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Dr Layla McCay

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Putting All Our Eggs in the Digital Basket: Health Service Resilience in the Digital Age

Posted: 03/29/2012 4:16 pm

Female hammerhead sharks in captivity can reproduce without the services of a gentleman shark, which is how they came to play a starring role at an intriguingly diverse conference I attended on "resilience" last week at the New America Foundation. The argument was that sharks do what any good business or health care provider ought to be doing: adapting to survive in changing and challenging environments. And we can learn from them.

In the wake of Hurricane Katrina, Dr. Sheri Fink told us how two very different hospitals adapted to the challenge of patient overload, loss of infrastructure (particularly electricity), and general fear and chaos. In summary, the whizzy, shiny, high-tech hospital apparently struggled, while the low-tech downtrodden hospital rose to the occasion and saved more lives as a result. Of course there were all sorts of factors and interpretations, but it made me wonder: Is our increasing reliance on technology and efficiency crowding out our capacity for resilience in health service delivery?

I can imagine why the answer might be yes. As a newly-qualified physician I spent many hours brandishing a mercury sphygmomanometer (a delightful word, being disappointingly usurped by the more prosaic "blood pressure meter"). After a year as a pathologist, I returned to the wards to find that these devices had vanished -- they'd been banned due to the risk of mercury poisoning if they smashed. In their place was an array of electronic blood pressure monitors. I wondered whether physicians of the future will even know how to work the manual mercury version.

It's the same with defibrillators (the machines that deliver an electric shock to restart the heart). Back in my day (which wasn't very long ago), we scrutinized the squiggles that are the heart's electrical signals to decide whether to deliver an electric shock. In my latest life support refresher course, I found my hospital had bought machines that made the decisions automatically, and instructed me whether or not to shock in a smugly patronizing electronic voice. These machines are found in shopping malls and can be operated by anyone, not just health care professionals. My instructors assured me that research has found automated machines are more accurate at deciding when to shock than highly-trained physicians, but again, will this automation mean that in time physicians will eventually forget how to interpret the squiggles?

Maybe it will. When the whizzy hospital lost its electricity, it apparently lost its capacity to ventilate people, while the less-modern hospital hauled out its hand-ventilation devices and settled down for a long night of pumping oxygen into patients by hand. But that doesn't mean that manual devices are better: We don't necessarily need to fear progress and cling to the old, laborious ways, just in case. When our cars fail, we don't revert to the horse and cart. Society has created back-ups that are congruous with a more modern and efficient way of functioning. And that's what needs to happen in health care. Digital innovation can create efficiency, freeing highly-trained professionals to concentrate on vital, skilled activities that save lives, rather than spending their time performing tasks that have been rendered menial and can now be done quicker and better by a computer. But when our ways of providing health care fail or falter, we need to have a Plan B. If it's not reverting to manual, it needs to be better ways of keeping digital working: electricity generators that provide full coverage and work for long periods, backed-up and accessible data, full-time programmers and technicians on call and able to solve problems fast... And all that needs proper investment.

One of my favorite definitions of "resilience" from the event was "not putting all your eggs in one basket." By discarding our mercury sphygmomanometers, or not knowing how to override the defibrillator machine's decisions, are we starting to put all our health care eggs in the digital basket? Maybe. But if so, we need to be fully aware that we're doing it and design resilience into our health care systems, and particularly into our cherished cost- saving and efficiency plans. Because as the health care repercussions from Hurricane Katrina demonstrated, we just can't keep all our eggs in one basket. Any hammerhead shark will attest to that.

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