
A typical day on the ward - jeeshan
http://listrunner.tumblr.com/post/91225625025/youll-cringe-when-you-read-this-but-this-a-typical
======
JoshMandel
When I was a med student in 2009, I did my surgery rotation at a community
hospital outside of Boston. Each morning two students were responsible for
copying down overnight vital signs from the EHR onto paper. The job took
upwards of 45 minutes, and morning rounds were at 6am...

I didn't mind driving through icy Boston roads at five in the morning -- but I
did mind the fact that I was doing a job that computers should be able to do
far faster and more accurately.

The EHR was a terminal-based system, and I wound up routing traffic through a
local proxy, analyzing the logs, and figuring out how the protocols worked.
(I'm sure that reading about terminal emulators would have been more effective
than reverse engineering them; I can only blame sleep deprivation.) I
ultimately built a Python script to drive the terminal based on a list of
medical record numbers, recording vital signs and slotting them into pre-
formatted progress notes for printing. It even plotted sparklines for fever
curves.

It worked. And the chief of surgery loved it. He wrote me a stellar evaluation
that prominently mentioned my work with the computer system (I also did good
clinical work and all).

Two months later when the medical school dean read my evaluation, I got a very
angry phone call. She was horrified that I had "hacked" into the computer
system and taken matters into my own hands. I tried my best to explain how the
system worked, and why it wasn't a threat. But I didn't really get the message
across.

The upshot, though: I realized just how broken healthcare information systems
were -- and that I enjoyed working on solutions. After medical school I joined
the research faculty at Boston Children's Hospital, where I'm working on open
specs, tools, and standards that make it easier to integrate third-party
health apps with clinical data and EHRs [1]. It's been an interesting ride --
and I've learned an incredible amount about health interoperability, politics,
data, and security along the way.

1\. [http://smartplatforms.org/](http://smartplatforms.org/)

~~~
winslow
Do you know the guys working on XTK [1]? They are also working out of Boston
Children's Hospital. They have an awesome medical library for webGL based
applications. If so, tell them I say hi!

Your story reminds me of my current struggle with a massive medical company in
orthopedics and when I learned to never say the word hack again. I was brand
new to medical working with WebGL to create a web based bone cutter app for
surgeons. Marketing was behind this project idea and had to have it on the
Ipad. I used ludei [2] to natively port it to Android and iOS support wasn't
completely implemented when I presented to marketing. They demanded it be on
the Ipad, I could promise if & when it would be available but suggested a
possible 'hack' to get around the Ipad's webGL limitation. They flipped shit
on the word hack and went bezerk. I feel your pain.

[1] [http://www.goxtk.com](http://www.goxtk.com)

[2] [http://www.ludei.com](http://www.ludei.com)

~~~
dropit_sphere
Somewhat offtopic---do you have an opinion on ludei vs. phonegap, or know
someone who does? Working on a js project I'd like to port to mobile, and
somewhat bewildered by the choices...

~~~
lnanek2
PhoneGap just runs on the built-in web controls of the platform. Ludei
reimplements the web control to run faster. Generally you only use the latter
for games and graphics intensive apps.

------
noonespecial
My mom who is an NP, (nurse then) used to say 20 years ago that the nurses are
the "rememberers" and the doctors, the "thinkers". The most important job of
the nurse was to remember what was going on with each patient and get the
doctors up to speed as efficiently as possible.

------
singingfish
I'm in the late stages of writing up a PhD on this topic (nursing
documentation in a community setting). The major problems are:

1\. EHR technology is sold to managers, not clinicians.

2\. The leadership of introducing the EHR is fragmented and highly dependent
on local conditions such that success in one location does not guarantee
success in another location. Likewise with failure.

3\. Researchers have a tendency to treat evaluation of health technology as
epistemologically equivalent to evaluation of pharmaceutical technology even
though a cursory examination of the logic underpinning this assumption clearly
demonstrates that this is not the case.

(point 3 makes my job very difficult and political. Fortunately this work[1]
and the very few others like it, generally from the same research group lends
my work instant legitimacy. Without it, getting my thesis through the
committie would I fear be impossible).

[1]
[http://www.ncbi.nlm.nih.gov/pubmed/22188347](http://www.ncbi.nlm.nih.gov/pubmed/22188347)

~~~
jeeshan
singingfish well outlined! would like to see more of the thesis. good luck!

~~~
singingfish
my other problem is that I've turned into a moderately successful software
developer and the phd is no longer necessary for my career. along with the
politics, that creates big motivations problems for me ;)

------
anigbrowl
After a 12-hour stay in the ICU a couple of years ago, this doesn't surprise
me in the least. I was given a different patient's discharge papers by
mistake, and when I got all the records of stay for reference afterwards some
of the clinician's reports were utterly illegible. I guess this is why I ended
up answering the same medical background questions over and over again during
the night.

-

This looks like a great tool How are you going to deal with the inevitable
hurdles of HIPPA compliance? (HIPPA = patient privacy laws in the US, for
people who don't know).

