Wednesday, May 04, 2011


Buttons are threatening health care.

A moderate number of years ago, a new innovation came to my field: radiofrequency energy delivery to burn (ablate) tiny areas of the heart. The lesions created with this form of energy were more uniform and controllable compared to the direct current energy we had used before. As a result, doctors quickly migrated to this form of energy to perform their heart procedures. In turn, manufacturers of the machines to deliver radiofrequency energy rushed to develop sophisticated devices that measured power, impedance, and the temperature achieved at the catheter tip within the heart. All of these measurements were used to assure safety of the procedure and with these machines came buttons, knobs, dials, digital displays, and analog displays galore.

It was an engineer's playground, but a technician's nightmare.

But as the years went by, I noticed something interesting. The device that ultimately gained the largest market share was the one with the fewest buttons. It was easy.

And also, safe.

Lately, I have notice a disturbing trend in the development of our electronic medical records: there's no more room for buttons (or menus) on our computer screens. Increasingly, I find I have to scroll up and down or find buttons in drop-down menus as I care for patients. Buttons and more buttons, many of which I don't use.

* Click Click Click *

* Scroll *

* Click Click * "Damn, where is it?"

Before people think this post will devolve into a screed against the electronic medical record (EMR), relax. I am not a non-believer.

But I am a realist.

One only has to look at the complexity of today's TV remote controls to understand the problem.

Electronic medical records are rapidly being developed to replicate exactly what we are currently doing to medicine to make sure the entire team of health care providers (doctors, nurses, technicians, secretaries, scheduling personnel, supply officers - EVERYBODY) do things in it a certain, pre-defined (and regimented) way as we care for patients. As they get more intricate, we see the integration, and the associated complexity, and are awed.

But as I step back and look at these systems from 50,000 feet, the engineer-doctor in me becomes concerned. That's because of several very human realities that we must accept:
  1. First is the shear number and volume of information we are asking our staff to enter for procedures. Electronic medical records are morphing from the classic written chart to supply systems, safety systems, billing systems and care systems incorporating every governmenal regulation known. Patient here? Entered. Timeout? Entered. By whom? Entered. Surgical sight? Entered. Groin prep? Entered. Type of prep agent? Entered. Duration of prep? Entered.

    Buttons. Buttons. Buttons.

    As more and more eyes are glued on the computer screen, fewer and fewer eyes are directed toward our patients.
  2. Second and perhaps more concerning, buttons are static. Because they are hard-wired, buttons replicate the status quo and deter innovation. What happens, for instance, when a new button is needed because of a new development in medicine? Will systems be able to be easily adapted by end-users or will a programming change (and the ripple effects to other programs) be required, debugged, and tested before they can be safely implemented? What about the risks to safety as more and more hospitals want to implement other button changes system-wide? Will programmers be reluctant to make changes because of the impact (and re-training costs) required? What if a simpler way is found to deliver care that removes the need and cost of all these tedious checks and balances, will we be able to change?
  3. Third, there will never be enough buttons to account for every variable seen in medicine. Free text will still be needed in data fields. Button-ology has limits.
  4. Finally, buttons are getting expensive. There are so many buttons now that scribes are increasingly being employed for data entry as doctors struggle to free themselves from their burden. For every person hired for data entry, the reliance upon (and cost of) our button-filled systems mounts. Might these additional personnel soon be requirements for successful EMR implemenation?
Our new EMR reality is this: programming developers better be careful.

Otherwise doctors and administrators might find the most cost-efficient way to perform data entry might evolve back to pen and paper.



Anonymous said...

I wholeheartedly agree. As a nurse, I see a change from taking care of the patient to taking care of the computer. With time stamps on notes it's difficult to work through a problem then come back and chart. Attention must be diverted from the patient to the computer, else the occurrence is flagged. Reminds me of an old ICD tenet- treat the patient, not the monitor.

Karen Swim said...

Dr. Wes, thanks for offering this perspective on technology. It is interesting and slightly disturbing that in all areas of our lives, technology designed to make life easier (tablets, smartphones, etc) divert our attention from life around us.

Keith said...

We are in serious danger of losing our humanity in this technological feast we now call medical care. We will spend ever more time attendig to documentation so our "numbers" can look good, but it is yet to be proven that any of this will improve care or outcomes.

Our medical system has long overvalued doing something to a patient vs talking to, properly diagnosing, and treating a patient. This is another case where we will be able to document our care (do we really think those 8 page progress notes are carefully reviewed by the writer when they are cut and pasted with all that garbage?!) when we may actually be delivering less of it. why do we continue to believe that what is written in the EMR is the true picture of health care when we all know it is not?

I personally think they need to create an EMR equivalent for beuracrats and hospital administrators who make the decisions to foist these Rube Goldberg contraptions on providers. I would even be willing to offer them 44 K per beuracrat for them to adopt!. Then we could truly monitor what kind of a job they perform and weed the good ones out from the bad. We could also develop clear measures (instead of just how much money the organization cranked that year) to put in place to measure administrator performance. After all, it is amazing how little computer use is actually required of our leaders! they could document what they do with their time so we can be sure of their performance. Alas, this appears to only be required for the working bees so we can more effectively communicate with each other in the new ACO paradigm (somehow hospital administrators are not part of this new "health care team". They just get to call the shots!

Tim said...

I am proud non-believer in EMR. It has removed nurses from patient care. They have to be more computer literate than patient care literate. The EMR generates page after bland page of documentation that will only be read by paralegals. That doesn't make it an instrument of patient care. It also falls prey to the governmental idea of one-size-fits-all, which is the only way government can think about anything. When I get an EMR note from a referring physician, it takes me much longer to glean pertinent facts. In a traditional note, ONLY pertinent info was passed along and took seconds to interpret. In, general, I LOVE technology, but how we use it is not left to us. It is being pushed on us by forces which don't really give a care about patient care. Get 'em covered and get it documented! Then we can say, "We have universal coverage!"

Jay said...

In a perfect world the EMR would be able to take care of all of the repetitious documentation tasks that exist only to maintain regulatory compliance and keep us from getting sued.

The real patient care then would be delivered in the form of a note with clear and succinct information that stands alongside of all of the garbage.

I'm trying my best to hold onto this model, but I see it slipping away all around me. It seems that it's just too tempting for most to cut, paste and run their pre populated form notes and leave very little of meaning for the delivery of care.

Those who assess our "quality" are then pleased and the billing comes through unimpeded. Too bad our reviewers really can't see what we're losing.



Anonymous said...

Dear Dr. Wes,
Our most recent "upgrade" included privacy protections. The screen locks after 2 minutes. I logged in at least 50 times today. Don't know how much longer I can do this.

Gene Moy said...

Yet, funny, there is no speciality that has more buttons than EP. For instance, the Bloom stimulator. But people love it. Techs tell me it is like flying the space shuttle when they're on that machine. Clearly usability must take precedence.