Tuesday, October 7, 2008

Health 2.0, limits of technology - Health 2.0: A Cautionary Note and a Modest Proposal

Health 2.0 (as well as the closely related concept of Medicine 2.0) are terms representing the possibilities between health care, ehealth, and Web 2.0 and has come into use after a recent spate of information in newspaper articles and in the physician and medical literature. A possible explanation for the reason that health has generated its own 2, 0 are its applications across health care in general, and its practically limitless potential in health promotion.

Wikipedia, 2008

Left-Brain Software

This is for left-brained software enthusiasts, who believe,

• clinical medicine is logical, linear, and linked closely to scientific rational thinking;

• there is a protocol for all, and for all a protocol;

• there is a set of guidelines for every specialty, and for every specialist a guideline to fit every patient;

• every clinician should dance to algorithms, and everything and everybody can be reduced to a sophisticated individual algorithm;

• if all doctors had an EMR with embedded best practice information at their fingertips, clinical medicine would be safer, better, and more efficient;

• clinicians are either have too little information or are overloaded with too much unsorted information generated by experts;

• if one would use the Net more to coordinate care for the Big Seven Chronic Diseases accounting for 80% of all costs - Coronary Heart Disease, Congestive Heart Failure, Hypertension, Cancer, Asthma, Depression, and Chronic Obstructive Lung Disease- and their derivatives, spending would drop, satisfaction would rise, and outcomes would be improved.

Right-Brain Wisdom

These software aficionados may be partly right, but I would remind them May there’s another world out there – an untidy, often messy, world based on the wisdom of crowds and the wisdom of pragmatists who have been there and done that. It is the world of the Right Brain – which organizes patterns into trends, relies on its gut instincts, and sees the world as a whole, not in bits, bytes, and clicks. I would also remind you them banks of computers, programmed by specialized experts in financial derivatives using the latest in software, missed the boat in spotting what was wrong with the system and predicting the economic meltdown.

A Messy World

The world of clinical medicine is messy, fickle, and full of artful decisions that have nothing to do with logic. Diagnosis, treatment, and trust in physicians do not always lend itself to computer resolutions. There is still a place for the clinician who can sift the relevant from the irrelevant; takers from the fakers, the really sick from the worried well. These clinicians have a Right Brain, and it functions on the basis of having seen this before, knowing the narrative of disease, knowing when there is a complicated diagnostic or therapeutic problem, sensing when or when not additional information is necessary, recognizing limits of data intervention.

A Modest Proposal

That’s what this little essay is about – the practical limits and the proper applications of Health 2.0. For you, those in the Health 2.0 crowd, I make the following modest proposal.

• Go directly to a busy clinician’s office. Do not pass Google. Disregard computer mindsets. Use your mind, your observational powers, and your common sense.

• Spend a month at the doctor’s office. The typical clinician sees about 500 patients with diverse problems. See how he or she handles the mix.

• Choose practitioners using your favorite EMR containing the latest best practice guidelines.

• Tag along with the clinician during his or her 10 to 12 hour day.

• See the patients as he or she sees them, and while you’re at it, record the expense of data entry and documentation required, who it benefits, and what it returns on investment

• Observe the variety of patients, their multiplicity of complaints, and their subjective and objective reasons for being there.

• See how the clinician sorts through the maze, guides the patient through the labyrinth, how he or she judges the severity of problems, and how he or she judges severity and reality of complaints, and what to do and what not do about them.

Questions to Ask of the Doctor

Once the clinician has done his or her work with a patient, present them with your best practice information on the EMR, and asks these questions.

• Did the information have any clinical relevance?

• Did it add anything to useful to diagnosis or treatment? How often?

• Was it helpful in those “soft” subjective clinical situations – the well patient just dropping in for a visit or an annual checkup? The elderly patient seeking attention or hand-holding? The wife concerned about her husband’s drinking? The vague complainer? The baby boomer armed with questions garnered from the Internet?

• Did the software give the clinicians a flash of insight, a warning of an incompatible drug interaction?

• Did it help identify the malinger, the psychosomatic, the addict looking for a fix, the unhappy patient looking for an excuse for a malpractice suit?

• How long did it take to enter the data into the EMR? Who entered it? At what expense?

• Is the embedded software useful as a diagnostic support tool, for unraveling complicated diagnostic problems or coming up with an unexpected diagnosis?
If so, how often?

• Did the EMR generate information that could be communicated or to be sent to the local hospital or another doctor? Can the patient understand and use the information? Is the EMR, in short, an effective communication vehicle?

• Did the doctor have any ideas on how the data might be easier to enter or rendered more useful?

After a Month in the Trenches

After you finish your month in the clinical trenches, consider again your position on the logic, linearity, limitations, and utility of Health 2.0 in clinical settings.

You may conclude your Left Brain was right in the first place, that the computer is an indispensable tool for the proper practice of medicine, for deciding what is the right and wrong thing to do, and being consistent across spectrum of care.

Or you may say: Hey! There’s a place for the Right Brain, too, for independent thinking outside of cyberspace, for thinking and action based on clinical experience and the idiosyncrasies of the patient.

Humankind may be too complicated, unpredictable, and variable with too many combinations and permutations to be reduced to finite algorithms. The computer may be too simple a tool for all or even most situations, , and its use may be restricted to a few select circumstances, not to the practice or patients as a whole.

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