There is a well-known concept in computer science called Garbage In, Garbage Out (or GIGO for short). You need not be a brain surgeon to figure out what it means. If you enter bad data into a program or an algorithm, you’ll get bad data as output. No duh. Seems self-evident to me. That said, I’m not sure everyone has adopted the GIGO way of life, and it’s making me sad.
In my last blog post, which focused on how to create an awesome helpdesk ticketing system, I wrote about mandatory fields that require the user to enter something in various boxes, even if he/she doesn’t know how to answer (or doesn’t understand) the question. This is classic GIGO: we need to know this information, darn it, and you’ll tell it to us or else you won’t go any further.
To keep moving forward, what does the typical user do? I’ll tell you what he/she does: types in some garbage. It works great from the user’s perspective. I can get my ticket number and all is good in the world. Except that somewhere else in the company, someone is trying to fix a problem with bogus information. You give me garbage, and you’ll get garbage in return.
Helpdesk ticketing systems aren’t the only sorts of software that can suffer from violations of GIGO principles. Talk to any practicing physician about EHRs, and they’ll regale you with epic stories of dumb things that have needed their attention (See what I did there?). Examples might include an imaging order that requires a doctor to enter their beeper number or office phone number. Or perhaps the requirement that a chief complaint be entered discretely in a box when a more complete description of what brought the patient to the office is already included in the narrative history of present illness (HPI). When we ask, or rather demand, that a box be filled with something, we often get… anything. And anything will do just fine for the input, but we must be suspicious of the output.
Whenever I see GIGO pop up in my IT systems, I naturally try to squash it. Sometimes I succeed, while other times I have to give in to The Man. For example, my hospital is preparing for the Protecting Access to Medicare Act of 2014 (aka PAMA) by implementing software requiring physicians to choose a discrete indication for certain imaging orders. That’s all well and good until you realize that since forever, we’ve required a diagnosis (e.g. ICD-10) code be attached to every outpatient imaging order. See what’s happening here? We’re about to require a physician give us a reason for ordering the study (aka the indication) and also a reason for ordering the study (aka the diagnosis). Not only is this taxing on the physician user of our EHR, but it’s a waste of time. And if you follow the GIGO train, you can predict that we might often see a major difference between the two terms that should likely be identical the vast majority of the time.
It’s considered poor form to contradict oneself in the legal medical record, so we try to avoid making it easy to do that. In the example above, we’ve configured the system to automatically associate the most appropriate diagnosis code to the indication that the physician has already entered. If he/she wants to change that diagnosis code, that’s easily done. But most of the time, the doctor will just go on with the business of taking care of the patient.
It appears that there is stupid stuff all around us.
I think a fair corollary of GIGO is the newfound principle called Getting Rid of Stupid Stuff. OK, maybe it’s not a fancy theory just yet, but last year the New England Journal of Medicine published an article with that title, so it’s definitely a thing. Melinda Ashton, MD, of Hawaii Pacific Health, wrote that she “asked all employees to look at their daily documentation experience and nominate anything in the EHR that they thought was poorly designed, unnecessary, or just plain stupid.” In the article’s conclusion, Dr. Ashton noted: “When the campaign was unveiled, it was largely met with surprise and sheepish laughter, then applause. We seem to have struck a nerve. It appears that there is stupid stuff all around us [emphasis added], and although many of the nominations we receive aren’t for big changes, the small wins that come from acknowledging and improving our daily work do matter.”
By getting rid of stupid stuff in our EHRs, we obey the principle of GIGO. If one thinks of the EHR as one big input device, we make the output better by not asking our users questions to which we already know the answers. I want to get rid of stupid stuff in my EHR, but I also work every day to try to prevent stupid stuff from getting in there in the first place!
Do you have stupid stuff in your EHR? Do you work to prevent garbage from getting in? Leave a comment and tell me about it.
Craig Joseph, MD, is the Chief Medical Officer for Avaap, an EHR and ERP consulting firm. He is a pediatrician and physician informaticist with experience in both clinical practice and the use of the EHR to improve patient care and physician efficiency. Dr. Joseph also currently serves as the Interim CMIO at El Camino Hospital in Mountain View, California. This piece was originally posted on Avaap’s blog page.