It’s Always about the People

In May 2017 the Boeing Corporation, legendary for the safety and performance of the aircraft it has produced since 1916, rolled out the latest update of its workhorse 737 passenger plane, the 737 MAX. Seventeen months later, in October 2018, an Indonesian Air flight crashed, killing everyone onboard that 737 MAX. Five months after that another 737 MAX, this one flown by Ethiopian Airlines, fell from the air, with the loss of all passengers and crew. A total of 346 people died in these 2 tragic events.The Boeing 737 MAX is constructed from 367,000 parts, strung together with 10 million lines of computer code. It’s a wonder that any device this complicated can fly at all, let alone be entrusted with hundreds of lives, day after day, year after year. Nevertheless, the 737 MAX is a bone-chilling exception to the amazing safety record of modern aviation. The plane is still grounded, as investigators pour over everything from crash debris to corporate minutes.Here’s an emerging picture of the 737 MAX disasters, as reported in the December 23 issue of Bloomberg Business Week. (The story is in Business Week because, needless to say, the loss in money is huge, about $5billion so far; in reputation, it’s incalculable.) “…the most fundamental breakdown at Boeing may have been a lack of appreciation of how humans respond under stress--both in the machine it was designing and in its own organization.” The pressure to make customer training a profit center and disputes with the pilots’ union over hiring outside contractors amped up the corporate chaos level as the new aircraft was being birthed. Moving flight simulators from Seattle, where the planes were designed and built, to Miami may have been Boeing’s biggest misstep. The company put a continent between the engineers who contrive the machine and the flight instructors who observe in their simulators (hopefully almost all) the things that can go wrong when human being meets silicon and aluminum, long before anybody is hurt.[caption id="attachment_531" align="alignright" width="300"]

working from home comic

... …better it should be your doctor![/caption]No matter how spectacular the latest disasters, the airline industry does way, way better than the medical industry. A study published in the medical journal, BMJ, in 2016 estimated that 250,000 Americans die every year from medical error, making it the third leading cause of death, after heart disease and cancer. Some estimates place the number at over 400,000. Going with the lower estimate, a quarter-million deaths per year comes to about three 737 MAXes, fully loaded with passengers and crew, crashing every day!If you think Boeing experienced a certain degree of corporate chaos that contributed to fatal outcomes, you ain’t seen nothing until you’ve stepped into the world of healthcare. Time after time the electronic systems that ought to foster communication and collaboration among the various people that literally hold people’s lives in their hands don’t even talk to each other. Even within institutions, systems are too often clumsy and make-work.Need I tell you that communicating electronically with patients, all of which falls under the rubric of telehealth, is woefully inadequate? Just think about how many things you can accomplish easily and securely online with your bank or how it is finding and purchasing the airline tickets that best meet your travel needs, compared with how you communicate with your healthcare providers.Every breakdown in communication increases the likelihood that sub-optimal, harmful or even fatal healthcare events will occur. If the oncologist (cancer doctor) isn’t informed about what the nephrologist (kidney doctor) is doing, the patient could receive a bigger dose of chemotherapy than their kidneys can handle. If an office-based nurse practitioner doesn’t know that a person was recently discharged from the hospital after hip surgery the clinician might not know to suspect a life-threatening blood clot in the lungs when the muddled patient calls because they’re anxious.The technology ought to be the easy part. Internet protocols are standardized. Most of what needs to be done can be accomplished with inexpensive devices. Nearly everybody has a computer and/or a smartphone that can transmit and receive data, including voice (that’s what a plain old telephone does), images and video. It’s the people that are the hard part; that is, the people individually and as they gang up in institutions.In order to maintain a market advantage, health system A doesn’t want health system B to get its hands on its proprietary patient data… and vice versa. One set of doctors uses Mac IOS, another uses Windows. Managers must decide either to support both operating systems, with added glitches and complications, or else risk disempowering and angering a large segment of their physician clients. In the interest of “upcoding” (increasing charges) the billing department has insisted that nurses and doctors use checklist templates to record all encounters with patients, detracting from the richness (stories) in the medical record, while alienating the people on the front lines, as well as adding an hour or two to their daily workload. The medical licensing board in one state insists that every out-of-state doctor who does a telemedicine consult on even a single one of its residents get a full medical license--a tedious, expensive and slow process--no matter that the out-of-state physician may be the best expert to care for that sort of patient or that there is a severe shortage of that specialty in the state.In healthcare, training simulators are at least a half-century behind where they are in aviation. To be fair, it’s way easier to simulate a standard machine made of metal and silicon and such than it is an infinitely varied, non-standardized human body. Still, electronic technology could be a great boon for healthcare quality and safety. The lowest hanging fruits dangle from strong limbs of well-tested communication protocols and simple devices. The willingness and structures for collaboration are what’s missing. It’s killing us.

January 12, 2020
 in the
Digital Healing
Written by
Marc Ringel, MD

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Digital Healing: People Information, Healthcare

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