The slippery slope for patients, nurses, and doctors posed by robots in healthcare

By: RoseAnn DeMoro, Executive Director of National Nurses United

For patients needing dialysis or care for acute kidney failure, there’s a new doctor in the nephrology ward at St. Joseph Hospital in Eureka, Calif. Meet the doc on a stick.

It’s not a scene from “Star Trek” or the latest X-box video game. And, like the smooth-sounding, but ominous “Hal” computer running the spaceship in “2001: A Space Odyssey,” those side effects might be a killer.

Eureka RNs have noticed an immediate impact. Dr. “doctor on the lamp post” can sort of see the patient, but can’t offer hands-on care, has trouble getting around, and doesn’t hear so well. So it’s up to the RN to babysit the machine, wheel it around, and clinically assist the remote doctor with patient communication and physical assessments. (The company name “InTouch Health” should be listed in the dictionary somewhere between “deceptive” and “Are you kidding me with this?”)

For RNs, it means more time away from other patients on often already short-staffed units. Involvement with this process at the patient’s bedside will take considerable time, “during which a nurse’s other assigned patients have no nurse available to meet their needs,” says St. Joseph RN Katherine Donahue

Further, “the robot doctor is very impersonal for the patient. It undermines the hands-on ability for the doctor with the patient, and if the electronic equipment malfunctions it can compromise the medical record,” Donahue added.

Computer-driven errors from the trillions of dollars the healthcare industry is spending to develop, market, and profiteer from in the not-so-brave new world of medical technology. That’s not a concern, right?

Or as Hal the computer states right before killing the human passengers and pilots, he is “foolproof and incapable of error.”

Problems with the machines might be a surprise to the consultants and industry executives, not to mention the politicians who enacted financial incentives to promote rapid expansion of medical technology as key components of the Affordable Care Act, and the 2009 budget stimulus bill before that.

But nurses have long been aware of the downsides for quality care and human healthcare employment, deriving from computerized diagnostic and prognostic protocols, and other skill-debasing and displacing mechanical overlords.

At the dawn of the healthcare restructuring wave of the early 1990s, the California Nurses Association’s research department was sounding the first warnings of the implications of turning nurses and other hospital personnel and the nursing process itself into digital bits, of how individual patients need individualized care, and of how the machines can and do actually fail.

We cited the example, told in a PBS special, “The Thinking Machine,” of artificial intelligence researcher Doug Lenat describing his rusting 1980 Chevy to a skin disease diagnostic system as a lark. It concluded that the patient had measles.

For a more recent anecdote, consider Hal’s great-grandfather, Watson, developed by an IBM research team and rolled out with great fanfare on the quiz show “Jeopardy.”

Viewers watched in awe as Watson steamrolled its human competitors, until they got to the “Final Jeopardy” question: “What U.S. city’s largest airport was named for a World War II hero; its second largest, for a World War II battle.” Watson answered promptly, “Toronto,” (uh, that’s in Canada), while the overmatched humans got it right, “Chicago.”

That story made lots of news. But less recalled is follow-up explanation from the lead IBM research investigator who concluded that the “category names were tricky,” only minimally suggesting an “expected answer,” and “the way the language was parsed provided an advantage for the humans and a disadvantage for Watson,” as reported by Steve Hamm in a blog for “Building a Smarter Planet.”

Or, in a nutshell, all the problems nurses, CNA and NNU have reported with computerized protocols – substituting digitalized systems that don’t necessarily respond to the diverse, complex health problems faced by real patients for human professional judgment, the ability to think and analyze.

Watson went on to a better life in, you guessed it, healthcare. Last month IBM announced that Watson will be making utilization management decisions for lung cancer treatment at Memorial Sloan–Kettering Cancer Center in conjunction with insurance giant WellPoint. IBM Watson’s business chief boasted that 90 percent of nurses in the field who use Watson will follow its guidance, reports Forbes magazine.

While RNs have long been the Cassandras on technology, many doctors have been late to the game and been in the forefront of cheerleading for how the Watsons and telemedicine practitioners are the solution for medical errors, improving overall quality, and cutting healthcare costs.

A physician walking the rounds in a hospital might only see five or 10 patients a day. Put that same doctor at a desk with a computer monitor miles or continents away, and they might see 300 patients a day. How many doctors do you think the CEOs will need in this future?

One last example from the retail grocery industry. When product scanners were introduced, a lot of checkers thought it would make their jobs easier. It did, required fewer of them and downsized their skills as well.

Today, walk into any Safeway and notice the growing number of fully automated check-out registers with no live workers and no ability to respond to individual problems – in other words, just another grocery commodity. That’s what the doc behind the doc on the stick might give a little more thought to.

