Disrupting Medicine: Check(kyrobeshay.com)
kyrobeshay.com
Disrupting Medicine: Check
http://kyrobeshay.com/post/37777614453/disrupting-medicine-check
12 comments
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
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
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...
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...
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.
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.
Yep, the problem is getting physicians to utilize them instead of dismissing them as "cookbook medicine".
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...).
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...).
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.
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.
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.
If there isn't a connection between a procedure and outcomes, it just becomes garbage in/garbage out.
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.
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.
but that's the point - different doctors do things differently, and there's not enough research to say which is best. Ethics committees add a weird result where it's hard to test which is best (http://www.badscience.net/2011/03/when-ethics-committees-kil...)
So, does a check list prefer one method over another? Or do you have one massive check list with sub-sections for each method? Or do you have a separate list for each method?
So, does a check list prefer one method over another? Or do you have one massive check list with sub-sections for each method? Or do you have a separate list for each method?
"... 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.
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.
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 ?
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 ?
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)
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)
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.
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.
IN the case of pilots , few factors combined together to build this culture:
1. Checklists were introduced when flying was very young,with very few trained pilots.
2. Pilots want to live, so they use checklists.
3. Pilots don't have a choice. All airlines companies enforce checklists. Probably it's an FAA requirement.
4. Checklists are a part of training.
1. Checklists were introduced when flying was very young,with very few trained pilots.
2. Pilots want to live, so they use checklists.
3. Pilots don't have a choice. All airlines companies enforce checklists. Probably it's an FAA requirement.
4. Checklists are a part of training.
Complexity of operations. Simple planes don't really need checklists. There are not that many knobs to turn and not many things can go wrong. As the planes got bigger, faster, and got more equipment, it became impossible to just "follow the flow".
Cowboy style? Do you actually believe this? On what basis are you suggesting that medical errors are related to the reckless behaviour of doctors? Do you have some secret research that goes against the current thinking on medical errors and how they are system problems, not related to a given individual? Do you have any evidence that subservience to mythical machines will improve health care? Do you work in healthcare? Do you deal with doctors and patients?
Atul gawande which is a surgeon coined the word cowboy in a new yorker article and in a lecture before new doctors.
There's some research that shows that decision support systems improve medicine. Too tired to look it up.
There's some research that shows that decision support systems improve medicine. Too tired to look it up.
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FTA:
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.
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?
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.
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...
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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.