Another reminder of systems failures

Why do we need to stop talking about it and do everything we can to overcome the fragmented nature of medical care?

Read Fumbled Handoffs: One Dropped Ball after Another, (abstract, full article by subscription or wait six months) by Tejal K. Ghandi, MD, MPH. And be sure to read the letters of response.

Effective care was substantially delayed because of systems problems including:

• Poor continuity (with multiple-provider involvement)
• Lack of communication of test results and other clinical information
• Several handoffs

There's a mathematical formula here someplace. It's simply matter of probabilities. Absent a very timely, effective (and, we hope efficient) system for passing information automatically with each handoff, the cumulative effect of lost, distorted, or misinterpreted information compounds with each handoff.

Let's assume that the first node of the system (say a physician) has perfect information regarding the patient. The greater the number of nodes and the greater the number of handoffs, the greater the risk that the last node will have less than perfect or timely information. Of course, the last node might be the same as the first node (i.e., physician to lab and back to physician). That's just the kid's game of telephone.

Let's assume that in each handoff the probability of passing information perfectly to the next node (say a lab) is 99 percent. Then the probability that the third node (two handoffs) will have perfect information is 98.01 percent (1 percent lost at each handoff). By the time, we get to the fifth node (4 handoffs), the probability that we have perfect information is 96.06 percent.

Now let's assume that the probability of passing information perfectly to the next node (say a lab) is 95 percent. Then the probability that the third node (two handoffs) will have perfect information is 90.25 percent (5 percent lost at each handoff). By the time, we get to the fifth node (4 handoffs), the probability that we have perfect information is 81.45 percent. Now assume that this is your healthcare personally

None of this takes into the account the:

• Probability that cases which require more handoffs are likely to be more complex, the uncertainty regarding the information to be greater, and the patients more at risk. Nor does it take into account that the less than perfect information conveyed at a handoff could not merely be lost, but wrong in a way that worsens the patient's condition.
• Cost of ensuring that information is passed cleanly and quickly at each handoff
• Risk to the entire system of weak information handoffs at a particular point in the process, especially early in the process.
• Likelihood that passing information between organizations (say a nursing home to a hospital and back) is slower and more prone to loss and distortion than passing information within a single organization

Designing good information flows is the heart of designing effective organizational systems and processes. This is not mere documentation for legal self-protection. It's good medical care.