healthy4u: deskilling

An Opinion piece "Texting While Doctoring: A Patient Safety Hazard" appeared in the Annals of Internal Medicine of 3 December 2013, authored by Christine A. Sinsky, MD and John W. Beasley, MD.  Dr. Sinsky is known to me to be what some would call a "heatlhcare IT iconoclast" (more accurately represented by the term "healthcare IT gadfly/realist" IMO). In the piece the authors comment on the distractions caused by the technology, leading to doctors missing important cues in the exam room and to and impaired problem-solving.  This is part of a larger phenomenon that has been called "skill-degrading" or "de-skilling", e.g., see my April 16, 2010 post "Health Information Technology Basics From Calif. Nurses Association and National Nurses Organizing Committee" at <a href="http://hcrenewal.blogspot.com/2010/04/health-information-technology-basics.html">http://hcrenewal.blogspot.com/2010/04/health-information-technology-basics.html</a>).   These effects are likely to be further worsened as more and more clerical tasks such as order entry, the authors point out, get shifted to medical professionals.  To new readers: note that computerized order entry is often a complex and convoluted process; the CPOE systems are most decidedly NOT mere "typewriters for orders."  See, for instance, part 6 of my series on "Mission-hostile health IT" at <a href="http://hcrenewal.blogspot.com/2009/02/it-makes-healthcare-easier-is-this.html">http://hcrenewal.blogspot.com/2009/02/it-makes-healthcare-easier-is-this.html</a>. Most of the Annals article is available as a free preview at <a href="http://annals.org/article.aspx?articleid=1784295">http://annals.org/article.aspx?articleid=1784295</a> as of this writing and is worth reviewing. <table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjCxGx3pchjD96z40o0nvd5V3ajmX-dfcQBAPJ3lg1DDvKwmpnSqlwNwHplkPhWZ4m9BCQYD8leE9-tNRfWS_Yy-QB0G5Y4Jp4VYFBEumMmTb3XZmw1lWhMv8yk8L67VrNiGJW0eY_3ukK4/s1600/sinsky1.gif" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjCxGx3pchjD96z40o0nvd5V3ajmX-dfcQBAPJ3lg1DDvKwmpnSqlwNwHplkPhWZ4m9BCQYD8leE9-tNRfWS_Yy-QB0G5Y4Jp4VYFBEumMmTb3XZmw1lWhMv8yk8L67VrNiGJW0eY_3ukK4/s400/sinsky1.gif" width="305" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Article preview, click to enlarge</td></tr></tbody></table> I found one passage in particular striking, though.  In my ongoing discussions with computer scientist/informaticist/polymath Dr. Jon Patrick at U. Sydney (<a href="http://www.healthll.com.au/?page_id=440">http://www.healthll.com.au/?page_id=440</a>) , the issue of hypervigilance necessitated by bad health IT came up, and we arrived at the definition of same seen at my teaching site at <a href="http://cci.drexel.edu/faculty/ssilverstein/cases/">http://cci.drexel.edu/faculty/ssilverstein/cases/</a>: <blockquote class="tr_bq">Bad Health IT ("BHIT") is defined as IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.  </blockquote> Note this passage in Dr. Sinsky and Beasley's opinion piece: <table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtHLHXSyRd0Dyolv6mcgLfhmp4J-4oYYVf3u2-ztDbSt0oW2ogHT3vz5rhAcr89y8SNkWv1ZAQB1_WZ5CH4mA7paPhsT8IpQBP_dFwsL5qNya5qnQ8OK6k6Y78jVn0Qsll6PrUa1LgR2o8/s1600/sinsky.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtHLHXSyRd0Dyolv6mcgLfhmp4J-4oYYVf3u2-ztDbSt0oW2ogHT3vz5rhAcr89y8SNkWv1ZAQB1_WZ5CH4mA7paPhsT8IpQBP_dFwsL5qNya5qnQ8OK6k6Y78jVn0Qsll6PrUa1LgR2o8/s320/sinsky.jpg" width="313" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">"I am always multitasking ... I am entering orders, checking labs, downloading information while I talk to the patient.  It requires chronic hypervigilance, which is exhausting and demands conscious effort to stay in the 'present' with the patient" (Day S., Personal communication.)  Click to enlarge.</td></tr></tbody></table> I don't know if Dr. Day had seen my materials, but I suspect the exhausting hypervigilance is all too common, just not much publicized due to the secretive, closed, retaliatory-towards-whistleblowers nature of the healthcare IT sector. I ask:  is this what we really want, in pursuit of some uncertain cybernetic miracle? I note that the healthcare IT experiment (and the technology is experimental), long usurped from the Medical Informatics pioneers who trained me and put in the hands of commercial interests and those of a mercantile/manufacturing/management computing background, is increasingly a failure. -- SS

On Hypervigilance Due to Bad Health IT: "Texting While Doctoring: A Patient Safety Hazard"

An Opinion piece " Texting While Doctoring: A Patient Safety Hazard" appeared in the Annals of Internal Medicine of 3 December 2...

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