Recently I experienced one of the most terrifying nights of my professional life. Having worked in six different hospitals since finishing my residency training, I am well aware of variations in work load. I've worked in a 700 bed hospital, and a 40 bed rural setting. Chaos in healthcare inevitably ensues  when more patients show up. Sometimes it is the hospital setting (urban vs rural), other times the day of the week (people avoid coming in during holidays), and sometimes simply the weather (patients don't like traveling during snow). This particular night captured how much harder my job is given that providers still don't have the correct healthcare I.T. tools to optimize their own work flow.

In the first half of my night- I received so many pages, phone calls, and admissions from the emergency room that I could barely scribble them down quickly enough on the printed sign-out document in my white coat pocket. Writing things down to relay back to the morning team was one thing; however the true challenge was efficiently executing a diagnostic or treatment plan with all the interruptions. I was on the verge of committing multiple medical errors as my pager rang non-stop, I navigated through four different computer systems (lab ordering, radiology, billing and patient charts themselves), and attempted to coordinate care with nurses other colleagues in different specialties.

My own momentary mental misery aside (12 hours go by fast) – I couldn't help but think of the care that patients receive. Put aside the tremendous delays in getting from ER bed to hospital bed once you are admitted (sometimes patients are 'boarded' downstairs for 24 hours). Forget the fact that you had to answer the same questions at least 4 times; to an ER nurse, ER provider (doctor, physician assistant or nurse practitioner), then to the Hospitalist/admitting provider when you reach your room, and then finally to your unit nurse. On top of all this - imagine a night filled with delays because your nurse, doctor, pharmacist and others are still relying on archaic communication methods.

A common scenario unfolds. You have severe abdominal pain, nausea and vomiting and you press your call button (yes, that tiny button on the end of a cord next to your bed). Now you wait. Your nurse arrives 1-5 minutes later (no idea whether you've fallen and hit your head or whether you're just hungry), pages your doctor (who is in the middle of something else), and they call back 1-15 minutes later. Either they come to assess you, or order something to treat empirically in the computer order entry system. The treatment must be released by the pharmacy, somehow arrive to the floor, and finally your nurse can administer it. Really.

It easier for me to reach a friend or family member using a variety of escalating techniques such as email, text message, phone call (and when I am really desperate Facebook) - than it is for me to coordinate with colleagues to provide life saving and efficient care. Simply replacing pagers and telephone call back with something 'digital' (like secure messaging)  is a really low bar to set ourselves. We should have surpassed that level of mediocrity a decade ago. Admitting that we're failing is a start. What we need is a complete overhaul of communication, coordination and work flow optimization in the hospital. Using existing technologies available in 2014, we should be able to pivot and rectify the chaos. We're just not doing it. This is despite knowing that chaos leads to decreased provider satisfaction, delays in care, medical errors and death. We don't need more studies. We need action. What more will it take? 

11/26/2014

Varun Verma, M.D. is a board-certified Internal Medicine physician who splits his time as a Hospitalist at Brigham and Women’s Hospital (Boston) and as a Senior Clinical Advisor to Possible (Nepal) 

@VarunVermaMD

One would expect that in an era where smartphones are more powerful than our computers were 5 years ago, healthcare providers would have an arsenal of healthcare IT solutions to enhance patient care but also optimize their own work-flow. Shockingly, in 2014 most healthcare IT solutions (such as EHR systems) are incapable of basic functions that we take for granted in other aspects of our digital lives (this is despite the fact that hundreds of millions of dollars have been invested by institutions). We have made information electronic, but continue to work with it as if all we had was an abacus. This is problematic since many providers are now involved in taking care of patients (physicians, nurses, physician assistants, clinical pharmacists, therapists, and trainees), and there is greater turnover of team members due to the shift work nature of inpatient care. Rather than having optimal information available – we have data chaos.

The situation is in stark contrast to my out-of-hospital life. In my Gmail I can (usually) easily find a specific message using a combination of ‘has,’ ‘to,’ ‘from,’ and ‘subject’ statements. Most EHRs on the other hand have me scrolling through consultation and progress notes in size 10 text, stacked one on top of each other, which are about as search-able as a Where’s Waldo scene. As a Hospital Medicine doctor who needs to rapidly assimilate information often in the middle of the night – EHR is my last resort. When I receive an emergent page, I rely on my examination, the patient interview (if they’re able to talk), and then a quick glance at a rudimentary ‘sign out’ document handed to me from the day-team. EHR is neither optimized for mobile in most cases, nor can I find anything I am looking for when I actually need it. This is true irrespective of whether I am working at a rural hospital in Maine with a 10 year old EHR, or at a major academic center with a ‘cutting edge’ EHR.

Despite heavy investment in healthcare IT from institutions – providers like myself still find ourselves carrying around printed patient lists with scribbled check boxes and to do lists. The sign out document – a purportedly succinct summary of the patient problems and suggested plan of action quite obviously has pitfalls. One night last week I counted 42 patients I was covering overnight on five different sub-specialty services; and some basic math revealed that in my 12 hour shift I was in charge of more than 120 active medical problems, and at least 1000 years of medical history (conservatively). All of this was summarized for me by other providers in a neatly typed word document extracted from copy-pasted snippets of EHR notes, printed, stapled, and then folded – ready in my white coat pocket for me to peruse while I bolted through corridors or took the elevator to where a patient was crashing.

On discussing the shortfalls of modern healthcare IT solutions; I often hear colleagues stating that change is coming ‘soon’ (read; 2–5 years). Given that medical errors now kill more than 400 000 Americans and are the number three cause of death in the United States – we need a greater sense of urgency about how broken IT systems are, and how we can fix them immediately. Infinitely more thought, investment and energy goes into social networking endeavors than how patient information is presented and made available to healthcare team members. (It is irrefutably easier for me to find out where you went to college – using LinkedIn, Google, or Facebook — than to find out who my patient’s primary care doctor is).

It makes little sense that modern medicine offer us marvels like whole genome sequencing, while simultaneously providing ridiculous solutions such as mnemonics to reduce errors during change of shift. Surely the bar must be set higher, and we must harness the technology we carry in our pockets.

11/4/2014 

Varun Verma, M.D. is a board-certified Internal Medicine physician who splits his time as a Hospitalist at Brigham and Women’s Hospital (Boston) and as a Senior Clinical Advisor to Possible (Nepal) 

@VarunVermaMD