A history of Computing in Medicine
Unexpected Consequences of the Computerization of Health Care
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- Depersonalization
- Outsourcing
- Medication Errors
- Faulty Information on the World Wide Web
- Unnecessary Procedures
- Care Expectations and Information Overload
- Centralization of Health Care
- Other Consequences
- Summary
Unexpected Consequences of the Computerization of Health CareWhile it is hard to disagree that computerizing health care is the direction we should be headed in, as we have shown there are obstacles and deterrents to the introduction of computerized health care systems. These include privacy issues, the cost of installing a new system and training the users, altering people’s habits, lack of interoperability and fear of lawsuits against hospitals that share data. There are also some less obvious consequences that bear consideration. DepersonalizationThe depersonalization of health care was the biggest complaint of Gale Thompson MD, an anesthesiologist at Virginia Mason Medical Center in Seattle who has been practicing since the early 1960s. He believes that computers have only gotten in the way of efficient patient care by diverting the physician’s attention away from the patient. Instead of monitoring clinical signs such as pupils and skin color, physicians now concentrate on a computer monitor with “blings and bleeps and charts and graphs”. He also stated that today’s providers have lost the art of clinical assessment due to the advent of computerized monitoring. Steven Angelo, a physician in Connecticut, echoes these sentiments in an editorial he wrote in the Journal of the American Medical Association about the day when his hospital’s computer system crashed. At first, the physicians were at a loss as to how to assess a patient’s condition. Then, they slowly started migrating to their patients’ bedsides to monitor them directly, evidently a practice that is no longer a natural reflex for some physicians. Angelo states of the period when the computers were down: “…for a brief moment, I saw what true patient care could be like, without technology’s oftentimes distracting presence”.59 That is not the only way in which medical care has been depersonalized by computers. Today it is common for doctors to enter notes into a computer as the patient describes his symptoms. In some examination rooms, the computer is even positioned in such a way that the doctor has his back to the patient as he types. Not only is this type of interaction more impersonal, it has also been reported that some patients are less likely to give a full and accurate description of what they are feeling in such an objectified environment.60 Electronic communications such as email and instant messaging have reduced face-to-face interactions between people in the world in general. In his blog, author Steven Johnson states: “…we’ve embraced technologies that help us block out the people we share physical space with”.61 The hospital setting is no different. Gale Thompson stated that medicine used to be about people working together to take care of patients. Today, instead of impromptu meetings in the hallway to discuss a patient’s care, for example, doctors and nurses often exchange notes and place orders via email and computerized order entry systems. Perhaps the situation is not as dire as it may at first seem, however. In at least one hospital, the Miami Children’s Hospital, the introduction of an electronic record system and the use of handheld devices has helped to re-personalize the doctor-patient relationship. Doctors and nurses there are using camera attachments on their handheld devices to take digital photographs of their young patients, which then get sent up to the patient’s chart; now there is a face to associate with each record. According to the article, “The images have restored a little of the humanity that the factory-inspired paper records diminished”.62 OutsourcingThe growth of the Internet and the availability of high speed network access have enabled medical images to be sent halfway around the world in a matter of seconds. This means that radiology work such as the analysis of X-rays, M.R.I.’s and CT scans63 can be sent to places like India, where radiologists make far less money and thus cost less. This trend of “teleradiology”, which started in about 2003, is appealing not only for the cost reduction, but also because when an emergency case arises at midnight in America, it is daytime in India. The interpreted results can be received back by the originating hospital in less than 30 minutes in some cases.64 Before computer networks made this possible, a groggy radiologist might have been woken from her sleep to analyze the image, or else the scan and its interpretation would have had to wait until morning. Other forms of “telemedicine” are appearing as well, such as surgeons operating robotic surgery machines from a remote location. While in some cases such a choice might be made in order to have the expertise of a specialist operate without the patient having to travel a great distance, in other cases it might just be a matter of cost savings. The outsourcing of medicine has caused some radiologists to worry about job security, and an adviser to President Bush suggested that fewer medical students would specialize in radiology.Error: Reference source not found There has also been concern about the quality of patient care given that the overseas radiologists may not have the same qualifications as those in the U.S. Medication ErrorsWhile electronic medical records and computerized order entry systems are touted for their ability to reduce the occurrence of medical errors, they are not foolproof. Daniel Warren MD, an anesthesiologist at Virginia Mason Medical Center in Seattle, commented that "there is a problem with relying on computers to reduce errors in the sense that computers still rely on human input. And the human input is the continued source of error, even in a "perfect" computer system". In addition, computerized systems may also introduce new opportunities for doctors and nurses to make errors. One study showed that a computer system could actually increase the risk