Thursday, January 4, 2007

clinical innovation, keep it simple, Twenty Clinical Innovations to Build Patient-Doctor Trust: Fifteenth in a Series

KISS (Keep It Simple Stupid): Or, Of Time, Templates, and Technology

Clinical innovations need not be complex. Indeed, they can be devastatingly simple. Nothing, for example, could be simpler than a video explaining in plain language with simple pictures showing exactly what to expect from surgery and what to do about your chronic disease.

Not many people realize it, but the acronym KISS (Kiss It Simple, Stupid) is a favorite expression of computer technologists. The KISS principle is a colloquial name for the empirical principle that simplicity is an essential asset and goal in systems and (industrial) processes. The use of KISS is common in software and engineering circles.

KISS is the basic thought behind “disruptive technologies,” a term for simple, convenient, less costly technologies that “disrupt” markets by replacing more complex, inconvenient, and costly technologies.

Disruptive technologies are a term popularized by Clayton M. Christensen in The Innovator’s Dilemma (Harvard Business School Press, 1997). Later Dr. John Kenagy, a vascular surgeon and a visiting scholar at Harvard Business School, applied the notion to health care “Will Disruptive Innovations Cure Health Care?” (Harvard Business Review, Volume 6, pages 102-122, September 1, 2000).

Kenagy and colleagues at Harvard Business School give these examples of disruptive innovations in health care.

•Minute Clinics – clinics in retail outlets where services are delivered by nurse practitioners rather than doctors.

•Balloon angioplasties – where coronary arteries are unplugged by balloon catheters rather than open-heart surgery.

•Nurse practitioners and physician assistants assisting, delivering services, and prescribing.

•Outpatient surgeries. Labs and imaging centers delivered in ambulatory settings rather than hospitals.

•Non-invasive vascular diagnosis by ultrasound and radiographic technologies.

Disruptive Technologies as Time-Savers

I think of disruptive technologies in a simpler way – as something that saves time for physicians and patients, thus allowing them to spend more time with one another.

That the shortage of time for patient-doctor interaction and a waste of time for reaching that interaction are major sources of doctor and patient dissatisfaction and distrust is obvious to many observers.

•In a 2004 New England Journal of Medicine article (“Dissatisfaction with Medical Practice,” volume 350,. pages 69-75, January 1, 2004), Dr. Abigail Zuger writes,

“Among the aspects of practicing medicine that particularly frustrate conscientious physicians around the world is the lack of time to accomplish necessary tasks. ‘Indicated’ tests and treatments must be scheduled, checked, and paid for; administrative and regulatory requirements mount; and financial considerations demand an emphasis on volume and turnover. E-mail and the Internet have conditioned many patients to expect instant responses to all concerns. ‘The single greatest problem in medicine today is the disrespect of time,’ said Kenneth Ludmerer, a physician and medical historian at Washington University in St. Louis, in an interview. ‘One cannot do anything in medicine well on the fly.’

•Lack of time is the driving force behind the concierge and cash-only practice movements. By supplementing their income with retainer fees and eliminating third party administrative hassles, doctors are able to spend more time with patients and to use their time for what they were trained to do – listening, treating, and spending time with patients.

In an unpublished book, You and Your Doctor, I described the patient’s dissatisfaction with time wasted before seeing a doctor with these words,
“You’re sick and tired of waiting -- waiting to get an appointment, waiting in the doctor’s waiting room, waiting to get the procedure done, waiting to get test results, waiting to see the specialist to whom you were referred, waiting in the hospital admitting suite, waiting in the emergency room, waiting to have your operation. Why can’t doctors and hospital be more efficient? Don’t they understand your time is just as valuable as theirs?”

The title of an August 20, 2005 New York Times article captures patient’s frustrations over wasted time, “Sick and Scare, and Waiting, Waiting, Waiting.”
Now, to return to my subtitle, “Of Time, Templates, and Technology.” I believe the simplest of ideas, a template, can save time for doctors and patients. A template is nothing more or less than a master, or a pattern, from which similar things can be made and which can serve as a repeated reminder of what needs to be thought of or done. A computer-generated template saves time for everyone. Re-inventing a constantly rotating wheel is of little use to anyone.

One of the biggest time wasters in health care is the need to re-document dialogue for repetitive or duplicative tasks that doctors do every practice day. To be paid doctors must document by writing or dictating in essentially the same words. What they have done a thousand times before.

•An example would be the medical history and physical exam, which consists of documenting the following: chief complaint, present history, past history, review of organ systems, physical examination, and treatment plan. A physician can document this through handwriting (30 words a minute), dictating (150 words a minute), or by downloading a template of the complaint, present and past history, review of symptoms created by the patient (which can eliminate the need for handwriting or dictation, leaving only physical findings and treatment plan to be recorded,) Other than physical findings and treatment plan, patients can generate most of this information using an interactive template consisting of a “ye” or “no” algorithm based on the patient’s complaint, age, and gender. Add physical findings and treatment plan, and you have a complete medical record that can be presented to the patient, as a template, if you will, of the patient’s complete electronic health record.

•Another example is the informed consent process, which involves telling the patients the risks and options of a given procedure and reaching an agreement signed by the patient that this or that can be done. As I have indicated in previous blogs, these consent firms can be automated and clarified by computer templates that document what to expect and what the risks. Having a computer creates this paper or video “templates” saves doctors’ time, achieves consistency, and educates patients.

•Yet another example is templates of procedures done in doctors’ offices, outpatient settings, emergency rooms, and hospitals. Templates can describe and document writing of a prescription, applying a cast, taping an ankle, using a needle to remove fluid from the chest or abdomen, draining an abscess, treating a wound, performing a tracheotomy or performing any other surgical procedure. These procedures are something the doctor does everyday in much the same way. Rather than spending hours dictating what was done, why not create templates, blocks of print or canned descriptions, varying only with the name of the patient, or any complications that may have occurred, and download the computerized template for the record – thus saving time for the doctor and allowing him or her more time for the next patient?

•The final example is templates for the whole field known as diagnostic support services. In the course of seeing and examining patients, interpreting findings, conducting a differential diagnosis, or reminding patients they need to be seen again, why not simple generate templates that serve as reminders for doctors what to look for and to think of as diagnostic possibilities, what tests to do diagnose these possibilities, and what steps to take to remind patients that some test is askew and that they need to be seen by a physician.

Maybe this blog has been a template in a teapot, but it seems to me we sometimes make health care more complex than it need be, and we can “disrupt,” i.e. simplify, the process by adroit use of existing template technologies.

The computer, after all, is matchless at instantly replicating repetitive tasks which may otherwise consume vast chunks of human time. Computer templates can free up more time for patients and doctors to spend together, building a more solid and trusting relationship.


Anonymous said...

From this patient's perspective, the template seems like a no-brainer. It systematizes in a way that does not strip the physician from his or her primary purpose; to practice the "art" of medicine. It seems preferable to a system of imposed practice guidelines that have been developed with the aid and oversight of a Congressional committee.

.... said...

Check out my blog about my experience with invasive cardiology: