Column written for Interactions, volume 15, issue 2. © CACM, 2008. This is the author's version of the work. It is posted here by permission of ACM for your personal use. It may be redistributed for non-commercial use only, provided this paragraph is included.
It's 6:30 in the morning. I'm with a group of surprisingly wide awake, cheery physicians and nurses, doing grand rounds on the pediatric ward of one of the best hospitals in the United States. I'm part of a study group for the National Academies, looking at the ways by which information technology is used in healthcare. This hospital is a leader: and I see computers everywhere.
I've been spending a lot of time in hospitals recently. No, not as a patient, as an observer -- following doctors and nurses on their grand rounds, watching patients get admitted, nurses doing shift changes, pharmacists filling prescriptions, and then watching nurses actually deliver the prescribed medication to their patients, waving barcode readers over the prescriptions, the medication, and the patients.
We walk down the hall toward the first set of patients. We are quite a crowd: the attending physician and approximately five medical residents (physicians completing the last stage of their training), plus one or two nurses. The attending physician is responsible for the patients' treatments and supervising the residents. Each of the residents is wheeling a computer cart in front of them. This hospital calls them "COWs", for Computer On Wheels. (One hospital explained that they had switched the name to WOW, Workstation On Wheels, after a patient heard physicians conferring outside her room mention "the cow" and thought they were referring to her.) A COW is a chest-high cart, with computer screen and keyboard at a height appropriate for reading and typing for a standing person, with the computer itself and batteries located at the bottom of the unit.
Five COWs, plus a nurse wheeling a big filing cabinet of papers, plus the attending physician, plus the several members of my observation team. We took up a lot of space. We stopped at each patient's doorway to review progress. The attending physician asked for a review and each of the residents would flip through the windows displayed on their computer screens and summarize the status: "potassium level fine, white count low." Each resident had a different piece of the patient, or to be more precise, had screens that described the test results of different laboratories.
As a result, from the physician's point of view, the patient was reduced to a bunch of numbers. Moreover, the numbers were not organized by symptoms or diagnoses: they were organized by what tests were run and which laboratory within the hospital had processed the results. The patient's history -- the record of past events and healthcare -- was in a different location than current test results. Current results were in a different place than past results. Different hospitals might have different laboratories, so their results would be organized differently. But the attending and resident physicians and nurses were experts at piecing together a mental model of the state of the patient from all these numbers. Or so they said: evidence is difficult to come by.
"That's interesting," I thought to myself, stepping into a room filled with displays. There were multiple infusion pumps, multiple computer readouts, multiple monitors. The entire room was filled with the red glowing lights of display readouts and the dim light of graphs on computer screens. "Interesting," I said aloud, "that you have brought these monitors into one place so you can see how all the patients are doing."
"No," said one of the physicians, "what do you mean?"
"So where are the patients?" I asked, expected to be told that they were in adjacent rooms to the instruments.
"Right there," said the physician, obviously puzzled by my request. "Right there in the room, right in front of you."
I looked closely and still couldn't see a patient. One of the nurses walked over and pointed. "Oh," I said.
There were so many medical devices, so many readouts and displays, that I could not even see the patient until someone walked over and pointed. Now this was an infant ward, so this particular patient was tiny, but even so this is a good illustration of modern medicine: From the point of view of the physicians, the patient is a set of test results and numerical readouts. The patient as a person tends to be forgotten.
I saw this later in a different hospital in yet another ward. The attending physician would stand outside of the patient's door and listen to the review of the test results by all the residents. They would then discuss the results and make further recommendations. Then, as we all left to go to the next doorway and the next patient, the attending physician would knock on the open door, stick his head in and say, "How are you doing today, Mr. Forbes?" That was the extent of patient interaction.
So many numbers we lose sight of the person. Scientists measure what they can measure and pronounce the rest to be unimportant. But the most important parts of life are qualitative. One of the physicians on my study team told us that it can take as long as 20 minutes to fill out all the required forms while she is in front of the patient, yet she is only allowed 15 minutes to attend to each patient. She has to force herself to look at and interact with the real patient. One hospital center estimates that nurses only spend 1/3 of their time in direct care of a patient. Half of the remaining 2/3 of their time is spent on documentation and medication record keeping. One physician told of watching a nurse busily record all of the numerical indications about a patient's circulatory and respiratory systems, but with insufficient time to think about the meaning of the numbers and insufficient time to look at the patient: a five-second glance would have sufficed to show that the patient was having extreme difficulty breathing.
Modern medicine is a complex undertaking. It is highly technical, highly specialized. The patient has been carved up into little kingdoms, with different specialties competing for ownership of each piece, leading to occasional flashes of territorial wars. Nowhere is this more vividly presented than in the operating room where a vertical sheet placed over the patient at the level of the neck divides the territory belonging to the anesthesiologist (the upper part of the patient -- the head) from the territory belonging to the surgeon (the lower part of the patient - the body). But even where everything works as planned, with the patient receiving the best care possible from the myriad specialists who are called in for assistance, the complexity of the process and the multiple disciplines, the fetish for numbers and regulations, all conspire to make attention to the needs of the patient seem like an afterthought.
Those of us who have spent time in hospitals, whether as a patient, relative, or friend, know how frustrating it can be. All of us, friends, relatives, and even the patient, are pushed aside in the interests of efficient medical care. And even when there is a caring physician or nurse attempting to aid, well-intended but onerous privacy laws can block attempts of the patient and especially of relatives and friends to gain access to information.
The modern hospital is a complex system, with multiple complex interactions among people, equipment, laws, institutions, and a confusing wealth of information. It is time to turn our attention to the multiple interfaces and design issues within this complex system. Healthcare is a problem that needs immediate attention. We need to start now, for the issues are life-threatening.
Don Norman wears many hats, including co-founder of the Nielsen Norman group, Director of a dual-degree MBA plus Engineering program in Design and Operations at Northwestern University, and author, his latest book being The Design of Future Things. He lives at www.jnd.org.