SOLUTIONS FOR LEADERS
What Else Can Health Care Learn From the Aerospace and Defense Industries? Adam L. Jung, MBA, MS,* Robert J. Szczerba, PhD,† and Marco D. Huesch, MBBS, PhD‡§∥
T
he practice of warfare and that of medicine seem antithetical. However, each is a high-consequence, high-intensity arena in which skilled and dedicated human operators focus on complex and intense missions. Opportunities abound for one arena to learn from the other. The most well-known concepts imported from the aerospace and defense industries are surgical and intensive care checklists.1 Checklists allow a common understanding of available patient information, treatment decisions, and shared responsibility. However, many other tools in daily use in aviation and national security remain unexploited in health care. A roadmap, and a commentary based on our own views, may help to bridge these gaps. Consider the 5 clinical tasks (Fig. 1).2 Health care delivery hinges on a correct understanding of the patient and his/her medical problem, a shared and clear understanding of what is to be done and by whom, as well as careful execution and follow-through. Unsurprisingly, military combat and aviation operations rely on a similar concept: the OODA loop of observe, orient, decide and act. Observations are made on an emerging situation, and incoming data are filtered on the basis of heuristics and experience. Such oriented data are fed forward, decisions are made and acted on, and checklists ensure that agreed actions follow a proven standard. However, data volume on the battlefield is generally too overwhelming for individuals to vigilantly monitor without fatigue and errors. These types of intrinsically dull tasks are delegated to automated data vigilance and surveillance tools. Such systems help to overcome excessive reliance on timely and accurate data entry by operators. In addition, a battlefield provides different information about the same thing depending on the perspective and capabilities of the data collector. The naked eye sees things differently than an infrared camera, a radar image, or another naked eye in a different position. Two infrared sensors may have different characteristics that yield different data, although the underlying phenomenon is the same. Fog of war and errors in data entry further confuse the picture. Through the use of automated data fusion, the military seeks to fuse these data sources into a common picture in much the way clinicians attempt to fuse medical data into information about a patient. The military uses computing power onboard and off board military platforms to try and make sense of the data it collects to make the best-informed decisions it can. Health care still relies too much on the heroic efforts of its providers to make these calls. With the failing heroic and often incomplete efforts by providers, most of the data in health care are simply ignored and nonfused. For example, some device data are available and collected continuously but are only intermittently sampled for analysis or recording. Rarely are all available data collected, recorded, or confronted, as the lack of follow-up on many patient laboratory tests ordered on the discharge day shows.3 For data fusion to work, data must be collected and made available in a meaningful form. Electronic medical records (EMRs) are only a part of the answer. Most EMRs are still not integrated with medical devices, making automated data collection difficult or impossible. More EMR medical device integration efforts with better device support are needed. For example, the HL7 standard support for imaging, such as Digital Imaging and Communications in Medicine, and for wave forms, such as annotated electrocardiogram, remains very young. Once stored, data need to be presented in a meaningful way to those with a need and a right to know. Information overload on the battlefield can be deadly. In defense, considerable effort is expended in making the controls and displays used by an operator quickly convey the most important and urgent information simply and clearly. This is viewed as an imperative on the battlefield, but information presentation anywhere, anytime, is only gradually being recognized as a need in health care. Clinical information needs to be similarly prioritized to highlight critical information at, for example, nursing stations and on mobile devices. These still suffer from limitations in common formats. For example, considerable effort has gone into Picture Archiving and Communication Systems to present Digital Imaging and Communications in Medicine data, but considerable effort is still needed to enhance human factors on devices for wave form and numerical data presentation. From the *Wayfinder Technologies, Spring, TX; †X Tech Ventures, Johnson City, NY; ‡USC Price School of Public Policy, Schaeffer Center for Health Policy and Economics, Los Angeles, CA; §Department of Community & Family Medicine, Duke School of Medicine, Durham, NC; and ∥Health Sector Management Area, Duke Fuqua School of Business; Durham, NC. Correspondence: Marco D. Huesch, MBBS, PhD, USC Price School of Public Policy, Schaeffer Center for Health Policy and Economics, 3335 S. Figueroa St, USC Gateway Unit A, Los Angeles, CA 90089 (e‐mail: [email protected]). Mr Jung is the founder and president of Wayfinder Technologies and a former employee of Lockheed Martin. Dr Szczerba is a former employee of Lockheed Martin, where he was the corporate director of Global Healthcare Initiatives. Dr Huesch discloses receiving salary and research support from a grant to his institution by Lockheed Martin. Dr Huesch also reports receiving payments for consulting to the Institute of Medicine, Precision Health Economics, and the Parkland Center for Clinical Innovation. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. Copyright © 2014 by Lippincott Williams & Wilkins
J Patient Saf • Volume 00, Number 00, Month 2014
www.journalpatientsafety.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1
J Patient Saf • Volume 00, Number 00, Month 2014
Jung et al
FIGURE 1. Unexploited tools and approaches from the aviation and defense industries.
