Billions for EHRs Mask Physician IT Progress
By Art Papier, MD
A 3-year-old child presented with a sore throat to a South Carolina emergency department (ED). She had a positive triage strep test and was sent to the ED “walk-in clinic.” William Finn, MD, was about to complete a 12-hour shift on the acute side of the ED and stopped in to make sure the child was ready for discharge. Though the test for strep throat was positive, Finn became concerned when the mother pointed out small purple skin lesions. Finn did not recall purple skin lesions to be consistent with strep throat.
He quickly referenced online diagnostic software that confirmed strep as unlikely. The software prompted the physician to consider meningococcemia, a life-threatening infection. Blood cultures were drawn and intravenous antibiotics were begun. Finn, noting the child’s rapidly worsening condition, had her immediately transferred to the tertiary children’s hospital. Blood cultures subsequently confirmed meningococcemia. Unlike most children with meningococcemia, an infection with a survival rate of 10% in children and a treatment that can take months if not diagnosed immediately, this child walked out of the hospital one week later.
If you are over the age of 50, it’s difficult to imagine Robert Young—the ever-reassuring Dr. Marcus Welby of 1960s and ‘70s television—using a computer or PDA to research a diagnosis. If you are under 40, it is difficult to understand why your doctor would not be using a computer as Finn does. Fifty years ago, physicians were thought to be omniscient, and the idea that they would need help in their thinking by opening even a medical book in front of the patient just did not jibe with the image doctors had of themselves and the confidence the patients had in them.
So when we spin the clock forward and consider the fact that a majority of patients use the Internet before and after a doctor’s visit and, for the current generation of medical students, computer use is second nature, we are challenged to reflect on this transition from the days of Marcus Welby to today’s physicians using computers to help them think. People in all walks of life and professions use computers, and they seem to be collectively wondering why, in many cases, physician computer use ends with patient scheduling and billing. But does it really?
The exciting, but not widely appreciated, news is that while only 15% of physicians use an EHR, a majority use their computers or handheld devices in their daily workflow for clinical decisions, such as medication dosing and interactions.
Yet the recent passage of the American Recovery & Reinvestment Act stimulus legislation, with $17 billion in incentives to promote adoption of electronic records by physicians, has been misinterpreted by some to indicate physician resistance to computers and modernization. The needed emphasis on computerizing the medical record may have an unintended consequence of setting us up to miss a near-term opportunity to expand physician IT use to address high-impact areas such as diagnostic delay, a leading cause of patient injury and increased costs.
While many doctors now prefer to resource medical knowledge electronically, some of the very same physicians dread the idea of computerized record keeping for a simple reason: It slows them down. Imagine two scenarios that are certainly occurring in medical practices today: In the first, a doctor quickly references computer-based medical knowledge to correctly diagnose the patient and then records that accurate diagnosis in a paper chart; in the second, the doctor uses an EHR to chart an erroneous diagnosis and an inappropriate treatment that he or she arrived at from memory. Which would you prefer if you were the patient?
Ultimately, universal, seamless use of an EHR with embedded clinical decision-support tools to improve accuracy, reduce errors, and increase safety will occur. Policy makers are taking purposeful steps now to achieve widespread use within five to 10 years. In the short term, an immediate parallel effort to expand the use of relatively low-cost Internet or handheld-based clinical decision support technologies will promote and spread the diagnostic and patient care efficiencies demonstrated by Finn and similar “leading-edge” physicians.
When the medical record industry finally turns to integrating meaningful decision support, vendors will be faced with doctors wondering what took them so long. Policy makers should encourage, fund, and spread this best practice now rather than wait for the EHR to be the only technology vehicle for improving care and lowering costs.
— Art Papier, MD, is an associate professor of dermatology and medical informatics at the University of Rochester School of Medicine and Dentistry in New York and the chief scientific officer for Logical Images.
