Dear Ethix – Issue 42

Starbucks Culture

Congratulations on your excellent article on Orin Smith in the March/April issue of Ethix. I am very impressed by a company so committed to a specific and well defined culture (the kind I dream of working in). It is proof that companies can be successful following this enlightened approach as opposed to the old style autocracy I have been accustomed to in my career.

Philip M. Bishop
Edmonds, WA

Medical Automation

The biggest obstacle to digitalization is ROI. Most physicians do not see a monetary advantage to putting patient records into a computer, as they do not have the time or the finances to do the job. Large clinics or hospitals are currently doing this, but it is very time consuming and I have seen a number of problems with the logistics — namely who is going to enter the past data to bring all the records up to the current date.

While I was in an OB/GYN office in Montana, they were converting to digital records. The nurses were asked to enter all of the past records as well as the new records when the patient came in for their appointments. This was extremely time consuming and created a lot of “push back” from the staff.

Digitalization has improved the delivery of test results and x-rays to physicians. A number of clinics now offer these results online.

Kevin M. Jones
Issaquah, WA

I think you went easy on the doctors. The quiet truth is that the paradigm shift for most docs going to an Electronic Medical Record (EMR) is painful. Most know that using one is the correct thing to do, and that it will eventually be the standard of care. We installed one here two years ago, and we still have a lot of gnashing of teeth.

EMR costs are coming down, but the rate of business failure in EMR vendors remains high. There is a lot of business risk to medical practices associated with buying one. We are using one of two in which the vendor is profitable, it has been around for over twenty years, and still has a lot of legacy code.

The core problem in clinical informatics is arriving at a complex yet flexible ontology. There are several medical nomenclatures and ontologies available. The problem is deciding who is right, and what standard to choose and design around. You mention snomed. I prefer a more complex one from Belgium (, as snomed has some ontological problems.

Greg Aeschleman, M.D.
Woodinville, WA

In automating the medication-use process two axioms need to govern our decisions:

1. Any system implemented should be as safe or safer than the system being replaced.

2. Any system implemented should be as efficient or more efficient than the system being replaced.

It is not long before these two are in conflict.

Some recently developed automated systems make the medication-use process safer, protecting nurses from making mistakes and patients from being harmed, but they are not as efficient as the old way of dispensing and administering drugs. Some automated systems are less safe than the manual systems they are replacing. Generally, this is because they simply are not ready. We are wise to keep developing technology, while resisting premature adoption.

But, even mature automation does not ensure a safer system, any more than state-of-the-game golf clubs ensure lower scores. One director of pharmacy told me, “Before we automated we had chaos. Now we have automated chaos.” The best technology can be used poorly. The goal is not to automate, but to make the process safer.

At its best, automation may augment, but it will never replace the value of the clinician. Putting pharmacists on rounds with physicians has proven to reduce harmful medication errors more than implementing computerized physician order entry—at a fraction of the cost. Sadly, hospitals with their limited budgets are having to choose between the two and being pressured to favor technology.

I offer this word from God: Ecclesiastes 3:1ff

“There is a time for everything under heaven.

A time to be born. A time to die.

A time to laugh. A time to cry.”

A time to automate and a time to refrain from automating.

May God give us the wisdom to know the difference.

Mark Neuenschwander
Bellevue, WA