• What will it take to make the health quality revolution succeed?

    The US health system has pervasive quality of care problems. Aaron showed this in comprehensive detail (start here). The famous report To Err is Human estimated that between 44 and 98 thousand Americans were killed each year by medical errors. Elizabeth McGlynn found that US adult patients receive only about 55% of recommended medical services and Rita Mangione-Smith found that children get only 47%.

    So how do we make things better? There have been successful quality revolutions in auto manufacturing and military flight safety. I used to employ a former naval officer as a software engineer. He told me that the Navy taught him that

    You get the results you inspect, not the results you expect.

    This is exactly right (and it’s true even if you work for yourself). Motivation helps, but quality doesn’t improve unless you also inspect what gets done and hold people accountable. Atul Gawande popularized the idea that checklists could standardize medical practice and make risky medical procedures safer in just the way that they made air travel safer.

    So what we need to do is implement lots of checklists in our electronic health records, so that healthcare providers can document that they have followed best practices. Right?

    I believe in checklists, but there are fundamental limits on what they can accomplish. I see two problems.

    First, clicking boxes isn’t the only kind of documentation that providers have to create. Providers also need to write a narrative about the case, so that other members of the team understand the state of the game and what they need to do next. A lot of important data about care goes into that “free text” but machines can’t read it. And if machines can’t read that data, you can’t efficiently inspect that care. So the provider has to document the care twice, once by dictating a note and again by clicking boxes. This is a bad use of provider time.

    Second and more important, the safety problem is a lot harder in medicine. The body is far more complex than an airplane. Airplanes, moreover, are designed to make inspection quick and efficient, while bodies aren’t designed at all. One upshot is that there are many more things in medicine that we ought to document but that we aren’t. Unfortunately, we are hitting a limit in health care providers’ available time:

    American Journal of Emergency Medicine. 2013 Sep 20.

    4000 Clicks: a productivity analysis of electronic medical records in a community hospital ED.

    Hill RG Jr, Sears LM, Melanson SW.


    OBJECTIVE: We evaluate physician productivity using electronic medical records in a community hospital emergency department.

    METHODS: Physician time usage per hour was observed and tabulated in the categories of direct patient contact, data and order entry, interaction with colleagues, and review of test results and old records.

    RESULTS: The mean percentage of time spent on data entry was 43% (95% confidence interval, 39%-47%). The mean percentage of time spent in direct contact with patients was 28%. The pooled weighted average time allocations were 44% on data entry, 28% in direct patient care, 12% reviewing test results and records, 13% in discussion with colleagues, and 3% on other activities. Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters. Total mouse clicks approach 4000 during a busy 10-hour shift.

    CONCLUSION: Emergency department physicians spend significantly more time entering data into electronic medical records than on any other activity, including direct patient care. Improved efficiency in data entry would allow emergency physicians to devote more time to patient care, thus increasing hospital revenue.

    Got that? These ER docs are spending 60% more time on data entry than they are on direct patient care. We can’t add more documentation because you can’t squeeze blood from a stone.

    So what’s the solution? Maybe we can make documentation more efficient, although what’s easier than a mouse click? Electronic health records will get smarter and acquire the ability to read and comprehend providers’ free text narratives. Then providers won’t need to dictate and redundantly click. But these are just stopgaps.

    The quality revolution will occur through the roboticization of routine healthcare. That is, care will get a lot better when we have machines that can interact intelligently with patients, including understanding what patients tell them. These will be machines that access enormous volumes of clinical data and use continuously improving algorithms to personalize care to the patient’s preferences and physiology. Robots are awesome at consistently following best practices and they will happily generate limitless machine-readable documentation.

    This won’t happen soon, but look around: you can see the foundations. This is, for example, where Google is headed. The company is not so much about search or cell phone operating systems as about solving fundamental problems of artificial intelligence, such as natural language understanding. Of course, the evolution of machine intelligence is a bigger event than a mere revolution in health care. We live in interesting times.


    • Bill, I wouldn’t construe any ratio of direct to indirect time as inherently problematic. If the docs are making effective use of charting time, this significantly enhances their preparedness for communication with patients, and continuity of care with other staff. If it’s all insurance related or CYA, then sure. But I wouldn’t want an ER doc spending additional with me if it meant he was less prepared or if it meant the next shift didn’t get the right information.

      • Mike,
        That’s a really good point. Charting time isn’t necessarily wasted time. But surely there is some documentation / direct patient care that is problematic, no?

        • Absolutely (as noted above re CYA), and I haven’t read the paper yet. The authors should be commended on getting good data on an issue that’s difficult to measure usually. The meatier issue is how this plays out in terms of operational flow, especially in an ER/ICU context. Does more charting time by ER docs lead to more consistent follow up by internal medicine? Does it matter? Is capturing more detail in ER helpful, if that’s indeed what the charting is about?

          I’d be stunned if nurses and therapists had ratios like that, but I’m less certain about MDs. I agree anyone could look at it and say it looks bad (as you could about lots of things), but if you tracked the distribution of non-care workloads throughout an entire patient’s stay (rather than a clinician’s day), what would that look like? What did it look like 10 years ago? That sort of thing.

          • Think about time spent charting in analog age, pre-digital.. What if 10 years ago, I told you ER docs spent 44% of their time writing vs 44% of their time clicking. Perhaps the issue is not technology and data collection, but work flow?

            Nice study just released looking at exact same question with trainees:

            Also, the solution to the problem above has existed for some time. Folks are called ER scribes:

            If you google, you will find loads of companies filling this roll.


