Wednesday, August 11, 2010

In Health Care, the Computer is Useful, but Sometimes It is Oversold and Gets in the Way

The computer is a moron.

Peter F. Drucker, 1909-2005

I don’t know what I would do without the computer. I use it to write these blogs. I use it to tweet. I use it to email friends and colleagues. I use it to connect to the world, to gather news, to conduct business, and to search the Internet.

But I am convinced it is sometimes oversold as a tool to improve health care, implement reform, cut costs, and empower patients. Useful, yes, but oversold as the Holy Grail, as OSHA (Our Savior Has Arrived), of health care.

You cannot look a computer in the eye. You cannot read its body language. You cannot sympathize or empathize with it. It is just there, an inanimate object for dumping, retrieving, and transmitting data.

These thoughts came to mind while reading a column in Connecticut Medicine by Kathleen LaVorgna, MD, President of the Connecticut State Medical Society.

Here is her lead paragraph.

"I WAS sitting in the office last week with a new patient, who said at the onset, 'Do you use an electronic medical record?' I paused, wondering why she was beginning her visit on this note. Is she a government agent trying to assess my compliance with some tally? Or perhaps a salesperson from one of the many EMR companies that solicit me daily? 'No,' I replied. I was prepared to launch into my spiel about how it is too expensive for me to purchase as a solo practitioner right now, and probably too late in my career to invest in, when retirement seem less than a decade away.. But before I could begin, she breathed an audible sigh of relief and said, 'That’s GREAT! I am so tired of going to doctors who spend what little time they have with me, staring into a computer screen or typing on their laptop. The last doctor I went to had his back to me the whole time, because he was using his electronic record during my visit! I want my doctors to pay attention to ME, not to their electronics!' "

Patients are smarter than EMR aficionados think. Patients know doctors cannot listen and talk to them while typing into the EMR. They know a computer perched between them and the doctor distracts from the relationship. And they know they can trust their doctor more than what they learned from the Internet.

At least that is what I would like to think. I am in the minority. The majority of big thinkers, the thought leaders, believe computer information spin-offs are the future and will dominate medical care because computers will document everything experts ever wanted to know about physician and patient behaviors.

Perhaps so. I take solace in this March 24, 2010 NEJM letter to the editor, which says, in essence, patients still trust doctors more than the Internet.

Surveys of Physicians and Electronic Health Information

To the Editor:

The role of electronically accessible health information in clinical care has been the focus of increasing discussion nationally. In 2001, we launched the Health Information National Trends Survey (HINTS) to provide an evidentiary basis for practice and policy decisions. Sponsored by the National Cancer Institute, the HINTS program provides data every 2 years from a nationally representative sample of U.S. adults 18 years of age or older.

We analyzed data across three administrations of HINTS (6149 respondents in 2002–2003, 5586 in 2005, and 4092 in 2008) to gain a better understanding of the public's trust in and use of sources of health information, especially information from physicians, the Internet, and other sources, such as the mass media.

Despite a decade's worth of exposure to health information on the Internet, the public's trust in physicians as their preferred source of health information has remained high and, if anything, increased from 2002 to 2008.
Conversely, trust in health information from the Internet, or from other sources decreased during the same period.

When asked where they went first for specific disease information (i.e., cancer), respondents reported going to the Internet first — a tendency that increased over the period of analysis. The tendency to rely on sources other than physicians or the Internet for initial information has diminished.

When Internet users were asked about their activities online, a small but growing number of respondents indicated that they used e-mail to communicate directly with their physicians.

These data on the changes that are being enabled by national investments in health-information technology indicate that accessing health information online does not appear to reduce trust in physicians, as some observers have feared. Trust may actually be increasing as consumers rely on their physicians to interpret the confusing nature of online information.

Nevertheless, consumers still appear to be taking advantage of the convenience of the Internet as an initial source of disease information, and reliance on information from other sources appears to be falling. The use of the Internet as a channel of communication between patients and their physicians is showing a small but persistent increase over time. These national survey data should have profound implications for practice and for clinical care, including compensation and workflow.

Bradford W. Hesse Ph.D.
Richard P. Moser Ph.D.
National Cancer Institute, Bethesda, MD

Lila J. Rutten Ph.D., M.P.H.
National Cancer Institute at Frederick, Frederick, MD

Down the road, patients will continue to trust doctors do not have EMRs but who will take the time to observe and listen to them, rather than being preoccupied and obsessed with entering data into the EMR.