Are Computers Getting Between You and Your Doctor?

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The age of digitzed medicine is here. But for all its promises of simplifying doctors' visits, the technology also risks alienating the very people it's meant to help.

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The use of computers in everyday medical practice has finally reached the tipping point.

The HITECH Act, part of the 2009 federal stimulus bill, has been the final kick in the pants that U.S. health care has long needed to make the conversion to digital. The act states that, by employing electronic health records (EHRs) in a fashion known as meaningful use, doctors are individually eligible for Medicare subsidies of $44,000, paid out over five years. Before now, only early adopters and deep-pocketed institutions like hospitals and large medical groups could afford the investment to convert to EHRs.

In general, EHRs are secure digital repositories of patient information--doctors' notes, lab and X-ray reports, and letters from specialist physicians. They are an electronic version of the paper chart. Newer, more advanced EHRs are integrated systems and allow doctors to order tests, generate bills, communicate with patients, and run analyses on aggregate patient data. In hospitals, nurses use EHRs to administer and record medication dosing and document other patient care activities.

Though medical practices have a high burden of proof to claim their bonus--the Department of Health and Human Services is still in the process of fully defining just what constitutes 'meaningful use'--there is now conclusive evidence that the carrots are working. Recent data demonstrates that solo and two-doctor offices, which still comprise over half of all medical practices in the U.S., have seen the biggest jump in EHR adoption over the last six months. These small shops are reaching the conclusion that they must participate, as they risk being left behind technologically and financially.

Lawmakers, too, seem to agree that the digital advancements are both vitally necessary and long overdue. What remains to be addressed is how the total adoption of EHRs in medical practice will impact patients.

Digitization of medical care makes intuitive sense: Medicine is a complex set of processes prone to error. Relying on fallible human memory or illegible handwriting seems downright shoddy in an era of "Watson" and personalized gene sequencing. And for the most part, patients view the transition positively, as medicine is following a path blazed by nearly every other customer-oriented business.

In fact, it's become an article of faith that the huge upfront costs for computerized systems in medicine are recouped in time saved and errors avoided. Yet medical computing has given rise to a growing class of apostates.

As a practicing primary care doctor, I feel I am slowly being pulled into the apostate camp. Our apostasy is not about EHRs; that game is all but over. Rather, there's a pervasive sense that our use of technology has become a wedge between doctors and just about everyone else: Nurses. Other doctors. Worst of all, our patients.

No one describes this more elegantly than doctor and author Abraham Verghese, who has lamented the rise of the "iPatient." For Verghese, the iPatient symbolizes the adoption of technology to a level that is eroding the foundational elements of the profession, like the physical examination. He decries trainees spending vastly more time at computer stations looking over their 'virtual' patient [the collection of progress notes plus lab and x-ray data, not an avatar] than giving face time to the sick person down the hall. Other commentators describe the sloppy habits of " copy and paste" medicine, in which doctors (especially trainees) perpetuate the same patient histories from one hospital admission to the next without applying fresh thinking. [Human nature is no different among doctors: Where possible, we take the path of least resistance.]

Further, doctors and nurses are now tethered to computer appliances. To perform any basic hospital function (e.g. admission, lab test, x-ray, pill delivery, discharge), an order needs to be sent via the computer system. The good in this is that all doctors' orders go through one standardized entry point: It eliminates issues with poor physician penmanship. However, the technology inhibits doctors and nurses from actually talking to one another.

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John Henning Schumann, MD, is a writer and physician based in Tulsa, Oklahoma. He runs the internal medicine residency program at the University of Oklahoma School of Community Medicine.

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