Thursday, September 15, 2016

Why do you say CPOE is clerical work?


“We can’t do that, they’re trying to get us to do clerical work.” – Physician overheard talking about electronic order entry and documentation

It’s an interesting observation that bears a little reflection, how did it come to pass that direct entry of an order into a computer, or typing in documentation become a clerical job?  How did using computers for these tasks become considered beneath the scope of a professional?  If history can shine any light on this, it is to uncover a bias that borders on classism and sexism.

Until the early 20th century, in contemporary Canadian culture, almost all professionals were men.  Middle-class women mostly worked in the home, raising the family or working on the family farm.  The exceptions were unmarried, usually younger women who could work in jobs that did not require as much time for education (as their working years often amounted to only a few before they were married).  So it came to be that medical office assistants and other clerical roles became associated as predominantly female jobs.  Now, even though much has changed with many women working in professional careers and men working in these traditionally female jobs, there still seems to be some of the legacy of these old divisions of labour that remain.

My father was a mathematician and was in fact, one of the first computer programmers in Canada.  He had been a student at UBC and was offered an opportunity in the mid 1950s to go out to U of T to work on programming the FERUT, a very expensive early computer.  One of the things that surprised me about his story was that he told me that – even though mathematics was a highly competitive and very male dominated field at that time – computer science was not.  In fact, many of the early computer science pioneers were female.

Beatrice (Trixie) Worsley was one of the first programmers in Canada.  She had trained with Alan Turing at Cambridge, UK where he was working after deciphering the German’s Enigma Code in WW2.   She was one of several women who met my father and guided him through his programming efforts.  I later asked my father why he felt the other mathematicians were not rushing over to learn about computers and he told me that many found it too clerical.  From the 1950s and 1960s, men tended to want to work with and design the machines and considered the programming as more of a female role.

Gradually, with the advent of the personal computer and next with the growing gamer culture, computer science and computer gaming became more and more a male dominated industry.  Today, 47% of the whole adult workforce in North America is female.  In contrast only 30% of Google, 29% of Microsoft, and 31% of Apple employees are female.  When looking at technical jobs, 80% of the people Apple hires currently are men.

So the question I ask is, is the perception that electronic health records are forcing doctors to do more clerical work based on anything other than historical prejudice?

Computerized order entry is simply more efficient than the historical paper process.  Consider the time it takes doing it the old way: a physician writes an order, holds on to the chart while finishing what s/he’s doing, carries the chart to the unit clerk where it sits in a bin until it’s transcribed and sent to the lab, pharmacy etc.  There is an obvious loss of efficiency and delay in that system.  In contrast, direct order entry sends the order immediately (point, click, enter, done), possibly done while the physician is still with the patient.  Similarly directly inputting documentation in a legible and immediately universally accessible format adds more intrinsic value to the patient’s record than a single minimally accessible often barely readable paper based record.  It is a cognitive error to assume that just because a given task reminds you of something a non-professional can do, that it is inherently non-professional. 

We may never be able to achieve perfect balance in gender equality.  There will always be differences between men and women.  But to berate a task because it was at one point in history associated with a subservient, female or clerical role, is insulting and a disgrace not only to the women pioneers of computer science but also to the those individuals we all rely on to perform those important “clerical” roles.

Monday, October 28, 2013

ACEP 2013

Just got back from ACEP in Seattle.  As always these conferences back so much into so little time.  Here are a few highlights:

1) There seems to be a move to half dose tPA in submassive PEs.  This seems to have no impact on mortality but decreases long term complications such as pulmonary hypertension.

2) Posterior dislocations of shoulders can be treated with simple should immobilizer and avoid that gunslinger cast that cant fit in any doorway!

3) Tranfusing GI bleeds seems to cause more harm.  A permissive approach had better results.

4) When you compare people on plavix vs warfarin after had injury the plavix group does worse and will likely need hospitalization after initial CT whereas the warfarin group might be able to go home with good follow-up.

5) Concussion management is complex.  Make sure you dont send that player back on the field too early.  Rest that brain means no computers kids!

6) There are some cool toys coming down the pipe - smaller ultrasounds, telemedicine robots, hemorrhage clamps, gortex treated lab coats...  I couldn't believe how big the display area was.

Monday, December 10, 2012

Subgroup Analysis (Ortho and Psych)

Subgroup Analysis (Ortho and Psych) - Poster Presentation to ICCH15 (Fairbanks, Alaska)

It was a busy summer of research presentations (and moving).  After helping to unload a moving truck in Victoria I flew up to Alaska to present the data on outcomes for orthopedic and psychiatry patients back in 2009.  What this study was looking at was the ability of clinicians to predict the acuity of these two sets of patients.  Does the gestalt that the receiving clinical get on the phone correlate with the patient's need for hospitalization?  The answer, according to this analysis is yes.

Impact of Teleradiology on Patient Transfers

Impact of Teleradiology on Patient Transfers (2012) - CAEP oral powerpoint presentation
ICEM (Dublin) Poster Presentation

In 2010, the GNWT rolled out a pan-territorial PACS system that allowed clinicians at any site across the territory to view xray, ultrasound or CT images from any other facility.  Given that the ER in Yellowknife was often the receiver of all the sickest patients I wondered what impact if any did the PACS system have on patient transfer rates.  What I did was simply compare the transfer rates pre and post PACS.  The data seemed to indicate a drop in transfers with the adoption of PACS.

Medevac Retrospective Review 2010

Medevac Retrospective Review - CAEP 2010 Poster Presentation

In 2009 I reviewed all of the data that Medical Travel (NWT) collected on medevacs and urgent transports for a one year period.  Here I found that there were far more people being transports on air ambulances than by using commercial flights.  Some of these patients (simple upper limb fractures for example) were getting medevacs when they could have likely come on the less costly commercial flights.  The question of how these cases were triaged and how the transport decisions were made was something I tried to improve on.  I realized that only with high quality prospective data could one develop an evidence based algorithm to sort this out.
Telephone Outcome Study: Power Point Presentation to ICCH 2009

In 2009, I presented some preliminary data at the Circumpolar Health Congress in 2009 about the experience in the Yellowknife ER with fielding calls from remote nursing stations and peripheral hospitals.  What we found was that there are a lot of calls asking to transport patients into Yellowknife.  We also found that there were lots of holes in the data that had been captured.  This lead to developing a better data capture process and to future studies on how we could improve pre-hospital care with the technology we had (at that time just a telephone and a fax machine).

The Meaning of Life (2/11) Movie CLIP - The Miracle of Birth (1983) HD