Healthcare; challenges at the frontline

Healthcare: challenges at the frontline..

Having identified that healthcare is under pressure across the world to change, , let us now look at healthcare at the frontline to identify some common challenges that may help explain the complex nature of healthcare and the scale of the change challenge.. ..

In order to do so, lets take a look at a patient-physician encounter at the frontline. Let’s use the Emergency Department setting for a number of reasons. Its the clinical environment I am personally most familiar with, it is at the critical interface between primary and secondary care, it acts as a pressure valve for the rest of the system as it is always open and some explain it as a good microcosm of the wider healthcare system.

Let us begin with a look at a single patient journey, a common case of a patient who has an acute episode of abdominal pain for instance…..

If the patients problem begins at home, they can (at least in some healthcare systems such as the NHS)  telephone an healthcare advice line and undergo a form of telephone assessment and get related advice…. e.g. please self-care/ go to your doctor/ go to the Emergency Dept/ an ambulance may be called.

If an ambulance is asked to attend, the paramedic will likely also perform another assessment, begin some preliminary investigations, commence some treatment before usually escorting the patient to the Emergency Department (ED).

At the Emergency Department the paramedic may hand over care of this patient to reception or nursing staff who will take over the care of the patient. Here they are usually seen by an ED nurse to reassess the patients condition, take a brief story from the patient and some vital signs (egg heart rate, blood pressure) , perhaps some more questions about the nature of their abdominal pain and then make a judgement their “acuity” (to triage), and assign them to a care “stream”.

Now  the doctor will review the patient and usually begin with what we call “history taking” ….this is a process that involves getting details on the patients most recent story (often a narrative of the patients problem) and more structured detail on past medical history, their medications, allergies, smoking, alcohol status etc.  Now while it is quite common for much of that information to be recorded somewhere else, i.e. scattered around the rest of the healthcare system.
Without access to a shared patient-centred electronic health record, the Emergency Physician is often unable to get access and so reverts to safety first principles and reassesses the patient from scratch. (While their is absolutely merit in reassessing the patients condition at regular intervals along the patient journey, some of your will already spot the inefficiencies in the current system and the room for improvement.)

After history taking, medical school teaches doctors to examine the patient and document related findings. Their is a common structure to the approach required for this and this should be reflected in the patients notes..

Investigations are often performed and the results of previous investigations may also be needed at this point. Ordering tests and getting the reports of results is another extremely common healthcare process, one that is also information intensive and again an area ripe with room for improvement.

A “differential” diagnosis or problem list may now be in mind at this time after reviewing the “history” and examination. (e.g. is this appendicitis? a urinary tract infection? constipation? inflammatory bowel disease?)
This may be drawn from the doctors memory and innate knowledge base, or they may need to go to the books/online to check up on their knowledge.
There is an acknowledged gap in the “bench to bedside” cycle of medical discovery and its implementation in clinical practice, which can mean a gap of years changing “what we know to what we practice”
This is another point where information and knowledge management is critical in helping with the decision making process and thereby patient care. Their is no doubt much room for improvement in the current approach to this, with many doctors currently relying on their tacit knowledge base at the frontline which, while mostly effective, is subject to human error.
Once the differential diagnosis or problem list is drawn up, then a related treatment plan should be formulated, and treatments in the form of procedures and/or prescriptions for medications may be required.

The medical notes that are made to document the patients journey are collated during the patient clinician encounter. These are critical in several aspects- aiding the decision making process, helping to share information with the next person involved in the care of this patient (e.g. inpatient team), as a medico legal record (increasingly important) and as a record of care that can form part of a wider audit of clinical practice (as per the clinical audit/and or research process).

The patient may then be admitted to an inpatient team or discharged to a clinic or to the care of that patients General Practitioner and so the cycle of care continues….

Of note, in looking at this single patient encounter, it should be evident that the majority of the patient provider care processes are very information intensive
Naturally any inefficiencies in the physician patient encounter of history-taking , examination, investigations, results, treatments are often replicated during successive encounters the patient will have with the healthcare system.
You can see that the current approach builds in much repetition as a safety measure though there remains considerable room for reducing both wastage and risk.

If healthcare systems need to adopt a more patient-centred, cross- organisational approach to care delivery/care pathways etc you can see that changes needed in healthcare information systems will be vital to the future.

Having just examined a single patient clinician encounter, consider the added layers of complexity when as a doctor you are looking after 2 or more patients at the same time in the Emergency Department, dipping in and out of these processes on an “interrupt-driven” basis..

Let us move up a level now, to explore healthcare from the departmental level…


Davis, D  (2003) “The case for knowledge translation: shortening the journey from evidence to effect” BMJ 2003, 327, 33


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