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Thursday, November 7, 2013

It's time to design better computer systems that take doctors back to patients

As I look back all those years ago to when I chose medicine as a career, I suspect that my motives were similar to most people who enter this wonderful profession. I wanted to become a doctor because I had a genuine and sincere desire to help people. I also liked the idea of a busy and energetic job, one where I was comfortably as far away as possible from a desk or computer screen. Lots of my friends may have liked the idea of a desk job, but I knew that wasn’t for me.

Almost 15 years have passed, and I still remember my first week of medical school like it was yesterday. All the experiences since then, the late night studying, the never-ending exam schedule, those exhausting rotations, have all been worth it, and I really have no regrets in choosing this path. The scientific knowledge that we are imparted throughout our formal medical education gives us the skills to truly make a difference in peoples’ illnesses and suffering. But those of us who work in health care also know that the practice of medicine is so much more than the basic science behind illness. It’s about people. Every doctor gets to experience memorable interactions throughout their careers, as we treat some truly inspirational patients (who often end up teaching us many valuable life lessons).

Hippocrates once said, “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” In other words, without really understanding the patient as a person, we are never really going to help them as much as we can. As an attending physician practicing hospital medicine at the frontline, I try my best to always remember this. Despite the challenges of modern medical practice, it’s always these one-to-one moments and the building of rapport with patients and their families that make being a doctor special—the noble profession that it should be.

But all nostalgia aside, it is this very basic premise of medical practice that appears most under threat in today’s medical environment, as the ability of frontline doctors to spend adequate time with their patients is shrinking faster than ever before. As I finish a 10 to 12-hour plus day, I often go home contemplating how much of that time I have actually spent with my patients and their families. Is it 50%, 40%, 30%? Inside, I know it’s probably much less. Having worked in several different hospitals since finishing my residency, my experiences are not unique to any one institution. There is of course nothing new about this complaint. We physicians have been bemoaning this issue for decades. But there’s one crucial difference in our new technological age of medicine. Now, instead of demands to see more patients in less time or increased bureaucracy from insurance companies, it is the time we are spending with computers that is increasingly taking us away from our patients. And sadly, most acutely affected are the frontline specialties where our interactions matter most, also including Family and Emergency Medicine.

A much discussed study published in the Journal of General Internal Medicine focused on the work habits of today’s medical interns. The results made depressing reading. Interns now spend only 12% of their time in direct patient care and up to 40% in front of computers. Comparison to prior studies shows that this percentage has gotten significantly worse since the 1980s. I can well believe it. In my capacity as a teaching attending, it seems to me that most times I seek out my interns and residents on the medical floor, I will usually find them sitting in their chairs, eagerly typing away on a computer or reading something online. (Maybe it’s because we conduct so much of our social lives online, or perhaps I’m a little old fashioned, but I always find something less studious appearing when I see anyone sitting in front of a computer as opposed to having their heads down reading or writing.)

And far from this problem being unique to physicians. Glance down any modern day hospital floor, and you will see nurses—the very heart of direct patient care—frantically wheeling around their portable computers, glued to their screen, typing notes and scanning their medications. How much are we taking away from our patients when we give our nurses such excessive demands for computerized data entry?

One solution that is bandied around is to take computers away from desks and into patient rooms, performing all documentation tasks at the bedside. Unfortunately, this will likely be even worse for patient care. Looking at a screen and typing away for most of our interaction will reduce physicians to semi-automated, robotic workers, not that dissimilar from an airport check-in agent or shop cashier. It will be so impersonal to patients, not to mention annoying, when they are divulging the innermost details of their personal illness.

As humans, we always value personal interactions, especially when it comes to our health. We wouldn’t be impressed in any other industry if the professional we desired to speak to kept flitting their eyes in between us and a computer screen (none of us would even put up with it in a regular conversation). Hopefully this isn’t the future of medicine, although it sometimes appears like the direction health care information technology is taking us.

All that being said, we must not forget the other side of the coin. We are living in an era of change like no other in human history. Science and technology are transforming health care in unimaginable ways, and the pace of change is only going to accelerate exponentially. Who can say with certainty that an iPhone won’t replace the stethoscope soon? People are living longer and healthier than ever before and cures for previously hopeless diseases are on the horizon.

Computers and information technology have brought enormous advantages to medicine in terms of information accessibility, data collection, and patient safety. Studies have proved the multifaceted benefits of initiatives such as computerized order entry. We still need faster access to complete medical records (those days when we trawled through piles of thick charts already seem so long ago). We also need greater communication between health care entities.

So, yes, medical technology is a force for good. Many doctors themselves have jumped on the bandwagon, and are dedicating their careers to health information technology, often admittedly as a way of getting away from direct patient care. Fair enough, but I also question why anyone who seriously enjoys computers and sitting in front of screens more than their daily interactions with patients, would have become a doctor in the first place!

In my specialty, much of the increased time with computers is as a result of policies such as meaningful use and a transition over to computer-based charting. But there just has to be a better way of doing this. And that’s the key to this whole problem. How can we make sure that all of these computerized tasks that we are doing actually give value to what really matters—the patient?

So here is my advice for all the Silicon Valley entrepreneurs and information technology whiz-kids (many of whom may have scarcely set foot in a hospital before) who want to create the new multi-billion dollar technology to “revolutionize health care.” Never forget the sacred doctor-patient relationship. Design your products with this in mind, and ensure that technology never comes in between the two. At every corner, enhance rather than take away from the interaction between doctors, nurses, and their patients. Far from advocating a withdrawal from technology, the answer is to design smatter and better systems that promote ease of use and maximum time with patients. Certain features should be utilized such as rapid logging in to the desired screen, minimal “clicking,” touch screens, and more succinct data entry methods.

The only way this will happen is for all of us to work together, with frontline physicians and nurses fully involved in every step of the design process. Some information technology professionals that I’ve met have asked me where “opportunities” lie for moving from pen and paper to digital. That’s the wrong question; it isn’t just an opportunity for business ventures (not to mention the fact that not everything we did in the days of pen and paper was wrong). The philosophy has to be about improved patient care.

So is this slide towards computers and impersonal medicine inevitable? It shouldn’t be, and it will be our generation of clinicians that will either allow ourselves to become semi-automated, or to keep the doctor-patient relationship where it rightfully belongs—at the front and center of all health care. The goal must be for the majority of our time to be spent with our patients, even if only 51%, that’s a start, as we tip the scales in favor of direct patient care. The course of the ship can still be turned, and collectively as a profession, we can do it.

So when I next have that thought at the end of the day about how little time I’ve spent with my patients, I will remember that the deal is not yet done on the future of medicine. I remember that I’m yet to meet a patient who thanks me for spending time in front of a computer. Until I do, I’m happy to keep trying to spend more time with them rather than my screen. There are certain universal truths when it comes to humanity, and Hippocrates had it right over two millennia ago when he offered another pearl of wisdom for everyone in health care: “Cure sometimes, treat often, comfort always.” That’s the human side of medicine that no computer can ever touch.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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