Wednesday, September 8, 2010

Hollywood and CPOE : Why you don't want to take the humans out of the silos

As a CMIO doing front-line informatics, I sometimes get asked, "Can't we make the computer automatically delete that order?"

This is a hard question to answer. The short answer is always "Well, yes....", but the longer answer is usually, "...but you probably don't want to do that."

The explanation why "you probably don't want to do that" takes some time, but interestingly, Hollywood can sometimes provide some good teaching examples. (Even if they are fictional, they are still useful to demonstrate the real answer.)

One of the most influential movies for me, growing up in the early 80s, was the movie Wargames, directed by John Badham and starring Matthew Broderick and Ally Sheedy. Interestingly, it provides some useful teaching examples for healthcare informatics. Allow me to demonstrate :

Pay close attention to this opening clip which parallels what nurses experience every day. Two men, in a nuclear missile silo, show up for work and get an electronic order to launch a missile. The codes authenticate, they have clear procedures and protocols to follow. And yet, before launching missiles that could kill millions of people, one of the men smartly asks the question, "Does this seem right?".

(Note, because he doesn't trust the electronic order he's received, he smartly picks up the phone and tries to get a human being to clarify for him - AKA he tries to page the doctor to make sure the order is real.)

I think most nurses watching this clip can relate to these two men.

I suppose some of it is human nature, to trust a human being more than a machine. We are tribal, and so it seems intuitive to want to speak to a human being, before carrying out an order received from a machine. A written order, despite all of its flaws, carries a certain amount of intuitive trust - The physician's pen hit the paper, the ink is dried in place, this is the handwriting of the doctor I usually work with - It provides much more confidence for a nurse.

An electronic order does not deliver the same trust. We worry that the machine may have interpreted the instruction wrong. Or perhaps the programmer didn't think of this particular scenario. We're trained from childhood on how to figure out machines that don't work. We know they sometimes make mistakes.

So getting back to the question about "automatically canceling orders", and "why you probably don't want to do that".

After this opening scene of the movie, the very next scene shows technicians ripping the chairs out of the missile silo, while a team of strategists deep inside the NORAD missile command say, "We had to take the men out because we learned we couldn't trust them to push the button... So now we've wired the WOPR computer directly to the button."

This then sets up the plot for the rest of the movie - The WOPR computer is wired directly to the button, and when David Lightman (Matthew Broderick's character) hacks into the WOPR to make it malfunction, they are stuck - There is no human being between the computer and the missile launch.

What does this teach us about the importance of human beings carrying out your order protocols, rather than the computer "just doing it automatically?"

Because computers are unforgiving. If you ask them to do something, they will do it. 100% of the time. No questions asked.

The problem with a computer discontinuing an order, then, is this : What happens if you ever have a patient, who for some bizarre and unplanned reason, shouldn't have the order automatically discontinued? What if this one patient, in a million, actually needs the order to continue longer?

1. If you have a computer automatically discontinue the order - That one patient will suffer the problems of being "the one-in-a-million" exception.
2. If you have a nurse following a protocol to discontinue the order - Then you actually have a chance that the nurse will ignore the protocol, knowing "it's the right thing to do". (Yes, good nurses know when to ignore orders and protocols if they could harm the patient.)

What does this clip help demonstrate?
1. Electronic Order Entry comes with an inherent fear, and rightfully so - This is why nurses page us to clarify orders, and when they do, we as doctors should be glad nurses are asking questions - I never want a nurse who is an automaton.
2. For patient safety and good care, communication between nurses and physicians should be ample, easy, and painless. Nurses should never feel forced to press a button without understanding the impact and reasons why they are being asked to do it. If the situation doesn't make sense to them - You want them to call!
3. Nurses are the last safety gap before the delivery of care / button gets pressed. (See the men in the movie clip above!) We should respect their professional judgement - It's there for very good reasons.
4. You generally don't want to take the nurses out of the silos. Imagine the risks of EMR software actually delivering the medications! :)
5. For safety reasons... you generally don't want the computer to automatically cancel the order. Why?
    a. Because a computer canceling it 100% of the time may not be safe for 100% of the patients.
    b. Because you can never create a protocol that is 100% safe for 100% of patients.
    c. Because for safety, in that unplanned circumstance - you want a nurse to know when to say "no".

Who works in Health Informatics?

So I have had a number of people recently talk to me about health informatics jobs. Being a physician, they are mostly physicians looking for informatics jobs.

The interesting thing is, I get the sense the healthcare industry NEEDS informatics, but isn't really ready for it. The CMIO position, despite being almost 20 years old, is still too new to most healthcare administrators, and from what I see and hear, many hospitals don't really know what to do with one. The job functions, from hospital to hospital, vary so widely.

And then there is the question about exact titles - what's the difference between a "CMIO", a "CNIO", a "Physician or Nurse [Embedded] Informaticist", a "Physician Champion", and a "Superuser"?

I will attempt to wax philosophic here, just in the name of starting the discussion on formal titles and formal job descriptions - which the healthcare industry needs badly, if it wants to take advantage of informatics help. Perhaps eventually this will turn into the holy grail of formalization - An actual Wikipedia page. :)

1. The CMIO (Chief Medical Informatics Officer) - Yes, you do informatics, so you have to believe in political neutrality. Yes, you try to guide the rest of the hospital about informatics issues.  You talk about EMR strategy, you help discuss budgeting issues for a solid informatics platform, you stress the importance of proper training. You monitor and guide the politics of CPOE and EMR in the Medical Executive Committee. You worry about administrative, physician, and nurse buy-in. You may do some training, but mostly you guide the education process. You may do some data mining and quality work. You get involved in project management, and help develop physician and nurse informaticists to work with you. This position is heavily involved in policy, however, and you should prepare to analyze and write a great deal of clinical policies. Lots of regulatory work too. In a smaller hospital, your salary line will probably come from a clinical line, and you will still work clinically. In a larger multi-system hospital, your salary line may come from an IT line, or other administrative line, and you probably won't be working clinically anymore.

2. The CNIO (Chief Nursing Informatics Officer) - The nursing equivalent of the CMIO. Yes, there is a big need for this role. The CNIO worries about administrative and nursing buy-in, and continues to work clinically.

3. The Physician or Nurse Informaticist (aka Embedded Informaticist or my affectionate term, Clinical Jedi Informaticist) - Think a mini-CMIO, but in an individual department. A physician informaticist (or nursing informaticist) is a slightly broader term, and could be an outside consultant called in to help the informatics development of a department in your hospital. The much cooler (and reliable and useful position) is the Embedded Informaticist, the doctor/nurse in a clinical tribe whose paid responsibility it is to develop the informatics platform for their clinical tribe. If the CMIO still works 25% clinically, the embedded informaticist works 75% clinically (and 25% informatics). In an ideal world, the hospital CMIO gets to work with an embedded informaticist in each clinical tribe, to coordinate the workflows between different departments. The embedded (physician or nurse) informaticist then analyzes their own tribe's workflows, maps them, redesigns them, and sees the changes through committees, policy work, and brings them to the Clinical IT staff to make it happen. Since they are embedded, they can also easily train and support the new workflows in their tribe. And because they are embedded, buy-in is never a challenge. The EMR works better, the docs and nurses feel more loved. This is an extremely effective model, by my experience. (If it's supported by administration.) This, I think, is the position that is going to explode in demand in the next year or two. Look out for it. The AMIA 10x10 class will train most of these embedded informaticists. 

4. The Physician Champion - This is a physician who is asked, or paid, to rouse the troops. Your main mission is to be a cheerleader. You encourage the docs around you, and you may get involved in training directly. Exposure to policy and strategy discussions will probably be minimal. You probably won't have the pay or time budget to do much data mining, and you won't be managing other informaticists. Your ability to motivate is much more important than knowing every detail of every workflow. For reasons I don't understand, nursing usually doesn't need a champion, but this may change.

5. The Superuser - This is probably the most misunderstood positions in healthcare informatics today. The superuser is a really, really advanced, highly-skilled educator. They need to know the details of the software and every detail of every workflow. Think of the superuser as an embedded informaticist without the workflow redesign responsibilities. Superusers have to be patient and love education. They don't get involved in the politics or budgeting discussions. And they need to be available, especially at the time of new software or hardware rollouts, to help smooth the transition between classroom training and the clinical front. Superusers are worth their weight in gold, and you can never have enough of them. Not having well-trained superusers makes any clinical go-live a challenge.

Unfortunately, these are all roles in healthcare informatics, but only the CMIO has any semi-reliable job descriptions and pay data. (And trust me, even for CMIOs, the human resources data is still pretty scarce.) Eventually, these all should be recognized, formal roles, but I'm having a hard time imagining a want ad saying :


So until we formalize the CMIO, the CNIO, the physician and nurse informaticist, the physician champion, and the superuser - Healthcare won't really be able to take advantage of these very important positions.

In the meantime, I'll keep working on it. :)