Where does the doctor stop and computer begin? 


Where does doctor stop and computer begin? Who is in charge? Do we care? Are these silly, academic questions from some sci-fi future or is it an onrushing tomorrow?


  • Ten years ago, the EMR recorded the date you or your nurse gave Sam his flu shot.
  • Today, the EMR reminds you it is time to have your nurse give Sam his flu shot.
  • Soon, the EMR will order the flu shot that the nurse will give to Sam.
  • Tomorrow, the EMR will instruct Sam when and how to administer his flu shot.

This is an exciting, natural and disturbing progression.

Doctors can no longer keep up with every piece of individual patient information, nor are they capable of storing all medical knowledge. Doctors are overwhelmed. Either we accept eternal second-rate care or we bequeath large parts of medical responsibility to those that are smarter, faster and more complete than us: silicon-based information and decision systems. An e-doc future. Care gets better, patients are empowered, physicians have room to breath.  And think.

This solution is not simple. Doctors cannot simply hang up their shingles, plug in an iPad and walk away. They remain vital for compassionate, quality and complete medical care. They perform vital tasks, address complex variance and unique events, lead transformative research and serve as the bridge between wetware and software. Where do we draw the line?

At our hospital, we have a common problem. Alarm fatigue. We have so many patients on wireless cardiac telemetry that the nurses and technicians are made numb by false alarms and beeps. We considered adding more eyes to watch the EKG monitors, but when we studied the issue carefully we discovered that many patients continue telemetry long after it is required.

The answer is simple.  Or not. EMR monitoring of the monitors. 36 hours after the original order is written, the computer will warn the treating doctor: “Telemetry will expire in 12 hours, unless you renew.” If the doctor ignores the warning, it will repeat every time he/she turns on any computer … 11 …8 … 6 … 3 … 1 hours. Then, at zero hours, 48 hours after the doctor put the patient on telemetry, if that doctor does not order the telemetry renewed, then the computer will … What will the computer do?

Are we going to allow the computer to discontinue the telemetry order? In every patient? With every disease? In every unit? What if the patient has chest pain? What if the potassium is high or the blood pressure low? Is it good medicine to allow a life-saving order to vanish by the soulless act of an information system? Can we trust the computer to understand that it is a “life-saving order?” What are we going to tell a family if, even by coincidence, their loved one has a catastrophic cardiac event, two hours after the EMR, the computer, orders monitoring removed?

This is a rudimentary example of an immense question; our quandary as we expand the use of electronic decision-making tools, artificial intelligence if you will, into the daily care of patients.

Do doctors need to make or be informed about every decision, whether affirmative or passive, thereby risking decision fatigue. How does the machine judge risk? How do we incorporate complex analysis; the art of care? Will doctors be willing to let go? What are the roles of nurses and mid-level providers? Will patients trust blinking lights, instead of caring eyes?

EMRs, big data, automatic decision analysis and doctorless orders will be at the core of medical care. Patient autonomy, reduction in error and the complexity of modern health science demand it. However, we have barely begun to understand or address that most basic question: Where does machine stop and man begin?

James C. Salwitz is an oncologist who blogs at Sunrise Rounds.

Image credit: Shutterstock.com


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