Digital Distractions: Time for a Diet

It’s been said that losing weight is much harder than kicking cigarettes or alcohol. After all, because one doesn’t need to smoke or drink, the offending substances can simply be kept out of sight (if not out of mind). Dieting, on the other hands, involves changing the way a person does something we all must do everyday.

It’s no surprise, then, that reports of problematic doctor interactions with social media are popping up with metronomic regularity. When it comes to the smorgasbord of information coursing through those Internet tubes, increasingly, we all have to eat. And that makes drawing boundaries a challenge.

While most early reports on the perils of social media concerned inappropriate postings by physicians, a new hazard has emerged recently: digital distraction. On WebM&M, the AHRQ-sponsored online patient safety journal that I edit, we recently presented a case in which a resident was asked by her attending to discontinue a patient’s Coumadin. As she turned to her smart phone to enter the order, she was pinged with an invitation to a party. By the time she had RSVPed, she had forgotten about the blood thinner – and neglected to stop it. The patient suffered a near-fatal pericardial hemorrhage.

In a commentary accompanying the case, the impossibly energetic John Halamka, ED doctor and Harvard Med School’s Chief Information Officer, described all of the things that his hospital, Beth Israel Deaconess Medical Center, is considering to address this issue. It’s not easy: whereas the hospital owns the Electronic Health Record and can manage access to it, the vast majority of mobile devices in the hospital today – at BI and everywhere else – are the personal property of the users. So Halamka is testing various policies to place some digital distance between the personal and professional, including blocking personal email and certain social networking sites while on duty. He’s even investigating the possibility of issuing docs and nurses hospital-owned mobile devices at the start of shifts, collecting them at the end.

But he knows he’s swimming against a powerful tide. “The consumer technology industry is bringing more tech to doctor hands faster than policy can be made,” Halamka said in an interview with Kaiser Health News. It may be that blocking people’s access to their Facebook feeds is as futile in Boston as it is in Beijing. Information will find a way out, particularly when people are as addicted to it – and the little Dopamine squirts that cheer our brains after every incoming message – as they are.

Of course, the patient safety challenges posed by distractions are not new, nor are they exclusively electronic. One time-motion study of nurses found an average of 1.2 interruptions (by people, not electrons) during every medication pass. Another study found that every interruption during the medication preparation and administration process was associated with a 12 percent increase in clinical errors. Some have even argued that these personal interruptions and distractions are more challenging than e-interruptions. Henry Feldman, a hospitalist and informatics expert at Beth Israel, recently made this point. “Unlike my mobile technology, which I can shut off and not pay attention to, I can’t not pay attention to the nurse who’s directly in front of me,” he said in an interview. “Shutting off the nurses is a quick career-ending move around here.”

While Feldman is undoubtedly right about dissing the nurses, I don’t buy his overall thesis. Humans have the capacity to see that a colleague is busy or trying to concentrate, and most – all right, some – will pipe down until the task is done. But Facebook updates and email incomings neither know nor care that you’re writing for chemo or d/cing an anticoagulant. As family physician Caroline Wellbery wrote in this week’s JAMA, “… the computer is a sort of enchanting – and ever-distracting – mistress to the plain and stolid wife of… physician-patient conventions. We are in the process of working out an open marriage that will allow seamless incorporation of technology into our daily professional lives.”

How do we do this? Aviation has the concept of the “sterile cockpit” – cockpit crews are prohibited from engaging in anything but mission-critical conversation when the airplane’s altitude is below 10,000 feet. This concept is being adapted to medical practice, and early results are promising. One hospital gave nurses a protected hour – during which they were not to be disturbed by telephone calls or pages – and saw fewer medication errors. Another put red tape on the floor to establish a “ No Interruption Zone” for nurses performing mission-critical tasks. This too led to fewer interruptions and improved medication safety. Granted, these fixes don’t solve the problem of the “open marriage” between our e-toys and us entirely, but they do illustrate that we are starting to take the problem of distractions seriously.

Can we legislate ourselves out of the digital distractions problem? I doubt it. It seems to me that virtually any highly restrictive solution is likely to be plagued by workarounds. My parents didn’t allow me to listen to Mets games after bedtime on school nights, but I managed to sneak my transistor radio into my pillow and plug in an earphone (sorry, mom). So too will it be if we try to block our workers from their Internets.

The solution will come from some thoughtful rules (let’s start with no texting or surfing during procedures or while giving anesthesia) and a vigorous call to professionalism. Healthcare providers need to be educated about the hazards of ubiquitous connectivity, and it must become second nature to log off or put away the smart phone during a complex task. My UCSF colleague Ryan Greysen has written about the hazards of physicians interacting with social media, calling for “online professionalism,” mostly in response to reports of inappropriate postings and interactions on the web. The boundaries of this professionalism need to be extended to avoiding web-based distractions.

