Posted by: notdeaddinosaur | February 5, 2012

Too much “T”, Not Enough “I” in Health IT

Marilyn J. Heine MD, oncologist and PMS president, quotes Paul Consolato MD, writing on KevinMD that “[a]doption of EHRs is a transformational event for physicians”. She goes on to say,

Can it be that information technology is now an integral part of any exam?

which leads her to:

I wonder if adoption of EHRs is the largest transformational event for physicians because it’s a generational role reversal within the ranks.  We may be at a time in the history of medicine in which freshly minted medical school graduates can teach our older, experienced physicians a thing or two.

because

“Our younger, computer savvy doctors took to this like a swan to water,” she was quoted in the January 2012 edition.  “It wasn’t as easy for some of our other physicians.” The phrase “other physicians” is actually code for older physicians. Imagine this … new physicians becoming mentors to those with decades more experience in patient care.

No, no, no!!

The polite response to all this is “poppycock”; my actual response being more along the lines of male bovine fecal material.

A patient is not his medical record, paper or electronic. The fact that we have morphed into a system where payment is tied to the medical record does not change this. Emphasis has shifted from the provision of medical care to the recording of documentation. There is far too much “technology” without sufficient attention to the “information” in Health IT (which by the way should be MEDICAL IT; subject of another post.)

The real transformational event on this pathway was when someone decided it would be a good idea to create a written record of medical care. I’m sure there were plenty of old Dinosaur Docs back then who grumbled, “I know what I did, the patient knows what I did, and that’s all that matters. Why should I write anything down?” Nevertheless, the value of “casebooks” was quickly appreciated as a memory supplement for the doctor, if nothing else. In fact, that’s the main role my charts play in my day-to-day practice. Who is overwhelmingly likely to ever see what’s written on the thousands of pages jammed onto shelves, and now 15 months of computer files, that contain the written record of my twenty years of medical practice? Me. Other doctors to whom patients may transfer; maybe a few dozen lawyers. Still just a tiny percentage of the information generated will ever be useful or needed in the future. The only change is that I now record the same information by typing on a keyboard instead of scratching with pen and paper.

Information technology is NOT (and never will be) “an integral part of any exam”. Physicians are perfectly capable of eliciting a history, performing a physical examination, generating a differential diagnosis, and treating a patient without writing anything down. The legal dictum, “If it’s not documented, it wasn’t done” is a fiction perpetuated for the explicit purpose of extracting financial gain from medical misfortune, and has nothing to do with reality.

So no, I will not accept as a “mentor” some twenty-something kid with no medical expertise and precious little life experience to speak of merely because of his alleged technological prowess. Learning to elicit the history with skill and compassion, performing the physical examination with expertise and sensitivity, synthesizing the information with the experience of decades of practice, initiating effective and appropriate treatment while educating the patient about the illness, treatment, side effects, course, prognosis, etc: that is the practice of medicine. All the rest is just scribbling; whether with ink or electrons makes no difference.

There is nothing “transformative” about EMRs because medical care is not the same thing as the medical record. Until everyone — policy wonks, doctors, and patients alike — comes to realize this fundamental truth, we aren’t getting anywhere.


Responses

  1. “So no, I will not accept as a “mentor” some twenty-something kid with no medical expertise and precious little life experience to speak of merely because of his alleged technological prowess. Learning to elicit the history with skill and compassion, performing the physical examination with expertise and sensitivity, synthesizing the information with the experience of decades of practice, initiating effective and appropriate treatment while educating the patient about the illness, treatment, side effects, course, prognosis, etc: that is the practice of medicine. All the rest is just scribbling; whether with ink or electrons makes no difference.”

    Interesting, there was a time when pit traders held similar opinion, trading was not about calculation or matching them faster, but about judging the pulse of the market, complex perception which came with years of experience, deep intuition, so on and so forth. However computers changed everything, now machines trade at a microseconds latency, while not providing or using complex physical cues which pit traders so heavily relied on. Algorithms digest history of millions of trades to understand the complex patterns in a way humans simply cannot. Pit traders went out of business.

    Medicine will go same way, algorithms are already creeping in.

  2. [...] Closing: on a related note; the important part; she’s right; stalagmites and climate change; don’t forget; and Death Valley [...]

