The Promise and Peril of Wired Medicine
One sure way to infuriate practicing physicians is to praise electronic health records (EHRs). The daily frustrations and stunning inadequacies of EHRs, their damage to the patient-physician relationship, and their resultant harms to patients and physicians have been the subject of countless hallway conversations and essays.
While I assign most of the blame to EHR vendors for manufacturing a product designed more for billing than for patient care, others blame hospitals and medical offices for failing to adapt their cultures to optimally implement them, or they blame the federal Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 that incentivized the seemingly overnight national mass migration from paper to electronic medical records.
Medical computing technology comprises a parallel but somewhat more successful digital medical development. Inventors and entrepreneurs have developed sophisticated programs to diagnose and treat patients, devices to monitor vital functions remotely, and networks that permit the practice of telemedicine. These emerging tools have the potential to enhance the accuracy and efficiency of medical treatment of inpatients and outpatients, especially those who lack direct access to physicians and nurses.
In The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age, Robert Wachter, MD, a founder of the hospitalist movement and a professor of medicine at the University of California, San Francisco (UCSF), has written a fascinating, comprehensive, and balanced status report weighing the benefits and burdens of digital technologies currently applied to medicine. He deftly combines his own perceptions and clinical experience with insights from nearly 100 interviews he conducted with technical experts at the forefront of the digital revolution and others who are implementing electronic technologies into medical care. The result is an authoritative and engaging romp through diverse technologies, punctuated by his incisive and often humorous descriptions of their current limitations and followed by his predictions of their eventual place in medical care. I found myself underlining many of his trenchant observations and aphorisms. (See examples in the box, “Notable Observations and Aphorisms.”)
Along the way, Dr. Wachter stops to explain how the EHR was implemented before it was perfected, and how its shortcomings have harmed medical office practice and inpatient care. For example, on inpatient rounds, the house staff spends far more time with their computers than with patients. Radiology rounds have been rendered unnecessary because all images can be reviewed on computers. What has been lost are the daily personal interactions between physicians and their patients and other physicians.
Dr. Wachter devotes several chapters to a systematic analysis of an astonishing medical error in which an inpatient was ordered and administered over 38 times the intended dose of an oral medication. He shows how such an error could have occurred only by e-prescribing and e-filling. Although there were missed opportunities by all involved professionals to question and revise the order, its occurrence ultimately was the result of both poor EHR and system design.
One strength of The Digital Doctor is that the author provides the historical context in which our current predicament arose. His sections about the evolution of the HITECH Act and the Centers for Medicare & Medicaid Services Meaningful Use program are particularly illuminating.
Dr. Wachter's detailed critique of the Epic EHR that UCSF bought to replace their former medical record (along with most other academic medical centers, including my own) hit the bull's eye. He pointed out how Epic's design of the EHR was driven principally by the compliance requirements of the federal HITECH Act and the institutional financial need for users to document all the arcane billing requirements for CMS — and not to facilitate excellence in medical care. Epic would have benefitted from more detailed input from practicing physicians. I applaud his conclusion that the suboptimal quality of the current EHR product shamefully fails to justify its enormous cost.
Despite all his skepticism, Dr. Wachter does believe information technology (IT) could benefit medicine in the future if all its problems are resolved. He offers a vision and predictions for the future of medical practice based on his interviews and his own clinical and administrative experience. He predicts, for instance, that there will be far fewer hospitals and that all inpatients will require ICU-level care in single rooms equipped with cameras, video screens, voice-activated technology, and videoconferencing capability. He envisions that EHR notes will be produced by speaking, that high-level programs will enhance diagnostic and treatment decisions, and that big-data analytic systems will allow collaboration of a multidisciplinary patient care team. Outpatients will have IT-assisted home care with data sensors and telemedicine. Patients will have access to all their medical records, patient-oriented educational resources, and peer-to-peer communication networks. A rational health care payment system will be based on the goal of maintaining population health.
Prudently, Dr. Wachter identifies the principal threats to this vision, which must be vigilantly monitored and prevented. The digitization of health care could allow improper bureaucratic micromanagement and harmful non-medical intrusion into patient care decisions, for instance. The desirable process of measuring quality and safety could interfere with the best care of the patient. Tensions could evolve between the technologies and those who use them. The time freed up by implementing technology may not be applied to the patient's care.
Dr. Wachter concludes by citing the warning offered years ago by Harvard informatics pioneer Warner Slack, emphasizing that these technologies are merely tools and that the physician's job remains much greater than any role technology can perform: “Any doctor who could be replaced by a computer should be.”
Dr. Bernat is the Louis and Ruth Frank professor of neuroscience and professor of neurology and medicine at the Geisel School of Medicine at Dartmouth College and Dartmouth-Hitchcock Medical Center. He also serves on the editorial advisory board of Neurology Today.
NOTABLE OBSERVATIONS AND APHORISMS
“Medicine, our most intimately human profession, is being dehumanized by the entry of the computer into the exam room.”
“The wiring of healthcare has proven to be the Mother of All Adaptive Problems.”
“Medicine is at once an enormous business and an exquisitely human endeavor; it requires the ruthless efficiency of the modern manufacturing plant and the gentle hand-holding of the parish priest; it is about science but also about art; it is eminently quantifiable and yet stubbornly not.”
“Today when I take care of patients in the hospital, my fees are governed by a strict set of guidelines that range from arcane to ridiculous.”
“The combination of checkboxes, templates, and copy and paste has led to notes that are so loaded with bilge — much of it of questionable utility and some of it of questionable veracity... — that, while the billers may be overjoyed, clinicians cannot do their work.”
“This checkbox mentality has even turned Larry Weed's beloved Problem-Oriented Medical Record — in which the patients' issues are articulated, assessed, and addressed — into a desiccated wasteland, devoid of thought or narrative arc.”