"Seven" things about communication

Yesterday, I posted a comment about the importance of linking high-end IT gadgets, things that often appear to be stand-alones, to the larger whole. I'm sensitive to this since my daughter has been hearing with a cochlear implant for the past 12 years.

I know from experience that it's easy to think you're being heard when you call a child to dinner and she shows up. She comes because she heard you say, "Time for dinner!" Or she heard something and decided to check it out since dinner is normally served at this time. Or she heard nothing but something smelled good. The outcome "showing up for dinner" is the same in each case. But you'll only replicate the results (and achieve them under tougher conditions) if the first statement is the accurate one.

In healthcare, regulators are focusing on closed-loop communication, techniques that are long-time norms in industries that deliver reliable results. Healthcare workers now have standards that prohibit transmission of high-stakes information--such as chemotherapy orders--by telephone. Clinicians receiving verbal orders have a duty to "read back," and clinicians who have given verbal orders must verify the information has been heard as intended. Other communication-sensitive initiatives include standard pathways and windows of time for notifying providers of critical lab values and radiology findings.

There's been more than a small amount of push-back from clinicians, especially from those who perceive they have never initiated, contributed to, or facilitated an error rooted in poor communication. (Every year, 1.5 million people in the US are harmed by medication errors, a statistic which substantively refutes the notion that entrenched communication patterns are sufficient.)

So I thought I'd share some communication "best practices" from my daughter, a reluctant but seasoned communication expert. She's a college student and, in the summer, the equine director at a residential camp who goes by the name "Seven." Here's what she shares with other camp staff and her campers, consider them seven from Seven:

Tips for Talking to Seven

The numbers below look different even though they're all the number “7.” Hearing with a cochlear implant is like that, too. I (“Seven”) don’t hear exactly like you do. My hearing “looks” different than yours (unless you hear with a cochlear implant, too!).

Even though I can use a cell phone and do many of the same things you do, when I miss words and exchanges that happen in “real time,” I may wind up lost, even though I was “with” you just a minute before. Here are things you can do to help me hear what you’re saying & stay current since I definitely don’t want to miss any of the fun!

I rarely overhear things, especially in noisy places (like the dining hall or a restaurant).

Be sure to talk to me directly when something important—like what we’re doing next or a change in the schedule—pops up.

I’m a really good lip-reader. Let me see your face when you’re talking whenever possible.

I’m “in my zone” when I’m around the horses. I usually know what’s going on or can guess what’s about to happen. So I may look like I’m a better hearer at the barn than I am in other places.

I don’t mind repeating things if you don’t understand me the first time I say them. I often have the same trouble with what you say. :)

I know sign language and will be happy to teach you how to make a “name sign” for yourself and help you learn some signs.

It’s okay to ask me questions about cochlear implants and how I hear.

Grand Rounds & Health IT: The man behind the curtain is..... Forrest Gump?

Good reading awaits at this week's Grand Rounds, where Dr. Joseph Kim invited bloggers to share how IT is changing healthcare.

Healthcare is full of tech-facilitated miracles. I think health care technology's best successes so far lie in applications aimed at individuals. My daughter's cochlear implant is one great example.

A cochlear implant (CI) does not make my daughter a "hearing person." But it certainly gives her the opportunity to access sounds and to make meaning of them in a way that's very similar to what people with normal hearing can do.

Deaf people don't have surgery and wake up "hearing" any more than you buy a computer and become Bill Gates. To realize the full potential of a cochlear implant, a user learns to make meaningful use of the data the implant provides.

Implant users can hear--and grasp the significance of--a toilet flushing almost immediately. But understanding and mastering a complex battery of sounds--like syllables, words, and sentences--has a much longer learning curve. Gaining meaningful use of a cochlear implant also requires concomitant support that's not technical at all: early education for language acquisition and ongoing speech therapy.

Think about another IT-facilitated product that fosters miracles: digital radiography. A lay person can see that digital images are sharper, brighter, more precise than those on old-fashioned films. But knowing what's normal, what's a normal variation, and what requires follow-up takes education and experience, an intimacy with both the imaging device and the anatomy it captures. Like a CI, radiography only becomes meaningful when the data is interpreted, communicated, and factored into a larger whole.

