

Disrupting Medicine: Check - chrisacky
http://kyrobeshay.com/post/37777614453/disrupting-medicine-check

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btilly
The problem is this. At some point, in every checklist, you need to interact
with other parts of the hospital. For instance suppose that one step is to
refer the patient to neurology. What if you're in a country hospital and there
is a neurologist on call, you can't simply call that department. You might
have to make a decision about whether this is a case that requires an
emergency call. So maybe you need to do another checklist, just to decide
whether to leave a note for the neurologist in the morning, or to make an
emergency call.

Suddenly your standardized checklist is no longer standardized across these
two hospitals.

Multiply this by a myriad of checklist across a myriad of different medical
facilities with a myriad of different differences, and suddenly the dream of a
standardized set of checklists becomes impossible.

This does not mean that the effort of creating and following checklists is not
worthwhile - it most certainly is. However if you start out expecting to
achieve an impossible dream, then you're guaranteed to be disappointed.

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richardlblair
The issue I have with this is that eventually every disease and diagnosis will
have an accompanying check list. This is an over simplification of a process
that requires professional opinion and deep knowledge within a specific
domain.

Psychiatry is an great example of how using checklists can cause a disease or
disorder to be over diagnosed. Depression, ADD, ADHD, Social Phobia (branded
as Social Anxiety) all have checklists and all three disorders are over
diagnosed.

Psychiatry also happens to be a great example of how Big Pharma gets their
greedy hands involved in creating these checklists. In some cases the
checklist come from Big Pharma themselves. Talk about a conflict of interest.

Doctors are paid to think, apply their knowledge, consult with each other.
They are not paid to check boxes on checklists and toss around diagnosis.

Edit: Typo

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davecap1
One of the main issues here is that medical care is largely non-procedural and
intuition-based. That's why doctors have to spend years doing training,
followed by years of experience. Their "checklists" are created one step at a
time, per-patient.

This is exactly what needs to be changed in order to disrupt healthcare. Once
medical care becomes procedural (ie generated by smart software, per patient,
based on the patient's electronic health record which includes genomic and
molecular data), we can begin replacing highly specialized doctors with non-
specialized ones (and eventually with nurses). Of course, there are probably
tons of areas where "simpler" checklists can be made to have a significant
impact on outcomes (for example making sure the right patient gets the right
drugs, etc..).

Clay Christensen's book, Innovator's Prescription, goes into a lot of detail
about how this will most likely play out: [http://www.amazon.com/Innovators-
Prescription-Disruptive-Sol...](http://www.amazon.com/Innovators-Prescription-
Disruptive-Solution-Health/dp/0071592083)

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sbzoom
It is called "Order Sets". 3 very large companies are doing it.

1) Zynx : <http://www.zynxhealth.com/Solutions/ZynxOrder.aspx> Very dated and
expensive.

2) Provation : <http://www.provationordersets.com/index.aspx> Slightly better
but small market share compared to Zynx.

3) Elsevier : <http://www.clinicaldecisionsupport.com/order-sets> New player
yet to launch. Cloud based.

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dan_yall
Yep, the problem is getting physicians to utilize them instead of dismissing
them as "cookbook medicine".

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christkv
Very Optimistic. Having worked on this problem around the year 2000 in the
Norwegian health care system and also in the public sector you'll quickly find
that funnily enough doctors don't agree on what is the "best" procedure most
of the time. Even in Norway where they register every single cancer patient,
treatment and outcome it's hard to make up completely standardized treatments
for cancer and that's just a single disease. Most countries don't have
anything close to that.

What could be damn useful however is good old fashion infection checklists.
Since the time of Joseph Lister there have barely been any progress in
infection control at hospitals. One might even say there has been a
substantial regression. Even something as simple as replacing all the steel
door handles with copper would help
([http://www.dailymail.co.uk/health/article-442135/Could-
coppe...](http://www.dailymail.co.uk/health/article-442135/Could-copper-door-
handle-help-beat-MRSA.html)).

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themcgruff
In the operating room, where some would argue where procedural checklists like
this might most count, they use a pre-op timeout procedure. Usually this is to
ensure the right patient is being operated on, in the right place(s), and that
the right operation is being performed. The same happens before the patient is
"closed". A count is taken of every bit of material / tooling used in the
procedure to make sure nothing is "left behind" (in the patient). Sources: 1.)
<http://www3.aaos.org/member/safety/guidelines.cfm> for more information. 2.)
My wife who was a surgery resident.

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DanBC
It's an interesting idea.

