It's 6:30 in the morning, and I'm with a group of surprisingly awake, cheery physicians and nurses doing grand rounds on the pediatric-care ward of one of the best hospitals in the United States. I'm part of a study group for the National Academies, looking at the ways in which information technology is used in health care. This hospital is a leader: I see computers everywhere.
I've been spending a lot of time in hospitals recently. No, not as a patient, but as an observerfollowing doctors and nurses on their grand rounds, watching patients get admitted, nurses doing shift changes, pharmacists filling prescriptions, and then watching nurses actually deliver the prescribed medication to their patients, waving bar-code readers over the prescriptions, the medication, and the patients.
We walk down the hall toward the first set of patents. We are quite a crowd: the attending physician and approximately five medical residents, physicians completing the last stage of their training, plus one or two nurses. The attending physician is responsible for treating patients and is also supervising the residents, each of whom is wheeling a computer cart. The hospital calls them "COWs"Computer on Wheels. (One hospital switched the name to WOW, Workstation on Wheels, after a patient heard physicians outside her room talking about "the cow" and thought they were referring to her.) A COW is a chest-high cart with computer screen and keyboard at a height appropriate for stand-up reading and typing; the computer itself and batteries are located at the bottom of the unit. Five COWs, plus a nurse wheeling a big filing cabinet of papers, plus the attending physician, plus the members of my observation team. We take up a lot of space. We stop at each patient's doorway to review progress. The attending physician asks for a review, and each of the residents flips through the windows displayed on their computer screen and summarizes status: "Calcium level is fine, white count low." Each resident has different information for the patient, or to be more precise, has screens that describe test results from different laboratories.
The patient was a bunch of numbers. Moreover, the numbers were not organized by symptoms or diagnoses: They were organized by what tests were run and which laboratory within the hospital had processed the results. The patient's history, the record of past events and health care, was in a different location from current test results. Current results were in a different place than past results. Different hospitals might have different laboratories, so their results would be organized differently. But the attending and resident physicians and nurses were experts at piecing together a mental model of the state of the patient from all these numbers. Or so they said: Evidence is difficult to come by.
"That's interesting," I said to myself, stepping into a room filled with displays. There were multiple infusion pumps, multiple computer readouts, and multiple monitors. The entire room was filled with the red glowing lights of display readouts and the dim white of graphs on the computer screens. "Fascinating," I said. "You've brought all of the monitors into one place so you can see how all the patients are doing."
"No," said one of the physicians, "what do you mean?"
"So where are the patients?" I asked, expecting to be told that they were in rooms adjacent to the instruments.
"Right there," said the physician, obviously puzzled by my question. "Right there in the room, right in front of you."
I looked closely and still couldn't see a patient. One of the nurses walked over and pointed. "Oh," I said.
There were so many medical devices, so many readouts and displays, that I could not even see the patient until someone showed me. Now, this was an infant ward, so this particular patient was tiny, but even so, it's a good illustration of modern medicine: From the physician's point of view, the patient is a set of test results and numerical readouts. The patient as a person tends to be forgotten.
I saw this later in a different hospital in yet another ward. The attending physician would stand outside of the patient's door and listen to the review of the test results by all the residents. They would then discuss the results and make further recommendations. Then, as we all left to go to the next doorway and the next patient, the attending physician would knock on the open door, stick his head in and say, "How are you doing today, Mr. Forbes?" That was the extent of patient interaction.
So many numbers, we lose sight of the person. Scientists measure what they can measure and pronounce the rest to be unimportant. But the most important parts of life are qualitative. One of the physicians on my study team told us that she is allowed only 15 minutes to attend to each patient in her internal-medicine practice, but it can take as long as 20 minutes to fill out all the required paperwork. She has to force herself to look at and interact with the real patient. One hospital center estimates that nurses spend only a third of their time in direct care of a patient. The remaining two-thirds is spent on documentation and medication record keeping. One physician told of watching a nurse who busily recorded all of the numerical indications about the patient's circulatory and respiratory system, but was too pressed for time to consider the meaning of the numbers or look at the patienta five-second glance would have revealed that the patient was having extreme difficulty breathing.
Modern medicine is a complex undertaking. It is highly technical, highly specialized. The patient has been carved up into little kingdoms, with different specialties competing for ownership of each piece, leading to occasional flashes of territorial wars. Nowhere is this more vividly presented than in the operating room, where a vertical sheet placed over the patient at the level of the neck divides the territory belonging to the anesthesiologist (the upper part of the patientthe head) from the territory belonging to the surgeon (the lower part of the patientthe body). But even when everything works as planned, the complexity of the processinvolving multiple specialists and disciplinescombined with the fetish for numbers and regulations, makes attention to the needs of the patient almost seem like an afterthought.
Those of us who have spent time in hospitals, in whatever capacity, know how frustrating it can be. All of us, friends, relatives, and even the patient, are all pushed aside in the interests of efficient medical care. And even where there is a caring physician or nurse attempting to help, nasty though well-intended legal restrictions block attempts of the patient and especially of relatives and friends to gain access to information.
The hospital is a complex system, with multiple complex interactions among people, equipment, laws, institutions, and a confusing wealth of information. The opportunities for improvement are numerous: Health care is a problem awaiting improvement, a problem that can keep many people occupied for many years. A problem so complex that we need to start now, for it is already life-threatening.
A final comment: Many hospitals recognize these issues and are working to improve them. Some have patient rooms with special areas for family. Others are trying to address the extreme attention to displays at the expense of the patient. Even more reason for us to be involved. The opportunity is right.
Donald A. Norman
Nielsen Norman Group and Northwestern University
About the Author
Don Norman wears many hats, including co-founder of the Nielsen Norman group, professor at Northwestern University, and author, his latest book being The Design of Future Things. He lives at www.jnd.org.
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