How nursing scripts and patient satisfaction surveys project a fantasy of care, not real care

By: RoseAnn DeMoro, Executive Director of National Nurses United

“Hello, Mr. Smith. My name is Joanne. I am your nurse. Are you experiencing any pain today? No? That’s good. Do you need help getting to the bathroom?” (check script) “Can I fluff your pillow, bring you a magazine, turn on your TV, move your water bottle closer?”

(check script) “I am so happy to be of service, this is all part of the excellent care we provide here at Happy Homes Medical Center and Resort.”

“We know you have choices when you go to the hospital, thank you for choosing Happy Homes.” (check script) “You will be receiving a survey from us after you leave Happy Homes, and I hope you will remember this excellent service when filling it out. Have a nice day, Mr. Smith.”

If this scenario seems far fetched, you’re probably not a nurse who has worked in a hospital recently. Strict adherence to scripts derived from exorbitantly paid consultants like the Studer Group and Press Ganey for every interaction between the RN and her patient is increasingly a job expectation.

Can’t recall it all? Not to worry, the hospital will provide acronyms and “important key words,” also known as the “Five Fundamentals of Service,” to help RNs remember their script, helpfully reinforced by their managers, as we noted in a 2010 NNU CE home study course and feature story (National Nurse, October, November 2010).

Scripting is one element, another is “rounding,” guaranteeing that every nurse document a visit to every patient at least once every hour, even if the nurse checks on the patient more frequently, as is typically the case, or misses the hour by a few minutes because another patient happens to be coding.

And, what happens if you fail to meet the scripting and rounding requirements? For the nurse, especially in a non-NNU hospital, it can lead to docked pay or other discipline. For the hospital, it can lead to reduced Medicare reimbursement, for which it will certainly exact punishment on the nurses.

Welcome to the not-so-Brave New World of faux patient satisfaction.

About 15 years ago, during an earlier wave of hospital restructuring, we told the story about a hospital where nurses being required to put lip gloss on a patient to improve their color before a family visit so that family members would think their loved one was receiving appropriate care. Even as the hospital was replacing RNs with unlicensed personnel, all that mattered was the perception of care.

As the years have evolved, so have the reengineering methods. And the hospitals have an added incentive to substitute service and the appearance of care for the actual delivery of quality care.

It pays. A lot. The Centers for Medicare and Medicaid Services announced last October that patient satisfaction survey results will be one significant factor in determining Medicare reimbursements, and for those executives lucky enough to meet the contrived guidelines, bonuses.

To make matters worse, patient satisfaction surveys are fully integrated into the 2010 Affordable Care Act, through healthcare quality initiative measures.

Are the nurses, doctors, and other staff constantly smiling? Check. Are there plants in the hospital lobby? Check. Attractive artwork on the walls? Check. Soothing music in the elevators? Check. An espresso machine in the cafeteria? Double check. Free wi-fi in hospital rooms and lounges? Triple check. And are the nurses scrupulously following those scripting and rounding demands? Checkmate.

If this sounds like something out of Disneyworld or the hotel and hospitality industry, that’s not a coincidence. Hospitals now use the same consultants and the same formulas. Call it Goofy on steroids.

Consultant-driven reengineering blueprints are destructive enough in the service and entertainment industry. In healthcare they can be deadly.

Witness a study, “The Cost of Satisfaction,” just published in February in the Archives of Internal Medicine. Correlating patient satisfaction surveys with outcomes, the study said the risk of death for the most highly satisfied “healthy” patients was 44 percent higher than their less “satisfied” counterparts. The article sparked a bevy of medical blogs and news accounts with titles like, “Do you like your doctor? It could be the death of you,” and a furious rebuttal from Press Ganey statisticians arguing the surveys are “here to stay.”

Just making the patient happy, with inappropriate care for example, has no bearing on quality of care, wrote columnist Theresa Brown, RN, in a March 14 New York Times commentary aptly headlined “Hospitals Aren’t Hotels,” and echoed by William Sullivan, MD in a March 20 article in Emergency Physicians Monthly titled, “Dying for Satisfaction.”

Nurses don’t need these high-priced consultants or CMS or the ACA to determine how to improve quality at the bedside. Studies have long documented that safe RN staffing, especially mandated RN-to-patient ratios, and other measures that reinforce professional nursing judgment and the application of an RN’s clinical expertise and experience have far greater impact on positive patient outcomes.

Indeed, nurses increasingly see that the patient satisfaction scam, and the scripting and rounding that accompanies it, are closely associated with hospital industry restructuring aimed at deskilling, displacement of RNs, and automating RN interactions with patients.