  3. “Transformative” my left hind foot.

  4. “Transformative?” I read lots of doctors’ articles and blogs making that claim. I don’t get it. Information technology is just a tool–like a tongue depressor or a syringe. Use it right, and it’s helpful. Use it wrong, and it’s useless or harmful. But “transformative?” It transforms nothing, changes little but information format and collection/recovery procedure. It doesn’t change if/how/when the information is used, whether the information is even meaningful, applicable, or usable. It’s how doctors and patients use the information, not the tool used to manage it, that matters.

  5. @AkshayB: Ah yes, the straw man of “computers changed other industries, medicine is sure to follow”, proffered by someone who, clearly, is not a physician. (BTW, I loved Moneyball, but medicine isn’t baseball either.)

  6. Well said. EMRs do not improve the quality of health care, they merely provide a way to track it and bill for it. Most of it is never read and the only part I refer back to in my own records are the parts I entered as text because that is where I remind myself of our last visit and the little details of a patient’s life that make them more than a chart. What I miss is a place to jot in a genealogy, especially in the big families I care for.
    And, now that my job includes data entry, I have to remind myself to still look at my patient and not just at the screen.
    It is a sad excuse for progress.

  7. @notdeaddinosaur
    It isn’t a straw man, consider Radiology for example [1].

    [1] http://radiology.rsna.org/content/262/1/370.2.full

    The rest of medicine and healthcare will surely follow.

  8. Shak: Your link is behind a subscription firewall. I’m surprised you didn’t reference anesthesia to support the use of checklists and guidelines to reduce errors (also a straw man, in that it only applies to repetitive similar procedures). Vis Radiology: It has been shown that computer aided detection INCREASES false positive readings of mammograms. ( http://www.ncbi.nlm.nih.gov/pubmed/19863409 )

  9. Computers, as a tool, are only as powerful as those who wield them. They can certainly transform how medicine LOOKS, but not how medicine WORKS. From the patient’s perspective, they see technology when there used to be papers, and they see doctors carrying iPads (which look a lot like the pads in Star Trek). From the doctor’s perspective, computers can help interpret data from more technologically advanced tests. However, no matter how great computer algorithms get, they will only be useful if the right information is inputted.

    With regards to young doctors mentoring old doctors, that is truly information excreted from a male bovine. As a 20-something tech-savvy individual, I have helped many people learn how to better use computers, but never have I ever considered myself a mentor to someone while teaching them about computers. Young doctors may be able to complement the skills of a more experienced physician by helping with the computer side of a practice, but as Dinosaur said, they will never become the mentor.

  10. teaching someone to do a task is NOT mentoring.
    and computers have become a great way to perpetuate simple errors, waste more human energy and ink/paper, and bury us all in an overwhelming flow of data.

  11. @notdeaddinosaur Since it is behind the firewall, here is the gist.

    The article is a letter from a chair of a radiology department who was reviewing his past correspondence with other members. And then he came across a note (written in last decade) from senior radiologist about delay in film processing. He comments that while a lot of things have remained same, digital imaging has ensured that imaging studies are available 24/7/365 from any where in the world. There is no longer delay associated with film processing. He concludes that old days were just old and not “good old days”

    As Medical records become digitized, they can be accessed from anywhere thus saving repetitive tests etc. This has not yet happened due to lack of adoption, standardization and byzantine regulations.

  12. Oh. Well when you put it that way… Still a straw man. Digitizing information changes its form, but nothing about its substance. Younger radiologists are not going to be more adept than more experienced ones at interpreting images just because they’re digital. Younger physicians can help older ones record information, but that is hardly “mentoring”. I stand by my thesis. “Transformational” my ass!

  13. “Emphasis has shifted from the provision of medical care to the recording of documentation. …The legal dictum, “If it’s not documented, it wasn’t done” is a fiction perpetuated for the explicit purpose of extracting financial gain from medical misfortune, and has nothing to do with reality.”

    I see this everyday in my job as CME Manager. So what do we do about it? Sadly, even with my liberal arts background, all I can think of is setting fire to someone’s front lawn.

  14. What about a 30-something mentor?


Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

Categories

Follow

Get every new post delivered to your Inbox.

Join 160 other followers

%d bloggers like this: