If the Symptom Fits

Electronic patient files advance care, up to a point.

Catheterized, put on electrolytes and given beta blockers, the hospital patient is doing better today. A case of obstructive uropathy, this morning there's no bladder distention or tenderness and no fever. Still some blood in the urine, however. Standing in a ward of the Veterans Affairs Medical Center in Washington, a resident physician reels off the information to Dr. Divya Shroff, a staff doctor.

The resident, Dr. Christina Hatara, looks up the patient's history with a few clicks of a mouse. As she and other postgraduate trainees go on morning rounds supervised by Shroff, they wheel around a wireless-connected laptop on a cart. Shroff presses Hatara on a point: Who will take care of the patient after he's discharged, probably with a urine collection bag strapped around his leg? In another hospital, it might not be so easy to find that information. The patient's paper file containing a social worker's report might be somewhere else.

"It's just such an advantage to have everything here and in front of you," Hatara says. Doctors can spend a lot of time tracking down files. The VA medical system is ahead of most in minimizing paper files in favor of electronic health records and computerized order entry. As a result, Hatara can answer Shroff's question right away. The patient has a niece living next door helping him, but nonetheless he might need professional help, she says.

VA offers a glimpse of where American medicine likely is headed. As federal standards for health records are promulgated, as patient expectations are bolstered and as digital communication increasingly becomes the norm, it's just a matter of time.

But inevitable is not the same as being entirely good. Every technology creates unexpected new problems, and not just things like software bugs. Beyond the programming layer is an entirely different world of unanticipated consequences generated by unforeseen interactions between the software and its users.

Each hospital and each clinic tends to have a slightly different process. Doctors often argue that their facility's unique approach has valid reasons for existing. Medicine is an art and a science-and not an industrial process, they say.

But software designers like standardized processes ordered in linear fashion. Sure, in real life nurses might order and administer patient medications on their own and later get a sign-off from a shift doctor (who might be busy elsewhere). But software designers are told that's not supposed to happen. So they design a system that assumes it doesn't. In that system, when the doctor gets around to authorizing the medicine, a new shift of nurses might not know it was already administered, and give it again. (VA says its system has safety checks that would prevent that from happening.)

Even just lining up a cursor with the correct command in a drop-down menu sometimes can require too much attention to a computer screen while other things are going on, says Joan Ash, an associate professor at the Oregon Health and Science University. Cognitive overload can occur pretty quickly, especially if a health system requires clicking through multiple computer views to get to the right information. But despite the potential for mistakes brought on by simple errors, people tend to assume that computerized information is always correct.

Shroff says these all are valid concerns. But she still wouldn't want to give up a computerized system and go back to the days when medical records had to be physically located and it was hard to get comprehensive information. For all the new problems that health information technology can add, it's still worth it, she believes. Part of a doctor's job is to think about the information on charts, checking to see if it makes sense. "It's not to say, 'OK, now we've got computers, so I as a doctor don't need to speak to you as a patient,' " she says. The same thing goes for the labs, other doctors and nurses.

Still, there's a line Shroff doesn't want health IT to cross. It's the medical note, the portion of the record where doctors make their observations about a patient's condition and diagnosis. The note should consist of freely composed text, she says, not be assembled from checked-off boxes of preselected vocabulary terms. "That would make me detest the computer," she says.

But the military's health IT system, the Armed Forces Health Longitudinal Technology Application, expects doctors will use standardized vocabulary contained in a menu. Such forced structure in medical notes makes statistical aggregation of symptoms and diagnoses much easier. It's a trade-off, and the military has decided it's a beneficial one. If soldiers suddenly were falling sick with diarrhea, "we need to be able to roll that up and aggregate it so the commander knows not to commence combat operations the next day without replanning their strength ratios," says Army Col. Bart Harmon, chief medical information officer of the Military Health System. Or, if there's a trend of symptoms consistent with weapons of mass destruction, quick detection is important. In such ways lives are saved, too. The military's needs are different than VA's. What's right for VA might not be right for the military.

Even within the military the need for structured data varies, Harmon says. Information flowing from the first line of medical defense-from primary care and emergency doctors-probably needs more standardization than that from specialists seeing patients already in the system.

The bottom line for software developers in any context? Know your users.

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