Miongoni mwa watu waliohusika katika tukio hilo ni daktari wa masks, Art Papier, ambaye amemweleza mtoto mwenye umri wa miaka mitatu kuwa anaugua na anaugua shingo katika kituo cha dharura cha jimbo la South Carolina. "Mwanamke huyo alipata matokeo mazuri ya mtihani wa Strep na kupelekwa kwenye kliniki ya ""walk-in"" ya ED, ambapo William Finn, MD, alikuwa karibu kumaliza zamu ya saa 12 katika sehemu ya ""acute"" ya ED na akajitahidi kuhakikisha mtoto alikuwa tayari kuachiliwa." Ingawa mtihani wa ugonjwa wa koo ulikuwa na matokeo mazuri, Finn alijali mama huyo alipokazia majeraha madogo ya ngozi yenye rangi ya zambarau. Finn hakukumbuka kwamba vidonda vya ngozi vya rangi ya zambarau vilikuwa vinafanana na ugonjwa wa koo. Alielekeza haraka programu ya uchunguzi ya mtandaoni ambayo ilithibitisha kwamba ugonjwa wa strep ilikuwa haiwezekani. Programu hiyo ilimchochea daktari huyo afikirie ugonjwa wa meningococcemia, ambao ni ugonjwa unaohatarisha uhai. Mimea ya damu ilichukuliwa na viuavijasumu vilivyoingizwa ndani ya mshipa vilianza kutolewa. Finn, akiona hali ya mtoto ikizidi kuwa mbaya, alimweka mara moja kwenye hospitali ya watoto ya tatu. Baadaye, uchunguzi wa damu ulithibitisha kwamba alikuwa na ugonjwa wa meningococcemia. Kwa mujibu wa utafiti huo, ugonjwa wa meningococcal, ambao ni ugonjwa unaoweza kuokoa maisha ya watoto kwa asilimia 10 na ambao unaweza kuchukua miezi kadhaa kama haujagunduliwa mara moja, umesababisha kuambukizwa kwa watoto wengi. Ikiwa una umri wa miaka 50 au zaidi, ni vigumu kuwazia Robert Young, daktari wa televisheni wa miaka ya 1960 na 1970, akitumia kompyuta au PDA kutafiti utambuzi. Ikiwa una umri wa chini ya miaka 40, ni vigumu kuelewa kwa nini daktari wako hatumii kompyuta kama Finn. Miaka hamsini iliyopita, madaktari walidhaniwa kuwa wenye kujua yote, na wazo kwamba wangehitaji msaada katika kufikiri kwao kwa kufungua hata kitabu cha matibabu mbele ya mgonjwa hakukubaliana na picha madaktari walikuwa nayo juu yao wenyewe na imani ya wagonjwa walikuwa nayo kwao. "Kwa hivyo, tunapozungusha saa mbele na kuzingatia ukweli kwamba wengi wa wagonjwa hutumia mtandao kabla na baada ya ziara ya daktari, na kwa kizazi cha sasa cha wanafunzi wa matibabu, matumizi ya kompyuta ni asili ya pili, tunatakiwa kufikiria mabadiliko haya kutoka siku za Marcus Welby hadi madaktari wa leo wakitumia kompyuta kuwasaidia kufikiri. """ Watu katika maeneo yote ya maisha na kazi kutumia kompyuta, na wao kuonekana kuwa pamoja ajabu kwa nini, katika kesi nyingi, daktari kompyuta matumizi mwisho na mgonjwa ratiba na bili. Lakini je, kweli ni hivyo? "Hii ni habari ya kuvutia, lakini haipendekezi sana, kwamba wakati tu 15% ya madaktari hutumia EHR, wengi hutumia kompyuta zao au vifaa vya mkono katika mtiririko wao wa kazi ya kila siku kwa maamuzi ya kliniki, kama vile kipimo cha dawa na mwingiliano.""" "Hata hivyo, kupitishwa hivi karibuni kwa sheria ya kichocheo ya ""American Recovery & Reinvestment Act"" na $ 17 bilioni katika motisha ya kukuza kupitishwa kwa rekodi za elektroniki na madaktari, imeelezwa vibaya na wengine kuonyesha upinzani wa daktari kwa kompyuta na kisasa." """Kufikiri kwa nguvu juu ya kompyuta ya rekodi ya matibabu inaweza kuwa na matokeo yasiyotarajiwa ya kutupatia fursa ya muda mfupi ya kupanua matumizi ya IT ya daktari ili kushughulikia maeneo ya athari kubwa kama vile ucheleweshaji wa utambuzi, sababu kuu ya majeraha ya mgonjwa na kuongezeka kwa gharama." Ingawa madaktari wengi sasa wanapendelea kupata maarifa ya matibabu kwa njia ya elektroniki, baadhi ya madaktari hao wanaogopa wazo la kuweka rekodi kwa sababu rahisi: Inawapunguza. "Hebu fikiria hali mbili ambazo kwa hakika zinatokea katika mazoezi ya matibabu leo: Katika kwanza, daktari anarejelea haraka maarifa ya matibabu ya kompyuta ili kugundua mgonjwa kwa usahihi na kisha anaandika utambuzi huo sahihi katika chati ya karatasi; katika pili, daktari hutumia EHR kuchora utambuzi wa makosa na matibabu yasiyofaa ambayo yeye au yeye aliwasili kwa kumbukumbu. """ Ungependa nini ikiwa wewe ndiye mgonjwa? Hatimaye, matumizi ya ulimwengu, seamless ya EHR na kuingizwa kliniki uamuzi-msaada zana kuboresha usahihi, kupunguza makosa, na kuongeza usalama itatokea. Wanasayansi wa teknolojia wanafanya kazi kwa bidii ili kufanikisha mradi huo kwa wingi katika miaka mitano ijayo. Katika muda mfupi, juhudi za moja kwa moja sambamba kupanua matumizi ya Internet ya gharama nafuu au teknolojia ya msaada wa uamuzi wa kliniki ya mkono itakuza na kueneza ufanisi wa utambuzi na utunzaji wa mgonjwa ulioonyeshwa na Finn na madaktari sawa wa "mwisho wa mbele". Wakati sekta ya rekodi za matibabu hatimaye inageuka kuunganisha msaada wa uamuzi wenye maana, wauzaji watakabiliwa na madaktari wakijiuliza ni nini kiliwachukua muda mrefu. Watengenezaji wa sera wanapaswa kuhamasisha, kufadhili, na kueneza mazoezi haya bora sasa badala ya kusubiri EHR kuwa chombo pekee cha teknolojia ya kuboresha huduma na kupunguza gharama. Art Papier, MD, ni profesa msaidizi wa dermatolojia na informatiki ya matibabu katika Chuo Kikuu cha Rochester Shule ya Tiba na Dentistry huko New York na afisa mkuu wa kisayansi wa Picha za Mantiki.