Nielsen Norman Group and Northwestern University | norman@nngroup.com
I’m with a group of surprisingly awake, cheery physicians and nurses doing grand rounds on the pediatric-care ward of one of the best hospitals in the United States. I’m part of a study group for the National Academies, looking at the ways in which information technology is used in health care. This hospital is a leader: I see computers everywhere.
I’ve been spending a lot of time in hospitals recently. No, not as a patient, but as an observer— following doctors and nurses on their grand rounds, watching patients get admitted, nurses doing shift changes, pharmacists filling prescriptions, and then watching nurses actually deliver the prescribed medication to their patients, waving bar-code readers over the prescriptions, the medication, and the patients.
We walk down the hall toward the first set of patents. We are quite a crowd: the attending physician and approximately five medical residents, physicians completing the last stage of their training, plus one or two nurses. The attending physician is responsible for treating patients and is also supervising the residents, each of whom is wheeling a computer cart. The hospital calls them “COWs”— Computer on Wheels. (One hospital switched the name to WOW, Workstation on Wheels, after a patient heard physicians outside
her room talking about “the cow” and thought they were referring to her.) A COW is a chest-high cart with computer screen and keyboard at a height appropriate for stand-up reading and typing; the computer itself and batteries are located at the bottom of the unit. Five COWs, plus a nurse wheeling a big filing cabinet of papers, plus the attending physician, plus the members of my observation team. We take up a lot of space. We stop at each patient’s doorway to review progress. The attending physician asks for a review, and each of the residents flips through the windows displayed on their computer screen and summarizes status: “Calcium level is fine, white count low.” Each resident has different information for the patient, or to be more precise, has screens that describe test results from different laboratories.
The patient was a bunch of numbers. Moreover, the numbers were not organized by symptoms or diagnoses: They were organized by what tests were run and which laboratory within the hospital had processed the results. The patient’s history, the record of past events and health care, was in a different location from current test results. Current results were in a different place than past results. Different hospitals might have different laboratories, so their results would be organized differently. But the
attending and resident physicians and nurses were experts at piecing together a mental model of the state of the patient from all these numbers. Or so they said: Evidence is difficult to come by.
“That’s interesting,” I said to myself, stepping into a room filled with displays. There were multiple infusion pumps, multiple computer readouts, and multiple monitors. The entire room was filled with the red glowing lights of display readouts and the dim white of graphs on the computer screens. “Fascinating,” I said. “You’ve brought all of the monitors into one place so you can see how all the patients are doing.”
“No,” said one of the physicians, “what do you mean?”
“So where are the patients?” I asked, expecting to be told that they were in rooms adjacent to the instruments.
“Right there,” said the physician, obviously puzzled by my question. “Right there in the room, right in front of you.”
I looked closely and still couldn’t see a patient. One of the nurses walked over and pointed. “Oh,” I said.
There were so many medical devices, so many readouts and displays, that I could not even see the patient until someone showed me. Now, this was an infant ward, so this particular patient was tiny, but even so, it’s a good illustration of modern
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