Recently I had the opportunity to observe a hospital emergency room in action up close and personal. Fortunately, it was not one of those frantic, life-and-death moments you see on TV. Instead it was a rather gross-looking dislocated elbow, the result of a skateboarding accident. The scene was unfolding in a brand new $110 million wing of a major regional hospital, so new the smell of fresh paint overpowered the usual aroma of rubbing alcohol and disinfectant.
As part of the routine examination, the doctor asked my teenage son, the death-defying skateboard acrobat, to breathe deeply as he listened through the stethoscope, the only piece of traditional medical equipment to be found in this ultra-modern facility. A strange look came over the doctor's face. His eyebrows crunched up. He grimaced, and frantically moved the stethoscope around, his demeanor growing more intense and puzzled-looking. He kept looking upward to the ceiling. Something wasn't right.
"OK, Doc," I asked, bracing myself for the worst, "what's wrong?" He angrily pulled away the earpieces, pointed to an air duct directly over the bed and said, "That's what's wrong. I can't hear a darn thing with all that loud hissing going on." "Wow!" I thought. Once again, two obvious dots that should have been connected were not. In designing and building a new emergency healthcare center, neither the architects nor the HVAC (heating, ventilation and air conditioning) engineers bothered to talk to the doctors, nurses or patients who would actually be using the place.
To be fair, they probably did confer to some extent, perhaps communicating through a consultant. I doubt if the whole thing was done in total isolation. In the case of HVAC design, it's all about airflow—volume, temperature, velocity, moisture. In a hospital emergency room, you want to maintain positive air pressure. But with pressure and velocity comes noise, and a high level of ambient noise is something you don't want when you're listening through a stethoscope for subtle abnormalities in breathing or heart function. That's the critical knowledge nugget that was missing.
I can't help but wonder how many other more serious disconnects are lurking, waiting to be uncovered.
Life and death decisions
In the medical field, two parameters are vitally important: speed and accuracy.
On the speed side, consider the glacial pace at which the results of medical research work their way into clinical practice. According to the U.S. Agency for Health Research Quality, it may take as long as one or two decades for original research to be put into routine clinical practice. A major reason for that is misalignment across various lexicons, skill and experience levels, age groups, geographic regions, ethnicities and cultures, to name a few.
On the accuracy side, medical errors remain a stubborn obstacle, much for the same reason. While we have been making excellent progress in the area of evidence-based medical research, the application of the results of that research is often inconsistent. Most of the knowledge flows in one direction, with little feedback from the field. If somebody in practice discovers a more effective way of implementing research results under certain conditions, that knowledge usually remains localized, only to be "rediscovered" in other places through needless trial and error.
As things currently stand, according to U.S. Health and Human Services Secretary Kathleen Sebelius, only about three out of five patients with chronic conditions are administered the proper treatment protocol. In addition, of the 36 million people who check into a hospital each year, more than 10 million acquire an infection or some other adverse effect unrelated to the condition for which they were originally admitted.
Even worse, the Institute of Medicine estimates that as many as 100,000 Americans die in hospitals each year from preventable medical errors. As one concerned healthcare executive explained to me recently, that's roughly equal to one 737 jetliner crashing each and every day. Even in a bad year, the aviation industry's safety record is several orders of magnitude better than that of our hospitals, due in large part to the extensive training and error-correction systems it has in place. It's time to start adapting some of those practices to the healthcare sector.
Knowledge is key
The good news is we have a tremendous opportunity. Excellent progress has already been made toward building a high-assurance infrastructure for electronic medical records. Simply eliminating the redundancy and errors associated with having those records scattered and fragmented across incompatible systems is a giant step toward increased efficiency and improved accuracy.
The next challenge is bringing expert knowledge along with patient data directly to the point of decision, which is where many of the errors causing injury and death occur. Sometimes it may be a single decision, with a person's life hanging in the balance. Or, as is often the case, it's a series of small, seemingly minor decisions that taken together can mean the difference between failure and recovery.
Connecting apparently unrelated dots like HVAC systems and stethoscopes is a must if we are to maintain a grip on our increasingly complex healthcare system. Medical practitioners, insurers, administrators, equipment manufacturers, operators and technicians, patients, families and researchers all need to be on the same page. That means not only connecting the dots, but also getting knowledge to flow among them quickly and easily, making sure nothing gets lost in translation. (For more on knowledge flow alignment, see "Unclogging the Knowledge Pipeline," KMWorld, November 2010).
Imagine how much we would all benefit by removing the guesswork that accompanies medical practice in our society. For example, by mapping the interdependencies among various known elements such as a patient's family medical history, food intolerances, metabolism, blood chemistry, cultural background, even stress and previous trauma, the chances of success are greatly increased. If the potential cost of all this seems daunting, consider that currently in the United States more than $300 billion per year is wasted through incorrect treatments and misdiagnoses.
In future articles, we'll take a look at some of the more exciting developments in this critical field, and how knowledge management will end up changing the very way we think about medicine. In the meantime, why not try putting together a health map for you and your loved ones, and start filling in those missing connections that might come in handy some day. You don't have to be a medical expert. You can start with simple things like wearing elbow pads while skateboarding, and work your way up from there.