My earliest years as a medical student and doctor were in a paper-based system, and over the last decade, I’ve been involved with a sequential introduction towards full EMR. For the last 16 months, I’ve had almost no use for a pen in my daily work. At the same time, the dynamics of medicine – and inpatient ward rounds, in particular – have changed. How much of this change is just ‘societal’ or ‘generational’, and how much of it is due to the changing technology we use in our work?
(Editor’s note: This post was written before COVID-19. We’d love to hear of its impact on your use of technology)
I asked Twitter, and received some thought-provoking concepts, in addition to some things I’ve been observing over the last several years.
Researching for a #DFTB post: How have EMRs, and in particular, the introduction of mobile computing changed the physicality of your inpatient ward round? @SwearyPaed @paediatric_KT @ccdaniels65 @tweediatrics @MikeSouthRCH and others? pic.twitter.com/bOvLIvev7E
— Henry Goldstein (@henrygoldstein) November 10, 2019
The more I thought things through, the changes occurred at many levels of the system, and I’ll try to dig into some of these changes within each part of our system.
WoWs (Workstations on Wheels) are large and can be quite physically awkward to maneuver into a room or bed space whilst positioning the thing suitably to enter information, view the consult, make eye-contact with both patient & the doctor leading the review and still remaining socially acceptable. And, for that training doctor – they’re often looking at the screen instead of the clinical interaction. I’ve seen and heard of trainees writing notes from behind the curtain!
We use COWs at my mothership hospital in Sydney; useful to have all info at fingertips, but I find them a bit too big and cumbersome, particularly when wheeled into the patient’s room. Infection risk too.
— Katie (@paediatric_KT) November 10, 2019
One hospital I’ve worked used, albeit infrequently, tablet computers in addition to the standard WoW. This provided a point of offset for results but was unsurprisingly unhelpful when it came to imaging or any data entry. I continue to advocate for their usage.
The challenge of wrangling a computer into the interaction with you patient is obvious, and with some strategies the affect can be reduced. But there’s more to the screen than doctor-patient blockade; the physicality of multiple handheld inputs (ie paper chart and bedside chart) usually meant that during a ward round there was some standing, well, around. Specifically, before entering a bed space, or in discussions afterwards, we stood in circles and looked at each other and listened.
Mobile computing requires that we stand side by side. This is either in order to read the screen, or because the computer is human-high, and we can’t pragmatically form a circle around it!
I think there’s something inherently powerful in this change – we no longer engage in routine confrontation. Standing in a circle means that you’re always opposite someone. The body dynamics are oppositional.
I acknowledge that these situations could, on occasion, be used negatively, but by the same token, standing opposite another human is not, in itself, shaming or humiliating. But these circles were the perfect opportunity to acknowledge all members of the team, to teach to level, to have a discussion. Micro-confrontations as a mode of education, learning, and accountability. Instead, mobile computing changes the dynamic – we stand next to each other, make eye contact less frequently, and can nod along to the words of the most powerful person in the group.
Because we are conflict and confrontation avoidant, and the text is there for all to see, we have nullified the ‘need’ to present a patient. Instead, we perch on one another’s elbows and read together.
Read what?! What does each doctor consider important? How do we know? What’s the framing? This is part of clinical reasoning. When we read in silence without the brief “Yes-no” questions like “Was there a trial of salbutamo?” or “Are they immunized?”, much more is lost in the thinking, learning and engagement of the ward round.
Infection control and accessibility of WoWs are inherently in tension. This was played out with medical charts not entering the bed space and the need to physically either put the notes into the chart afterwards or write on the move to the next patient.
The same pattern occurs with WoWs exists; either the machine is (appropriately) left outside the room and catching up occurs afterward, or if there’s a computer that remains at the patients’ bedside, then the operator must log in, invoking the Latency issue.
I have on occasion witnessed a mobile computer being wiped down, and not just because one of us has tipped over a cup of coffee! Folks, remember your 5 moments for hand hygiene!
But what other aspects of physicality of having a workstation the size of a small person on the round?
Rightly or wrongly, operating the mobile computer frequently falls to the most junior member of the team. Under a diffused system with multiple devices, or the classical paper charts for vital signs, medication charts and so on, much of the pressure was relieved from the person actually writing the notes.
Instead, a single operator system means that – latency notwithstanding – the rate-limiting step to all information and all documentation is through the same person. This can become quite stressful, quite quickly, and if not considered can exacerbate the load for junior staff.