~~~
vacri
As a medical technician in a neuro department, I had to take an illegible
referral to the neurologist who wrote it (luckily he was in-house). Even he
couldn't read his own handwriting: "But I know the patient, and he needs...".

~~~
bglazer
Why is this tolerated? It seems like such an absurdly basic problem to fix.
Years and hundreds of thousands of dollars of advanced medical training is
distilled into a note/prescription that looks like a fucking five year old
wrote it. It's pathetic.

A personal anecdote: I went to a doctor recently. He opened my notes, squinted
at them, and then asked me what medications he had prescribed me. That was my
last visit to him.

~~~
vacri
It's actually an extremely difficult problem to fix. Anything new that
restricts doctors in any way, shape, or form has to come from up high, and it
also has to be across the board. Few hospitals have the luxury to turn away
doctors, and few areas have enough doctors doing general practice. Make a new
regulation, and some doctors will sigh and do it - but other doctors will move
on... unless there's nowhere to move to that doesn't also have the new
requirement.

------
jvdh
This description of a typical day on the ward is of course ridiculously
inefficient to us as digital natives. We deal with information flows every day
and can imagine ten different systems that could do this without even opening
the door to the hospital.

The big 'but' is that there are so many hidden requirements here. Privacy is a
huge concern. Data on patients may not leave the hospital. With the devices we
have these days, it is almost impossible to create a near offline system.
Almost all devices are connected to "the cloud" in some form or another,
making them vulnerable.

The fact that health insurers are grossly incompetent in this aspect does not
mean that hospitals should go down to that level.

Another hidden requirement is that this system has to work, always, no matter
what happens. Paper notes may not be efficient, or complete. However, you can
be pretty sure that while the hospital is still standing, this system works.
Making a digital system that is as reliable is a very hard task.

All this will make such a system a huge investment, not only the system
itself, but also in training. Balanced against the cost, it is not so evident
that this is really an acceptable investment.

~~~
ACow_Adonis
I dunno about the "always works" claim. I have nothing to do with health care,
per se, but I always tell everyone to factor in a base 1%-5% error rate for
basic information and data entry that a human beings end up doing manually...

I imagine the number of errors/deaths/kerfuffles due to the opportunity cost
of professional time, not to mention transcription and human errors of such
systems are not inconsequential...even if they aren't at the forefront of our
minds, and even if some of them haven't been measured accurately.

~~~
jvdh
You are never going to take away the human from this equation. Notes are taken
over the course of the day, and many of the proposed systems end up taking
_more_ time: nurses do their rounds, use pen and paper to take notes while
walking around, and at the end of the shift copy the notes from the paper into
the system.

