EHRs, ATMs, Patient Safety and Air Travel: Top 3 Reasons to Stop the Analogies Here


This is the first (in my humble opinion) controversial article to be published on the Galen blog and was inspired by the challenge issued  by John Lynn over at EMRandHIPAA.

I personally like to call it blog sparring. Basically, you take someone else’s post and provide the opposing perspective or at least you add to the conversation that they started. I love these types of interactions with other bloggers. Plus, I love the deep dive into a specific topic that happens when you do this type of blogging. As a reader, I think it’s fun to read the various blogger’s perspective on the topic. So, on that note, I’m going to make the next week, Blog Sparring Week.

Let the parallels between the EHR and the ATM, and between patients safely visiting the hospital and flying in a plane stop here. I find it interesting that humans natural gravitate towards drawing comparisons on past experience. It’s a lot like how the federal government based the model for Regional Extensions Centers (RECs) on the model for US agriculture, which was intended to disperse new info to the family farm. Alike agriculture, the goal is to ensure that HIT is reaching the family physician and providing advice in terms of selection and implementation. Yes, it’s true that there are lessons to be learned from other industries, but as Keith Boone of at the Healthcare Standards blog recently pointed out, it must be done thoughtfully.

Recently, Brad Waugh, CEO of Navinet, brought up another Healthcare IT analogy – that of Air Travel and Interoperability – on the Navinet Blog:

The patient in the National Journal article, after being sold a flight departing months past his desired travel date, after he is required to fax in a consent form, and after he must call a separate company to handle his baggage, informs the customer service representative that in a modern system, he would be sold “a safe round-trip journey, instead a series of separate procedures. It would have back-office personnel using modern IT systems to coordinate my journey behind the scenes. The systems and personnel would talk to each other automatically. At the press of a button, once I entered a password, they would be able to look up my travel history. We’d do most of this stuff online.” He’s describing the way most industries operate today, from air travel to banking to freight transportation, all of which are able to successfully communicate between systems, companies and types of data.

While it’s true we often wish that the healthcare industry was as efficient and safe as the aviation industry, the fact of the matter is, patient safety is harder and will require more effort as Jeff Terry, Managing Principal, Clinical Operations, asserted on the GE Healthcare Quality & Safety blog.

Why is patient safety harder? You be the judge:

  1. On any given day in the United States, there are about 800,000 inpatients and many more outpatients. By contrast there are about 30,000 flights per day.
  2. The major US airlines fly about 25 different types of planes. By contrast, the ICD-10 lists 12,420 diseases. Each plane, like each disease, requires different protocols to manage.
  3. There are 2.5M nurses compared to 200,000 pilots

And that brings us to the recently asserted Boone’s Law, first published on Keith’s aforementioned blog:

Boone’s Law

It’s very similar to Godwin’s law, but related specifically to Health IT.  In any sufficiently long discussion of Healthcare IT, the probability of a comparison being made to the financial sector approaches unity. Keith’s corollary is that that in any sufficiently long discussion of patient safety, the probability of a comparison being made to the aviation industry also approaches unity.

Key points:

  1. Transaction payload – Single pieces of data are not being transmitted in the payload with healthcare. Conversely, financial transactions however are very small (include account holder identity info, merchant identity info, and a transaction amount.
  2. Business model – in financial transactions, there’s a payment model already built in, who would pay for it in healthcare transactions and why?
  3. Regulation, Trust and Security – The financial industry deals with audit trails, logging and security, but again, back to point #1, single pieces of data aren’t in the payload, there are instead hundreds or thousands – especially with imaging studies.

I’ll leave off the debate with an article I read while taking the train home last evening –  “Point to Ponder” written by Greg Gillespie, Editor in Chief, Health Data Management.

Aviation experts quoted in a Wall Street Journal article predict the accident will result in a shake-up of pilot training over concerns pilots have abdicated too much responsibility to computer aids and, when those aids malfunction, can’t handle emergencies because of rusty piloting skills.

Not sure anyone would argue the health care industry is in any immediate danger of being over-automated, but the question of whether automation serves the user, or vice versa, is an important one. Industry gurus typically point to aviation as a model for medical reform, and there is absolutely no question that automation has increased aviation safety. But automation shouldn’t lead us to a point where a pilot stops being a “real” pilot, or a clinician a “real” clinician.

Well put Greg. As much as computers aid our decisions, we should never completely remove or undervalue the human element.

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2 Comments

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  1. 1
    John Lynn

    Nicely done. I love the analysis. Although, as the person who loves to use analogies for learning, I think it’s worth considering lessons from other industries even if it’s not a perfect match. For example, the checklists by pilots being applied in hospitals. Some definite similarities. Certainly any analogy can be taken too far. Plus, you have to always apply something called intelligence to any analogy to see if it really applies to your analogous situation.

    Of course, you know where the airplane analogy blew up right? It was when HIMSS invited Sully (he landed the plane in the Hudson) to speak at the annual conference in 2009. Turns out it was actually a pretty interesting speech by Sully. I was surprised that he actually did provide food for thought.

    Also, your last point is an interesting one. How much automation is too much automation. Although, I think you can also argue that those that many of those that become so reliant on technology that they can’t perform are also likely the ones who weren’t very thorough in the first place. Plus, just because technology makes mistakes sometimes doesn’t mean it’s not better than the status quo.

  2. 2
    Michael Tamlyn

    For me, analogies and metaphors are particularly important when you are trying to bridge a gap between two very different types of professionals. Within healthcare IT, that gap is often between a healthcare provider and a technical professional. Often their only overlap are things outside our professions such as sports, cooking, finances, etc. The key is to focus on the original intent of the comparison and recognize that no analogy is so perfect that it covers every aspect of the topic at hand.

    For example, when one likens healthcare to aviation there are a lot of parallels. Yet, they are fundamentally different. No one will argue that flying is a right. A person who is desperate to get from point A to point B cannot simply show up at the Emergency Flights Room at an airport. The opposite is quite true for healthcare. The analogy has clear limits and that’s OK.

    Ignoring this critical point often leads to a comical game of Stretch the Metaphor: Everyone in a meeting works as hard as they can to fit every aspect of complicated topic into a tight analogy that was originally only made to make a specific point more understandable. Everyone leaves confused and wondering what the point of it all was to begin with. I’ve seen too many meetings crumble to pieces that way!

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