Chaos and Organization in Health Care

5. What Kinds of Systems Improve Health Care?

5 What Kinds of Systems Improve Health Care? Physicians, patients, and nurses sit in different spots in the health care system, but they all face one common impossible task. They are constantly bombarded by information, most of it mundane and reassuring. But some of those data are potentially ominous, and the consequences of missing warning signs or abnormal test results can be tragic. The flood of information is overwhelming. Abnormal mammograms are occasionally overlooked. Medications are given even though patients have allergies to the drugs. Tests are repeated because the results from earlier examinations cannot be located. Patients leave the hospital or physicians’ offices confused about what medications they should be taking and which doctors they should see next. A basic problem that plagues health care is that these doctors, patients, and nurses are human. They try their best, but they make mistakes. Those mistakes frequently lead to wasted time and resources. Sometimes they endanger the health of patients. Of course, doctors and nurses should be intelligent, hardworking, and well trained. But trying to fix our problems in health care by exhorting doctors and nurses to learn more and work harder only helps a little. To create real improvement, we need clinicians to interact with each other and their patients, and to do so using systems that improve coordination and reduce the risk of errors. Some of these systems are electronic in nature—such as EMRs with decision support that helps physicians order the right drugs and tests. Some systems are humanware—such as teams of physicians and nonphysicians that provide chronic care to patients with conditions like heart failure or complex medical conditions. For providers, these systems demand difficult cultural changes if they are to lead to meaningful improvements in care. 72 Chapter 5 The first major change is an orientation toward error reduction. Physicians make hundreds of decisions per day based on their stored knowledge and clinical judgment. Because they cannot know everything they need to know, some of their decisions are not as efficient or safe as they could be. The use of information systems with decision support acknowledges that such errors occur, and that systems like EMRs might help physicians “get it right the first time.” For example, if physicians have computerized decision support that guides them toward safe and cost-effective choices, there should be fewer calls from pharmacies to doctors’ offices asking for the prescription to be changed. A second cultural change is that these systems force everyone to speak the same language. The use of common systems mandates that clinicians interact with the world through the same “interfaces”; these systems simply won’t work unless the clinicians use the same terminology as the rest of their colleagues—such as the same abbreviations for diagnoses like diabetes (AODM, which is short for “adult onset diabetes mellitus”) and congestive heart failure (CHF). Common terminology is a basic requirement for communication, and communication is a basic requirement for collaboration. The third and most fundamental change is the recognition of the importance of team care. Doctors cannot work alone in the care of complex patients with multiple conditions, and the truth is that they should not work alone in the care of other populations, including patients with chronic diseases, or people who are basically healthy and trying their best to remain that way. In effective provider organizations, physicians are members of teams that track and improve the care of populations (e.g., patients with diabetes), and also provide care to individual patients outside their physician office visits. Many physicians complain that using EMRs and working with teams slows them down. In some instances, electronic records can actually reduce work for physicians by automating tasks like writing renewals of prescriptions. Yet in general, these systems do not reduce work for physicians. The truth is that electronic and human systems add new types of work to the physician’s day, such as entering data into lists of medications and clinical problems, and answering emails from patients and colleagues. Physicians are not happy about adding work to their alreadydif ficult days, of course, but these new types of work can have considerable payoffs for patients. The work of entering information into the EMR leads to more reliable interactions among colleagues and What Kinds of Systems Improve Health Care? 73 with patients. These interactions (e.g., the sharing of knowledge of what medications a...