of medication errors due to factors such as having to scroll through 20 screens of information to find all of a patient’s medications.65 Another study showed that a computer for physicians failed to warn of many adverse drug effects66, an advertised feature of information technology pharmacy systems that some doctors and nurses may be depending on. In addition, computerized systems can make it easy to drag and drop a medication onto the wrong chart, or to confuse the charts of two people with very similar names. In the end, it has not been shown that these risk factors outweigh the benefits of the electronic systems, and it is only through iterative development that these systems can improve. As Dr. Herbert Pardes put it in a letter to the editor of the New York Times, “[medicine] also unfortunately experiences mistakes on the way to innovation. When we identify the mistakes and push to correct them, then advances occur.”67 Faulty Information on the World Wide WebA 2002 article stated that more than 50 million adults in the U.S. use the World Wide Web as a source of medical information. A well-informed patient is better equipped to maintain good health and to recognize serious problems when they occur. However, much of the health-related content available on the Internet is “inaccurate and even potentially life-threatening”.68 This can mean, for example, that a person could make a self-diagnosis based on faulty information and decide not to visit the doctor. In some cases, misleading numbers inaccurately communicate the risk of a disease.Error: Reference source not found The solution to this problem is to implement quality standards for publicized health information. Unnecessary Procedures“It’s very, very, very hard to control a technology.” These are the words of Dr. Hlatky of Stanford University, referring to the overuse of multidetector CT scans of the heart.69 While this scanning technique, developed in 2004, takes only seconds, produces detailed images of the heart and arteries, and can be used in place of painful angiograms, its very ease of application has led to much debate in the medical community. It is technologies like this that can cause doctors to apply them to people who do not need them, for example scanning people who do not need to be scanned. Sometimes these unnecessary scans uncover "problems" that do not need to be fixed, leading to undue worry for the patient, or worse yet, unnecessary procedures. Every medical procedure carries risk and if there is no demonstrated benefit, that risk cannot be justified. Care Expectations and Information OverloadElectronic access to years of case histories and patient data can put everything a physician needs to know at his fingertips as he works through a case. One of our interviewees, Dr. Daniel Warren, reported that while it is beneficial to have all that data, patients expect their care to be based on all of it. In reality that can be an insurmountable task given that the physician would need to weed through all the information and pull out only that which is applicable to his specific case. Centralization of Health CareThe development of technically advanced medical instruments for diagnosis and treatment has “centralized” health care by creating a wider gap between wealthy urban medical centers that can afford the machines and less wealthy rural clinics that cannot. This means that some patients may now have to travel greater distances for a procedure than they did in the past. Other ConsequencesThere are various other less serious but nevertheless interesting consequences of the continuing computerization of medicine. In the emergency department of a New York hospital, doctors pointed out that the arrival of their computer system had brought some peace and quiet to the place. Whereas before the department was “positively cacophonous” with announcements, now they hardly use the intercom.70 In the same department, a system called LastWord that tracks patients in emergency care makes it easy to see how many patients each nurse is caring for. This feature has led to some disgruntlement and complaints from nurses who believe that the workload distribution is unfair.70 SummaryComputers have been used in medicine since about the 1950s. We showed a timeline of historical events in computerized medicine as well as the broad spectrum of medical applications where computers are used today. We discussed two of these applications, electronic records and decision support systems, in detail, listing their advantages and disadvantages. There are many incentives for clinics and hospitals to computerize various processes and techniques: to increase quality, reduce errors, reduce costs, provide greater accountability, and increase efficiency. However, the associated policy issues are enormous and government will have to step in with funding and other measures if medicine is to move convincingly into the computer age. We ended with a discussion of some of the hidden consequences of computerized health care systems. 1REFERENCES 0 Brody JE. From Psychiatric Aid to Space, It's a Power Tool for Sciences. The New York Times January 9, 1967. Bush V. As We May Think. The Atlantic Monthly July 1945. 2 Honeybourne C, Sutton S, Ward L. Knowledge in the Palm of your hands: PDAs in the clinical setting. Health Inf and Libr Journ 2006:23:51-59. 3 Freudenheim M. 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U.S. Doctors Turn to Outsourcing to Help Diagnose Ills. Associated Press December 1, 2004. 65 Lohr S. Doctors’ Journal Says Computing Is No Panacea. The New York Times March 9, 2005. 66 Bakalar N. Prevention: Computer Fails Its Drug Test. The New York Times May 31, 2005. 67 Pardes H. Mistakes and Innovation (letter to the editor). The New York Times March 17, 2005. 68 Risk A, Petersen C. Health Information on the Internet. J Am Med Assoc 2002:287(20);2713-2715. 69 Kolata G. Heart Scanner Stirs New Hope and a Debate. The New York Times November 17, 2004. 70 Schiesel S. In the E.R., Learning to Love the PC. The New York Times October 21, 2004. 71 Freudenheim M, Pear R. Health Hazard: Computers Spilling Your History. The New York Times December 3, 2006. 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