There’s an “easy button” in the hospital that I press a hundred times every day. With each press, I make myself a better doctor. It’s not a button on a computer. It’s not electronic at all. It’s a hand sanitizer.
A decade or two ago, hospital handwashing compliance rates were in the single digits because washing with soap and water took too long. When Purell and other alcohol-based hand sanitizers became popular, hand cleaning went up and infection rates went down because it was so much easier for a provider who needs to enter patient rooms a hundred times each day to provide good care.
What’s remarkable about the popularization of hand sanitizers is that a simple technological innovation achieved better results than years of training, cajoling, and admonishment about handwashing ever did. Instead of forcing providers to slow down their workflow, hand sanitizers adapted to the existing workflow. Suddenly, well-meaning providers did not feel excessively burdened by the requirement to clean their hands before entering a patient’s room.
There are times when such a technological innovation is not an option. An example is the pre-procedure checklist, which has saved thousands of lives by requiring a procedure team to stop and ensure certain safety measures are completed before a surgery or procedure. Checklists inevitably take one or two minutes to complete. This time is well spent because rates of infection and other complications drop dramatically when checklists are used.
Implementation of a time-consuming safety innovation like a checklist requires a major cultural shift. Peter Pronovost, an anesthesiologist at Johns Hopkins who helped pioneer these checklists, has pointed to culture change as essential to successful implementation of a checklist. Physicians need to believe that checklists can improve their outcomes and other team members need to feel comfortable speaking up to make sure checklists are used. This culture change is far more difficult to achieve than the creation of the checklist itself.
As in the example of pre-procedure checklists, changing culture in healthcare can be both necessary and tremendously successful. Yet it is never easy. In terms of convenience, it can never compete with the instantaneous ease of hand sanitizer. So, whenever possible, we should seek technological solutions that make it easier to practice good medicine.
Opioids have received a great deal of regulatory attention recently because of the devastating burden of disease caused by these dangerous medications. Several states have recently passed laws intended to reduce the risk of opioid abuse. Unfortunately, some of the requirements, while important, will interfere with provider workflow significantly. This makes these regulations less likely to succeed.
For example, many states have passed laws requiring physicians to consult a prescription drug monitoring program (PDMP) website to see whether a patient is secretly receiving opioids from other providers. This is an excellent way to deter “doctor shopping” and reduce inappropriate opioid prescriptions. Yet it takes several minutes each time a physician needs to prescribe opioids to open a browser, log in (and remember the password), look up the patient, and review the prescription history. This inconvenience, small as it is, limits how consistent physicians are about complying with this rule.
A technological solution could greatly increase use of PDMP data. For example, if the data were imported automatically into the electronic medical record, it would greatly speed up the process. Rather than requiring a major cultural change to create a new expectation for physician behavior, this approach would make it easier for physicians to do what they already know is right. As with hand sanitizers, compliance rates would jump.
Whenever a regulator or hospital administrator identifies a healthcare quality problem, the natural reaction is to place extra requirements and responsibilities on providers. This is well-meaning, but fails to recognize that the education and culture change needed to implement new requirements is extraordinarily time-consuming. More focused investments of time in technology solutions to safety issues would save considerable time in the long term, and would lead to more successful interventions.
Healthcare does not need more burdensome rules dictating providers’ behavior. It needs more easy buttons.
Alex Harding is a resident physician in the primary care track of Internal Medicine at Massachusetts General Hospital. He has no financial interests to disclose. Follow @alexharding7