As you sign off on the electronic medication chart you fail to realise that you are still logged in to the previous patient. Unfortunately the previous patient now ends up having an apnoeic arrest and dies from an opioid overdose. On reflection you can’t help thinking that you would never made this mistake if the hospital was still using the old paper based system…
I love this image taken by Dr Bob Wears. It was first shown to me during a presentation by Dr Terry Fairbanks on Health IT. It demonstrates an E-Health solution that has been introduced into an emergency department to replicate what has for years been done on a white board – note how all the staff are still using the white board.
There are numerous advantages to using a computer based health system however there are also many pitfalls. Everyone learns how to use a pen when they’re at school, however no-one has learnt how to use the specific E-Health system at your hospital until it is introduced. Many of us work across different institutions – this often means unfortunately that we are forced to learn a different E-Health system at each site. In turn we lose autonomy, and are unable to perform the tasks we were previously able to, which in turn leads to unnecessary frustration.
The software providers need to painstakingly assess how we are interacting with our environments to produce the optimum software solutions. This process is called ‘User Centred Design’.
Software designers range in their understanding of User Centred Design, from those who have no understanding of it to those at the top of their game.
This picture is also from Terry Fairbanks Health IT presentation. It represents a flight control centre. Staff in this flight control centre use a process of sending information to one another on paper strips – each with a number of symbols on it referring to information about a particular plane. A software designer at the top of their game was employed to introduce a software system to replicate this. 8 years later the software designer was still unhappy to introduce their system as they were too concerned that it would lead to planes crashing unnecessarily.
This is in contradistinction to how things are often done in healthcare – we are invariably provided with a system and then just need to get on with it, potentially ironing out any bugs as we go along. Sooner or later the hospital management may receive sufficient complaints to realise they need to do something – unfortunately this often means they end up introducing another poorly designed E-Health solution. (Sadly to the patients detriment.)
Patientsafe is looking to introduce a ‘User Centred Design’ software solution for a relatively simple clinical record keeping process. We will keep you posted on progress.