Despite the best efforts of data vigilance, data fusion, and information presentation, information overload remains a serious threat for the war fighter. Decision support systems that provide guidance, limit choices, or mandate actions are indispensable. In the military and in aviation, friendly fire and controlled flight into terrain are the direct counterparts of iatrogenic harm in health care. To counteract the risk for such harms, automated identification friend or foe systems prevent or minimize friendly fire, whereas ground proximity warning systems enhance situational awareness at low altitudes or in difficult terrain. Longstanding experience with such systems has also built trust on the part of pilots and warriors alike in system capabilities. Cultural acceptance of automated decision aids in health care is gradually evolving. Prescribing physicians still routinely override computer-generated medication interaction alerts.4 Sophisticated electronic medication administration systems commonly lack built-in clinical decision support functionality. Missing time-based inference means that total daily medication consumption cannot be tracked, sometimes leading to supratherapeutic dosing.5 Contributing to the only slowly evolving acceptance of such systems is the realization that the human element still plays a large part in entering data and that decision support systems may not yet be entirely reliable. Overcoming these 2 challenges requires greater use of automated data entry and data fusion without excessive reliance on human operators, as well as a greater longitudinal provider experience with such systems. As in the aerospace and military sectors, trust will be built slowly and through direct experience of the performance benefits of strong decision support systems. Aside from cultural acceptance, interoperability must be achieved. In defense, systems integration means gathering subsystems from
2
www.journalpatientsafety.com
various manufacturers and coaxing them to work in concert as a complex system that is greater than the sum of its parts. Standards are developed and adhered to by suppliers. Health care still needs to do a far better job on standards and systems integration before the benefits of interoperability and decision support can be realized.6,7 Coupled with these aids to decision making are automated delivery tools. Unmanned systems serve intelligence, surveillance, and reconnaissance functions on the battlefield but can also be weapons platforms. Time-critical systems such as the Phalanx Close-In Weapon System used in every U.S. Navy surface combatant ship have automated weapons release. In health care, few compelling examples of automated delivery exist to date beyond infusion and insulin pumps. Technological innovation in this space requires far more centralized funding as well as research and development in the area of health care delivery as opposed to more basic science.8,9 Finally, in peacetime or on “downtime,” the military and aviation industries train, prepare, and rehearse both in live battle simulations and in computerized force-on-force simulations. Training also builds confidence in the automated systems and understanding of their limitations. Although clinicians do train, most of what they do is practice.10 Automated training and simulation can help examine what-if scenarios in health care or to play out, for example, different patient arrival rates, different facility layouts, procedural changes, or changes in response to extraordinary events such as epidemic or mass trauma.11 Much has been taken from the aerospace and defense sectors to improve health care. However, much abides and represents unexploited opportunities to make health care safer and more effective for both clinicians and their patients. © 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Patient Saf • Volume 00, Number 00, Month 2014
REFERENCES 1. Hales BM, Pronovost PJ. The checklist—a tool for error management and performance tracking. J Crit Care. 2006;21:231–235. 2. Pendleton D, Schofield T, Tate P, et al. The Consultation: An Approach to Learning and Teaching. Oxford, England: Oxford University Press; 1984. 3. Ong M, Magrabi F, Jones G, et al. Last orders: follow-up of tests ordered on the day of hospital discharge. Arch Intern Med. 2012;172: 1347–1349.
