Technology and Health Care, 1 (1993) 85-87 0928-7329/93/$06.00 © 1993 Elsevier Science Publishers B.V. All rights reserved
Clinicians' requirements. 1. A pragmatic operational viewpoint Nigel Zoltie Consultant, Accident and Emergency Department, Leeds General Infirmary, Leeds L51 3EX, UK
In these remarks I shall discuss the needs and requirements of clinicians from a practical, pragmatic, and operational viewpoint. I shall not discuss (though Dr. Henriques will later do so) the more philosophic and conceptual aspects of providing decision support for doctors. I shall merely address a number of practical questions - such as, "do doctors need help?", "what sort of help do they require?", "what sort of help do they not require?", and finally consider what are the practical conclusions of these points.
ness, asthma, and social problems all in a period of an hour or two. Specialist help may well be available, but not immediately; and moreover it cannot be provided for every patient. Our own emergency room for example sees tens of thousands of new patients per year, covering every aspect of clinical medicine. Given the argument that the medical database contains 15 000000 facts, and given the further argument that (in the emergency room) anyone of these 15000000 facts may become crucial to patient management within a period of minutes, the need for decision support becomes obvious - if it can be provided.
Do clinicians require help?
Type of support required
The argument set out later by the rapporteur's comments is a cogent one. As a day-to-day worker in an extremely busy emergency department, I would add one further point. Many readers might imagine that some of the problems posed by the knowledge explosion can be solved by "super-specialisation". This might be true in some medical areas, but it is not true in the emergency department in which I work. A typical emergency session may include urgent or emergency treatment for patients with acute abdominal pain, acute chest pain, major trauma, disorders of conscious-
The most usual argument advanced for failure of information technology to assist with clinical decision making is that doctors reject computers per se because they do not wish their decision making process to be taken over by automated systems. There may be something in this argument - but there are throughout medicine examples of clinicians using technology to supplement their own decision making. On a much more practical1evel there are other simpler reasons why doctors do not use computers for decision support.
It is tempting to remark that unfortunately the type of support most required by doctors in a busy emergency situation is almost identically opposite to that which is currently on offer. It may therefore be only realistic to begin by discussing the type of assistance and support systems which busy clinicians do not want! Doctors do not want systems which take up their time. They do not want to use systems which are difficult to understand, difficult to use, different from each other, and whose results are difficult to interpret. They do not want systems at all for decision support - until such systems have been demonstrated to improve clinical care and patient outcome; and finally they do not want systems, the cost of which impinges seriously upon a departmental or unit budget. Unfortunately, as earlier remarked, this is all too frequently what doctors have been offered; and it is not surprising to those of us in the "front line" of clinical medicine that (until very recently), very few decision support systems have been utilised in routine clinical practice.
The corollary of these earlier arguments is that, being simplistic, doctors want systems which provide them with relevant decision support information instantly, without any effort on the part of the doctor, with 100% reliability and with zero cost. Fortunately, however, doctors are also practical people; and they realise that such a panacea is not available - nor is it likely to be in the foreseeable future. More realistically, many clinicians nowadays would welcome a decision support system which provided relevant information likely to improve patient care and outcome without a significantly increased input of time and effort by the doctor, and would welcome a system associated with concrete evidence of improved performance whose cost could be contained to a level where it does not affect other departmental budgetary items significantly. Pursuing this theme, there are a number of specific practical requirements which are seen by
N. Zoltie / Technology and Health Care 1 (J 993) 85 - 87
most clinicians as being quite fundamental to the usage of decision support systems in routine clinical practice. These may be grouped under four headings. • Location • Operation • Function • Integration As regards the first of these (location) decision support must be available where it is needed. This means in practice that the computer terminal through which support is provided must be avail- . able on the wards, or in the emergency room. The concept that doctors in the emergency situation will walk down a corridor to obtain help from a different department has been shown time and time again to be totally unacceptable. As regards the second (operation) doctors want as little to do with the computer as possible. This is not directed at the computer per se, for there is an important lesson to be learned from the worlds of biochemistry, haematology, and electrocardiography. All three were initially regarded as "side room tests" i.e. tests which were to be performed by the doctor who would break off from busy clinical practice, go into a side room, perform the test personally, and return some time later to the patient. Busy clinical doctors used to dislike such "side ward" tests and procedures (sometimes intensely!). They impinge upon clinical routine; and it is saddening to see the way in which the mistakes of these other disciJ?lines are being repeated by those concerned with computers in medicine. This implies that if computer aided decision support is to be widely introduced, the role of the doctor clearly needs to be restricted to (a) gathering data and (b) interpreting the output. The history of these bio-medical disciplines suggests that only then are computer systems likely to be welcomed. As regards the next concept (function) clearly doctors require (as discussed later by Davey) "safety critical" software; with a high degree of reliability both as regards the hardware and software - and as regards the output of the system. I subscribe to his remarks - especially concerning "trade-offs", every doctor wants the results instantaneously, and with zero effort!
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Finally, an absolutely vital aspect which has been little considered to date is that of integration. Duplication of effort is the bane of doctors' lives; and there is clear need for integration between decision support systems and other hospital implementation software. However excellent computer systems become, they will never be attractive to doctors if data have to be entered twice because two systems (for administration and decision support) are incompatible. Actually, this is an area where with a little forethought, computer systems can be made very attractive to practising doctors. All doctors would like some return for their efforts in putting data into the system - and if decision support and administrative systems are properly integrated a number of facets enable return to be given (quite apart from the benefit in improved performance or patient care). For example, decision support systems can (coincidentally) save considerable time spent writing, by generating case records, letters to doctors, and can also provide useful information, - for quality assurance procedures, subsequent research and teaching. Conclusions
To return to my initial comments, in this brief presentation I have attempted to discuss the prac-
tical and pragmatic requirements of clinicians in a busy emergency environment. What doctors actually want is set out in Table 1. If these constraints can be accommodated by current and future systems, then my own view is that we may see considerable expansion of decision support systems in the next decade. If on the other hand these practical considerations are ignored by innovators and system designers, then for the reasons I have outlined (however effective the system intrinsically may be) their implementation routinely ill clinical medicine will be delayed indefinitely.
Table 1 Clinicians' pragmatic requirements Location
On site No travel to use
Doctors provide data Technicians deal with computer Doctors interpret results
Safety critical software "Advice" not "dictat" Fail-safe procedures Instant availability Demonstrable benefit
Single hospital / dept. system Single operating system No duplication of effort