Dr. Abraham Verghese wrote in the New York Times recently about the threat of technology to proper patient care. This is an excellent piece and although I do not disagree with the overall message, I think Dr. Verghese conflates different issues currently plaguing our health care system.
Below, I provide some comments on a few of the major points Dr. Verghese writes about: “This computer record creates what I call an “iPatient” and this iPatient threatens to become the real focus of our attention, while the real patient in the bed often feels neglected, a mere placeholder for the virtual record.”
Electronic medical records (EMR), while providing exponentially more information and easier access to such information, have come at a price. For a moment, let’s set aside issues with workflow and productivity (the primary complaints among physicians dissatisfied with EMR systems) and focus on the impact of EMRs on patient interaction.
As described by Dr. Verghese, many clinicians spend their time focused on the computer screen (often with their back to the patient) instead of the patient while in the exam room. Many argue this is a reason to stick with paper and pen. I could not disagree more. The problem is not the EMR, it is the implementation and design of the EMR and computers used to access it. We have gone from holding and writing on a clipboard in our hands to sitting at a computer against the wall. Tablet computers have the potential to take us back to sitting in front of the patient with the chart in our hands. Don’t throw the baby out with the bathwater; EMRs are a necessary component to modernizing the flow of information within hospitals and clinics. We simply need to tweak how we access that information while with our patients. Several hospitals experimenting with the iPad are demonstrating how beneficial tablets may be in the future.
Better still, if Watson could harness data from all the patients in our hospital and in every other hospital in America, we might be alerted to mini-epidemics taking shape. For example, Watson might recognize that the kidney failure in our patient is linked to kidney failure in a patient in Buffalo and another in San Antonio; all three patients, he might inform me, were taking a “natural” weight loss supplement that contained a Chinese herb, aristolochia, that has been associated with more than 100 cases of kidney failure.
We don’t need Watson to do this. What we really need is widespread adoption of comprehensive EMR systems that are interoperable (Watson would need this before it could do any of its magic anyways). Remember a few years ago when Macs and PCs were so diabolically different you couldn’t do anything across the two platforms? That is the current state of our EMR systems. Dozens of software companies are providing services to hospitals and clinics and few of these programs “talk” to each other. If I am admitted to Hospital A and need to be transferred to Hospital B for more advanced care, it is likely that all of my information will have to be re-entered by hand at Hospital B (or scanned in as a PDF which is not searchable or able to be incorporated into existing data—i.e.-my fever curve from Hospital A couldn’t be incorporated into the current trends at Hospital B). Only within the VA system can you have true, nation-wide access to patient records.
As Dr. Verghese points out, having such a system provides tremendous capabilities for disease monitoring, adverse drug event identification, and all manner of epidemiological research. A few health care organizations have begun pooling their records to allow for such monitoring and research, but a true, nation-wide comprehensive system is needed.
[W]e still teach medical students how to properly examine the body. In dedicated physical diagnosis courses in their first and second years, students learn on trained actors, who give them appropriate stories and responses, how to do a complete exam of the body’s systems (circulatory, respiratory, musculoskeletal and the rest)…But all that training can be undone the moment the students hit their clinical years. Then, they discover that the currency on the ward seems to be “throughput”—getting tests ordered and getting results, having procedures like colonoscopies done expeditiously, calling in specialists, arranging discharge.
Unfortunately, this is a highly idealized version of what actually happens during clinical training in the first two years of medical school. Because of the increasingly cramped medical school curriculum, not very much time is dedicated to teaching medical students proper exam techniques and the little training students do get is not thoroughly reinforced through repetition with trained actors and faculty supervision. When 3rd year med students hit the wards, they have not yet formed good examination habits. Physical examination techniques are not undone by the “throughput” culture on the wards so much as they are never properly formed prior to students participating in patient care. Better preclinical training in physical exam skills may abate the indoctrination into the “throughput” culture of the wards but the real change must happen on the wards themselves and our overarching approach to patient care.
Dr. Verghese presents an important subject in modern medicine. The over-reliance on technologies such at CTs and MRIs increases costs dramatically, poses certain health risks, often provides little value over careful physical examination, and takes our attention away from the actual patient, focusing us instead on “data”. However, it’s important not to conflate this issue with other design problems inherent in current implementations of information technologies. Many problems exist but wholesale denunciation of technology advances threatens to move patient care backwards. Judicious use of new technologies, such as tablet computers or clinical decision support supercomputers like Watson, have the potential to dramatically improve patient care and increase physician satisfaction—something that is often overlooked.
Josh Herigon is a medical student who blogs a Number Needed to Treat.
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