Thursday, September 8, 2011

I Have Seen The Future, And I Weep....

I recently returned from a temporary ED assignment in a city to remain nameless. As part of the 'system' in the ED, the hospital had implemented a Computerized Provider Order Entry System (CPOE).

I have used such systems in the USAF and for a one year stint in which I worked as a contract cardiologist for the VA. As such, I thought I had seen as much mischief as the systems could cause. For example, in the VA system, using a computerized order entry from the ICU for a "STAT" order could result in total loss of awareness of the order. That is depending on the amount of distractions facing the pharmacy significantly longer delays until time of delivery of the medicine could occur. When the nurse is in the loop, there are repetitive pings built into the order delivery system. These did not occur in the system I was using at that time. And until I penetrated to the possibility that a STAT order could be misplaced by those required to implement the order, several near misses occurred.

However, last weeks CPOE was a new low in process engineering. I favor and support CPOE for high risk areas such as medication ordering. However in this intermediately busy ED, ALL ORDERS had to be entered into the system by the physician. Thus, if I wanted one of the nursing staff to put a splint on an injured limb or if I wanted a wound irrigated I had to enter it into the CPOE system. The net result was that I was functioning as the unit clerk. And furthermore I was exposed to an entirely new set of distractions, as harassed and harried nursing staff were 'pinging' me to enter orders for them into the system at the times of their convenience and not those of my own choosing. This was distracting to say the least.

What is in the mind of those who profess to make our profession a highly reliable enterprise such as aviation? I routinely work in an environment in which intense concentration on ones work and thought is impossible. The party never ends at the nursing stations of some hospitals in which I have worked. And there is generally no place reserved for the physician to work. Now perhaps for many of my colleagues they don't need to think about their tasks and it is a matter of charting a few throw away lines for their note and signing a few standard orders. But if this is the case for some of them, than it is an exception, however, from my standpoint, I think it remains the exception.

However, for me, there is always a great deal of thinking about a case with intense concentration required for the specific orders required for the specific patient in front of me. Thus concentration and being relatively undistracted is an important thing for me.

Imagine how safe an airplane trip would be if the pilot on short final was subject to cell phone cold sales calls or an irate passenger walking into the cockpit demanding that his in-grown toe nail be dealt with ..... NOW. And yet this type of behavior happens routinely in my daily practice(s). There is little planning in hospitals for appropriate work spaces for physicians or for dedicated computer terminals or computer systems for the physicians who work in the hospitals.