They interfere with nursing care, undermine the culture of safety, can lead to increased medical errors, and subject RNs to intimidation, offensive scrutiny, and discipline from managers for not following the consultant’s script and doing enough to artificially inflate patient scores.

It’s a safe bet that when Disney executives themselves are in the hospital, they’d rather have safe nursing care than a potted plant at the bedside.

How the ACA is restructuring care and nursing itself

By: RoseAnn DeMoro, Executive Director of National Nurses United

With all the clamor over website woes during rollout of the Affordable Care Act, much less attention has been paid to changes in the delivery of healthcare that will have far-reaching, adverse effects on healthcare quality and access long after the signup problems are a distant memory.

As we have said, some components of the ACA are clearly welcome, especially the Medicaid expansion in those states where the governors are not standing with pitchforks in the door to block health coverage for the working poor. Yet there’s plenty of trouble in the fine print, especially on the care delivery side.

For RNs, these changes are achingly apparent. Just ask Kaiser Permanente RNs who have spent much of the fall protesting cuts in hospital and patient services that Kaiser executives paint as the face of future healthcare. Much of this latest wave of hospital and healthcare restructuring was, of course, wreaking havoc before enactment of the ACA.

However, financial incentives buried deep in the new healthcare law add a whiff of healthcare restructuring on steroids. The ACA rewards hospitals and insurers for shifting care delivery out of the hospital, regardless of patient need, stepped-up use of labor- and skill-displacing technology, gimmicks like patient satisfaction surveys, the transfer of more costs onto patients and workers, and other worrisome trends.

To get the full picture, I strongly encourage those who are able to attend one of our educational offerings, “What Does the ACA Mean for RN Patient Advocacy? The Bedside From the Bottom Line,” “RN Patient Advocacy in an Ecological Context,” both now open for registration on the NNU website, or one that will start soon, “Keeping Sight of Patient Protection: Insurance & Patient Care After the Affordable Care Act.”

Like those bad Halloween movies, the worst abuses long associated with managed care are back. Private health insurers, and hospital chains like Kaiser that are also insurers, or hospitals that form their own integrated networks through the new Accountable Care Organizations (ACOs) have an economic incentive to restrict care.

Other insurers simply pass along their financial risk to providers, who then, to boost their own revenues and profits, shift the burden onto patients through steeper co-pays, require cash up front before administering care, determine if patients are a payment risk using medical credit scoring, and hound patients for payment afterwards.

Hospitals also set cost reduction targets by limiting patient access to hospital care, increasing out-of-pocket expenses for patients, and targeting RNs.

The latest wave of the restructuring emphasizes two interrelated objectives: eroding the patient advocacy role of RNs through deskilling, displacement, and division, weakening the ability of RNs to act collectively.

Fewer patients are admitted, held in “observation units” up to 24 hours then sent home, and pushed out the door prematurely to lesser-staffed, lesser-regulated sites or home.

Kaiser, for one, has reduced its average daily census by 11 percent the past four years. They’re not alone. Henry Ford Health System in Detroit had a 6 percent drop the first seven months of this year, Modern Healthcare reported in August. Health consulting firm Sg2 predicts a national 3 percent drop in inpatient admissions the next five years, coupled with a 17 percent growth in outpatient services.

Hospitals overall, note our researchers at the Institute for Health and Socio-Economic Policy, have profit margins of 35 percent for elective outpatient services, compared to just 2 percent for inpatient care.

Kaiser, a national model, is seeking to move 1,000 RNs out of hospital care to other settings in Northern California alone, thus dispersing RNs and undercutting their ability to act together to fight for patients, while closing hospital services in a number of facilities, as seen in an array of cuts which have outraged seniors in Manteca, Calif. and the closure of pediatric care in Hayward, Calif.

In a 2012 Health Week presentation in Copenhagen, former Kaiser CEO George Halvorson said that in the near future, “for most people the home will be the primary site of care” dominated by in-home monitoring, self-care, and increasingly “cheap.”

That will increase the burden on families, especially women. A Gerontologist study in 2012 predicted an up to 15 percent likelihood of adverse events for home care patients in drug side effects, falls, and equipment malfunctions, and a huge increase in levels of stress and strain for the new home caregivers.

For RNs, the restructuring wave hits in multiple other ways as well. Technology is used to displace, not enhance, professional skill; to increase surveillance of nurses; and to routinize care by chopping it up into discrete, factory assembly line-type parts.

If managers can fragment and standardize the nursing process, they can automate it with technology, and intensify the workload with speed-up and short staffing. Sound familiar?

NNU RNs are heroically challenging these trends, and it is a major reason why we continue to campaign for a more humane healthcare model, not based on maximizing profit, but on ensuring a single standard of excellence in quality care for all. But it is going to require all of us; everything we represent is at stake.