Beware the digital dinosaur

I’m not good with technology – I never have been.?I remember inheriting my first iPhone, looking up someone’s number - and having no idea how to call them.?There was no ‘call’ button anywhere!?Before too long I accepted the quirks of this new device, and embraced it – together with all the data it gave me at my fingertips. But I will never forget that moment of panic - “How do I make a call??!” – and feeling very angry at that overly ‘smart’ phone.

You see, I’m of the generation that had to clumsily transition from paper to digital records, at a stage of my life when I was already so used to doing things a particular way – that is, putting pen to paper.?I was also accustomed to the workflows associated with paper records.?In my day, we would push trolleys of manila folders through a ward round, scrambling for the right patient record at each stop (catching bits of paper that sometimes fell out). And that was when things were organised well.?On other days we would scamper through the ward, frantically hunting down a patient’s history while the round went on without us - then trying to catch up with the team, and scribbling on scraps of paper until the file could be located (usually after the overnight nurse had finished writing up his/her notes before he/she came off shift).?That question, “Have you got the patient’s history?” would fill me with dread, because inevitably it meant the folder could not be found. And please don't get me started about obs and med charts!

Then, with the benefit of electronic records, we knew exactly where to find a patient’s history, any time we needed it.?Yet because I was so used to paper records, I preferred them – I was more comfortable with the routine, as chaotic as it was - it felt 'natural'.?That is, until a digital record saved my patient’s life (and as such, my psychological well-being).

A man presented to emergency with rapid atrial fibrillation (which has multiple potential causes) - he had driven himself to hospital and did not speak a word of English,?but I had a sense he was agitated and confused.?We had no interpreters on site, and his cochlear implant meant he could not hear the phone interpreter – so I was unable to obtain any history from him.??Instinct told me he was quite unwell, so I ordered a few screening investigations (I had no idea what was going on - due to the absence of information, which is so often diagnostic). In the meantime, I was able to very quickly access his past history through the hospital’s clinical system, and noted a history of benign prostatic hypertrophy.?Straight away – joining several dots – I suspected urosepsis, precipitating rapid atrial fibrillation.?I treated this patient immediately with broad spectrum antibiotics, and called the urologist.?I was right.?It turned out this man had and an obstructive uropathy which had become infected, and he needed urgent surgical intervention.?This man survived – thanks to a digital record.

So this dinosaur (ie. me) finally embraced the digital world – though it was not without its challenges.

As a permanent locum doctor, I had no permanent identity anywhere.?I was rarely given a log-in when I rocked up to a shift, and often had to borrow someone else’s – which of course would make the system think someone else was looking at that record, or ordering that investigation, or writing that note.?I remember accessing a clinical system (which was different everywhere I worked) in the middle of a busy emergency department, juggling patients and tasks, and feeling boggled.?All the ‘tabs’ in the system were different to the ‘tabs’ in my head – it was not obvious to me where to look for what I needed.?I would click and click and click until I found the information I was looking for - or scamper through the department frantically (like the old days), looking for someone who could help me.?

I would order urgent pathology – there were no paper forms – how was this done again? Click, click, click (or scamper frantically). I might have spent half a day being inducted on the system, but until I started using it in real time, ?it was always going to be far from second nature (which those paper forms were).

I’d prescribe medications through drop-down boxes.?I would take extra care because it was too easy to accidentally select the wrong dose.?Then I’d have to check a patient’s x-ray – so I would need to log into a different clinical system yet again, and again with someone else’s log-in.?

I’d return to the other electronic system to complete my notes – which sometimes required selecting more drop-down boxes.?Sometimes I just couldn’t find the exact option I wanted, so I’d have to settle for next best thing (otherwise I would not be able to ‘close off’ the record).?Before saving an entry, a box might pop up - asking me to confirm if I was 'sure' about something - with the ‘yes’ (or 'no'?) box highlighted.?I would just click the button (without thinking) because there were so many notifications that I took them all for granted, and they just got in the way of getting the job done (only now do I understand this as ‘clinical reminder alert fatigue’ – see for example R. Backman et al: https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-017-0627-z.)

Then OOOPS... I’d realise I was logged into the wrong patient record!!

Clinical systems are GREAT (and can be life-saving), but their ‘usability’ is absolutely critical to their success - and most importantly, to supporting safe, effective and quality care.?Usability may become less of a challenge as younger generations emerge – perhaps those who have been brought up on iPhones, and who intuitively know how to make a call.?In the meantime, you may wish to be mindful of those 'digital dinosaurs' in the workforce when creating or implementing any clinical system.