Bandwidth

          Bandwidth is a computing term, originally referring to the maximum rate of data transfer across a given path, that has entered the vernacular to mean “the energy or mental capacity to deal with a given situation.” I have had a long-standing concern that we have ignored the notion of bandwidth as it impacts individual physicians, so I was interested in a
recent article by Kissler and associates titled “Attention Among Health Care Professionals: A Scoping Review.” 1 They note patient-complexity continues to increase, but so, too, does the complexity of the systems used to provide that care. Overloading physician attention
leads directly to cognitive medical errors.

          “A well-functioning environment enables good care without overtaxing the clinician’s cognitive or emotional resources. But simply creating a “sterile cockpit” for a distraction-free environment is unrealistic…To achieve the goal of well-divided attention, it is necessary to take an ecological approach in which interdependent elements are considered and measured together.”

          The literature on this topic is quite diverse, but they were able to synthesize it into three broad categories that influence clinician attention: the salient environment, the health IT environment, and provider factors. In the environmental frame, they included items such as noise, design of the workspace, workload, alarms, and alerts. In the health IT frame, they included flow of information, interruptions and distractions, and user interface design. In the provider frame, they included items such as sleep deprivation, work preferences, and intrinsic cognitive abilities. They also found considerable heterogeneity in the quantitative scales used to assess the various factors, as might be expected. Consistent with their stated aim, they made no judgments about next steps.
          One major change in the practice of medicine is the electronic medical record. Issues with the EMR receive major blame for the epidemic of burnout, which has been considered in other articles on this website. In this article I want to focus on a couple of different, but related, issues.
          Recently, I decided to tackle editing the digitized version of the home movies made by my parents. I started with a YouTube video, which made it seem fairly straight-forward, but as I investigated, I found a consensus the best approach was to use full-function, cloud- based software, which one “rents” by the month. After several weeks of working with this software, I have now come to understand some of the basic terms, and have managed to get the first project completed, but it was neither easy nor straight-forward. The problem, at its
root, is the software is designed to do almost anything one would include under the title of video editing, while all I wanted to do was clean up and label some old home movies. There was no method to “simplify” the software for the specific task I had in mind. So, too, is the problem with the EMR. The software is designed to work in a variety of settings, but the
busy clinician wants the software to work in his/her specific setting and for specific needs. Maybe “AI” will make it easier to customize EMR’s, but somehow, I am skeptical.

1 Kissler MJ, Porter S, Knees M, et. al. Attention Among Health Care Professionals: A Scoping Review. Ann
Intern Med 2024;177:941-952. doi. 10.7326/M23-3229.

          The second issue is not a programming issue. All flows in the EMR come back to the clinician. All lab orders, all lab results, all medication orders, all messages and alerts are presumed to require the attention of the clinician, ostensibly for legal reasons, but the net effect is that little or no actual attention is paid to the data—the bandwidth issue. I recall
once when routine monthly lab orders for my dialysis patients, which had been covered by a standing order, had to be changed to individually ordered and signed orders for every patient, every month. While there turned out to be ways to expedite this, I still spent about 30 minutes every month, and the staff spent considerably more, signing off on these orders.
All of this was done to preserve the fiction that these lab tests were required on an individual patient, when in fact the vast majority were ordered to satisfy CMS mandates.
          Or consider the “guideline” frenzy, which we have also examined previously. Almost all guidelines presume it is up to the primary clinician to see that these recommendations are followed, (and their quality score depends on it,) but we also want “patient-centered” care. I find I get many consults generated by guidelines that don’t correspond to the needs
of the individual patient, which the consulting clinician generally knew, but we don’t make it easy for him/her to mark the chart so the issue is resolved. There is no “one and done” in the EMR—it is do it again, because we need the answer to be yes. Here, too, we face the bandwidth issue. How is a busy clinician supposed to provide the care, keep up with the
guidelines, resolve conflicts between guidelines, and customize the care for individual patients, while dealing with the deluge of computer-generated alerts and messages?
          Clearly, we need to re-think exactly when, and for what, a clinician’s attention is really needed. Much of the frustration clinicians express reflect demands that exceed the bandwidth of normal clinicians. Any candidates for “stupid stuff” to eliminate?
22 July 2024

Further Reading

More on Physician Work
The changing nature of physician work is decreasing the availability, and probably the quality of care at a time when demand is increasing. Two recent articles provide data supporting these effects.

Human Capital - Physician Burnout
If physicians are important human capital, then burnout is a waste of a valuable resource, but the problem is getting worse, not better.

New Ideas About Electronic Health Records
The data entry burdens of electronic health records contribute to physician burnout and may harm patients. Two recent articles give hope that people are beginning to search for ways to turn EHR's into aids for patient care instead."

Simple Ideas
Making simple ideas work turns out to be complicated and hard.

Stupid Stuff
Wouldn't it be wonderful if we got rid of stupid stuff?