Are We Automating Critical Thinking Skills Out of Healthcare?

The clinical information systems that we deal with every day have had a significant impact on the quality of care we deliver and the safety and efficiency of that care. The electronic exchange of data between systems and between organizations has the potential to put an incredible amount of information into clinicians' hands at the point of care. Order sets and other decision support tools guide clinicians' behavior and ordering patterns through evidence-based guidelines and care pathways.

Sounds like we are heading toward nirvana, right? Occasionally, I have discussions with clinicians and IT staff as to whether this "progress" is really for the best. How does automation and embedded decision support impact critical thinking skills? How will the evolution of health IT impact physicians in training and those who have never had to handwrite admission orders from scratch (remember, ADC-VAN-DISL?)? What is the impact on the skill sets of nurses who electronically chart by exception and administer medications via barcode?

We have all seen examples of potential or real medication errors related to "the computer said so" syndrome. Medications are ordered through computerized physician order entry close to the standard administration time and either a dose is missed (it is scheduled for tomorrow) or an extra dose is given. The ordering clinician doesn't typically think about administration times. As nurses become busier, they increasingly rely on the computer-generated worklists and the eMAR (Electronic Medication Administration Record) to determine their tasks.  They may not take the time to step back and consider whether the orders actually make sense. In the "old days," the nurse would interpret the 8:30 a.m. order as, "I know that Dr. Levick only wants the one dose at the standard admin time of 9 a.m."

For physicians, critical thinking is far more complex than learning the mnemonics for order sets and looking up drug-drug and allergy interactions. The clinical information systems should clearly be doing that work for us, so we can concentrate on determining the true diagnoses and most appropriate plan of care for each patient, and so we can spend more time with the patient and family.

The answer is not to go backwards in time and return to paper. The answer is complex, and will require clinical information systems to truly enhance clinical efficiency and provide real-time, context-sensitive guidance. It is up to management and management engineers to redistribute work and tasks that leverage the intelligence of our systems and provide true cognitive load balancing. And, it is up to clinicians to rethink how work gets done and by whom and adapt what we are teaching the next generation of physicians and healthcare providers.

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