Healthcare Staff Shouldn't Be Robots

September 8, 2014
Daniel Essin, MA, MD

Real healthcare reform will remain elusive as long as management accepts the notion that the way to fix healthcare is to automate it.

Automation: the technique, or system of controlling a process by highly automatic means, as by electronic devices, reducing human intervention to a minimum.

In a revealing lapse back in 1997, the CEO of my hospital said he expected the new computer system to "automate" healthcare. A CEO's dream! Healthcare with a minimum of human intervention and fewer full-time employees!

He immediately started the layoffs. Having an entire hospital at your disposal provides a great opportunity to experiment without Institution Review Boards, informed consent, controlled trials, or evidence of safety and effectiveness? Just implement and see what happens. Then, as now, the feds were offering to offset the cost of the experiment. Anything that goes wrong can always be blamed on someone, just don't dare to question the concept - certainly not with that CEO. It's a compelling idea, but could it possibly work?

It takes about 900 robots to build something mundane like a car. The average physician's production line has 3.5 support staff (robots?). Each auto robot is programmed to perform a specific task. Get something wrong and you're recalling a million vehicles. The 3.5 support staff must deal with every unpredictable situation that arises, usually with a bare minimum of training (programming). Healthcare has no analog of the recall. The "defects" die, sue, or look for another doctor.

It's daunting. Neither the support staff nor the physicians can possibly have the necessary breadth of experience to handle every patient perfectly. Nevertheless they talk about doctor shortages in terms of numbers, not abilities, as if doctors are just robots that can re-positioned according to some population-based formula.

Healthcare organizations are stressed out. Their response is to call consultants. Those pushing "lean" and "Six Sigma" are popular and their answer is right out of "Modern Times"  - automate healthcare. Break it down into a series of pre-defined steps (called workflows in many EHRs). As long as reality cooperates by providing only those situations that were anticipated and each step is performed to perfection, the desired result will be obtained. The actual results are often an affront to common sense.

The nurses at my surgeon's office have been instructed to weigh patients fully clothed, no matter how heavy the clothing. They are warned that failing to do this will run afoul of meaningful use. How can meaningless data result in meaningful use?

A physician friend of mine works at a federally qualified health center.  He says they are required to implement a certified EHR and comply with the meaningful use requirements but that their EHR project seems to be in trouble. The evidence? Consultants have been hired and they are busy "re-engineering" the staff so that they will be more compatible with the computer system. It's called "lean." According to lean.org, lean focuses on increasing value while eliminating waste by creating processes that need less human effort, less space, and less capital compared with traditional business systems.

The "lean" consultants have apparently concluded that the clinic's EHR is fine; the people are the problem. They keep using paper and "extra-legal" (outside the EHR) work-arounds. The obvious solution is to make the clinic 100 percent paperless and force the staff to rely on the EHR.

To prevent backsliding they have removed pens, pencils, and paper and, inexplicably, the stools and chairs as well. Apparently the staff is supposed to be willing and able, like robots, to perform the prescribed tasks, reproducibly, each time an assembly (patient) reaches their station and to do it in the prescribed number of seconds. They have no need to think. The proper procedures and the proper sequence have been "designed" and pre-programmed into the EHR by experts.

Like the emperor in the child's story, managers seem to believe that computer automation, like new clothes, will solve their problems and make them happy. The consultants are content to spin solutions out of invisible but expensive gold thread. Only a few, like the small child, have the nerve to say what everyone can see - the emperor is naked.

Real healthcare reform will remain elusive as long as management accepts the notion that the way to fix healthcare is to automate it.