In a seminal 1982 article in The Atlantic, criminologist George Kelling and political scientist James Wilson posited that an essential way to maintain order in a community involves paying keen attention to small, seemingly unimportant details. They argued that “...at the community level, disorder and crime are usually inextricably linked, in a kind of developmental sequence. Social psychologists and police officers tend to agree that if a window in a building is broken and is left unrepaired, all the rest of the windows will soon be broken.” Ultimately, they concluded that “one unrepaired broken window is a signal that no one cares, and so breaking more windows costs nothing.”
This research led to the Broken Windows theory that can be defined as “visible signs of disorder and misbehavior in an environment encourage further disorder and misbehavior, leading to serious crimes. The principle was developed to explain the decay of neighborhoods, but it is often applied to work and educational environments.” In New York City, this theory led police to aggressively pursue minor crimes such as vandalism and panhandling. While proponents argue that this type of policing can actually decrease crime and improve living conditions, detractors note that much more harm is done by tactics such as “stop and frisk” than any benefits that have been shown.
As I have worked with electronic health records (EHRs) and the health systems that use them across the country, I’ve developed my own sort of Broken Windows theory. My version goes something like this: when minor problems like typos in note templates and non-functioning hyperlinks to educational materials go unfixed in the EHR, clinicians lose trust in both the competency of the information technology (IT) team, but potentially also in the accuracy of the patient information itself. In other words, small, seemingly inconsequential problems can lead to cultural mistrust among physicians and nurses of the main tool that most of them use all day long.
It should be no surprise to those of you in healthcare that the vast majority of clinicians are picky, detail-oriented, and hyper-focused on every element of patient care. Do the words anal retentive ring a bell? Why is it that doctors and nurses behave like this? Perhaps it’s part of the personality that is sought from students when interviewing for medical or nursing school. Perhaps it’s drilled into us during training that missing minor physical findings or a stray abnormal lab result can make the difference between life and death. Perhaps it’s a bit of both. Under any circumstances, clinicians sweat the small stuff. We expect those around us to sweat the small stuff along with us.
Minor problems in the EHR are the ones that typically make us crazy. If a cable is dug up during construction outside our office and everything goes down, we get it. If data from our state’s prescription drug monitoring program (PDMP) suddenly stops flowing due to an upgrade, we’ll generally cut the IT team some slack, at least for a few minutes. Stuff happens, as they say. But when a documentation template that we use every day has a typo, and the typo is never fixed, it can cause insanity! Why? Because many doctors believe that they need to DELETE THAT EXTRA PERIOD AFTER THE THIRD SENTENCE IN THE SECOND PARAGRAPH EVERY SINGLE TIME. Once they sign that note, it’s their note. And their note can’t look sloppy.
Besides grammar and typo problems in documentation templates, other areas of IT focus should include such things as inconsistent naming, unintuitive ordering, and confusing navigation. If one patient handout is called “2-Year-Old Well-Child Check” and another is called “WCC 6 Months” it seems like there was a disconnect between the authors and folks who configured the system. When physicians must remember to order a chest X-ray by typing in “XR CHEST” but must order a chest CT by entering “CHEST CT,” expect annoyance to rule the day. (Of course, if the EHR vendor offers synonyms and/or advanced searching, this problem can be mitigated, but I digress.) If your IT team has workflow tools to help transfer patients from pre-op into the OR, from the OR into PACU, and from PACU to the floor, I salute you! If those workflow tools are not located next to each other in the EHR, or even worse, require multiple clicks and page views to get from one of the tools to the next, it’s understandable for clinicians to wonder about broken windows.
It’s reasonable, I believe, for clinicians to see what they perceive to be sloppy work in the EHR and postulate that such sloppiness extends further. Fix these minor problems and the bigger, more obvious ones are often forgiven. How do you find out about these issues if you’re not using the EHR day in and day out to care for patients? That’s the topic for a future blog post.