This means that you have basically added another data entry level, increasing
both time and error rate.

~~~
ACow_Adonis
Well I can't comment on the system/app offered by the author of the OP, but
obviously the point of designing a system to fix/improve such operations
wouldn't just be adding another level of data entry and subsequently multiply
risk, but instead to minimize it.

The goal is not to remove humans from the equation, since that is probably
both impossible and undesired, but to separate humans and computers into
supporting each other in the task at hand by specialising into what they do
best: computers for tasks that can be broken down into repetition,
replication, automation, speed, validation, and volume, and humans for
creation, ambiguity, complexity, context, service delivery and interpretation.

At the moment i'm guessing there's a fair bit of humans doing the jobs
computers are good at in hospitals around the world...

------
tricuspid

      Oh my god, we still have to write things down on paper?!
    

Yeah, and so what? Writing things down on paper is a damn tough pnemonic
system to defeat.

The problem arises when _others_ have to discern an individual's short hand
notes.

So, an array of shitty post-notes is weak and lacks integrity, but similarly,
so do disparate plain text files, haphazardly saved in an array of folders
with haphazard file names. And yes, you could theoretically grep such a data
store for meaningful details, but then again: Have you ever actually tried to
parse someone else's randomly sorted plain text notes? It's a brain nullifying
experience sifting through someone else's disorganized stream of
consciousness.

This is a garbage-in-garbage-out scenario, and coping with a tide of
inadvertently injured humanity does not lend itself to well-formed XML and
proper SQL grammar. People don't plan on coughing up a lung, or getting shot,
or run over. No one plans on syphlis dimentia.

You can bulldoze a landfill of printed circuit boards onto this problem, and
still come back and say "boo-hoo, healthcare broken."

It's a hard problem, and there's always going to be a 50% share of elbow
grease to pony up on the buy-in. Hospitals are hotels where people
disintegrate in the most controlled manner possible.

Feel free to try and automate garbage collection in this environment. You'll
assuredly end up with more bloated heap space than a Windows virtual machine
running a JVM that emulates a .NET runtime environment.

------
leonth
The article glosses over the fact that wards rounds are typically an exercise
that requires vast amount of highly dimensional data. Hidden in the article is
the requirement that the information - lab values, vitals, patient location /
status, problem list - must be maintained electronically. This by itself is
already very hard, especially as paper records never have downtime / network
issues and do not talk back when invalid values are written.

Please be assured that the state-of-the-art is not as described. Sufficiently
advanced hospitals would have means for healthcare workers to access vitals,
lab values, patient location, current medications, current problem list /
diagnoses, medical history from previous days and even previous visits, and
even medical history from other institutions - all electronically. Staffs
enter data into system directly and no transcribing is required. These are
available as discrete data i.e. not freetext strings only decipherable by
humans.

Also don't forget about electronic prescribing of drugs, glorified vending
machines with pockets that only open when there is an order for that
particular medication, and barcoded medication administration system.

~~~
phren0logy
MD here. I agree that many EMRs can do the things you list. What you have
missed is how painful/clunky it is to do so, which is why it's still so often
done by hand.

Of course, some EMRs may be good... just none of the 10 or so I have used.

------
chasb
When I first shadowed on a post-op floor in Detroit, I was shocked to see how
much information nurses had to copy by hand during a shift change. Even new
medicine orders and drug administration schedules were being penciled into the
margins of already-crammed pages.

~~~
jeeshan
In a lot of ways, nurses have it even worse. They're constantly on the front
lines they lose so much time in having to rewrite the same information over
and over again.

~~~
vacri
I have a friend who's been a QA engineer at a couple of hospitals. At one
hospital, he noted that the doctors would have their ward meeting half an hour
before the nurses would have their ward meeting. One nurse would attend the
doctors' meeting, and transfer the information. In order to prevent errors
from occurring due to being given second-hand (or the 'transferer' not asking
the right question for a patient), he suggested melding the two meetings,
which were only half an hour apart. The doctors wouldn't move their meeting
"because we consult in the morning", and the nurses wouldn't move theirs
because "the doctors meeting happens at a scheduled break time". So errors
keep on happening...

He had a few other glorious stories of the amazing politics that goes on in
hospitals - sometimes it seems like a bloodsport.

------
Robin_Message
It seems like the essentially free work done by interns/medical students is
instrumental to these bad systems and procedures continuing.

I wonder what would happen if an intern group got together and said "No. This
is a stupid and dangerous way of doing things. We're no longer going to turn
up an hour early for a 12-hour shift to copy out notes that should have been
taken in a more sensible way to start with."

~~~
pak
Interns are typically not fully licensed to practice medicine without
supervision, which is the point of a residency program (they take more exams
to this effect at the end of the residency). This is why the hospital has
enormous bargaining power over them and the hours/wages are markedly different
from those of attendings. Unionization of residents is still very rare because
the hospital essentially has the power to end the residents' careers for such
behavior.

------
munrocape
"Don't abuse the text field in the submission form to add commentary to
links." [1]

@jeeshan, I'm assuming you're the author. Why have these practices (archaic
maintenance of lists) been maintained?

[1] - HN Guidelines
-[https://news.ycombinator.com/newsguidelines.html](https://news.ycombinator.com/newsguidelines.html)

~~~
jeeshan
Good and (complex) question. Essentially, the person deciding or purchasing
technology in a hospital (an IT administrator) is not the person seeing
patients (the doctor). They often work in completely different buildings and
no have overlapping experience.

My bad incorrectly submitting.

------
prawn
There are a few mentions of ListRunner in there but no links to the site - you
should update the blog template to handle that if you can.

For anyone else, the URL is:
[http://www.listrunnerapp.com/](http://www.listrunnerapp.com/)

------
kevinwang
What's the easiest way to learn about and work towards changing/improving
these places as an individual?

~~~
sskates
The most difficult part is selling to a hospital. So if you can crack that
half of the problem the technology is the easy part.

