Brave New World: Technology Transforms the Medical Workplace

    • June 23, 2011

As iPads replace physician memos, smartphone apps become medical texts and health care providers invest in computer-based records systems, health information technology is rapidly changing life for the health care workforce, in ways both good and bad. The Department of Labor projects a 30 percent increase in health technology-related jobs by 2014. “It’s a really exciting time to be in medicine,” says Adam Landman, M.D., a 2008-2010 Robert Wood Johnson Foundation (RWJF) Clinical Scholar. “And new technologies can definitely improve patient care,” adds Landman, the clinical lead on the design of Brigham and Women’s Hospital’s new emergency department (ER) electronic medical records system.

But Landman is also realistic about the pros and cons of technology. “As the latest technologies become available, we need to study them and very carefully decide what to use and when,” he says.

Electronic Health Records: Teamwork Equals Progress

That warning is especially relevant to the growing adoption of electronic health records (EHRs). As the federal government pushes for every American to have an EHR by 2014, and backs up that promise with financial incentives to hospitals, Landman says, “I worry about the push for implementation. Technology must be accepted and effective for users. If not, it can create errors by changing workflow.”

“I try not to introduce too many new technologies at once because there is a learning curve for everyone,” says Mary Ellen Smith Glasgow, Ph.D., R.N., ACNS-BC, an RWJF Executive Nurse Fellow (2009-2010) and professor of nursing at Drexel University. “I’m a great fan of mobile, bedside technology,” Glasgow adds, “but nurses also experience alarm fatigue from an overload of call buttons and other devices. All of this has to be considered as new technologies come into the workplace.”

“Some practitioners see electronic medical records as an intrusion and many nurses and physicians view much of this as extra work,” explains Alan Cohen, Sc.D, executive director of Boston University’s Health Policy Institute and national director of the RWJF Scholars in Health Policy Research program. “We also have a long way to go before we have fully interoperable EHR systems across the health care system,” adds Cohen, who is also the author of Technology in American Health Care: Policy Directions for Effective Evaluation and Management. “Fewer than 50 percent of hospitals and medical practices have fully capable EHR record systems at this point.”

Research also suggests mixed results from EHR use. While recent Agency for Healthcare Research and Quality data shows that newer systems reduce medical errors, a study published in the May Archives of Internal Medicine reports no consistent relationship between EHR use and a better quality of care. The study authors suggest that more mature EHR programs and better physician training might improve those results.

For these reasons, Landman’s approach to the design of the Brigham and Women’s EHR system may serve as a valuable model. “We are trying to capture the rich information that can be lost with structured data entry, such as drop-down menus. Some software packages make it difficult to understand what’s happened to a patient because some of the richer data [care provider’s written notes] are missing. We are also gathering input from all of the potential users of the EHR system—nurses, physicians, medical assistants—everyone participates in meetings and contributes to design ideas.”

Landman is also preparing for the next step for EHRs. “Eventually, ambulances, fire departments and other pre-and-post medical entities will need to exchange data across the entire health care delivery system,” he says.

An excellent idea, says Jeremy Moody, a paramedic with 21 years on the job. “Because of HIPAA, we cannot access hospital information now, but we create an electronic record the moment someone enters the ambulance. We report vital signs treatments and other information, then give it to the emergency room staff,” explains Moody, who was named Pinellas County Florida’s Emergency Medical Technician (EMT) of the year in May.

“It’s a wonderful tool,” says Moody, who also trains new EMTs on the ZOLL software used to record patient information. “You can identify problems you would not have known existed and it cuts errors.”

And EHRs are not the newest kids on the block. “We’re rolling out our first computerized physician order entry (CPOE) system,” says Sherrill Hardgraves, an applications administrator at Asante Health System in Oregon, who trained for her new health informatics career in the Jobs to Careers (J2C) program. “Our nurses already do orders on computers at bedside, but this system will be for physicians. There is a lot of opposition,” says Hardgraves, “but other doctors want an iPad so that they can enter their orders from anywhere, anytime,” says Hardgraves, who is part of the team that trains physicians on the new software and gathers their input for the tailoring the CPOE system.

Linking Oral Health and Primary Care

“For us, new technology is a major plus,” says Donna Grant-Mills, D. D. S., principal investigator for the RWJF Dental Pipeline program. “Many of the medically underserved patients we see at our Washington, D. C. clinics require extensive dental work. Electronic records link us across disciplines to help us care for them. I can look at blood sugar, cardiovascular health and other issues right away and know how to proceed with treatment.”

At Chicago’s Goldie’s Place dental clinic for the homeless, Dental Pipeline program graduate Esther Lopez, D. D. S., says, “we use electronic records and digital X-rays to save money and staff time. Digital X-ray set-ups are more expensive at first, but it takes an assistant two or three minutes to pull up the X-ray, as opposed to 30 minutes with the old method and it cuts patient radiation exposure by 80 percent.” Lopez also adds, “having an electronic database in a low-income community dramatically increases care continuity for patients.”

And both Lopez and Andre Farquharson, D.D.S., who works on Grant-Mills team at Howard, are excited about innovations such as “the smartphone app that allows us to pull up pharmaceutical data (Epocrates Medtools),” Farquharson says, “especially the contraindications that are so important for dentists. The [Orasphere] app also lets us show patients a dental procedure so that they know what to expect.”

Simulation: Tech’s Win/Win

In the world of medical technology, simulation lab training is one area with benefits solidly supported by research. That’s why Landman will be training his ER team on simulated EHR systems at Brigham’s STRATUS Simulation Center. Medical simulators—most often sophisticated robots with carefully engineered anatomy, vital signs and responses that can be programmed for a variety of situations—allow students and professionals to practice code blue scenarios, surgeries even general patient care. While a single simulator can cost $40,000 or more, “the return on the investment in some cases has been shown to be seven to one,” says Chuck Pozner, M. D., director of Brigham and Women’s Neil and Elise Wallace STRATUS Center for Medical Simulation, citing a recent study.

Other studies show that simulator trained medical professionals are able to operate in less time, make fewer medical errors and in some cases, have lower rates of certain types of infections among their patients.

A leader in the use of medical team simulation, the STRATUS Center, unlike some medical schools, consistently trains interdisciplinary teams, in an effort to “get people to work across the silos and hierarchies that exist in medicine,” Pozner says. “It can change the culture of an institution and improve patient care.”

Ultimately, technology will bring physicians, nurses and frontline workers toward a safer, more efficient practice of medicine, but like all revolutions there will be battles and casualties before victory. The best advice, says Cohen, is to collaborate, be vigilant and stay the course. “Today’s care providers will do best if they accept the fact that the world will continue moving quickly in this direction. They can and should question the value of new technology as it emerges, but as long as they focus on working as a team, they are more likely to find the benefits for patient care.”