Disrupting Medicine: Check

The problem is this. At some point, in every checklist, you need to interact with other parts of the hospital. For instance suppose that one step is to refer the patient to neurology. What if you're in a country hospital and there is a neurologist on call, you can't simply call that department. You might have to make a decision about whether this is a case that requires an emergency call. So maybe you need to do another checklist, just to decide whether to leave a note for the neurologist in the morning, or to make an emergency call.

Suddenly your standardized checklist is no longer standardized across these two hospitals.

Multiply this by a myriad of checklist across a myriad of different medical facilities with a myriad of different differences, and suddenly the dream of a standardized set of checklists becomes impossible.

This does not mean that the effort of creating and following checklists is not worthwhile - it most certainly is. However if you start out expecting to achieve an impossible dream, then you're guaranteed to be disappointed.

The issue I have with this is that eventually every disease and diagnosis will have an accompanying check list. This is an over simplification of a process that requires professional opinion and deep knowledge within a specific domain.

Psychiatry is an great example of how using checklists can cause a disease or disorder to be over diagnosed. Depression, ADD, ADHD, Social Phobia (branded as Social Anxiety) all have checklists and all three disorders are over diagnosed.

Psychiatry also happens to be a great example of how Big Pharma gets their greedy hands involved in creating these checklists. In some cases the checklist come from Big Pharma themselves. Talk about a conflict of interest.

Doctors are paid to think, apply their knowledge, consult with each other. They are not paid to check boxes on checklists and toss around diagnosis.

Edit: Typo

One of the main issues here is that medical care is largely non-procedural and intuition-based. That's why doctors have to spend years doing training, followed by years of experience. Their "checklists" are created one step at a time, per-patient.

This is exactly what needs to be changed in order to disrupt healthcare. Once medical care becomes procedural (ie generated by smart software, per patient, based on the patient's electronic health record which includes genomic and molecular data), we can begin replacing highly specialized doctors with non-specialized ones (and eventually with nurses). Of course, there are probably tons of areas where "simpler" checklists can be made to have a significant impact on outcomes (for example making sure the right patient gets the right drugs, etc..).

Clay Christensen's book, Innovator's Prescription, goes into a lot of detail about how this will most likely play out: http://www.amazon.com/Innovators-Prescription-Disruptive-Sol...

It is called "Order Sets". 3 very large companies are doing it.

1) Zynx : http://www.zynxhealth.com/Solutions/ZynxOrder.aspx Very dated and expensive.

2) Provation : http://www.provationordersets.com/index.aspx Slightly better but small market share compared to Zynx.

3) Elsevier : http://www.clinicaldecisionsupport.com/order-sets New player yet to launch. Cloud based.

Very Optimistic. Having worked on this problem around the year 2000 in the Norwegian health care system and also in the public sector you'll quickly find that funnily enough doctors don't agree on what is the "best" procedure most of the time. Even in Norway where they register every single cancer patient, treatment and outcome it's hard to make up completely standardized treatments for cancer and that's just a single disease. Most countries don't have anything close to that.

What could be damn useful however is good old fashion infection checklists. Since the time of Joseph Lister there have barely been any progress in infection control at hospitals. One might even say there has been a substantial regression. Even something as simple as replacing all the steel door handles with copper would help (http://www.dailymail.co.uk/health/article-442135/Could-coppe...).

In the operating room, where some would argue where procedural checklists like this might most count, they use a pre-op timeout procedure. Usually this is to ensure the right patient is being operated on, in the right place(s), and that the right operation is being performed. The same happens before the patient is "closed". A count is taken of every bit of material / tooling used in the procedure to make sure nothing is "left behind" (in the patient). Sources: 1.) http://www3.aaos.org/member/safety/guidelines.cfm for more information. 2.) My wife who was a surgery resident.

It's an interesting idea.

What do you do where there are going to be multiple lists? EG: Full thickness burns - you do some debridement then use a dressing. Different doctors like different dressings. Some will use a manuka honey dressing; some will use flamazine; some will want to use stuff like inadine or jelonet etc. So now you have a branching checklist?

The companies making dressings have a significant financial drive to be included in the procedure check list - imagine every hospital in the world wanting to use your product - and so you'd need to protect against corruption and external pressure and fake research.

"... Imagine if we optimized every single facet of medical care, from patient admission to discharge, and all intermediary processes, top to bottom..."

Let's separate standardizing and optimizing. A checklist lets you standardize. It does not optimize anything.

As the author continues, he gets into a scheme of various agencies all working together in various ways -- this is the core of the optimization problem. I'd suggest he doesn't have a clue here as to how to actually accomplish this. But still, overall this is a great idea. Standardization in many rote procedures, especially those involving health, is desperately needed.

FTA:

   The underlying question throughout the book is “If people
   like architects and pilots use checklists to both avoid    
   and minimize errors, then why in the hell aren’t
   physicians and nurses doing the same?”

   And that got me thinking. What if every 
   hospital procedure had an accompanying checklist, 
   from all types of surgeries to administrative 
   operations?

Whoa there. The jump from the first statement to the second completely bypasses the entire challenge. The problem is not that there aren't standards already, but that the various regulations and laws, both at the governmental level and at the hospital board level, make such "optimizations" very difficult to implement.

Until you have a real solution to removing the resistance of bureaucracies, then all of this is putting the cart before the horse. There is not much in this post that hasn't been talked about or already agreed on by medical reformers.

there is an interesting TED talk from this year about this, how checklists for surgical teams has been designed and implemented in a few hospitals around the world: http://www.ted.com/talks/atul_gawande_how_do_we_heal_medicin...