the bottom of the ad, with no bonus offered, clearly in a second class position. No wonder they can't attract enough help.

One thing to know is that in many if not most hospitals, physicians are not employed by the hospital. They are independent contractors that are free to take their business to competing hospitals. So there is much less power to enforce the use of a given system than in other industries like banking and manufacturing. "Forcing" can be counterproductive.

As a teleradiologist, (a doctor who reads xrays over the internet) I have seen dozens of different systems, possibly hundreds. Most of them are barely functional and are an impediment to the task of getting the job done. The author's peception that the systems are largely designed by and for admin types is assumed throughout the industry. IS is historically banking oriented and is only approved when there is money to be made or saved. Few systems were ever installed that didn't make financial sense, regardless of how good a performance impact they had on workflow. Go figure. All the same, there are now some motivated physicians out there who, through sheer frustration and willpower are writing open source code to move the bar to a higher level. Frankly, I look at all vended software with the jaundiced "Caveat Emptor" relising that the purpose of the channel is to make the channel money, not improve my performance.

Once data collectors can change their pitch and capability to show doctors actual use cases and VERY easy to use tools that demonstrate how accurately storing this information can lead them to saving time, lives, and minimizing suffering of patients- THEN they will demand and use it. Until that time, forget it. It will be a very uphill battle.

Bob, You hit one point but should elaborate more because it has to do with all IT. If there is no user benefit, they won't use it. Most frontline medical staff has yet to see any real benefit from process automation. In fact they become merely cogs in the administration, which probably doesn't benefit the patient directly either. What needs to happen is either direct benefits to the doctor/nurse (easier information access or direct increase in productivity in there work) or a full explanation in how their participation in the automation process will help them, their patients and healthcare as a whole (decrease costs, quicker diagnosis, better information). Most of the time IT use is a mandate without proper presentation and explanation (or thought about what the real benefit will be).

This is true with any business automation process. There will be resistance if IT is just implemented for IT sake. It is good to see that there are several posters above that actually came from the medical field to the IT field. Their input is of tremendous value.

As a patient, watching a nurse use the latest tablet PC doesn't impress me if my cost is higher, visit takes longer, or doesn't provide me with any direct benefit.

As an IT professional and customer of heath care (who isn't?) who has had some good and some horrendous experiences, I don't disagree with anything said here.

But the most telling comment is from Bob, where he states the focus on IT in healthcare has been from an administrative point of view instead of supporting the individual processes of the professionals.

A simple example: How about a large display in an Emergency Room, indicating patient status (replacing the whiteboard), time elapsed (as in retail; Sears pickup has this great feature). This could track triage status vs time waiting and proactively identify potential problems.
This is a an inexpensive support application and assists/supports the medical professionals who are multi-tasking several critical issues at once.

How about on-demand paperwork? High speed printers and scanners with a back-end imaging system produces charts on demand and updates them automatically making them available near-time wherever a patient is located and reducing clerical (and administrative) time? I have seen this work with X-Rays after a recent accident.

Also, the best registration experience I had was in a hospital emergency room, with an administrator with a tablet working alongside a medical professional; I was triaged and registered efficiently.

I am sure there are many other ways of optimizing the patient experience while minimizing the 'sub-optimization" which occurs with traditional IT solutions.

It just takes some care in indentifying them.

There's a bigger issue in my experience -- the systems don't work! For example, most hospitals have switched to digital radiology. But the servers crash and now the entire department is idling while someone tries to fix it. There are never enough workstations so physicians end up taking turns on them. Then the image systems are separate from the dictation systems which have their own problems. The doctors I know would be happy to use the technology if it made their work easier. Unfortunately, the implementation is generally poor and so they naturally resent it. When I have visited physicians at a local hospital, they can't pull up complete computerized records from the system. In contrast, the paper system worked acceptably for generations.