Learning From the Aerospace and Defense Industries
An-embedded-solution-for-medical-device-interoperability. Accessed June 2, 2013. 7. Trochim WM, Cabrera DA, Milstein B, et al. Practical challenges of systems thinking and modeling in public health. Am J Public Health. 2006; 96:538–546. 8. Pronovost PJ, Goeschel CA. Time to take health delivery research seriously. JAMA. 2011;306:310–311. 9. Szczerba RJ, Huesch MD. Does healthcare need science or technology more?. BMC Med Inform Decis Mak. 2012;12:103.
4. Isaac T, Weissman JS, Davis RB, et al. Overrides of medication alerts in ambulatory care. Arch Intern Med. 2009;169:305–311.
10. Huesch MD. Forgetting? Impact of breaks in surgery on Californian cardiac surgeons. J Healthcare Qual. 2014;36:42–49.
5. Zhou L, Maviglia SM, Mahoney LM, et al. Supratherapeutic dosing of acetaminophen among hospitalized patients. Arch Intern Med. 2012;172: 1721–1728.
11. Boosman F, Szczerba RJ. Simulated clinical environments and virtual system-of-systems engineering for health care. Proceedings of the Interservice/ITSEC Conference. 2010. Available at: http://ntsa.metapress.com/link.asp?id=q64725057633q751. Accessed June 2, 2013.
6. Leone A. An embedded solution for medical device interoperability. 2011. Available at: http://www.eetimes.com/design/medical-design/4212659/
© 2014 Lippincott Williams & Wilkins
www.journalpatientsafety.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
3
What Else Can Health Care Learn From the Aerospace and Defense Industries? Adam L. Jung, MBA, MS,* Robert J. Szczerba, PhD,† and Marco D. Huesch, MBBS, PhD‡§∥
T
he practice of warfare and that of medicine seem antithetical. However, each is a high-consequence, high-intensity arena in which skilled and dedicated human operators focus on complex and intense missions. Opportunities abound for one arena to learn from the other. The most well-known concepts imported from the aerospace and defense industries are surgical and intensive care checklists.1 Checklists allow a common understanding of available patient information, treatment decisions, and shared responsibility. However, many other tools in daily use in aviation and national security remain unexploited in health care. A roadmap, and a commentary based on our own views, may help to bridge these gaps. Consider the 5 clinical tasks (Fig. 1).2 Health care delivery hinges on a correct understanding of the patient and his/her medical problem, a shared and clear understanding of what is to be done and by whom, as well as careful execution and follow-through. Unsurprisingly, military combat and aviation operations rely on a similar concept: the OODA loop of observe, orient, decide and act. Observations are made on an emerging situation, and incoming data are filtered on the basis of heuristics and experience. Such oriented data are fed forward, decisions are made and acted on, and checklists ensure that agreed actions follow a proven standard. However, data volume on the battlefield is generally too overwhelming for individuals to vigilantly monitor without fatigue and errors. These types of intrinsically dull tasks are delegated to automated data vigilance and surveillance tools. Such systems help to overcome excessive reliance on timely and accurate data entry by operators. In addition, a battlefield provides different information about the same thing depending on the perspective and capabilities of the data collector. The naked eye sees things differently than an infrared camera, a radar image, or another naked eye in a different position. Two infrared sensors may have different characteristics that yield different data, although the underlying phenomenon is the same. Fog of war and errors in data entry further confuse the picture. Through the use of automated data fusion, the