A typical day on the ward

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/

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

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

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.

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

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/