GIDI-Up!...and OUT!

A golden oldie post from 2007. We now have integrated digital voice recording, which magically crashed following server upgrades. Seems the XML codes from iRecorder aren't being heard by IMPAX. My partner Dr. Killer longs for the days of the GIDI. How nostalgia clouds our memories...

Image courtesy of: http://www.kinkelder.org/

Just about every medical student has read Sam Shem's novel, "The House of God" and most can recite the 13 Laws by heart:

1. GOMERS DON’T DIE.
2. GOMERS GO TO GROUND.
3. AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE YOUR OWN PULSE.
4. THE PATIENT IS THE ONE WITH THE DISEASE.
5. PLACEMENT COMES FIRST.
6. THERE IS NO BODY CAVITY THAT CANNOT BE REACHED WITH A #14 NEEDLE AND A GOOD STRONG ARM.
7. AGE + BUN (Blood Urea Nitrogen) = LASIX DOSE.
8. THEY CAN ALWAYS HURT YOU MORE.
9. THE ONLY GOOD ADMISSION IS A DEAD ADMISSION.
10. IF YOU DON’T TAKE A TEMPERATURE, YOU CAN’T FIND A FEVER.
11. SHOW ME A MEDICAL RESIDENT WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.
12. IF THE RADIOLOGY RESIDENT AND THE MEDICAL STUDENT BOTH SEE A LESION ON THE CHEST X-RAY, THERE CAN BE NO LESION THERE.
13. THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

I can attest to the fact that these laws are really fairly accurate. But I wanted to bend one of the laws a bit as an introduction to today's topic, the GIDI.

The GIDI is an example of Dalai's version of the 11th law: SHOW ME A PROGRAM OR TECHNOLOGY DESIGNED BY ENGINEERS FOR I.T. WITHOUT PHYSICIAN INPUT THAT ONLY TRIPLES MY WORK AND I WILL KISS IT. This will make sense shortly.

You are naturally asking, "What is a GIDI?" Well, the official title of this software extravaganza is "Generic IMPAX DTMF Integration," and it was designed to help us communicate reports to the outside world. It was a good idea, with all the right intentions, but we all know what the road to Hell is paved with, don't we?

Here's the problem the GIDI was designed to solve: We have Agfa Impax PACS, as if you didn't know, and we also have an older Dictaphone analogue voice dictation system. As we dictate happily along, there must be a way to enter the patient into the system for the transcriptionist to know whose report she is typing. Prior to the GIDI, we had the option of simply reading the patient ID, or the accession number, or something like that into the mike as the beginning of the dictation. There is also the option, if it is set up to do so, of keying in that same number with the pad on the dictaphone head-unit. From the Agfa GIDI manual:

GIDI was written because tones describing the images must be manually dialed into the dictation system. This is slow, tedious, and error prone.

I'll agree with that. So, Agfa was commissioned to write the GIDI!

GIDI introduces a more efficient workflow. The application automatically starts at boot time with Impax and waits for a user to press the "start dictation" button on Impax. GIDI is aware that the button has been pushed and uses the modem to dial into the dictation system a series of tones based on Impax study information and user specified settings. The radiologist then makes their recording. GIDI is also aware when the user presses the end dictation tone, which causes the Impax study to be updated such that the dictation is complete.

If you're interested, this is the control panel for the GIDI set-up.

On our particular Dictaphone implementation, The GIDI buys us two things: first, we don't have to enter the accession number (although we usually dictate it anyway), and second, the voice dictation can be called up by telephone from the system if you know the patient's ID. This allows for instant gratification when transcription turn-around just isn't good enough.

To this point, everything sounds great. Now, here's how it works in practice. A SoundBlaster board is placed in your workstation computer if there wasn't already one there, and it is connected to a modem output. The modem AND your dictaphone are connected in parallel to the telephone line. You start the GIDI by double-clicking its icon, if it didn't start by itself, or if it shut off, and then you activate the Dictaphone, which dials into the tank. When you begin a dictation by clicking the proper button, Mr. GIDI transmits the tones over the phone line, Dictaphone gives a voice prompt, and off you go. When done, you click the "Dictated" button, the termination tone is sent through, just like pressing "end" on the mike, and you are ready for the next victim.

Sounds pretty straight-forward, right? This should be a labor-saving device for all involved. Except for one little problem. It is a true pain in the backside to use. It was overengineered and undertested. In actual use, the tones are transmitted VERY SLOWLY. Yes, an extra 6 seconds per study is no big deal, unless you are reading 200 studies a day as we do some weekends. That would be 1200 seconds, or 20 minutes. Let's see...even an extra 10 minutes per day, working, say, 200 days per year, adds up to 2000 minutes or 33 hours. That would be just under four 9-hour working days per year. You get the idea. All that time wasted because of a program that is supposed to be helping me.

As Ron Popiel says, "Wait! That's not all!" The thing has a bad habit of hanging up the dictaphone, crashing IMPAX, or decoupling itself with the dictation system, requiring restarting of the GIDI, redialing into Dictaphone, and sometimes rebooting the computer altogether. So, add another 10-20 minutes to the daily toil. The system only allows dictating one exam at a time, so we have to re-GIDI every study on a multiple trauma patient. (And I'm talking about a CT of the head, C-spine, T-Spine, L-spine, chest, abdomen, pelvis, and at least one extremity, as well as CR's of all of the above, so there could be 10-20 different clicks for one patient.)

And, there's more! Occasionally, when the GIDI blows up, the study that was on the screen disappears, and if you weren't paying very close attention in those first few seconds, it is rather difficult to know who just left your screen. Thus, a number of studies are accidentally lost from the worklist, only to be rediscovered hours or days later.

The punch-line is that we don't even need the damn thing. Our human transcriptionists are rarely more than 10-20 minutes behind our dictations, and they are very good about getting STAT reports online, well, STAT! And, we type in our preliminaries for the ER, so they are not in desparate need of this technological tour de farce either. But no one will let it go.

Sadly, we have in the GIDI yet another example of a solution designed without regard to the actual workflow of the actual human being that actually uses it. Again and again and again, we are delivered products that the engineers (keep in mind, I am an engineer by training as well) think we should like, but never asked us if we actually do. Maybe it all boils down to communication. Somehow there needs to be dialogue between the end-users of these things and the folks that create them. Don't go looking for something you can patent, guys, but try to come up with something that will truly help me do my job. And please listen to me when I tell you how I do my job, don't just show me newer and shinier gadgets that you think will enhance my workflow. Most of the time, they just get in my way. Like the GIDI. Which really has to go. Soon. Very, very soon. Like today.