military seeks to fuse these data sources into a common picture in much the way clinicians attempt to fuse medical data into information about a patient. The military uses computing power onboard and off board military platforms to try and make sense of the data it collects to make the best-informed decisions it can. Health care still relies too much on the heroic efforts of its providers to make these calls. With the failing heroic and often incomplete efforts by providers, most of the data in health care are simply ignored and nonfused. For example, some device data are available and collected continuously but are only intermittently sampled for analysis or recording. Rarely are all available data collected, recorded, or confronted, as the lack of follow-up on many patient laboratory tests ordered on the discharge day shows.3 For data fusion to work, data must be collected and made available in a meaningful form. Electronic medical records (EMRs) are only a part of the answer. Most EMRs are still not integrated with medical devices, making automated data collection difficult or impossible. More EMR medical device integration efforts with better device support are needed. For example, the HL7 standard support for imaging, such as Digital Imaging and Communications in Medicine, and for wave forms, such as annotated electrocardiogram, remains very young. Once stored, data need to be presented in a meaningful way to those with a need and a right to know. Information overload on the battlefield can be deadly. In defense, considerable effort is expended in making the controls and displays used by an operator quickly convey the most important and urgent information simply and clearly. This is viewed as an imperative on the battlefield, but information presentation anywhere, anytime, is only gradually being recognized as a need in health care. Clinical information needs to be similarly prioritized to highlight critical information at, for example, nursing stations and on mobile devices. These still suffer from limitations in common formats. For example, considerable effort has gone into Picture Archiving and Communication Systems to present Digital Imaging and Communications in Medicine data, but considerable effort is still needed to enhance human factors on devices for wave form and numerical data presentation. From the *Wayfinder Technologies, Spring, TX; †X Tech Ventures, Johnson City, NY; ‡USC Price School of Public Policy, Schaeffer Center for Health Policy and Economics, Los Angeles, CA; §Department of Community & Family Medicine, Duke School of Medicine, Durham, NC; and ∥Health Sector Management Area, Duke Fuqua School of Business; Durham, NC. Correspondence: Marco D. Huesch, MBBS, PhD, USC Price School of Public Policy, Schaeffer Center for Health Policy and Economics, 3335 S. Figueroa St, USC Gateway Unit A, Los Angeles, CA 90089 (e‐mail: [email protected]). Mr Jung is the founder and president of Wayfinder Technologies and a former employee of Lockheed Martin. Dr Szczerba is a former employee of Lockheed Martin, where he was the corporate director of Global Healthcare Initiatives. Dr Huesch discloses receiving salary and research support from a grant to his institution by Lockheed Martin. Dr Huesch also reports receiving payments for consulting to the Institute of Medicine, Precision Health Economics, and the Parkland Center for Clinical Innovation. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. Copyright © 2014 by Lippincott Williams & Wilkins
J Patient Saf • Volume 00, Number 00, Month 2014
www.journalpatientsafety.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1
J Patient Saf • Volume 00, Number 00, Month 2014
Jung et al
FIGURE 1. Unexploited tools and approaches from the aviation and defense industries.