System-level application of IT, a late-comer in healthcare, is likely on a similar journey toward meaningful use. Right now, I'd say health care stakeholders are hearing toilets flush and noticing that some things are brighter than others.

I think there's a lot of other things that could be said about that.

But since I'm feeling a little like Forrest Gump today, I think that's all I'm going to say.

Grand Rounds: More than good stories found

One of the things I like best about Grand Rounds is that I find inspiration to help bring my hodge-podge of loose thoughts and impressions together.

Healthcare reformers and activists have begun to focus on the $20 billion American Recovery and Reinvestment funds that--God-willing-and-the-creek-don't-rise--will make IT in healthcare "meaningful." The National Committee on Vital and Health Statistics' Report of Hearing on "Meaningful Use" of Health Information Technology captures multi-stakeholder concerns well. It's a worthwhile read about the realities we face in harnessing strong IT solutions to transform healthcare efficiency and outcomes.

I jumped at the chance to talk about meaningful use last week, both here and over at On Your Meds, the Medscape medication safety blog I write. Although I'm techy by nature, it doesn't take a specialist to see that the current state of IT often makes front line clinical people tie the horse to the Edsel's bumper to advance a care goal. (If you missed Gina's story a few weeks back, it's worth a read to sample just a few of the unintended consequences front line clinicians face when e-systems fail to communicate.) So I posted call-to-action pieces about meaningful use, advocating for IT outputs that would make patient data central and help get front line clinicians out of the manure.

Then I started reading what cutting edge e-patient advocates and health 2.0 innovators were saying about what "meaningful use" might really mean. E-patient Dave's remarkable story is one that has drawn attention to health IT's intention-outcome mismatch. The power of high-end patient involvement left me feeling that my "make it work for those on the line" approach was like suggesting we replace "Mr. Ed" with "Rachel Alexandra" on the bumper.

But today at Grand Rounds, I stumbled across the story of a man, and his family, movingly told through the fresh eyes of a soon-to-be nurse in Brain Death, Part 3. The patient and family in the story, especially when contrasted with e-patient Dave, show the vast continuum of abilities and circumstances of people in our care.

We most certainly need to get the horses off of the bumpers. But we also need to be certain that we advocate for models of care--which are ultimately what IT solutions support--that allow all kinds of horses to make it around the track.

Health care reform at Grand Rounds

Grand Rounds is hosted this week at Healthcare Technology News with a special edition focusing on Health Care Reform. Interesting reads about what ails--and what may fix healthcare--from a wide range of perspectives make a trip over to the tech blog today particularly worthwhile.

Florence dot com, busy contemplating a move to Wordpress didn't go to Grand Rounds this week, but her sister blog over at Medscape did. (At On Your Meds, the topic Flo & Bo took on--how to spend $20 billion for health IT in a meaningful fashion--also came up, but no mention of bodily fluids occurred during the making of that post!)

I think the role of the consumer in healthcare is one worth exploring, and Grand Rounds is a great place for front line health care providers to hear directly from them. Seeing people at their most vulnerable, and benchmarking patients by the capabilities of those who are unlikely to be effective self-advocates is yet another huge disadvantage of our "in sickness and in more sickness" model of care. People who bring the same sensibilities to managing healthcare they bring to other high-stakes endeavors should help set the bar for patient engagement, with default strategies made to protect patients when they cannot assume these functions. (If you've missed how I once saved myself from a significant warfarin overdose, you can find it here.)

My parents, retired teachers living in central Florida, have online access to their medical records via a portal in their physician's EMR. The system also churns out a printed and up-to-date medication list following each visit. In the land of IT possibilities, these are modest things to be enthused about, yet they represent cutting edge patient involvement in health records.

Enjoy Grand Rounds today! (Judge Judy will not be attending, no need to roll up your pant legs.)

Meaningful use: Don't pee on my leg and tell me its raining

Standardizing and automating processes within a complex system makes the system more reliable, that is, more likely to produce an expected outcome. This is a core principle of system design although one infrequently taught to front line healthcare professionals, most of whom came-of-age in an intention-based ethic.

