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Category Archives: Medicine and Technology

The Digital Health Revolution: A Mixed Blessing

digital health records

The recent revelation of the NSA’s top-secret mass surveillance program by Edward Snowden has spotlighted the benefits and burdens of our increasingly digitally connected world.  According to President Obama, monitoring our phone calls, emails, and web activity has helped thwart dozens of terrorist attacks.  But the idea of the government keeping track of what had hitherto seemed private raises the specter of an Orwellian world in which everyone is under constant surveillance by “Big Brother.”

The growing and changing use of information technology in the delivery of health care is likewise a mixed blessing.  As a primary care physician, I often encounter patients and their problems without access to a record of the care they received elsewhere.  Knowing what tests have been run and treatments tried would enable me to provide more effective, efficient care and avoid wastefully duplicating services.  To this end, governments and hospital systems are establishing health information exchanges (HIEs) that allow patients’ data to be seamlessly shared by practitioners.  These exchanges also promise to provide a rich database for researchers and public health authorities.

But electronically collecting and sharing millions of Americans’ health information presents the real risk of large-scale privacy violations.  A wide variety of individuals, from clinicians and clerks to government and insurance company employees will have access to among the most sensitive and intimate aspects of our lives.  It is all too plausible that somebody seeking notoriety or a thrilling display of power could take it upon himself  (a la Wikileaks) to disseminate millions of individuals’ health data on the world wide web.  Perhaps more concerning are the subtler yet still serious privacy violations that are likely to regularly occur.  Thus, it is crucial that our ethics, laws, and privacy protection technologies keep pace with the threats to privacy inherent in the growing and evolving use of health information technology.

Health information technology will also play an increasing role in how we pay for health care and judge its quality.  The current fee for service system rewards the volume of services delivered rather than how well they make us.  This is believed to result in a number of excessive and sometimes even harmful interventions.  Health information technology should facilitate better measuring quality of care.  Utilizing this data will enable the government and insurers to pay for good results, rather than for merely more tests, hospitalizations, office visits, and procedures.  Patients will also be better equipped to select hospitals and practitioners with a record of robust outcomes.

But this commendable quest to measure and pay for performance carries the risk of overshadowing and deemphasizing less quantifiable yet equally vital components of the healing profession.  It is surely important to control blood pressure, cholesterol, and diabetes, to avoid complications from surgeries and hospitalizations, and to prescribe the best medications.  But there is much more to being a good doctor than this.  There is pulling together the disparate elements of a long-suffering patient’s story and arriving at an elusive diagnosis.  There is breaking the bad news of dementia, autism, or cancer honestly, but without taking away all hope.   There is discerning when an anxious patient with a headache needs reassurance or an urgent MRI.   There is being a compassionate presence and a trustworthy guide during the most trying moments of a person’s life.  There is taking the time to learn what gives meaning and purpose to a patient’s life and arranging his or her care accordingly.   It is quite difficult, if not impossible to measure these virtues and character traits, to put a numerical value on these essential elements of the healing arts.   So if quality is defined solely by what can be quantified, we risk creating a culture that values certain marks of technical excellence, but neglects the human, personal art of care.  The result could be a practice of medicine greatly impoverished for both patient and physician.

Preserving the human touch in healthcare does not mean resisting its growing use of information technology.  It is inevitable that the digital revolution will transform the way healthcare is delivered, yielding improvements in quality, cost, and convenience.  But even as we enjoy and celebrate these changes, it is essential to honor and preserve important values such as patient privacy and the personal art of care.

 
 

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Are EMRs making healthcare more or less patient-centered?

EMR-centered care

EMR-centered care

A new study in the Journal of General Internal Medicine revealed that doctors spend substantially more time with their computers than they do with their patients.  Reflecting on this study, physician Danielle Ofri argues that “we need to rethink the role of technology in medicine, especially the EMR.  The new mantra of ‘patient-centered care’ needs to apply equally to our computerized systems.  With each new iteration of the EMR, we need to ask ourselves how patients are benefiting, as opposed to whether we are merely satisfying administrative documentation mandates.  The EMR needs to exist in service to patient care, not simply as an end in itself.”

I first became aware of the challenges of EMR use while rotating through the VA in my third year of medical school.  After meeting a pleasant physician I’ll call Dr. Smith, we began our first day together seeing patients.  Following handshakes with patients and their family members, Dr. Smith face turned to his computer screen for most the remainder of the clinic visits.   Asking patients questions about their conditions, Dr. Smith typed away as they responded, recording the relevant data they produced.  After a brief physical exam, patients were handed their prescriptions before being ushered out to the nurse or clerk.  I remember thinking that the encounter seemed more like a business transaction than something to do with healing.  The patients had completed a necessary errand and were moving on with the rest of their day.  The following morning, it was my turn to take over patient care and be supervised by Dr. Smith.  As I negotiated the demands of computer data entry and providing care, I began to sympathize with and adopt his approach.  To listen with eye contact as patients talked and then afterward type what they had just said while they continued to talk and present more information was not practical.  And if I gave the patients my undivided attention during the visit and tried to document afterward, I found myself getting quite behind schedule, to the chagrin of Dr. Smith, the staff, and patients.  Soon I too was shouting out questions as I furiously typed away, rationalizing that this was the only practical way to get through the day.

My story echoes many doctors’ experience of EMRs as a hindrance to effective physician-patient communication.  As pediatrician Anne Armstrong-Coben writes in the New York Times, “Doctors in every specialty struggle daily to figure out a way to keep the computer from interfering with what should be going on in the exam room — making that crucial connection between doctor and patient. I find myself apologizing often, as I stare at a series of questions and boxes to be clicked on the screen and try to adapt them to the patient sitting before me. I am forced to bring up questions in the order they appear, to ask the parents of a laughing 2-year-old if she is “in pain,” and to restrain my potty mouth when the computer malfunctions or the screen locks up.”

Why is recording data often more difficult and time-consuming using an EMR than it is utilizing paper charts?  Part of the problem is that the EMR documentation format is not designed solely for the purpose of providing quality care.  It also aims to ensure that adequate data is provided to justify payment for services should an insurance company or the Center for Medicare and Medicaid Service (CMS) audit the chart.  Since incentives and other forms of reimbursement from CMS are affected by Meaningful Use (MU) of the EMR, EMRs must also ensure that they meet MU standards. This may require physicians to enter data and perform EMR tasks that are not necessarily germane to helping the patient address their health issues.

How can physicians effectively respond to the greater time demanded by EMR documentation?  One approach is using staff to do some of the data entry work.  For example, some physicians have hired scribes to enter data so that the physician can concentrate on being fully attentive to the patient and responding to his or her health issue.  But the expense of paying for a scribe is not an attractive option for many physicians, particularly those in primary care.   There is also hope that as dissatisfaction with the current EMR data entry technology becomes better recognized, software engineers will work with physicians to develop more functional systems.  Already, some EMRs are using improved voice-recognition technology to recover some of the greater efficiency that traditional dictation delivered.

Has using an EMR enhanced or hurt your ability to communicate with patients? Does entering data in the EMR take away time from the other parts of patient care?

 
 

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