What about cognitive errors?!

The latest issue of Time has a review of Dr. Jerome Groopman’s new book “How Doctors Think” which presents the four categories of cognitive errors that doctors make in thinking about their patients’ problems.

Much has been made about “technical errors,” such as mixed up lab orders, and how they contribute to up to 98,000 deaths among American hospital patients each year, and thus the errors of our decision-making, the “cognitive errors,” are totally overlooked.

These errors, Groopman claims, have graver consequences. He learned that about 80% of medical mistakes are the result of predictable mental traps, or cognitive errors, that bedevil all human beings. Only 20% are due to technical mishaps -- mixed-up test results, hard-to-decipher handwriting and the like.

So what are the four cognitive errors doctors make that can harm their patients? Using stereotypes instead of facts to inform decisions, being influenced by having “seen something like this,” a bias toward action over thought and negative emotional reactions to certain patients.

I believe it's hard for physicians to change these types of errors. We should be aware of them and do our best to overcome these mental traps. However, as the neuroscientist Antonio Damasio asserts (and which too many economists were blind to because of their faith in rational motives as the end-all be-all explanation for why we buy what we do), emotion plays a central role in cognition and decision-making.

And human nature, because it relies heavily on emotion and cannot shortcircuit emotion's influence on reasoning and logic, will force physicians to fall back on these errors despite the best of efforts. (I’m making the case for most doctors, as I’m sure there are some exceptions to the rule.)

So I say instead of trying to change fundamental human nature, let's create tools to overcome it. Patients’ health must not suffer because of human folly if it can be overcome. And it can. Technology after all is used to reduce technical errors, so why should it not be used to reduce cognitive errors too?

It seems to be happening under the radar, actually. I wrote about the Isabel computer diagnostic tool before. Of course, more must be done to spur the adoption of these tools as well as to develop new ones. This seems like a big opportunity for entrepreneurs!

The VA may be ahead of the technology curve, but...

I have written about the VA hospitals in the past, impressed by the use of EMR/EHR systems. It's a sign of progressiveness.

However, every so often one is reminded that technological advacement does not a better service make by itself if money and quality people are lacking. The news about the poor conditions of the Walter Read barrack opened investigations into military hospitals. One VA hospital here in Texas (luckily not Houston's) was shown to provide very poor care over & over again.

The patients range from terminally ill Vietnam-era veterans seeking cancer treatment, to a decorated Marine wounded in Northern Iraq who is now dealing with post-traumatic stress disorder and drug addiction.

Their complaints begin with the long wait just to be admitted to the hospital, but they don’t stop there. Once in the system, they describe an uncaring and unresponsive staff unwilling to provide even the most basic care. The most serious allegations suggest misdiagnoses, if not malpractice.

This is an excerpt from "Investigation Reveals VA Hospital Conditions" by Ginger Allen for Dallas' CBS station.

Preventive Medicine using Imaging but at a High Price

Two days ago I had the privelege of shadowing a great endocrinologist in Austin. It was at his clinic that I was introduced to the idea of doing both ultrasound imaging and fine needle biopsy of the thyroid in-house.

What was far more interesting to me -- because it doesn't fall within "endocrinology" (e.g., diabetes/pancreas, thyroid and reproductive organs) -- was that the clinic sonographers can also take an ultrasound image of the carotid arteries and then tell you if there is too much thickening of the intima and media, the inner two most layers of the carotid artery, and thus determine one's risk of ischemic stroke.

Called CIMT (for Carotid Intima Media Test), this is a non-invasive procedure that takes less than 3 minutes. And the cost? $299, though the clinic is currently running a special for $199. Does insurance cover this screening test? No.

And there is another non-invasive imaging test called this review article.) Cost at the heart hospital in Austin? $199.

I believe focusing on preventive medicine is important for preserving or enhancing a patient's quality of life and for lessening the cost burdens on our healthcare systems as a large portion of complications can be averted.

However, in these cases the barrier is high cost. Only a small segment of Austinites can afford to get screened for the health of their carotid and coronary arteries. Which means for the most people this kind of preventive medicine is unavailable.

Still, this is a step in the right direction. And with most technology costs, it will fall in time so that more can afford it.

Time will also tell if these preventive measures help reduce stroke and heart attacks. If they are found to be effective and also become cheaper, then insurance companies and the government will more likely cover them in the future to the benefit of most Americans.

However, in time the promise of these imaging-based screening tools can prove false, as a recent study showed with CT screening for lung cancer. As one NY Times article judged it, based on the article published in JAMA in March 2007:

Lung cancer screening with CT scans does not appear to save lives and exposes people to serious risks of injury and even death from needless surgery, researchers are reporting today.

None of this is to say that we shouldn't keep trying to find effective screening tools that will prevent disease and death. We should, by all means. All this does is puts the promises of new untested screening tools in perspective.

Tablet PCs (finally!) for healthcare

In searching for news on Catalis, about which I wrote my last post, I learned about another Austin company that exists in the health IT field: Motion Computing. Led by a former Dell exec, Motion has redesigned the tablet PC specifically for doctors, nurses and other healthcare workers.

Their tablet PC is called the Motion C5 and seems to be -- according to this Austin American-Statesman article -- either endorsed or designed with the help of both Intel and UCSF's medical faculty. Features of the C5, as quoted in the article, are:

The book-size device comes with a built-in bar-code scanner for tracking patients and medications, a video and still camera for documenting patient problems, and radio frequency identification tracking technology.

It has the ability to store, access and update patient records wirelessly from anywhere in a hospital. It also is spill-resistant and easy to disinfect.

Executives say the device will help nurses cut down on paperwork, freeing them to spend more time with patients. It also is designed to reduce medical errors and improve efficiency in hospitals.

It is, according to the CEO Scott Eckert, the only tablet PC that currently packages all those features in one computer. This seems a boon to healthcare workers. However, in the short-term there will be the usual source of resistance: the difficulty of teaching old dogs new tricks. And the C5 is competing in a tough field, tough not because of competition but due to lack of demand.

A few years ago, after Microsoft Corp. introduced the operating system for Windows-based tablet computers, some analysts predicted as many as 14 million of the devices would be sold by 2009.

Today, the projection is closer to 3.5 million, according to Roger Kay, a computer industry analyst who runs Endpoint Technologies Associates Inc.

Still, the article notes that one strong area of demand for tablet PCs is the healthcare industry. In fact Motion makes a large portion of their revenue by selling tablet PCs to healthcare workers. And at $2,200, it's in the same price range as high-end desktops (which hospitals and practices often buy) and laptops.

A Different Kind of Electronic Health Record

My friend Karthik, who's in Health/Info Sciences, told me to check out an Austin-based company called Catalis. It's not just another company with an EHR product, but a company making a graphical-based EHR product.

The graphical-based part is what makes it stand out in a crowded field based on my experience using many different kinds of EHR systems (the VA's VISTA, a McKesson-made system and a GE product called Centricity) for over a year now as a med student.

Catalis does a nice job of showing off the features of its EHR software. (Caveat: I don't know if these features are unique to Catalis' software versus other EHR systems software.) The three I found most compelling -- and most represent a step up from EHR systems I've used -- are:

1. You can document such problems as fracture sites graphically instead of (or in addition to) textually.

2. Typing is replaced by handwriting, which means docs won't have to learn new habits when it comes to charting.

3. The EHR system will warn you if a drug you prescribe is contraindicated, something I lobbied McKesson to do with a couple emails -- and to no avail I might add (although the company did start having monographs linked to drugs in patient charts after I emailed them).

Apparently this isn't just on the drawing board, according to the press release where a few doctors endorse Catalis' EHR software.