Information technology (IT) can be an extremely useful tool. It allows us rapid access to patient records, treatment protocols and other useful clinical information. However, it may provide an additional distraction in an environment filled with interruptions. It can also expose physicians to liability in many unappreciated ways. Institutional policies may help clarify the role of IT in the workplace. As medical professionals, we must recognize our role in determining what constitutes appropriate and inappropriate use of information technology in the O.R.
In December 2011, Matt Richtel coined the term “distracted doctoring” in a New York Times article to describe the phenomena of computers, smartphones and other technology creating a distraction to patient care.1 In his article, Richtel describes how clinicians can be “focused on the screen and not the patient, even during moments of critical care.” His examples include a survey study published in Perfusion in which 55.6 percent of perfusionists reported the use of a cellphone during the performance of cardiopulmonary bypass.2 Richtel also describes anesthesiology trainees being found texting in the O.R., a neurosurgeon talking on his cellphone during an operation and other clinicians visiting eBay on computers in the ICU.
Distraction or Tool?
Certainly, IT creates an additional distraction above the usual disruptions in the O.R. However, as Richtel alludes to in his article, IT may also afford opportunities to quickly reference medical texts, utilize clinical calculators, access treatment guidelines and obtain other information pertinent to patient care on one’s smartphone or PC. Additionally, anesthesia information management systems (AIMS) provide for automatic vital sign documentation, which may afford more time to focus on the patient. But at what point does IT become a distraction? For example, is it acceptable to allow anesthesiology residents to study during a case? Is PubMed O.K.? What about looking up information pertaining to your next add-on case? Is it possible for a device to be both a distraction and a tool, like the alarms on a patient monitor? The increase in electronic equipment in the O.R. has increased safety but can result in information overload. Ultimately, it is the responsibility of the individual physician to determine where the focus should lie. And while this is true in most aspects of patient care, some hospitals are creating policies that restrict access to IT within the O.R. Development of these policies may not only be related to concerns about patient care. According to the legal department at one author’s institution, few clinicians appreciate the legal consequences related to inappropriate use of technology in the O.R.
“Anything You Say or Do (Electronically) May Be Used Against You …”
Internet browsing history is stored locally, and depending on how you use your browser, may be stored in an account linked to your personal information. Internet use in the O.R. is trackable and is monitored by most health care institutions and may be discoverable in court.
Inappropriate use of the Internet or other non-secure communication technology may result in loss of patient confidentiality. Consider the act of posting patient information to Facebook – even if one were to realize his or her mistake and try to immediately delete the communication, it may still exist. Facebook posts are not easily removed. Though you may be able to completely delete your account, according to Facebook’s Data Use Policy, “some information may remain in backup copies and logs for up to 90 days.” Additionally, Facebook warns that “Some of the things you do on Facebook aren’t stored in your account, like posting to a group or sending someone a message (where your friend may still have a message you sent, even after you delete your account). That information remains after you delete your account.”
Even Facebook posts that do not contain patient information, and that were not posted to Facebook during the course of patient care, may be used against you in legal proceedings. For example, personal communications sent via Facebook surfaced during the deposition of an anesthesiologist in Texas involved in a medical malpractice suit.3 Not only are the Facebook posts revealed in his deposition as published by the Dallas Observer Blog now part of the public domain, they may also be admissible in court.
Mobile text messages can also be found and used to imply that a health care provider was distracted from patient care. Deleting a standard SMS text message from one’s mobile phone does not remove all traces of the text message. If you are billed for your texts, the time and date of the text is reported on your phone bill. Additionally, some cellular phone companies temporarily store the content of your messages on their servers. According to a document published by the Department of Justice obtained by the ACLU under the Freedom of Information Act, the content of your texts may be stored for days to months. Though the “text of the text” may be gone, some details about your texts may be stored for up to five to seven years.4
These mobile phone text and Facebook communications, whether deleted or not, can be uncovered in a civil or criminal suit during the course of discovery. Sending, displaying or saving HIPPA-protected information in an unsecured form is illegal and may result in fines or imprisonment. Texting and email services are generally not secure unless designed to be so. Taking pictures on a smartphone could be a HIPPA violation.
Destroying Evidence Is Illegal
When an attorney suspects that someone’s social media or other electronic activity may be required in discovery, a “preservation-of-evidence” letter is sent to that person or their lawyer. Failure to comply with a preservation letter can result in serious legal consequences. Deleting electronic communications in the absence of a preservation letter may also result in legal penalties. For example, in the state of Illinois, notification of the possibility of a lawsuit may create an obligation to preserve evidence, including any electronic communications, involved in the case.5 Unfortunately, it can be difficult to predict the circumstances that lead to a lawsuit and whether or not one’s personal mobile device or computer usage in the workplace will be probed in discovery.
Lack of Useful Policy
A global survey of more than 34,000 companies in 2009 suggests that only 25 percent of companies have a formal policy on social media.6 Technologies emerge faster than they can be legislated. While some hospitals are starting to create policies restricting use of information technology in the O.R., many others have no policy whatsoever. These policies are difficult to create. Should some information technologies be forbidden? Should eBay be blocked? Should all information technology be forbidden in the O.R.? Should it be used only when an individual clinician decides that it does negatively affect patient care? How about smartphones? What if they are used to call the Malignant Hyperthermia Hotline? Despite these challenges, development of a technology policy for the O.R. may allow our profession to keep the benefits of increased connectivity, including the ease of access to medical information, while addressing many of its shortcomings.
Technology in the O.R.
Health care systems in the U.S. are under increasing pressure to adopt information technology and are publicly recognized for their efforts.7 While this expansion of IT has the potential to have a significant positive effect on anesthesia practice, we must remember to maintain our vigilance. We must also become involved in local policy regarding Internet and network use to ensure that the benefits of IT are not lost, and to remind clinicians of their responsibility. Unfortunately, there are no easy answers and this process will likely continue for years to come.