One aspect of the different strokes for different folks theme - many years ago, I heard a radiologist observe there was a direct correlation between the competence of the radiologist and their acceptance of his system for capturing readings and generating reports (available on paper). His hypothesis was that those with sharper diagnostic ability appreciated the time that the automation saved (more patients treated, lower error rates, higher income), while those not so sharp resented the loss of a forum where disembling could mask the weakness of their diagnoses.

My background is electrical engineering and then an MD with graduate work in neurohyusiology. I started using a computer in clinical medicine in the 60s using a Packard Bell 440 and progressed to setting up information systems at three major teaching centers until my retirement a few years ago.
One major problem with the commercial systems that are introduced into Physician's offices, even tho primarily intended for coding and billing, is the way they are presented by individual with little insight into medical practice. They can be an important timesaver and very useful in this application and take a load off the office. Unfortunately they are often awkward and time wasting.
Hospital systems can be a different matter. As used in radiology, anesthesiology, pharmaclogy and in ICUs they are often efficient time and even life savers. However when an attempt is made to inject computer technology into medical practice and the parient-physician interface trouble arises. One reason in the closed nature of medical practice, a century old tradition, and the other problem is handling "soft" / "fuzzy" data which is outside of the experience of the average information specialist. We have all experienced this rigidity of the computer mind in filling out forms on the internet. ie - 5 or 9 digit area code, unacceptable but correct entry ---etc.
I strongly believe this technology has an important role to play in medical practice but we have to get over the stage of engineers bringing fine equipment into an environment they don't know or understand. Hopefull by dialogues like this we can expedite the use of this technology.

I've been working in IT for the past dozen years or so; my wife as an RN for half again as long. I have spent time (about two years total) performing systems support in the Healthcare field. The issue as I perceive it is at least twofold: medical personnel are at best knowledge workers. I don't know how many times I've heard comments to the effect of "Hey, I turn it on and it just goes to where I need to be. I enter my labs (or discharg or admit or...) information and shut it down again. Why do I need all this fancy hardware? I don't have time to learn this new software"

Also, much of the IT improvements are pushed down "from the top" so to speak. In one instance, a state of the art (for the time) monitoring system was installed for one floor (department). It worked great, tracked a slew of important parameters and had a central (as opposed to individual room) monitoring console as well. Unfortunately, the department had not been consulted as to their actual requirements, and the learning curve was rather steep. Three (+/-) years after the project was completed (from an IT standpoint, the (several million $$$) system is installed but not powered on...

On the other hand, the medical records department, an area for which indexing and document management systems are well suited, has a state of the art digital asset management system which allows quick retreival of patient historical data from any of the several hospitals in the local system...

I work in a healthcare setting, and most of the comments here are on target.

For instance, hospital management is, on the whole, keenly interested in documenting the money. Most large-scale Health Information Systems do this really pretty well because they must. Their clinical modules might be fine, but they are, to state the current situation plainly, optional.

Many is the healthcare organization that has an HIS. Implementing the G/L, A/P and A/R (to select a few) is typically mandatory. Implementing online charting for instance, is a lower priority.

Also, the relationship of Doctors to their hospitals is rather interesting. For all intents, Doctors are independant contractors. They are not employees of the hospital. As a result, most organizations cannot enforce use of the HIS by them. This question isn't even asked when it comes to true employees!

Finally, the standardization of clinical terminology is problematic. There are well-documented problems with coding systems like ICD-9/10. These have to do with a certain lack of clinical focus/relevance, backwards compatibility, and standardized practices for code obsolescence.

My experience with this subject is strictly from the patient's point of view. I started seeing my current doctor about 3 years ago when my arm swelled up like a football. Before even introducing himself, the first words out of his mouth were, "oh, my god!" and I was on my way to the hospital 5 minutes later.

Every examining room at the doctor's office has a computer terminal, and every person who looks at you (the aide who shows you in and takes your vital signs, the nurse -- if needed, and the doctor) immediately logs in to have your record. While flipping through paper charts might be a little bit quicker, that only works if you can read everyone's writing (I'm not a doctor, and sometimes I can't even read my own).