Sharing information via the same screen can lead to people almost standing on top of each other. Wanting to read the screen leads means that in the clamor to see, personal space is quickly eroded. My practice is now to show new staff how to MAKE THE TEXT BIGGER, so that I can see the information from a distance without the feeling of standing too close to their shoulder, especially as a male in a senior role.
Conversely, and also as a consequence of mobile computing, we spend less time in the immediate physical presence of our nursing and other medical colleagues. Proximity is part of forging a small professional community. It’s part of being in a team and if you spend your entire day behind shelves and screens rather than openly and effectively communicating with colleagues, well, I hope that’s not what being a doctor is.
When tech is slow, it can feel as though the entire ward round is covered in treacle. Time begins to stand still in response to simple questions. The clinicians believe the answer is contained in the machine, yet the machine is too stuttering, slow or confused to provide the information you need. Where and how you vent this frustration? Do your patients sense it? Do you look or feel incompetent? Almost all of the above pose a threat to professionalism.
Copy+ paste digital vs analog. There’s something engaging with re-copying, by hand, text. That’s why monks spent many an hour laboriously lettering pages of Latin text. Many of us have even studied this way throughout our academic careers. The essential thoughts and actions required to process and idea leave, I suppose, a beautiful residual trace in our memories. We have the chance to identify and fix errors, lest we are blamed for recreating them with our own hand. Digital copy+paste is the opposite. It is unthinking, impersonal, disengaged. It can compound & perpetuate errors.
Diagrams and patient drawings were a feature of paper charts. A surgical note here or the old favourite of lungs and abdomen sketched side by side. In paediatrics, the ease of giving a child a page of clinical notes on which to draw has evaporated.
Demonstrate your reasoning. Clinical reasoning and the context in which we make decisions is what medicine is about. Whilst both EMR and written notes can use full sentences to articulate thinking, I have memories of marginalia, small diagrams, relational arrows of all different shapes, intensities, and directions. Variable intensities or shapes encircling words for emphasis help frame or direct clinical thinking that transcends written language as we know it. I miss seeing this in the work of others.
There is a litany of nuances in note-taking that are subsumed by electronic records. But I’ve never seen illegible or dangerous lookalike terms in the EMR; they’re always surrounded by logical context, be that medication chart or notes proper.
Finally, mobile computing is a serious threat to professional boundaries. Many of us have work-related apps and email on our own devices. Beyond this, remote access to clinical information is growing. Ironically – and as I highlighted in this post – we’ve all worked on MET teams. We know what critically urgent looks like, and yet, we are challenged by the need to step away from our work.
Mobile computing encourages us to just log in to find out how the patient went overnight, instead of reading the back of a cereal box or whatever you do in the morning. Likewise, reviewing results late at night – or whilst out to dinner – is a boundary failure.
We need to be better at defining the way we use our tech. Whilst at ACAH19, I thought of this framework:
Using this diagram helps us to understand why it’s okay (awesome!!) to review the program for #DFTB20 during a loo break, but definitely not okay to reply to a parents’ email about their child’s asthma whilst in the toilet cubicle.
Here’s the larger point: We need to practice small scale, low risk confrontational clinical communication so that when we need to have big discussions, our discomfort is around the clinical challenge, not the awkwardness of professional communication.
In summary, mobile computing has profoundly changed the way we work. Everything from satisfying our impulses to know what is happening with a patient, to how we demonstrate clinical reasoning, to how we interact with each other & patients. I’m not saying it’s all good, nor all bad. Only that we must remain mindful and develop insight into how these changes influence our practice, our thinking and our relationship to patients and families.
I’m grateful to be able to work with some sophisticated, reliable technology on a daily basis. I want that tech to be able to bring out the best in doctors and medical care.
What kind of mobile computing does your hospital use? How does it improve care? How does it change it?
Thanks for such a reflective and important post Henry, I’m a big believer in electronic medical records in principle but we’re in a pretty awful transitional stage at the moment. Watching my nephew engage online home schooling with his iPad that neatly uploaded sketches from the camera, record audio statements for his teachers and upload in a few seconds suggests to me that tech that reinforces human connection and supports rather than hinders human communication is possible, but that in pursuit of the cheapest possible acceptable software our public services have a tendency to shoot us in the foot.