On Jack Hammers, Concrete and Medical Open Source

It was 2:00 am last week and I was admitting a patient to the hospital. It was a night to remember for what it wasn’t.

The nurse handed me the nursing workup as well as a workup from the transferring hospital the patient came from. For once the paper wasn’t illegible scrawl. For once it wasn’t legible writing run through that notorious illegibilizer: a fax machine. For once I could read what medications the patient was on and their doses. For once, I could actually use work people had previously done so that my workup on the patient went smoothly and swiftly.

The whole episode from beginning to end took 30 minutes instead of the usual 1 to 1.5 hour fumble attempting to make sense out of the laboriously produced garbage that most previous medical records are.

These thoughts brought memories of my transition from hot-shot software engineer to medical student some years ago. The astonishment I felt in those days of playing the intensely irritating (to a software engineer), time-wasting fumble of ‘Where’s the chart?’ or worse: having to wait for it until someone else was through with it.

I’ve mellowed through the years in a way I don’t care to mellow. Idiotic delays don’t bother me nearly as much as they should. But, I was reminded of it anew after breaking concrete in my condo.

You see, my subfloor sucks. Built 20 years ago in the go-go oil boom years in Houston, they put down too thin plywood. In places the joists are too far apart and the thing flexes. The concrete on top doesn’t and it cracks badly. Years ago, lawsuits against the builder were followed swifly by bankruptcy that left the bad floors in place for 20 years.

I’m a home improvement type and intentionally buy places in good areas that have problems. Being both an engineer and in medicine, I have a double dose of obsessional characteristics so of course I elected to break out the whole mess and start over. The board of directors wanted to do just a patch job, but I wanted it done right to put down nice flooring. I told them I was going to jack hammer it out. ‘You won’t need a jack hammer, it will just come out by hand.’ was the reply.

Good lord, are they out of touch, I thought.

My reaction was predictable. A character trait of engineers is they don’t like to be contradicted when they say how they are going to do something. They’ve usually discarded unworkable methods, carefully thought things through and have a confidence in their method because they can usually demonstrate its superiority. If you ever work with a really good engineer, don’t tell them what they can and can’t do. They just need the parameters and they’ll usually come up with the best solution to the problem. Ignore their opinion at your peril.

Naturally, I pretended I didn’t hear their remarks and rented a nice little electric ‘demolition hammer’ for $35 a day. The concrete flew, things were shaken off the shelf and I had a ball!

My wife is a gentle creature and eschewed the violence of my method for the hand one. She gave it up quickly in the face of her agonizingly slow progress with hammer, chisel and wrecking bar. Lest you think I am a wife abuser, let me say that the floor re-do was her idea and she declined the offer of using the hammer.

I thought about all this while admitting the patient late that night. There was still much wasted time even in this rare case of a quick 30 minute admit. Yet the usual frustrations surfaced: I had to re-write the patients medications twice: in the workup and on the Doctor’s order form to continue the patients current medications. This was a total of 3 people writing the same thing four times.

Lots of time wasted. More importantly, there is much talk these days about medical errors being the 8th leading cause of death in the US. Not a surprise to an engineer. There were four opportunities for a medication error to be propagated with the above patient. More if you count the transcription by the pharmacist.

These problems are well known in medicine. So is the solution. There have been conclusive studies in one of the most major medical journals (JAMA) that electronic ordering of medications cuts down on errors as much as 50%.

So where is my medical jack hammer? Where was my medical jack hammer in medical school? Why weren’t the medications already embedded into the electronic workup that I should have been doing? It should have merely required a quick check with the patients medication bottles or a quick talk with the patient without the laborious write out. Electronic medical records have been attempted for decades. For Pete’s sake, where is my jack hammer?

It is lying at the bottom of the ocean. It is there because of the difficulties of getting to it and how much software engineering there is to be done in medicine. But even the most basic things like medication writing and medical records are not readily available. Sure there are services for electronic prescription writing cropping up. They show promise, but none appear to have much chance of becoming universal. Services like these are all too busy carving out their turf. Sure, there are companies that will sell you an electronic medical record at a steep price, frequently with poor quality. But what if you change jobs? Move? Rotate? Graduate? Start over. With all the painful re-learning and inherent risks to patients that this entails.

The answer to all this, of course, is freedom. As in Free and open source (follow the links to read about what these are) software holds the greatest promise to liberate medicine from the tyrannies of software incompatability, poor quality and errors in medicine.

People say things like: ‘But, it would be too hard. Where’s the profit motive? Doctor’s will never change. Medicine is too complicated. You can’t do that.’

Did you say can’t? Too late, it is already being done. The real question is when will medicine embrace it.

Leave a Reply

Your email address will not be published.