In addition, this clinic actually has 15 locations in our suburban area. The reason I mention my hospital stay at the beginning is because the infectious diseases specialist (I had cellulitis) has his office in the main clinic, while my doctor is at the one in my own town. Nobody ever had to make copies of charts and fax them to the other office, or anything of the sort. Everything is readily available to any practitioner (including at the four walk-in clinics, should they ever be necessary).

The software also allows my prescriptions to be transmitted directly to the pharmacy of my choice (as faxes, since the pharmacies aren't part of the clinic system), so there's no scrawls on paper that can be misread.

It's all within the clinic, but the same applies to lab orders, x-ray orders, and the like. The doctor enters the information, and the other department has it before I've even walked across the waiting room to get there.

This is an instance where the primary purpose of the system is to improve medical administration, but I think it's obvious to all the providers that it's vastly improving the quality of the service. Being in the computer field myself I've talked with a few of the users about it, and there have been absolutely no complaints about the system. Indeed, some have even volunteered how much it has improved their work environment.

With the right reasons to have the system, it's a lot easier to change the attitudes of those who need to use it. My clinic is a case in point.

My wife's company provides diabetes management services for large insurance companies and state governments. She is on the bleeding edge of IT technology for this sort of thing. The systems are written with the data consumer in mind, not the data input person. The input forms are huge with required field scattered all over what would be a 6 foot by 8.5 inch sheet of paper. Combine this with a requirement that you can only save when all required fields are filled in and a less than reliable VPN arrangement and you get screaming coming from the kitchen where my wife fills in forms at night. I try and hang out in the attic where I can't hear the screaming.

Having had some contact with both the health care and financial industries, my experience is that health care systems (not restricted to automation) have a built in tolerance for bad outcomes that financial systems seldom do. This may be because, at its core, health care inherently has bad outcomes, and the people in the business develop expectations that accomodate them.

Bob, you've made some good observations here.

My wife is a physical therapist at a hospital automating its charting. There are many good reasons for doing so. If you have back pain, she can really help. But she is computer averse to say the least.

I'd like to separate the benefits of automation from the actual input into the system. To force her into this online charting is taking a therapist that bills $200/hour for the hospital and converting her into a $12/hour typist. They will have nothing to do with having her dictate notes, then approve them after typing. This isn't being obstinate or a case of massive ego. This is just bad business.

They also insist on using their computerized form. However, there are many ways to do a physical therapy evalutation. So to fit the system you force the patient to wait while you fill out the mandatory forms. That's really not serving the customer.

The IT people think they have come up with a tremendous system. They did it with very little input from the therapists.

The inmates are running the asylum!

Hello:

As a practicing, teaching, physician, my 2 cents worth.

As much as I love the technology, it is hard to embrace something that takes two and four times as long to complete as doing it with paper and pen. Until there is only a slight time penality to the electronic medical record (EMR), it will be difficult for users to embrace it.

I left a full-time teaching position in the past year. I consider each EMR system like learning a foreign language. Every July 1, a new group of bright young physicians would start specialty training. The Outpatient clinics used one system of EMR, the one tertiary care hospital had its own in house EMR, the other teritary hospital across town had purchased the core system from a major vendor. The was *no* compatibility between these systems from layout of screens, flow of logic through the system, keyboard shortcuts, etc, etc, etc. They are three distinctly different systems.

HIPAA requirements for privacy and security are well intended, and perversely construed, and as a consequence, many tasks take longer to complete under conditions when time is at a premium. Productivity and throughput must improve. Voice activated systems, and wireless tablets have a great future, but until there is the same programatic flow, the system is designed to facilitate the classical chief complaint, history of present illness, past history, review of systems, etc, clinicians are not going to use it. What is required is the ability of the clinician to lay out the display and replicate their own logic flow pulling up data from the underlying data bases. I don't like learning three or five different systems at three or five facilties where I go to work.

