I have spent a good portion of his career working to come up with ways to make healthcare better, faster and cheaper through the appropriate use of computer and information technologies. Given the vitriol that I have periodically heaped upon many of the electronic medical record systems commonly deployed and mandated by the government, this enthusiasm for computers and telecommunications may come as a bit of a surprise to some of our readers. How is it possible to rail against Meaningful Use and CCHIT and federal punishments for not mindlessly adopting healthcare information technologies (HIT), and yet insist that computers have enormous potential for improving the lives of doctors and patients?
The answer, of course, has to do with the context in which these technologies are used and the quality of implementation. These determine whether the result is, to borrow a phrase from Dr. Scot Silverstein “IT done right,” or simply a waste of time, money and human lives.
When undertaking or evaluating any healthcare project that involves computers and telecommunications, we have found it useful to ask for the answers to just a few basic questions before risking time, money and human lives in the effort.
- What are the specific benefits that we would like to obtain as a result of this effort. Please let’s not hear any platitudes like “to improve quality,” “facilitate communications,” or to “build a 21st century healthcare system.” Exactly who would you like to have communicate with whom, and for what purpose? Quality of what, exactly, and how will you measure this in a way that isn’t just checking boxes? How will whatever you’re doing make the 21st century healthcare system clearer better than the one we had in the 20th century?
- What is the easiest and simplest technology that we can use to generate the desired results? Not which one is the most sophisticated, or has the most features, or which ones might gather the most information. Keep your eyes on the specific mission to be accomplished. The perfect is the enemy of the good.
- What will the impact of this technology be on the productivity of clinicians? Let’s be frank, the primary purpose of any healthcare system (aside from preventing disease with public health measures) is to diagnoses and treat patients. Clinicians are the only people in any healthcare system who have the ability to do so. That makes clinicians, and the patients they treat, the most important people in the entire healthcare system. Mess with them, and you’re messing with the whole point of 17% of U.S. GDP. It’s nothing short of stupid to reduce the efficiency and productivity of these people. If you want value for your money, the rest of the healthcare system needs to serve them, not the other way around.
- What will using this technology do to the physician-patient relationship? One of the things we’re going to miss most about the 20thcentury was the genuine opportunity to have a physician-patient relationship. Marcus Welby, M.D. might seem like a cliché, but the fact is that small offices and clinics who relied upon market-based customer satisfaction for their livelihood had all of the incentives necessary to produce the best possible experience and outcomes for their clients. Properly nurtured, the physician-patient relationship is a wonderful thing.
Given these simple questions – call them rules if you will – there are dozens of ways in which to destroy the positive impact that information technology can have in the healthcare setting. And slowly but surely we’re finding them all. One of the most recent examples comes from Oregon, in the self-styled “forward thinking” Pacific Northwest.
In the most recent issue of the Oregon Medical Board Report, the Oregon Medical Board (which is the licensing and disciplinary entity for the state of Oregon) published a short article entitled “Statement of Philosophy: Telemedicine,” that was adopted by the Board as of January 2012. The entire statement reads as follows:
The Oregon Medical Board considers the full use of the patient history, physical examination, and additional laboratory or other technological data all important components of the physician’s evaluation to arrive at diagnosis and to develop therapeutic plans. In those circumstances when one or more of those methods are not used in the patient’s evaluation, the physician is held to the same standard of care for the patient’s outcome.
This makes perfect sense, unless you think about the purpose of employing telemedicine technology in the first place.
Telemedicine can be defined as the use of computers and telecommunications technologies to provide healthcare services at a distance. The basic idea is simple: sometimes it’s a heck of a lot easier and cheaper to use computers and telecommunications to get an opinion or some advice from a doctor than to physically ferry someone from point A to point B. Depending upon where you are and where the doctor you’d like to consult might be, the cost and convenience benefits can be considerable. Truly remote places with hostile weather are the poster children for telemedicine – think of a village in Alaska in the teeth of a howling snowstorm – but the ultimate benefit is always in the eye of the beholder. An elderly patient who is feeling ill in the middle of the night might feel that it’s priceless to avoid calling an ambulance to be taken to the disorienting and potentially traumatic environment of an Emergency Room ten miles away, whereas another person might think nothing of driving two hundred miles to the nearest clinic. It’s all a matter of preference, and the type of medical interaction desired.
Is telemedicine “as good” as an in-person visit? Again, it depends on what one is trying to accomplish. If you’re trying to adjust a the insulin dosage in a diabetic there may be little or no difference between evaluating blood sugar values in-person or 10,000 miles away. On the other hand, if someone at home needs immediate surgery, all of the telemedicine technology in the world may not be of much use. Just as important is the balance between the potential benefits derived by patients – such as the cost savings that they derive from avoiding travel, the inconvenience (or even danger) avoided, the ability to have loved ones around them, and a host of other preferences – and the potential absence of medical information that might be available if you were to force both doctor and patient to be in the same room at the same time. Would you as a patient, for example, trade off a 100 mile drive through a snowstorm in order to have a 1% greater chance of having your doctor’s diagnosis of your skin condition be the correct one? What if you knew that there was only a 10% chance that it would chance the therapy you’d receive as a result? How about 5% and 50%? It probably depends on how much the problem is bothering you, how skilled you are at driving in snow, whether the condition was potentially life-threatening and a host of other factors.
The point, as it almost always is in medicine, is that just about every case is unique. Moreover there are so many variables involved that the only people who can reasonably say whether the risk of not having a telemedicine consultation be as “perfect” as an in-person consultation is worth taking are the individual patients and practitioners involved. On one hand, the patient is taking a risk that they may not be getting care that is just as good as they might otherwise receive at the cost of trekking across the globe. On the other hand, the clinician is taking the risk of not getting every last particle of information that might be useful in formulating a diagnosis and treatment plan. Every physician is acutely aware that any mistake they might make can be turned into a lawsuit at any time. To help any patient under less-than-perfect circumstances represents both a risk and an act of faith.
Given the reality of telemedicine – the benefits, the disadvantages and the tradeoffs involved – the language adopted by the Oregon Medical Board is stunning. What the Board essentially says is this: “We don’t care about the advantages, the benefits, the tradeoffs or what the alternatives may be; we are going to hold every doctor who dares to use this technology to the same diagnostic and therapeutic standards that would apply if conditions were absolutely perfect. Patients and clinicians are not adults. They are not capable to weighing the risks and benefits and deciding for themselves on a case-by-case basis. Instead, we intend to set up every clinician in the state for a lawsuit and/or disciplinary action by the Board if this technology is used and anything goes wrong.”
If you’re not in the healthcare business, it’s important that you understand that the medical licensing board is King to all of the professionals they govern. They can take away your livelihood, mandate fines and essentially ruin any career within the blink of an eye. Having a medical licensing board take this stand regarding telemedicine technology tells doctors that they have little to gain and potentially everything to lose if they agree to see a patient remotely and the slightest little thing goes wrong. Any rational clinician will decide that it’s just not worth the risk. Patients will have to travel if they want to be seen no matter what the cost, what the risk or what their preference would otherwise be.
Thus with the stroke of a pen, a single group of a dozen people can neutralize the potential benefits of an emerging technology for millions of people.
There is a stupidly simple way in which the Board’s concerns and those of others might have been addressed constructively, while preserving the telemedicine option for patients. They could have established a policy that clinicians must explain the risks and benefits inherent in telemedicine before patients agreed to use it. That they did not choose to do so shows us just how difficult it is for doctors and patients to obtain the benefits of “IT done right.”
Doug Perednia is an internal medicine physician and dermatologist who blogs at Road to Hellth.