If Mr. Rogers were explaining what it means to come from a culture of intention , he'd say, "Can you say, 'The Five Rights of Medication Administration?' or 'Hippocratic Oath,' boys and girls?" But I'm not channeling Mr. Rogers here. This is a Judge Judy day.

Judy Sheindlin, you may recall, is the TV judge and author known for her sharp-tongued assessment and analysis of problems, most of which arise from choices made by imperfect humans and result in less-than-desirable outcomes. Judge Judy pulls from a strong personal moral center, but her opinions are informed by years as a family court prosecutor in New York City.

So what advice might Judge Judy offer to stakeholders who are about to get $20 billion dollars from the American Recovery and Reinvestment Act of 2009 to develop IT solutions that have meaningful use? I'm thinking it should start with, "Don't blow it!" and include a lot of input from front line clinicians.

To date, efforts to automate healthcare processes in clinical settings have produced, on a good day, variable results, especially when compared to what others (like Walmart, Chili's, AirTran, and hell, even Thrifty Car Rental) have achieved. This doesn't mean that automation doesn't work. It means that automation, like every other human endeavor, will rarely produce a desirable outcome spontaneously. (Or as my dad would say: "Fail to plan, plan to fail.")

Few, if any, health IT solutions in the public domain today were built on a strong patient-centric scaffolding, one that saw creation of a static stream of data to and from front line clinicians as a key objective. IT vendors have produced many satisfactory products and solutions. But their wares evolved in response to a market demand for piece-meal solutions, many arising in a reactionary fashion to address narrowly defined needs or mandates. We're now trying to satisfy a champagne appetite for high-stakes patient information that's been built on a beer pocketbook.

Making the patient the center of IT endeavors has the potential to make patient data the default output. And patient information is what professionals closest to the secretions need most to produce reliable outcomes: current medication histories; real-time medication profiles; provider orders; lab results; alarms signaling that an at-risk-to-fall patient has left the bed; that pharmacy-review of medication orders has occured; that an off-service test has been scheduled; that a patient is allergic to this food but likes that one; that an infusion is complete; DNR status; the list goes on.

Today's healthcare IT solutions are like puzzle pieces, with inter-operability specifications (enabling pieces to interlock with one another) in their infancy. Absence of shared platforms & standards may confer a competitive advantage to vendors in an unregulated marketplace, but it's the practical reason why your lab computer system often doesn't "talk" to your pharmacy computer and why patients admitted for community acquired pneumonia may receive a double dose of antibiotics when the ER's system doesn't "talk" to the inpatient system (an outcome, by the way, that standard quality reporting doesn't capture or penalize, but one that's not good for patients, not good for pocketbooks, and one that wouldn't be endemic with more robust communication systems.)

Front line clinicians often aren't enthused by the net effects of healthcare IT, and it's not because they don't recognize and enjoy the benefits of technology while grocery shopping, booking a vacation, or downloading music. But when patchy automation increases complexity and decreases efficiency--outcomes opposite those that normally found with tech-mediated solutions--don't blame the victims for not loving what torments them. Or, as Judge Judy would say, "Don't pee on my leg and tell me it's raining."

With $20 billion and a mandate to create IT solutions that result in meaningful use, maybe success can be measured by the whether the front line wears dry pants.

While it's sometimes tempting to eat the young, here's a better recipe

Welcome to Flo & Bo's continuing series on nursing sensibilities. This week hundreds of colleges in the US are graduating students, celebrations that herald the arrival of a new wave of graduate nurses, pharmacists, PAs, and therapists who will soon join the ranks of seasoned professionals providing healthcare. Welcome! We surely need you.

A month or so ago NPR ran a story in which a woman answered questions from her young son about how she met his father. I hope you'll have time to click on the link and listen to the 3 minute story from NPR's Story Corps.

If you can't, here's the part that spoke to me: This storyteller's mother had died when she was 7, and she was on her own by age 16. As the mother interacts with her son, she doesn't hesitate to answer his probing questions, but takes care at the beginning of their conversation to say, "So, what I did and what you get to do are going to be two different things because ...."

