A Tool Doctors Should Control
Once I lost a hammer. It was a tool I earned in my youth while working to finance my education. It taught me to respect the tools I use in my work. On a past occasion (30 years ago), I wrote how doctors should view their tools: a major one being hospitals. My hope was that practicing doctors would work to influence those institutions for the better. Oh, such were the dreams of my youth. Hospitals are now conglomerates operated by boards and individuals steeped in the profit motives common to all corporations. These are boards and individuals who are far removed from our Oath. They are focusing on the growth and profit for the corporate owners, not on a profit to benefit the community, patients, employees, operations and doctors that it serves. It is a tool that I believe is lost for the lifetime of most current doctors. Now a newer tool already widely used is my current concern: the electronic medical record.
This story begins with my Apple IIe. No, it actually begins much earlier than that. It begins my senior year in high school. An opening in my class schedule allowed me to choose a class of my choice. I chose typing. As a result, I had the advantage of being able to type in college, medical school and even now. My time in high school was before electric typewriters and computers. Since I could type, buying my IIe let me explore the world of computing. It was great fun and allowed me to explore simple basic programing, even writing a program for the interpretation of blood gas test results. Within a short time, professional programers were producing much more sophisticated versions. My skills were in the medical, not the computer field. I need not burden you with the progress in the computer world.
As my medical practice matured, my use of computers kept up with their ability to make life easier. My specialty practice needed quality reports to keep its referring physicians informed as did my work interpreting hospital studies. The computers of the 90’s and since, allow for the creation of these. More ominously, the financial aspects of medical practices began to require computerization. Progress in technology and increased control over fees and payments by outside businesses and government required more and more computerization. Then, a little more than a decade ago, the electronic medical record appeared. It first was a way to organize the doctor’s medical files, but integration with the financial aspects of practice rapidly followed. The electric, digital medical record was born. Hospital and medical practices, with significant government encouragement, widely adopted the electronic system. Use became mandatory for some.
“Open the Pod Bay doors, Hal.” Requested astronaut Dave Bowman.
“I’m sorry, Dave. I’m afraid I can’t do that.” Responded Hal, the 9000 Computer
“The X system does not allow that. I think you can work around it. You will need to go to the ‘order’ tab, then the ‘misc’ tab. That will get the dropdown menu for other items. It is probably listed there.” The support staff cheerily reviewed for me. Their acceptance of the complexities of the digital medical record is probably based upon their knowledge of its inner working. Most of the staff were born after my IIe was manufactured. Raised with and around computers, their acceptance of these difficulties is as understandable as it is disturbing. Though their followup comment indicates dependency on a higher authority, “Sharon, Medical Record X’s representative, can probably help us with that. I will reach out to her. I can have something for you in a few days.” This interaction has become more and more common when a doctor working for a large group or organization runs into issues with documenting, placing orders or communicating with their patients.
Don’t misunderstand me. They are trying to be helpful. They definitely know more about the X electronic medical record than the physicians do. What is irritating is their acceptance that it is the holy grail of records. Their entire lives have been during the computer age. It leads them to accept all its faults and I suspect, to not fully understand why just a few more clicks to memorize and perform does not leave me happy. What happens when the business Medical Record X changes the clicks, deletes the item or task needed or I forget the clicks? I am back to square one.
“Dave, this conversation can serve no purpose any more. Goodbye,” concludes Hal when it tires of discussing opening the pod bay doors with Dave. Hal has made a decision and it will not change. Dave will be left in space. Dave using human ingenuity ultimately finds an alternate way back into the space craft.
Recently it was announced, company X had added an upgrade that some of the support staff were using. It is a program to change a prepared patient message to a calmer more comforting tone and words. We were told it has helped improve the patient’s perception of a few of the staff messages where it has been used. How does it work? A message is prepared. You ask the program to review it. It does, and then changes how the message is phrased and addressed the patient. Red flags flew in my head. Is it the first step in eliminating the human contact in medical care? For example, just feed the result of a test to the system and it prepares and sends the message. Will it be become similar to the multitude of robo calls, messages and commercial computer chats to which we are now exposed? Yes, I am being a bit paranoid. At the least, it does indicate some of the support staff need to improve their communication skills.
Hal, Where are my Medical Records?
:Data Center Stock photos by Vecteezy
“Just what do you think you’re doing, Dave?” Hal asks.
“Dave, stop. Stop, will you? Stop, Dave. Will you stop Dave? Stop. Dave.” Hal attempting to stop Dave from deactivating it.
Hal’s finial vocalizations, “I’m afraid. I’m afraid. Dave. Dave my mind is going. I can feel it. I can feel it. My mind is going.”
Dave completed his mission without Hal. Following Dave’s guidance, maybe we need to disable X. No, that would be like doing away with the car, a terrible thought. Without the automobile, modern society would crumble. There are cars made to go 180 miles per hour and travel through deserts and mountains with ruts for roads, but few will purchase them and even fewer use those features. Unfortunately, the typical electronic medical record system comes with the 180 mile per hour and off-road options. Unlike the car of your choice, you are more a passenger than the driver of the record.
Those options on the electronic record are controls that constrain the medical practice to conform to insurance and government standards. We should recognize the dangers of its controlling nature. It is very similar to government. Governments have an essential role in allowing a free society to flourish and too much government results in tyrannical control. In our era, China, North Korea, Cuba and Russia are good examples of too much control. The computer has an important, almost essential role in medicine, but when controlled by self-interested parties, it can become tyrannical.
As the ultimate users, doctors, and maybe patients, need to police the features included in the computerization of the medical record. Let’s not buy those controlling features. Remember, your role in most systems will be that of passenger, not driver, and it is going to be a long, frustrating, expensive ride.
*From “2001, A Space Odyssey,” a movie by Stanley Kubrick released in 1968 to mixed reviews. Now considered one of the greatest and most influential films ever made. These quotes are taken from a section of the movie on a space voyage from Earth to Jupiter where Hal, the human like computer controlling the flight and the space craft, has lock the human astronaut out of the space craft and refuses to let him back in. You see, Hal had made a mistake and could not admit it. How very human like.