What do you do where there are going to be multiple lists? EG: Full thickness
burns - you do some debridement then use a dressing. Different doctors like
different dressings. Some will use a manuka honey dressing; some will use
flamazine; some will want to use stuff like inadine or jelonet etc. So now you
have a branching checklist?

The companies making dressings have a significant financial drive to be
included in the procedure check list - imagine every hospital in the world
wanting to use your product - and so you'd need to protect against corruption
and external pressure and fake research.

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zmanian
If there isn't a connection between a procedure and outcomes, it just becomes
garbage in/garbage out.

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FireBeyond
Perhaps so, but the human body is an analog system, not a digital.

To wit: the rule of 9s for "surface area burns" is an estimate, but treatment
will vary based on what surfaces are burned to what extent. One 25% burn
patient will differ from another.

Another (over-simplified) example: GCS (Glasgow Coma Scale -
<http://en.wikipedia.org/wiki/Glasgow_Coma_Scale>): a score between 3-15 on
three axes to measure neurological consciousness. Even in interpretation, the
number is often referred to as a single score, when in reality, the three axes
(eye response, verbal response, and motor response) can indicate vastly
different neurological components and treatment/assessment options.

Where I'm getting at with these examples is that systemizing and optimizing
checklists and treatment plans can lead to hugely complex branching that
seemingly become unfeasible to realistically manage without (exaggerated for
effect, but similar in practice) a doctor or RN going to a computer between
each treatment step to see the process and branches.

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DanielBMarkham
"... Imagine if we optimized every single facet of medical care, from patient
admission to discharge, and all intermediary processes, top to bottom..."

Let's separate _standardizing_ and _optimizing_. A checklist lets you
_standardize_. It does not optimize anything.

As the author continues, he gets into a scheme of various agencies all working
together in various ways -- this is the core of the optimization problem. I'd
suggest he doesn't have a clue here as to how to actually accomplish this. But
still, overall this is a great idea. Standardization in many rote procedures,
especially those involving health, is desperately needed.

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ippisl
I think that those things are not even new. There are already decision support
systems(medical expert systems) and protocols of evidence based medicine - for
standardization.

And research works around the world is flowing into those systems and
improving them.

And the line-infection rate checklist the author talks about, does exist for
something like 10 years.

Those are the relatively easy parts.

The hard part is: how do you change the culture of medicine, from "cowboy
style" that comes with a lot of authority for the doctor, to a more boring job
, with much more subservience to machines and protocols ?

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stcredzero
The question to ask is, how is it that pilots made the switch from "cowboy
style" to more reliance on machines and protocols? The answer is probably
cultural.

Which brings me to another thing that occurred to me: Is medicine ready for "5
whys?" Checklists aren't going to work until the culture of the medical
profession is ready for it. I get the impression that doctors are treated as
"functionally infallible" (so long as they consult with other doctors when
they need to) and mistakes are treated as flukes and aberrations. (If not
entirely swept under the rug.) It's pretty clear that medicine's capacity for
self improvement is not entirely mature from the performance of infection
control. There are still hospitals that spread infections.
(<http://www.ehso.com/ehshome/washing_hands.htm>)

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ams6110
It's more than cultural. All airplanes of a type are basically the same. They
have the same parts, the same operational and maintenance requirements, and
the same procedures work to fix them when something fails.

Humans aren't so standardized. Not everyone with a disease responds to the
same treatment in the same way. They may not even display the same symptoms.
Some people have allergies to certain medications, etc. Medicine is just way
more complicated than ticking through a pre-flight before takeoff.

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danso
FTA:

    
    
       The underlying question throughout the book is “If people
       like architects and pilots use checklists to both avoid    
       and minimize errors, then why in the hell aren’t
       physicians and nurses doing the same?”
    
       And that got me thinking. What if every 
       hospital procedure had an accompanying checklist, 
       from all types of surgeries to administrative 
       operations?
    
    
    

Whoa there. The jump from the first statement to the second completely
bypasses the entire challenge. The problem is not that there aren't standards
already, but that the various regulations and laws, both at the governmental
level and at the hospital board level, make such "optimizations" very
difficult to implement.

Until you have a real solution to removing the resistance of bureaucracies,
then all of this is putting the cart before the horse. There is not much in
this post that hasn't been talked about or already agreed on by medical
reformers.

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m_rcin
there is an interesting TED talk from this year about this, how checklists for
surgical teams has been designed and implemented in a few hospitals around the
world:
[http://www.ted.com/talks/atul_gawande_how_do_we_heal_medicin...](http://www.ted.com/talks/atul_gawande_how_do_we_heal_medicine.html)

