Monday, May 18, 2009

Thoughts on Care

Well, my wife is pretty much recovered from her hospital stay, and we finished our last follow-up visit which went even better than expected. As I've said before, I'm not usually on the patient side of the health care environment. The experience was frightening, and I can readily admit to being an annoyance to all of the very patient people who provided for my wife through our four-day tour of Hunterdon Medical Center, despite trying to be as pleasant as possible.

My only real previous experience with the patient end of care was when I was on vacation in Gatlinberg, Tennessee and wound up in the ER at Fort Sanders Sevier Medical Center, which has the distinction of being one of the busiest ER's in the whole state. While they had a very nice EMR and seemed quite technologically enabled, I spent about 16 of the 20 total hours in that place waiting for a chance to talk to a medical professional of any variety. The staff was overworked, their triage was unable to keep up with demand and space was so limited patients were literally lined up along the halls in gurneys, with the scene reminiscent of the Crimean War imagery so often invoked during historical discussions of Nursing. Care focused on technical achievement of patient outcomes at the expense of expressive activities.

Fast-forward to Hunterdon, and this sleepy community medical center couldn't be more different. The EMR was underutilized and paper charting was the norm, and there were moments where I questioned the technical competence of the care provided. However, their expressive functions were so good, the environment so precisely engineered to promote calm and healing that the technical aspects of care seemed like a much more workable deficiency. Coming from a technologically enabled, large-scale care environment in Cleveland where two major health systems are currently engaged in fairly intense competition for patients and acquisition of hospitals, I've felt for some time that there was little difference in the quality of care delivered from one hospital to another. Indeed, barring large differences in the typical quality indicies used to compare hospitals nationally, how should a patient choose between patronizing one institution over another?

After my (albeit limited) experience on the patient side, combined with my knowledge of care delivery, I would say the greatest single factor should be the patient experience. I'll even get heretical here, and posit that the patient experience within a competitive care environment is more important than use of technology such as EMRs and novel devices. Why do I say this? Well, because if a patient's health care provider only spends about 10 minutes with them each hospital day, or if that patient waits for several hours in a glorified holding pen, they really stop caring about the information technology and high-tech devices of that institution. Those things don't let them communicate that they need more pain medication, or that the vesicant solution currently running through their IV burns so badly they burst into tears. That pump may be accurately delivering its dose, but it still can't adjust the fluid concentration to relieve suffering.

Disney is now getting into healthcare, and have several case studies on the effectiveness of improving the patient's perception of care and expressive functions over technical achievement. I watched one of their webinars, and while I wouldn't rush to call them in at $300 an hour (or whatever they charge), it did make me reconsider my role. IT is not care; it is facilitative technology. No EMR implementation is going to be successful that does--as its end result--improve the perception of care delivery by the patient. You may wow them on Day 1 with Tablets, COWs, and CPOE, but by Day 3 the patient doesn't give damn. They just want their fears to be allayed and their suffering to be relieved, and everything else just falls to the wayside.

Sunday, May 10, 2009

Here I Sit

Next week--May 11th--will mark the second graduation I have failed to attend. Both were voluntary decisions; the first because my family lives in Oregon and wasn't about to fly out to Cleveland just to watch me put on a cap and gown, while the second was the result of my wife Amanda and I deciding we would rather spend time with her family in New Jersey than spend another week in our crappy one bedroom apartment.

We left on May 7th, and on May 9th Amanda was admitted to the hospital. The last few days she's been battling with a small papule that grew into full-blown preseptal cellulits, and I've been keeping vigil at her bedside to make sure that she gets the best possible care. This has turned out to be a pretty easy task, because the quality of care here is excellent, and the facility is both well-designed and contemporary.

I almost never get sick, and have never been hospitalized (exempting a couple brief ER visits as a kid), so my knowledge of the health care delivery system is a little one-sided. I think that's what made it so easy to get into the field in the first place. It seemed in school like my experience was not out of the ordinary, with most of the nursing students rarely getting ill and having experienced health care delivery vicariously, rather than principally. Hell, I didn't even have vicarious experiences to draw on--my family is also of remarkably good health.

There's no proxy for a sudden shift in perspective in regards to your work environment. I think we have all had the experience of attempting to use technology or a service, and being forced to wonder "did the person who designed this thing ever have to use it?" According to my Computer Science friends, the answer is probably "no".

So as a nurse, as a husband, and as an informaticist I'm trying to mine this experience for all its worth. I blogged before "blog" was coined by Peter Merholz, instead just writing what I thought of as short essays and posting them to a Tripod account in order to teach myself HTML. I haven't done it in a while though, because I've been busy. As most nurses can appreciate, nursing school isn't a picnic at any level, and this last year was a marathon of academic coursework and a full-time internship that left me barely enough time to get married to Amanda and still get out with my sanity.

With no school, employment, or personal obligations right now, my wife's care is all I'm focused on. That said, there are large breaks in the day (like now) where she's asleep and there's no work to do, so I've decided to blog again, and what better to blog about than the thing I know best. So the next few posts are going to dedicated to my experience on the client-side of care, and how they reflect pertinent issues within the healthcare delivery system and health information technology.