When the computers crash

February 18, 2005

This internist says computerization is overrated and erodes the doctor-patient relationship.

Our clinic computers went on the blink last week, and work ground to a halt. The receptionists couldn't confirm scheduled appointments or make new ones. The nurses had no way to record vital signs or transmit phone messages. The billers couldn't bill.

We doctors couldn't read our old notes or write new ones. We couldn't figure out if Mr. Jones needed blood tests today (as we suspected) or if he could put them off until November (as he maintained). We couldn't click the mouse once to prescribe a dozen medications; now every slip had to be laboriously written out by hand. And who remembers how to spell pyrazinamide anyway, let alone what size pills it comes in?

When the computer prompts our every keystroke, we are lean, mean prescribing machines. Without it, we are just people with pens and pads fumbling through reference books. An hour into the chaos, a nurse muttered that as far as she was concerned, we might just as well all go home.

And indeed, the average supermarket processes artichokes with more finesse than most hospitals do people. There are the scrawled, notoriously illegible doctors' orders. There are the handwritten signs that may or may not be noticed, taped to charts ("Caution! Patient with similar name!") and above beds ("No blood drawing in left arm"). There is the pesky symmetry of the human body that leads proactive patients to ink arrows on their bodies before surgery.

It's easy to fantasize that computerized orders, bar-coded patients, and wireless communications can straighten everything out. Some hospitals are on their way to streamlined electronic perfection, and do report improvements. But others linger at the back of the pack, with computers that have yet to smooth the jolting, sometimes terrifying, potholes of working in a hospital or being admitted to one.

The various computer systems in a hospital may not speak to one another. Patients may report that they have had tests of which there appears to be no record at all, until a last-ditch phone call to an administrator of a separate computer system locates the results. Elisa Green and Elias Green may still get all mixed up, as may the three James Johnsons; their computerized charts often carry the same flag as their paper ones did: a pop-up box announcing "Caution! Patient with similar name!" that's pretty easy for someone in a hurry to ignore.

Computers were no help in averting one of the worst near-disasters I'd seen in years: A tired resident pointed and clicked one patient's powerful dose of blood thinning medication onto another patient's orders. Some hospital systems might have been intelligent enough to balk, but hers wasn't. It's anyone's guess if the pharmacy or the patient's nurse would have caught the error; fortunately, her supervisor happened to check her work that day. Both doctors, white-faced, learned instantaneously that computerization alone doesn't eliminate medical errors.

Perhaps more computers or wiser computers are the solution, especially if they are programmed with whatever combination of fear, suspicion, and conscience makes supervising doctors compulsively check trainees' orders.

Sometimes, though, it's tempting to wish for fewer, dumber computers instead. After all, if the intern had been writing orders on a bedside clipboard, the mistake would never have happened. Computer screens all look alike; patients' faces do not.

In an essay published in The Journal of the American Medical Association in 2002, internist Steven Angelo wrote about the day his hospital computer crashed. For a few hours, the intensive care unit staff was unable to track a patient's blood pressure or heart rate by looking at a monitor. The chairs in the unit's nursing station, he wrote, slowly emptied out: The doctors and nurses had gone to sit with their patients.

In our clinic, the computer monitors are placed so that the doctor can watch the screen or the patient, but not both. Frankly, it's not much of a contest. The monitors are mesmerizing, with their colors and windows, boxes and beeps, menus of pills ripe for the prescribing. Walk down the row of offices and you see the patients looking at their doctors, and the doctors looking at their screens.

Last week, when the system crashed, we looked at our patients instead.

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Copyright © 2004 The New York Times Company. Reprinted by permission.