    • I was a software engineer and blazingly fast typist before I went to medical school and this is my favorite topic. I was really gung-ho about EMR until I tried my first big-name system. The design standards were stuck in the early 1990s (Neanderthal code by software standards). Data had to be entered in a particular order or start all over again. No distributed processing and server processing no matter how many servers we added was ploddingly slow. Error checking didn’t exist where you needed it and did exist where it was useless. Implementation was remarkable for the number of unhandled C exceptions. Common standards like double-clicking, right clicking, and jumping from field to field were ignored or implemented haphazardly from screen to screen. The UI was absolutely miserable compared to inexpensive home software. The notes that were produced by the software were larded with boilerplate and just dreadful to read. And to top it off, the check lists didn’t work for two years until they issued a significant rev!

      We were given reduced schedules to get used to the system when it went live, but we never could get our productivity back up to the number of patients we had been seeing. The old system consisted of hand written notes scanned into the system and available electronically at every office. A little voice in the back of my mind sometimes suggested that was a more appropriate level of technology

      • It wasn’t just a bad implementation, though, it was also a poor concept. It was an accounting system where a project management system was needed. It was good for billing and avoiding Bad results on Medicare audits, but provided no support for enhanced patient care. None. It even presented test result data in a misleading and dangerous manner. It was really a bad experience.

        • StellaB, you’ve identified a profound market failure. There’s a need for a product that meets clinician needs, yet the product isn’t available. Why are systems that meet clinician needs not being developed? Where are the clinicians in the development process? Surely, there’s a business need/opportunity here – why is not being filled?

          Thanks. These are honest questions – EHRs are not my area of expertise and I’ve long pondered these issues.

    • A lot of the data could be done by the patient. Whenever I’ve been in an ER, I sat around for ages, between each step: registration, triage, nurse taking vitals, initial doctor visit, x-ray, orthopedist. I’ve had tons of time.

      Second, unified medical records would answer a lot of questions about stuff like medicine and past history. The trick would be to summarize the important stuff for the doctor to see at the right time. Next, instrumentation should record stuff directly into the chart. The thermometer, blood pressure cuff, X-ray, etc.

      Then they need to work on voice recognition, so the doctor can dictate to the chart while talking to the patient.

      I’m skeptical about robots. I’ve had a few minor issues that turned out to be not what the obvious answer was. Perhaps if the robot did the test and got the results immediately (rather than prescribing the logical drug and hoping the tests didn’t contradict the result). Plus, how will a robot tell the difference between someone with unexplained pain and someone trolling for oxycodin?

      • SAO,
        Your suggestion that much of the data could be entered by the patient herself is excellent. And this is direction we need to do.

        The question about how a robot will tell the difference between someone with unexplained pain and someone trolling for pain medications is also terrific. My counter would be, “How good are doctors at this?”

        I’m not imagining that robots will replace doctors. What I think is that robots will do a lot of the more routine tasks by themselves and they will work in teams with humans on the really hard problems. It’s possible that humans will always be better judges of human emotions than robots. But robots will be better at quickly accessing a person’s drug prescription history and comparing it to the profiles of known abusers of prescription drugs. That combination would likely be better at identifying an abuser than either a human or an intelligent machine by her/it self.

        • The problem with getting data from the patient is that human memories are fallible. I know that I had surgery while I lived in Palo Alto, but am fuzzy on the year, don’t remember the surgeon’s name, etc. Every time I see a new doctor I have to make up my medical history again–I know that there are inconsistencies. Why can’t we have a data base built from our past claims, or a consolidated medical record on a read/write smart card like they have in Europe? Folks take their cards to the doctor and s/he just adds in the info for the current visit.

    • What will it take to make the health quality revolution succeed?

      An important feature of U.S. health care is the lack of accountability whether for medical errors or lack of delivery of services to adults and children. How many health care professional were fired or suspended by their professional organizations for the 98,000 dead patients? Whose fault is it that 1/2 the population isn’t getting “recommended medical services”? Who is responsible for reducing health care spending?

      The related feature of U.S. health care is that everyone in the system is in it to maximize their bank accounts (with certain Good Samaritan exceptions). Whether it’s doctors, hospitals, or insurance companies, profit maximization is the driving force. Individuals have nearly no power in disputing the excessive level of medical invoices and insurance premiums.

      Everywhere else in the developed world, health care is a political issue. Here’s one example from last month: “Alberta’s health minister has ordered an investigation into a Lethbridge care facility, after word a staff member found mice nibbling at a patient’s face.” http://globalnews.ca/news/831439/investigation-launched-after-dementia-patients-face-bitten-by-mice/ (The care facility has categorically denied the story.)

      • Don,
        One quibble. In my experience, the Good Samaritans are not that exceptional. There are some jerks. But a remarkable number of doctors, liberals and conservatives, do pro bono work. It’s either Medicins sans Frontieres or medical missionary work depending on your subculture.

    • Doctors and lawyers are notoriously bad pilots; so bad, that Cessnas are known as doctor/lawyer coffins. Years ago an engineer friend got his pilot’s license and asked me to go flying with him. I did without hesitation. My wife thought I was crazy. My response: he’s an engineer, used to following checklists; if he were a doctor or lawyer, no amount of money would get me to fly with him. Sure, doctors have protocols for everything. But checklists? Maybe more engineers should be encouraged to attend medical school.

      • I was an engineer for 5 years before going back to med school.

        You obviously dont have a clue about what engineering is. Hint it is NOT following checklists.

        Engineers are no better at following checklists than doctors.

    • I would to read what you think of the idea that to improve the quality of care, we need to lower the status of doctors because medical care delivered by skilled artisans rather that by people working in systems.

      Also I wonder if care not paid for by 3rd parties is better or worse care quality wise.