Despite the best efforts of data vigilance, data fusion, and information presentation, information overload remains a serious threat for the war fighter. Decision support systems that provide guidance, limit choices, or mandate actions are indispensable. In the military and in aviation, friendly fire and controlled flight into terrain are the direct counterparts of iatrogenic harm in health care. To counteract the risk for such harms, automated identification friend or foe systems prevent or minimize friendly fire, whereas ground proximity warning systems enhance situational awareness at low altitudes or in difficult terrain. Longstanding experience with such systems has also built trust on the part of pilots and warriors alike in system capabilities. Cultural acceptance of automated decision aids in health care is gradually evolving. Prescribing physicians still routinely override computer-generated medication interaction alerts.4 Sophisticated electronic medication administration systems commonly lack built-in clinical decision support functionality. Missing time-based inference means that total daily medication consumption cannot be tracked, sometimes leading to supratherapeutic dosing.5 Contributing to the only slowly evolving acceptance of such systems is the realization that the human element still plays a large part in entering data and that decision support systems may not yet be entirely reliable. Overcoming these 2 challenges requires greater use of automated data entry and data fusion without excessive reliance on human operators, as well as a greater longitudinal provider experience with such systems. As in the aerospace and military sectors, trust will be built slowly and through direct experience of the performance benefits of strong decision support systems. Aside from cultural acceptance, interoperability must be achieved. In defense, systems integration means gathering subsystems from
2
www.journalpatientsafety.com
various manufacturers and coaxing them to work in concert as a complex system that is greater than the sum of its parts. Standards are developed and adhered to by suppliers. Health care still needs to do a far better job on standards and systems integration before the benefits of interoperability and decision support can be realized.6,7 Coupled with these aids to decision making are automated delivery tools. Unmanned systems serve intelligence, surveillance, and reconnaissance functions on the battlefield but can also be weapons platforms. Time-critical systems such as the Phalanx Close-In Weapon System used in every U.S. Navy surface combatant ship have automated weapons release. In health care, few compelling examples of automated delivery exist to date beyond infusion and insulin pumps. Technological innovation in this space requires far more centralized funding as well as research and development in the area of health care delivery as opposed to more basic science.8,9 Finally, in peacetime or on “downtime,” the military and aviation industries train, prepare, and rehearse both in live battle simulations and in computerized force-on-force simulations. Training also builds confidence in the automated systems and understanding of their limitations. Although clinicians do train, most of what they do is practice.10 Automated training and simulation can help examine what-if scenarios in health care or to play out, for example, different patient arrival rates, different facility layouts, procedural changes, or changes in response to extraordinary events such as epidemic or mass trauma.11 Much has been taken from the aerospace and defense sectors to improve health care. However, much abides and represents unexploited opportunities to make health care safer and more effective for both clinicians and their patients. © 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Patient Saf • Volume 00, Number 00, Month 2014
REFERENCES 1. Hales BM, Pronovost PJ. The checklist—a tool for error management and performance tracking. J Crit Care. 2006;21:231–235. 2. Pendleton D, Schofield T, Tate P, et al. The Consultation: An Approach to Learning and Teaching. Oxford, England: Oxford University Press; 1984. 3. Ong M, Magrabi F, Jones G, et al. Last orders: follow-up of tests ordered on the day of hospital discharge. Arch Intern Med. 2012;172: 1347–1349.
Learning From the Aerospace and Defense Industries
An-embedded-solution-for-medical-device-interoperability. Accessed June 2, 2013. 7. Trochim WM, Cabrera DA, Milstein B, et al. Practical challenges of systems thinking and modeling in public health. Am J Public Health. 2006; 96:538–546. 8. Pronovost PJ, Goeschel CA. Time to take health delivery research seriously. JAMA. 2011;306:310–311. 9. Szczerba RJ, Huesch MD. Does healthcare need science or technology more?. BMC Med Inform Decis Mak. 2012;12:103.
4. Isaac T, Weissman JS, Davis RB, et al. Overrides of medication alerts in ambulatory care. Arch Intern Med. 2009;169:305–311.
10. Huesch MD. Forgetting? Impact of breaks in surgery on Californian cardiac surgeons. J Healthcare Qual. 2014;36:42–49.
5. Zhou L, Maviglia SM, Mahoney LM, et al. Supratherapeutic dosing of acetaminophen among hospitalized patients. Arch Intern Med. 2012;172: 1721–1728.
11. Boosman F, Szczerba RJ. Simulated clinical environments and virtual system-of-systems engineering for health care. Proceedings of the Interservice/ITSEC Conference. 2010. Available at: http://ntsa.metapress.com/link.asp?id=q64725057633q751. Accessed June 2, 2013.
6. Leone A. An embedded solution for medical device interoperability. 2011. Available at: http://www.eetimes.com/design/medical-design/4212659/
© 2014 Lippincott Williams & Wilkins
www.journalpatientsafety.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
3
