Mike Magee

I wrote recently about the “meaningful use” regulations that define the requirements for federal grants and tax relief to physicians who adopt EMR’s. I’ve questioned whether the vision for the use of these technologies is under powered.

To answer this question, it helps to look back if you want to look forward. Why? Well, a look back not only provides a check on current ideas and theories, but as importantly gives some indication of the pace of change. Today’s case in point will be Edward (Ted) Shortliffe MD, pictured at right, a Canadian-born American biomedical informatician, physician and computer scientist. More about him in just a moment.

Many “visionaries” will tell you that their ideas have often been on the mark (in part or in whole), but their timing of future events has been far less reliable. This is on my mind these days because we seem to be entering a period of increased readiness for change – a populist uprising if you will, from differing corners of our society suggesting that incremental adjustments at the edges have become futile, and that transformational change requires new leaders armed with powerful new ideas.

There is truth to that, but as often, the big ideas and big leaders may be present, but readiness and receptivity – for a wide range of reasons – has been absent. Align the direction of change, the need for change, and the readiness for change and you create “an overnight success”.  But if you have the first two, but not the third, too often it’s “an uphill battle”.

To illustrate the point, let’s consider the ideas of Dr. Shortliffe.

Regarded widely as the founder of the field of biomedical informatics, in 2006 he received one of its highest honors, the Morris F. Collen award given by the American College of Medical Informatics (ACMI). His work and presence have influenced the Institute of Medicine, the National Science Foundation (NSF), National Institutes of Health (NIH), and National Library of Medicine (NLM). It is fair to say that he has influenced the development of medicine, computing and biomedical informatics nationally and internationally. His work has carried him from the west coast (Stanford) to the east coast (Columbia) and back again, was the founding Dean of the University of Arizona‘s new College of Medicine campus in Phoenix, and now is a professor at the University of Texas.

As with many forward thinkers, he’s been considerably ahead of the curve. I will only take you back to 1991 to an address he delivered to The American Philosophical Society in Philadelphia. (I was an administrator at Pennsylvania Hospital at the time.)  The title of his address: “Doctors, Patients and Computers: Will Information Technology Dehumanize Health Care Delivery?”  Here’s part of what he had to say:

“…the number of physicians who personally use computers while providing clinical care remains small, and the reactions of many doctors to the notion of incorporating computers more actively into their professional practice can range from skepticism to outright hostility.”

“For those physicians who did not grow up in the computer age, this sense of mystery breeds mistrust and, yes, even fear. ‘How can I possibly learn about these devices? How will my use of them, or failure to use them, affect the way in which I am perceived by my colleagues, or, more importantly, by my patients? Will the nature of my work be changed over time by this machine? Is it a threat to the traditional role of the physician as caregiver?’ ”

“No one really believes the computers will replace physicians, but there is still a gnawing concern that such machines will detract from those aspects of medical practice that have drawn physicians to the field in the past…It is ultimately the sense of control over the technology, rather than by the technology, that will allow practitioners to feel comfortable in adopting computer based tools for record keeping and decision support.”

“We tend to anticipate the future influence of computers on society by imagining their introduction into social settings drawn from our current world…we must realize that people will change just as much as computers do. The resulting impact on human relationships must be anticipated in the context of the way people have (will) come to expect the value and role of information technologies in their lives.”

“Any effort to anticipate the effect of information technology on relationships between patients and physicians must be viewed in this larger context of social change. Both doctors and patients will be very different…As the computer becomes increasingly woven into the fabric of our society, if there is any resulting dehumanization, it will occur because we allow it to happen, not because there is something inherently dehumanizing in the technology itself.”

“For us to imagine the doctor’s office of the future, and its ability to attend to the human needs of patients, we must try to envision the future of computing itself. Many scientists anticipate a rapid merging of technologies that we have previously considered to be distinct: television, video, computing, networking, telephones, and paging…High-speed networks will at last allow physicians to bring together a broad range of functionalities in single workstations…Many of us believe that physicians will begin to use computers more routinely only when such broad functionality is brought together in a unified and integrated environment that requires minimal training and that fits smoothly into the work flow of the doctor’s practice.”

“…computers will need to be much smaller and more mobile, even while they are simultaneously more powerful. The physician’s workstation is likely to become a clipboard-sized device….We may even imagine a day when the patient will be likely to have his own hand held computer, a descendant of the “personal digital assistants’ that have recently been announced, and may use this device to record health information at home or work so that it can later be shared with his personal physician.”

“…computing will recede into the background and become part of the environment. (Weisner in 1991 writing on ‘ubiquitous computing’ said) ‘The most profound technologies are those that disappear. They weave themselves into the fabric of everyday life until they are indistinguishable from it.’  Imagine a world in which a typical room has hundreds of computers – ones that are built into light switches, lamps, tabs on books, badges worn by employees, and even disposable post-it notes.”

“The greatest threats to these ideals (of relationship based care) in our current world are the fiscal, organizational, and time pressures that can prevent even the most well-meaning physicians from finding the time to sit with their patients, to listen and teach, and to demonstrate the kind of concern and caring that was, ironically, probably one of the reasons that they entered the medical field in the first place. As computers recede into the environment, but increasingly help physicians find information quickly and easily, the result may be a release of time that will become available for building precisely the kind of caring relationships that both patients and physicians have always sought.”

“Meaningful use, right? Here’s the dilemma. I know the technology has changed. And I know the people have changed. But have the people caring for the people changed?

On the answer to this last question may hang the results of the current EMR push and the immediate future of Health System reform in the United States.

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