If the Symptom Fits

Electronic patient files advance care, up to a point.

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.

NEXT STORY: Remote Access

X
This website uses cookies to enhance user experience and to analyze performance and traffic on our website. We also share information about your use of our site with our social media, advertising and analytics partners. Learn More / Do Not Sell My Personal Information
Accept Cookies
X
Cookie Preferences Cookie List

Do Not Sell My Personal Information

When you visit our website, we store cookies on your browser to collect information. The information collected might relate to you, your preferences or your device, and is mostly used to make the site work as you expect it to and to provide a more personalized web experience. However, you can choose not to allow certain types of cookies, which may impact your experience of the site and the services we are able to offer. Click on the different category headings to find out more and change our default settings according to your preference. You cannot opt-out of our First Party Strictly Necessary Cookies as they are deployed in order to ensure the proper functioning of our website (such as prompting the cookie banner and remembering your settings, to log into your account, to redirect you when you log out, etc.). For more information about the First and Third Party Cookies used please follow this link.

Allow All Cookies

Manage Consent Preferences

Strictly Necessary Cookies - Always Active

We do not allow you to opt-out of our certain cookies, as they are necessary to ensure the proper functioning of our website (such as prompting our cookie banner and remembering your privacy choices) and/or to monitor site performance. These cookies are not used in a way that constitutes a “sale” of your data under the CCPA. You can set your browser to block or alert you about these cookies, but some parts of the site will not work as intended if you do so. You can usually find these settings in the Options or Preferences menu of your browser. Visit www.allaboutcookies.org to learn more.

Sale of Personal Data, Targeting & Social Media Cookies

Under the California Consumer Privacy Act, you have the right to opt-out of the sale of your personal information to third parties. These cookies collect information for analytics and to personalize your experience with targeted ads. You may exercise your right to opt out of the sale of personal information by using this toggle switch. If you opt out we will not be able to offer you personalised ads and will not hand over your personal information to any third parties. Additionally, you may contact our legal department for further clarification about your rights as a California consumer by using this Exercise My Rights link

If you have enabled privacy controls on your browser (such as a plugin), we have to take that as a valid request to opt-out. Therefore we would not be able to track your activity through the web. This may affect our ability to personalize ads according to your preferences.

Targeting cookies may be set through our site by our advertising partners. They may be used by those companies to build a profile of your interests and show you relevant adverts on other sites. They do not store directly personal information, but are based on uniquely identifying your browser and internet device. If you do not allow these cookies, you will experience less targeted advertising.

Social media cookies are set by a range of social media services that we have added to the site to enable you to share our content with your friends and networks. They are capable of tracking your browser across other sites and building up a profile of your interests. This may impact the content and messages you see on other websites you visit. If you do not allow these cookies you may not be able to use or see these sharing tools.

If you want to opt out of all of our lead reports and lists, please submit a privacy request at our Do Not Sell page.

Save Settings
Cookie Preferences Cookie List

Cookie List

A cookie is a small piece of data (text file) that a website – when visited by a user – asks your browser to store on your device in order to remember information about you, such as your language preference or login information. Those cookies are set by us and called first-party cookies. We also use third-party cookies – which are cookies from a domain different than the domain of the website you are visiting – for our advertising and marketing efforts. More specifically, we use cookies and other tracking technologies for the following purposes:

Strictly Necessary Cookies

We do not allow you to opt-out of our certain cookies, as they are necessary to ensure the proper functioning of our website (such as prompting our cookie banner and remembering your privacy choices) and/or to monitor site performance. These cookies are not used in a way that constitutes a “sale” of your data under the CCPA. You can set your browser to block or alert you about these cookies, but some parts of the site will not work as intended if you do so. You can usually find these settings in the Options or Preferences menu of your browser. Visit www.allaboutcookies.org to learn more.

Functional Cookies

We do not allow you to opt-out of our certain cookies, as they are necessary to ensure the proper functioning of our website (such as prompting our cookie banner and remembering your privacy choices) and/or to monitor site performance. These cookies are not used in a way that constitutes a “sale” of your data under the CCPA. You can set your browser to block or alert you about these cookies, but some parts of the site will not work as intended if you do so. You can usually find these settings in the Options or Preferences menu of your browser. Visit www.allaboutcookies.org to learn more.

Performance Cookies

We do not allow you to opt-out of our certain cookies, as they are necessary to ensure the proper functioning of our website (such as prompting our cookie banner and remembering your privacy choices) and/or to monitor site performance. These cookies are not used in a way that constitutes a “sale” of your data under the CCPA. You can set your browser to block or alert you about these cookies, but some parts of the site will not work as intended if you do so. You can usually find these settings in the Options or Preferences menu of your browser. Visit www.allaboutcookies.org to learn more.

Sale of Personal Data

We also use cookies to personalize your experience on our websites, including by determining the most relevant content and advertisements to show you, and to monitor site traffic and performance, so that we may improve our websites and your experience. You may opt out of our use of such cookies (and the associated “sale” of your Personal Information) by using this toggle switch. You will still see some advertising, regardless of your selection. Because we do not track you across different devices, browsers and GEMG properties, your selection will take effect only on this browser, this device and this website.

Social Media Cookies

We also use cookies to personalize your experience on our websites, including by determining the most relevant content and advertisements to show you, and to monitor site traffic and performance, so that we may improve our websites and your experience. You may opt out of our use of such cookies (and the associated “sale” of your Personal Information) by using this toggle switch. You will still see some advertising, regardless of your selection. Because we do not track you across different devices, browsers and GEMG properties, your selection will take effect only on this browser, this device and this website.

Targeting Cookies

We also use cookies to personalize your experience on our websites, including by determining the most relevant content and advertisements to show you, and to monitor site traffic and performance, so that we may improve our websites and your experience. You may opt out of our use of such cookies (and the associated “sale” of your Personal Information) by using this toggle switch. You will still see some advertising, regardless of your selection. Because we do not track you across different devices, browsers and GEMG properties, your selection will take effect only on this browser, this device and this website.