~~~
angersock
Amen to that.

The tech parts of these problems (from personal experience) are pretty mundane
and pedestrian--like, summer intern pedestrian.

------
hblanks
Golly. I thought this was going to be about a hospital ward in sub-saharan
Africa, some abandoned corner of Asia, or even a VA hospital here in the US.

I'm glad people care, but for me, these are first world problems compared to
drug shortages, inadequate facilities for water and sanitation, missing
diagnostics, payroll shortfalls, and so many things.

Sadly, though, these are not problems that programmers can do much to fix.

~~~
rictic
I empathize with your compassion but I've downvoted you because the existence
of worse problems shouldn't preclude all other discussion.

------
konzi
I would love to have a list of tasks for each of my patients on my phone. This
would make being an intern far easier. In fact, I'm currently validating and
building a solution for this exact problem, which I will talk about below, but
first it's important to understand what an intern (at least here in Australia)
does during the actual ward round where most of their tasks for the rest of
the day are created.

An average intern during a ward round has to do the following things for each
patient : 1) Handwrite notes into the patient's bedside notes as the senior
doctor takes a history / examines the patient. 2) Look at the patient's vitals
chart and medications chart. 3) Handwrite a plan in the patient's notes at the
end (this is essentially a list of tasks for the intern to do during the day).
4) Often while the intern is still writing the plan, into the patients notes,
the rest of the team is already moving onto the next patient. The intern will
hurriedly re-write any tasks from the plan onto their personal printed patient
list (takes < 5 seconds) and then quickly go get the notes for the next
patient and begin this process again. Also note that often the patients are
scattered around multiple wards in the hospital.

Now Listrunner, in their demo video shows a list of tasks for each patient on
an iPhone. Awesome!

But where in the ward round does my list of tasks get copied into Listrunner?
If I have to manually find the patient in the app and then manually add the
tasks to an app it would take minutes, not the <5 seconds it does to rewrite
the tasks on a personal list in super shorthand. And no senior doctor is going
to wait a couple of minutes for you to write each patients tasks into your
phone (this would add 40 minutes to a 20 patient ward round).

I've been thinking about this a lot, and I think a solution using google glass
would be super amazing here. I'm currently in the prototyping and validation
stage of the project (following Eric Reis' 'build-measure-learn'). Happy to
talk to any doctors interested in it.

It works as follows:

1) After you finish writing the patient's plan you take a photo of it with
google glass. 2) OCR is performed on the photo, right then an there (hopefully
in <= 1 sec) and the OCR is shown to the google glass wearer who can confirm
that the OCR is correct.* 3) Those tasks are then synced to the doctor's
phone, or for security reasons perhaps a hospital owned phone or tablet.

The advantage of this system is that it doesn't change the current workflow at
all. It doesn't affect the speed of the ward round. Thus, faces a lower level
of resistance to adoption.

Disadvantage - doctor's are notorious for bad handwriting, thus it will not
work for all doctors. It's expensive. However, as google glass (and perhaps
other similar tech) gets cheaper this may not be significant.

*Patient labels are already affixed to the top of the page (so OCR can be performed on the label to associate the tasks with the patient). But if the solution became widely used, a simple QR code could be added to patient labels, to make this easier.

~~~
ghkbrew
As a techie with a medical doctorate, I've considered these sorts of things
too.

The basic problem is that if you want to have records in the computer someone
has to input them in a more or less structured manner. This is the issue that
is usually left out of EMR discussions. Electronic health records are a
_trade-off_. Everyone realizes there are benefits, but if you ignore the costs
when making important decisions, it usually turns out badly.

Because of this, usually what happens is that skilled medical professionals
end up saddled with a second data-entry job.

OCR and voice recognition (which you didn't mention, but I think is also a
good fit) are both useful tools. However, if you really think about it, the
minimum viable product in this space is actually a medical transcriptionist
service. Let doctors (and nurses) use the easiest, fastest system they can for
recording data (ie paper, or voice), let the DBA's store everything in a
massive database for efficient retrieval and make money by providing an
efficient reliable method for converting between the two.

------
nowarninglabel
Hospitals already put a bracelet on every in-patient, right? What if you had
an RFID chip in the bracelets and scanned at entrances/exits to the ward, to
keep track of where the patients are and have been?

~~~
robbiep
why? I think you are mis-understanding the problem, which is not where
patients are but what teams they belong to and what has happened to them
overnight

