Tuesday, November 1, 2011

Tips from a Road Warrior (17): Checklists are Critical!

I have been burned several times upon returning from a flight by either not being able to find where I parked my car, or finding it with a dead battery. The airport I fly out the most is DFW in Dallas-Fort Worth, which is very spread out and has five different terminals. It seems that every time I fly out of, let's say terminal C, I seem to return to any terminal but terminal C. I have come back at the height of summer, hauling two suitcases in more than 100-degree heat through the parking garage trying to find my car. I ended up getting a taxi to drive me around to find it.

On another occasion, I returned to a car without a battery as I left my interior light on. In this particular case, I was at a remote parking lot at JFK airport in New York City trying to call AAA road side assistance and could not convey to the person on the phone my car’s location, I fortunately ran into someone with jumper cables who could get me started. Having learned my lessons, I now have a "system" by which I always write down my parking space, and always check the car before I leave it at the garage for any lights etc. that might drain the battery.

Having a well-defined system for documenting status and locations really helps, not only when traveling but also when dealing with complicated systems such as healthcare IT systems, especially when multiple people are involved. I find that the institutions that have a very well defined checklist seem to have the least down time and fewest problems.

One of the hospitals I deal with has three shifts for their PACS administrators so they can provide 24/7 support on-site. There are always two or three people available, and at night typically one person. Needless to say this is a very large institution, which has a very high degree of availability of its PACS system. They have not had any considerable downtime in more than a year. In addition to having a robust and mature PACS system, I find that the main reason is the way that the PACS team monitors their system. They have a detailed checklist that helps them to regularly monitor all critical processes. Some of these are checked hourly such as the RIS feeds while others such as queues in the database or archive, as well as error files, are checked every four hours or as needed.

Some of the checking can be conducted by active monitoring software, which will page or e-mail an administrator that a process is going down, however, performance and intermittent issues are hard to detect automatically and require that someone has the finger on the pulse on a regular basis.

Checking a system on a regular basis and making sure that all errors and problems are addressed immediately as they occur will not only pay off in the short term, but also in the long term, especially when the data has to be migrated. When changing vendors, it is not uncommon that all of the information from the database and archive has to be migrated to a new vendor’s platform and, at that time, information that was mismatched, unidentified or incorrectly identified will rise to the surface. Upon migration, it will become obvious how well the system was managed during the lifetime of the system.

I learned my lesson when traveling by carefully documenting where I left off so I can get back on the road upon my return. For me, documenting is a necessity when dealing with multiple airports, parking garages, hotels, and facilities I visit. The same applies when managing complex systems: the better the documentation, the better the hand-off and ultimate quality of the information that is managed. 

What About the End-user?

I recently came across a couple of examples showing how healthcare providers still do a poor job of providing products services and even physical facilities that truly meet the needs of end-users. As a case in point, when I asked my chiropractor why he still requests film for the MRI's he has done for his patients instead of getting the images on a CD, he told me that the viewing software that is embedded on those CD’s is so hard to use that it sometimes takes him up to 30 minutes to figure out how to line up two series on his monitor. Taking a set of films out of a envelope and placing them on a viewing box is much faster. The second example was when I talked with a local primary care physician who is considering scaling down her practice because the meaningful-use requirements for implementing electronic health records require her to implement an EHR to continue to get full reimbursements from Medicare and Medicaid. The fact that she can get between $40k and $50k in grants to implement an EHR does not counter balance the additional work needed to enter all of the information into the system. She told me that she has looked at several EHR products and none of them meet the requirements for her to enter the information effectively and efficiently. The last point is when I talked with a nurse who is just moving to a brand new wing in her hospital, which was built without taking any input from the nurses who are going to be working there. Instead this brand new facility, which was most likely designed to meet all building standards, does not meet any of the potential workflow improvements that could have been made. 

The US government is trying to improve the efficiency and quality of healthcare, but the industry is lacking products, services and facilities that focus on what the user really needs. This appears to be less the case when one considers the acquisition of devices such as new ultrasounds or CT’s, but appears to be common with the software, larger systems and infrastructure. I am not sure what the solution is except for encouraging end users to continue to press the industry to focus on the end-user.