Technology: The Whipping Boy for Mistakes Made by Committees

Technology: The Whipping Boy for Mistakes Made by Committees

A Texas hospital was quick to claim a technology defect for the miscommunication that led to the death of an Ebola patient and subsequent infection of health care workers.  The deaths were tragedies, but technology had nothing to do with the miscommunications that contributed to the missed diagnosis.

Technology—the combination of software and hardware—was as much to blame as the pencil when my grocery list fails to include almond milk.

At the hospital, the nurse entered the patient history on one or more web pages.  The doctor conducting the examination didn’t look at the page that included the patient’s travel history to learn of his recent travel to West Africa.  Even had the physician looked at the travel history, there is no certainty a connection to Ebola would have been made.  Perhaps in the design of the Electronic Health Record System (EHRS) the doctors listed the information they wanted to see, and it didn’t include the same information considered important during the triage process.  Let’s hope the hospital’s idea was not to count on the triage nurse to verbally pass the word down the hall for information that was known not be to on the doctor’s favored page layout.

One might ask why the EHRS didn’t include a link to information on symptoms or illnesses typically associated with exotic locations or even why it didn’t sound an automated alert when the nurse entered Liberia, ground zero for the Ebola outbreak, as the patient’s travel destination.

The doctor didn’t see the Liberia connection either because he (it was a man in this instance) was in a hurry, or was conditioned to only look at one main web page, or had one training session six months ago and needed a refresher on the system’s features and functions.

It would seem obvious that the World Health Organization would maintain a list of disease outbreaks from around the world that could be published as a web service.  Every vendor of electronic health systems could readily consume the service to alert health care providers of conditions to check for patients who have travelled overseas or even to another State or county.  The Centers for Disease Control could maintain a web service for US outbreaks and the California Department of Public Health could offer a web service for regional concerns (remember West Nile virus??).

So the failure to consider Ebola in a Texas hospital had nothing to do with technology.  It could have been a difference of opinion between doctors and triage nurses as to what information was important to know about a patient; or it may have been a case of a doctor who had an unrealistic patient workload, or who needed a refresher on how to use the records system; or a doctor who received a one-shot training course and couldn’t possibly remember everything; or it may have been that process improvement sessions were not conducted to collect best practices among the doctors and nurses.

Whatever the combination of reasons as to why the nurse and doctor were not on the same page, it had nothing to do with technology used to capture and display critical health information.  All of the real possibilities for the oversight were the result of actions taken by committees—groups of people—on how to conduct business.  But technology does not make decisions on how to conduct the business, technology is used to enforce the rules made by those committees.  There is an insidious consequence to blaming technology rather than holding decision making committees responsible.  That dangerous consequence is that future groups of people will not work as hard to: understand their responsibilities, to think through their business process, to train the participants in the new environment, and to provide ongoing support to ensure that learning can occur on a continuous basis so that people can make effective use of the technology-enabled business process.

We need to pay more attention to process, clarity and confidence around what patient intake and record review requires, and practice, how to ensure that doctors have the resources – including time – necessary to fulfill those processes. Until we are able improve process and practice, let’s hope that we don’t shift the blame from technology to the tools used to build the technology; we would be moving further away from the real issues if we were to transfer blame from the technology used to the pencil used to take notes during the requirements gathering session.

By | 2016-12-14T11:35:16+00:00 November 4th, 2014|Tags: , , , , , , , |

About the Author:

Steve Williamson is a business process architect and enterprise technology planning consultant. He has over 30 years of experience working with executive and project management and is an expert at defining and delivering information management and technology solutions. You can find him on Linkedin.

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