At this point in the dialogue her son abruptly, but confidently, interrupts her and finishes her sentence by saying, "I always have somebody looking out for me. That's you, dad, and pretty much everybody else in our family."

I could have used this story on Mother's Day. But I think the message transcends parenting, and speaks more to what people in the Judeo-Christian tradition call original sin, acting on the urge to subject the next generation to trials and tribulations that caused pain, dysfunction, and disorder in previous ones.

If you're about to orient new graduates, you'll likely use some sort of skills checklist and an evaluation process to document their mastery of core skills and validate emerging competencies. These are important tools, but the mother-son conversation illustrates another, equally important, measure of successful transition. It happens when the next generation can speak confidently of what's to come, without having to walk the same painful path that you did.

Resisting the urge to "eat the young" is the right thing to do. But today I'm also going to make a business case for why you should go out of your way to include novices, facilitating their transition to professional practice, and advocating for their voices to be heard.

Just two months ago, a Business Roundtable Health Care Value Comparability Study commissioned by CEO's of leading companies in the U.S., described a 23 percent “value gap” in the cost and performance of healthcare in the U.S. when compared to five leading economic competitors, all industrial nations. Foremost among the criticisms of the current system offered in the report?

"......basic practices untouched by the productivity revolution that has transformed every other sector of the economy." - Ivan Seidenberg, Chairman and CEO, Verizon Communications

Each and every day, seasoned healthcare professionals bring unmatched clinical expertise to mind-boggling, soul-wrenching problems, expertise that drives innovation, outcomes, and miracles (something I experience first-hand every time I speak to my pre-lingually deaf, cochlear-implant-using daughter by cellphone.) And I thank you.

But, having finessed high-tech miracles using antiquated infrastructure for so many years, seasoned professionals may no longer recognize the gap between what we find acceptable when shopping at the AT&T store and what we find acceptable when we go to work.

The "digital natives" about to join your ranks will see this gap. They're going to ask why a second registered nurse is paid to re-enter data previously entered by another registered nurse. (And, "The ER's system doesn't 'talk' to ours" won't satisfy them.) They'll ask why 17 distinct, but clinically irrelevant, variants of a penicillin allergy can't be purged from admission assessment documents containing over 100 distinct patient queries. They'll understand the inherent safety problems that arise when a pharmacy's computer system doesn't interface with those used to display laboratory results (and they probably won't think "tubing" or "faxing" a hand-written slip to compensate for electronic snafus is an acceptable way to communicate high-consequence data). They'll wonder why a bar-code scanner isn't attached to every anesthesia machine and why checking a price tag at Target is easier than checking a high-alert drug at work.

Digital natives will adapt their social media skills (like facebooking and twittering) and harness modalities (like iPhone apps and blogs) to communicate deficits, network, and help redefine best practices, allowing the productivity revolution that has transformed every other sector of the economy to illuminate the corridors of healthcare.

Welcome, sunshine! We need you more than we know.

Human Factors

The bi-weekly nursing blog carnival, Change of Shift, is up over at Emergiblog. I love the name "Change of Shift" because the view of healthcare that emerges there, like a Change of Shift hand-off, provides a window into the system we use to deliver care. The realities faced by clinicians on the front line are good reads for anyone interested in understanding the physical and mental challenges involved in providing care, and these accounts show how much relationships matter.

I especially loved a post by Drug Pusher (and not just because I have a keen interest in medication safety!).

The summary of nurses' views about barriers to providing safe care at Better Health is definitely worth reading, especially for people working to develop health IT products. I have an untested hypothesis that goes something like this: Few industries interested in producing reliable results or maintaining strong financial performance would support "humans babysitting machines" to the extent that we currently see in healthcare. Watching "safety" fight with "efficiency" is like watching "healthcare" fight "education" for scarce resources. These are not "pick one" issues. "Nurses dish on communication lapses that harm patients" seems to support my hypothesis.

I hope you'll visit Change of Shift every other Thursday: it's a good place to benchmark practices and keep an eye on emerging trends.

Next up: Deconstructing an error-prone IV medication set-up in a pediatric patient. Review Part 1 here.