Truly,

John

I hate to bring it up, but doctors and lawyers are personally responsible for what goes wrong in the work they do, even if it is not their fault. Like the captain of a ship if anything goes wrong they have to answer for it. If the prescribe an IV antibiotic, and the IV pump fails and delivers it to fast or to much then guess who gets the heat??? Yes the doctor.

This makes doctors and other medical practitioners very skeptical of any technology they don't fully understand and can control. While not quite so critical as a IV pump, computers are technology that these people don't ether fully understand or control. Add in the level to which they do experience failure and there is an obvious problem.

I've had two experiences that I think provide some insight. Several years ago, I was interviewing a job applicant (I don't work in the medical field). When we were discussing the job she was potentially leaving she said "I'm only working at the hospital until I find something better. You can never tell the doctors they are doing something wrong. They expect 10 year old computers to keep working. Worst of all, the job only pays $12 an hour. Everybody there looks down on people who didn't go through some sort of medical school and they can't imagine paying good computer people what they are worth." Bob already mentioned this with is rock star analogy. I just wanted to point out that it affects their ability to retain good people.

The second experience I had was my last doctor's appointment. When the nurse did the standard weigh-in and blood pressure stuff, she entered it all into a tablet-PC. I asked her about it and she said her biggest complaint was that it locked up a lot and their IT guy was no help when that happened. I couldn't help but wonder if he was making $12 an hour and their good IT people had long since left to pursue other opportunities.

From the Doctor's point of view, their opinion that IT people are useless gets reinforced every time something like this happens. How can you blame them when they might never have seen a well developed system with the support it needs. I don't mean to condemn or insult everybody who support IT in the healthcare industry, but I'm sure there are enough examples of bad departments to make the intelligent people who observe them conclude that the problem is industry wide.

I have worked with several people who were not comfortable giving up their paper in favor of computers. I worked for a couple years in a materials testing research lab. When I was successful in getting a convert, it was almost always because I could point to a shortcoming in the paper based system, and I could eliminate obvious glitches in the computer based system. This strategy is much harder in the healthcare industry. Everybody you are working with made it through their respective medical school. That means there is a real good chance that they know how to handle paperwork. It was easy for me to find shortcomings in the research lab. I imagine it's hard to find shortcomings in a doctor's paper trail - or at least shortcomings that the doctor cares about.

In his comments above, Dave may have had a really good experience as a patient going from one branch to another and not waiting for the paperwork to follow him, but John who has to learn a different system at each place he works. John is a lot more likely to make decisions about what the process will be. If he gets exposed to bad IT and good paper, which do you think he will choose?

As a physician who works implementing IT systems for clinicians, the above comments were a very interesting read, and all on-target. Without reiterating them, I'd add in some "inside" thoughts on why this happens.

First off, the american legal system and insurance industries, backed by the law-making bodies, have made practicing healthcare in the US very challenging. The combination of E&M coding (designed to guarantee quality reviews every time a note was written, but really resulted in large, redundant notes), HIPAA, and general litigious nature, have made the daily work for MDs very tedious. The note a Canadian doctor writes for a patient follow-up could be one line long, the equivalent american doctor's note is half a page at least, 95% of it identical to the latest note, or else they don't get paid and could get torn apart in court.

The healthcare IT vendors have also not helped the situation. They have focused on automating a paper process, rather than trying to optimize the processes for an electronic version of them. They've also ignored the "practice" side of healthcare almost entirely, largely because I don't think they understand it, and by the time they get to a position where they could address it, they have all sorts of rigidity built into their system that changing mentalities doesn't seem to happen. Most of them started out as more concrete lab information systems or something like that, so clinician practice is a new thing to them.

They have also gone out of their way to bundle all aspects of their applications tightly together, so even if you wanted to use a better, practice-oriented system from another vendor, it's nearly impossible to do so. They all preach compatibility as their goal, but don't do anything to actually achieve it. The rest of the IT industry is 5-10 years ahead of them, and SOA is something that they're all "thinking about". Given that most hospital administrations (who haven't gone through this before) feel that purchasing a big system is the only way to go, there's little drive for the vendors to address this issue.

In the end, all of these things kind of feed off each other in a way that has maintained the status quo for quite a few years. Here's to hoping that some form of disruptive technology comes along to break the logjam.

"The determination and desire dictate the outcome" someone said. (Bob great blogsite)I wish RGB, WAffleck, PRessler and DrMike would join in the collaborative efforts of the below mentioned!! Posted on KevinMd. com
What is IT? Informative, innovative, intellectual, incongruent, inconcievable, incomparable--- talk, technology, tacit, telling, tawdry? The "mother of invention was necessity" someone said. George Anders in his book "Health Against Wealth" spoke eloquently when he said "Doctors , employers, regulators and HMOs need to combine forces to develop treatment guidelines that people can trust". What better way to convey that message and sentiment than the medium we are currently using to express the same thoughts. Erecords and Ecommunications best serve us all. If Wikipedia developed and continues to develop from an "IT" gene there is no reason why -- gasman; gregp; anon612; anon844; anon915 can't collaborate to evolutionize a better VA IT HealthCare System. (KevinMD will deserve some credit).

6:56 AM

As I read all of these comments, all of which seem valid to me, I'm struck by the variety of valid problems people have encountered in applying automation to the world of medicine. Perhaps the most important factor to note is that each medical organization is unique and the location and scope of of areas suitable for automation will be unique to that organization.

Some years ago, my manager and I had great success automating the claim forms for a home health care agency. We had a top flite billing staff, experienced developers using highly flexible tools and highly competent medical staff in the field. Combine this with good communication between all parties and we produced a product that automated what could be cost-effectively automated at the time and left everything else alone.

But, I don't think our system would have worked for everyone else. Other organizations have different strengths, weaknesses and personalities though they be just as successful.

Understanding what our organization's success keys were, making the various departments our partners and having a firm understanding of what computer technology would be able to do at implementation time, how robust that technology would be and what would be involved in supporting this technology were our keys for designing and implementing a system that people successfully incorporated into their work life in less than 2 days, on average.

I find the responses to this thread stunning. I have rarely, if ever, seen so many responses to an issue, all thoughful, all perceptive, all true and mostly, all different.

Rock star/SFA gets to the heart of the issue, but trivializes it. The diagnosis is based on the practitioner's training and life experience, i.e., their knowledge. That is based on an understanding of the indicators for their field, e.g., an orthopaedic surgeon uses digital xrays and is probably amenable in other computer support programs. An internist is dealing with echo cardiograms, lab tests and their stethoscope. They are not going to be an easy sale. My wife and I deal with close to 20 doctors. Each one has a unique need for presentation of the data generated by medical history, lab tests, xrays and personal observation. This needs to be the key point of any support of the medical profession. The medical practionier must be provided the view of appropriate data in a form that supports their medical decision making technique. A similar problem was the changing of flight instruments from 'steam dials' to cathode ray tubes. You must provide value added to the user to get acceptance.

I feel I need to expand on my earlier comment.

Doctors being independant contractors is not some peripheral issue. Nor is the desire to get them to use some totally inappropriate system, or to suboptimally get a high skills clinical person to perform administrative tasks, or to simply frustrate.

You see, most computer systems have problems of various kinds, often interface or functional concerns. If use of these systems is mandated (as is normally done), then real pressure is brought to bear against the vendors to address the concerns. The system becomes better with use.

Doctors, however, have an easy out. They can and do simply refuse to use the system. The software doesn't get much better because now it's not a high priority. Who better to raise issues than a concerned, engaged physician? Lose them and you lose a lot of momentum to improve a system.

Also, there's a rule of data quality. The closer to the source that a system gets it's data from, typically the higher the quality of the data. Physicians generate lots of data but normally delegate data entry. This creates longer turnaround times and loads of opportunity for errors.

Disengaged physicians are bad news for medical systems. It's real and it's happening everywhere.