Wednesday, August 13, 2008

E-medicine, health 2.0 - Physicians Moving Towards the Internet:

Technology is a queer thing. It brings you great gifts on one hand, and it stabs you in the back with the other.

C.P. Snow, New York Times, 1971

To know and not to do is not to do; Knowledge does become power until it is used.

Harvey McKay, Swim with the Sharks without Being Eaten Alive

Big Brother is watching you.

George Orwell, 1984

To hear Health 2.0 and Health 3.0 seers tell it, Internet medicine is already upon us and will revolutionize medicine.

But for physicians, Internet medicine has yet to prove itself. The Internet may bring great gifts, but it brings trouble too and often does not translate into human terms or address practical practice problems. In its current state, most information technology (IT) does not bring useful clinical knowledge, and it is used more for clinical surveillance than advancing care. Physicians do not use much of this new knowledge, and it remains fallow information.

This, in essence, is what I told a reporter who interviewed me for The Record Magazine, an online publication for IT health care professionals.

Here are a few of my thoughts on why Internet Medicine adoption is so slow.

1) Elephant in the Room

Before resigning as President Bush’s health information czar, David Brailer, M.D., said small physician practices were the elephant in the room – the main obstacle blocking progress toward a national interoperable functioning system. He was right. Small practices do not have money, time, and human resources to install and adopt EMRs that disrupt practice flow, show return on investment, or tangible incentives for using. These are some of the reasons why only 4% of doctors have fully functioning EMRs and only 14% have basic EMRs. Until IT gurus walk in the doctors’ moccasins, they will be like blind men feeling the elephants.

2) Hammers and Nails

Two thirds of U.S. doctors are specialists. Medical specialists have a hammer – a set of skills – to hit a nail – to perform procedures for patients who need those skills. IT specialists also have a hummer – computer software – and they also have a nail to hit – building software to minimize: unneeded procedures. IT specialists sometime forget. The suffer from funnel vision and forget that every specialty has different EMR needs. Conflicts are inevitable, and medical specialists will be skeptical and even hostile towards IT specialists.

3) Giant Invoices Vs. Communicating Software

I once interviewed a gung-ho pro-EMR doctor who was building a Regional Heath Information Organization (RHIO) allowing medical groups, hospitals, businesses, and patients to communicate. He said current EMRs are nothing but Giant Invoices used by payers to document what doctors do. “Wouldn’t it be wonderful,” he said, “if we could use EMRs to talk to one another?” Until then, EMRs are of marginal utility to doctors and patients.

4) Virtual Vs. Face-to-Face Realities

In the IT world, virtual means something generated by a computer to simulate reality for reasons of economics, convenience or performance. Examples in the physician world would be computer interviewing of patients prior to seeing the doctor, judging the need for erectile dysfunction drugs through an online history questionnaire, or virtual colonoscopies without rectal colonoscopy. Doctors resist the notion that computers can substitute for them in taking a history, and drug companies fight the concept that anything could replace a person-to-person prescribing doctor. Regulatory agencies will have to decide.

5) Online Practice

In my experience, young entrepreneurial doctors embrace the idea that they practice medicine online - getting referrals online, documenting payers online, setting up appointments online, referring patients to others online, communicating with patients online, getting diagnostic support information online, communicating with patients online, and collecting fees online. A staff and an office may not even be needed. These types of practices remain rare, and most physicians remain leery of anything done without seeing the patient.

6) Big Brother is Watching You.

The mainstream use of sophisticated algorithms to slice, dice, analyzes, aggregate, predict, customize, and personalize clinical data to judge the performance and value of physicians, to intervene clinically, and to steer patients to specialists offering the best care, using the “best practices,” and practicing “evidence-based medicine” is now a major industry, particularly among major health systems and health payers. The major problem among physicians of this electronic onslaught is that the data may be used against them without knowledge of its limits and complexities of human interactions and desires for the best individual choices on the ground. Algorithms can never track all the subtleties of the more than 2 billion health care transactions that occur at the site of care. IT intervention and analysis has limits, freedom of choice is still important, and it is arrogant to think otherwise


1. Mark Munger and others, "Safety of Prescribing PDE5 Inhibitors, via e-medicine, vs Traditional Medicine," Mayo Clinic Proceedings, August, 2008m pages 890-896

2. Richard Reece, New Parksinons’s Law: No office, No Staff, No Bureaucracy, No Problem,, April 10, 2008.


kevinh76 said...

"Revolutionize medicine"? Like Revolution Health? Someday, yes. Not now, not yet.

Richard L. Reece, MD said...


I agree, not now, not yet. My subtitle, which somehow I deleted, of the physician movement towards the Internt, was "Slowly but not Surely." The so-called "revolution" is a way off. By the way, I notice that Revolution Health is looking ofr buyers.