Laws that ban texting while driving haven’t completely solved the problem, but the combination of such laws and changing social standards (even my kids now know that texting while driving is “not cool”) are making a difference. It is time for a similar approach to digital distractions. While it would be too much to ask physicians to give up their digital food entirely, the time is right for a digital diet.

8 Responses to “Digital Distractions: Time for a Diet”

  1. Kevin B. O'Reilly March 30, 2012 at 8:10 pm #

    Good post, Bob. You may be interested in my recent look at this subject, featuring some of the usual suspects: http://goo.gl/RRlXt.

  2. Menoalittle March 31, 2012 at 6:39 pm #

    Bob,

    Finally, thank heavens for facebook and CPOE simulcasting on mobile medical devices to enable an alert to be sounded on the adversity of HIT. Did the AHRQ adverse event from the handheld mobile medical device get reported to the FDA?

    What you describe is merely the tip of the iceberg of dysfunctions and toxicities associated with and caused by these new unregulated medical devices.

    I find it striking that the social media is being targeted as the culprit, when, for years, there have been deaths and injuries of patients who were unwitting guinea pigs of the HIT vendors’ devices including CPOE, eRX, EHR, and CDS, each of which have embedded user unfriendliness and pages of nonsense jabberwock, all of which distract and disrupt cognition. This is in addition to their intrinsic death causing defects.

    So what’s the big deal about blaming addictions to a third party email or facebook when the basic EHR and CPOE devices are flawed, defective, and toxic to safe and effective medical care and no one is gathering the data?

    The magnitude of the problem is formidable, enough so that the CDC ought to be investigating this iatrogenic disease.

    Best regards,

    Menoalittle

  3. Sandy Brady, RN March 31, 2012 at 9:39 pm #

    The case is an example of infrastructure failure. The injury occurred due to the flawed design of the MDDS component of the EHR, that has no warning that new results have been electronically deposited in the EHR. I have read reports on the FDA MAUDE database on this topic.

    The failure of the doctors to review the results MDDS on a daily basis appears to stem from the time it takes to sign on and the reflex avoidance of having to waste that time. In addition, the original order was flawed which is common with CPOE systems when clicking in warfarin doses.

    May I ask, where were the minds of the nurses who gave the warfarin, and where were the minds of the pharmacists who sent the warfarin to the nurses? Were they all on Facebook?

    This is yet another defect in the infrastructure of CPOE. Critical judgments are blunted. If the computer lists the med to be give, it must be correct. In this case, despite the failure to cancel the warfarin, no one else was thinking.

    In all due respect to Professor Halamka and his titles, his commentary missed the gravity of the failure of the entire infrastructure of medicine administration in this case, and it is all due to the adverse affect of CPOE on medical care.

  4. Chris Paton April 1, 2012 at 4:31 am #

    There are a couple of fronts on which these problems can be tackled. One is to educate about how to be most productive with any particular technology. For example, you should try to keep your inbox empty, check emails and texts only 2 or 3 times per day, use the “only handle it once” technique and turn off notifications when you need to concentrate. Most people, if trained properly, would not see this as an imposition but would value the help managing information overload.

    The second front is to properly assess and design clinical systems for the environment that they will be used. We need a good processes to both iteratively improve existing applications (so that mistakes don’t happen twice) and to enable highly innovative tools to be implemented when appropriate.

    Over time we’ll establish a good evidence base about how systems should be designed and implemented that removes bad features (such as the ability to be able to be messaged in the middle of ordering a test) and ensures good, evidence based design principles are followed.

    To achieve this second aim, we need a rigourous science of health informatics that produces reliable evidence which we can use to design and improve health IT systems. The healthcare professions can’t leave this to the software companies and IT departments – they have to be involved themselves as clinicians and insist upon a scientific approach (as they do with drugs and other medical devices).

  5. 999999999999999999% April 1, 2012 at 1:14 pm #

    Chris Paton, above, provides insight :

    “… and ensures good, evidence based design principles are followed.

    To achieve this second aim, we need a rigourous science of health informatics that produces reliable evidence which we can use to design and improve health IT systems.”

    It is shocking that this has not happened before the vendors sold EHR and CPOE instruments to hospitals.

    I am interested in the number of deaths from similar CPOE faciliatated coumadin cases like this are out there.

    I hold the same interest for every other CPOE ordered drug with a narrow therapeutic ratio.

    Who knew?

  6. Jake Levinthal June 28, 2012 at 3:55 pm #

    Speaking of social media and your earlier piece about cutting the cost of healthcare, I believe that healthtap.com provides a positive step in that direction by providing a platform for physicians to answer questions posed by real patients.

  7. Latarsha Puga August 25, 2012 at 1:34 am #

    You’ve created a good article with plenty of good information.that will serve us all.

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