Monday, May 29, 2017

The Broken File Effect


The three most important pieces of equipment that I have to improve neurological outcomes and perhaps even save lives in Zambia are my stapler, staple remover, and hole punch. Most people would wonder how this is possible. These three simple tools help me address what I call "The Broken File Effect".

This term is adapted from "The Broken Window Effect" which was felt by some to be responsible for the high crime rate in New York City in the early 1990's. When it was addressed, the result was a dramatic, almost unfathomable drop in the city's crime rate. "The Broken Window Effect" is elegantly described in Malcom Gladwell's book "Tipping Point". In its most simplified form, "The Broken Window Effect" describes how the environment such as broken windows, abandoned cars, and graffiti on subway cars contributes to crime because of the behavior it "permits". The book goes on to describe how cleaning up the environment and addressing smaller crimes like targeting turnstile jumpers on the subways helped police to prevent larger crimes in the long run. It turns out that turnstile jumpers were often perpetrators of larger crimes and arresting them prior to getting on the subway was an effective tool for prevention.

I think the same principles can apply to health care in Zambia particularly as it relates to patient files. A patient's medical file is essentially the only record that exists related to a patient's medical history. The same medical file is used to document clinic visits as well as notes during an admission. Most patients take these files home. It is a valuable source of information.

The main problem is that these files are often in horrendous condition. Notes, laboratory studies, and radiology reports of varying sizes are thrown together, most commonly attached by a swarm of staples in the upper left-hand corner. Often, there are no blank pages at the end of the file for further documentation. Instead, random pages, that are blank on one side, are stapled to the last page adding chaos and instability to the file.

I have become obsessed in my outpatient clinic with cleaning patient files. The first thing that I do after recording a patient's biographical information is to go through their file and remove excess staples, reorder the papers in chronological order, save vulnerable laboratory results or radiology reports that are loosely placed in the file, punch holes in all the papers, add continuation sheets, and finally ask the clerks to bind the papers into a new file if necessary. They have become accustomed to my emerging from the clinic room with a dilapidated file stating, "This file needs love!".

I am convinced that addressing "The Broken File Effect" saves patient's money, reduces unnecessary testing, and improves outcomes. There is no greater waste than performing a test and not having the result. It is worse than not performing the test at all because a resource has been used for no reason. A CT scan in Zambia costs US $120. This makes up a substantial portion of a family's income for the year. Yet, patients often find a way to raise some or all of the money to have the test done. Often, the only record of the test is the radiology report and/or a CD that is placed in an envelope and attached to their file. I frequently have seen these envelopes fall out of files or hanging on to the file for dear life by half a staple.


If this radiology envelope is lost, there may be no record of the study if it has been erased from the CT scanner. This happens frequently. As an example, a patient may develop chronic headaches after losing their spouse to HIV infection. During the course of their initial evaluation, they had a normal CT scan but lost the radiology envelope. So, what happens? Instead of getting what they need which is grief counseling they may see a new provider who orders another CT scan.  This waste of resources, unnecessary financial cost, and delay in the initiation of proper care could be avoided simply by addressing "The Broken File Effect".

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