Modern Medicine and the Computer Age

Op-Ed Contributor

Published: March 5, 2009

A version of this article appeared in print on March 6, 2009, on page A27 of the New York edition.

The Computer Will See You Now

By ANNE ARMSTRONG-COBEN

FOR 20 years, I practiced pediatric medicine with a “paper chart.” I would sit with my young patients and their families, chart in my lap, making eye contact and listening to their stories. I could take patients’ histories in the order they wanted to tell them or as I wanted to ask. I could draw pictures of birthmarks, rashes or injuries. I loved how patients could participate in their own charts — illustrating their cognitive development as they went from showing me how they could draw a line at age 2 and a circle at 3 to proudly writing their names at 5.

Now that I’ve been using a computer to keep patient records — a practice that I once looked forward to — my participation with patients too often consists of keeping them away from the keyboard while I’m working, for fear they’ll push a button that implodes all that I have just documented.

We have all heard about the wonderful ways in which electronic medical records are supposed to transform our broken health care system — by eradicating illegible handwriting and enabling doctors to share patients’ records with one another more easily. The recently passed federal stimulus package provides doctors and hospitals with $17 billion worth of incentive payments to switch to electronic records. The benefits may be real, but we should not sacrifice too much for them.

The problem is not just with pediatrics. Doctors in every specialty struggle daily to figure out a way to keep the computer from interfering with what should be going on in the exam room — making that crucial connection between doctor and patient. I find myself apologizing often, as I stare at a series of questions and boxes to be clicked on the screen and try to adapt them to the patient sitting before me. I am forced to bring up questions in the order they appear, to ask the parents of a laughing 2-year-old if she is “in pain,” and to restrain my potty mouth when the computer malfunctions or the screen locks up. I advise teenagers to limit computer time as I sit before one myself for hours each day until my own eyes twitch and my neck starts to spasm.

In short, the computer depersonalizes medicine. It ignores nuances that we do not measure but clearly influence care. In the past, I could pick up a chart and flip through it easily. Looking at a note, I could picture the visit and recall the story. Now a chart is a generic outline, screens filled with clicked boxes. Room is provided for text, but in the computer’s font, important points often get lost. I have half-joked with residents that they could type “child has no head” in the middle of a computer record — and it might be missed.

A box clicked unintentionally is as detrimental as an order written illegibly — maybe worse because it looks official. It takes more effort and thought to write a prescription than to pull up a menu of medications and click a box. I have seen how choosing the wrong box can lead to the wrong drug being prescribed.

So before we embrace the inevitable, there should be more discussion and study of electronic records, or at a minimum acknowledgment of the downside. A hybrid may be the answer — perhaps electronic records should be kept only on tablet computers, allowing the provider to write or draw, and to face the patient.

The personal relationships we build in primary care must remain a priority, because they are integral to improved health outcomes. Let us not forget this as we put keyboards and screens within the intimate walls of our medical homes.

Anne Armstrong-Coben is an assistant clinical professor of pediatrics at Columbia.

Somehow it doesn't make sense to me to use a doctor's time doing data entry. My mother-in-law was a medical transcriptionist at a hospital for many years. If I understood her description of her job correctly one of the things she did was to type up the charts from the doctors' written and verbal notes made during rounds. These medical records were then used by doctors in subsequent examinations and by the billing department in making insurance claims, etc. She started in the job in a pre-computing era, but by the time she retired her work was fully computerized. I'm no computer guru, and my expertise in medical operations is even more limited. But I wonder, as we pour money into health care reform, and looks for savings, why not use trained support staff to click the boxes and fill out the forms. If a pediatrician or other doctor thinks it's important for something the patient writes or draws to be included in their chart then why not just scan it into the record. There has to be a simple way to gain all the benefits we expect from electronic medical records without turning highly trained and educated practitioners into clerk-typists.

There is great little book that the people of power and influence should read, Only Yesterday. (Actually, they should have read it in the mid-90's as I recommended then). Published in 1931 shortly after the Crash of '29 and as the economy was in total freefall, it's a history of the Roaring 20's written by a prominent newspaperman of the era, Frederick Lewis Allen. He mostly chronicles the trends and cultural and technological changes of the period, but since the '20's was also a period of economic boom and the average guy getting wealthy, he spends quite a bit of time dealing with economics. One of the things he points out is that the Crash was in some respects inevitable since most folks "wealth" was really only paper wealth. There was no real money behind their asset holdings, only credit. And that the economy and the growth of the big corporations was all based upon future earnings. So with everything based upon the wealth of overextended average families, when the weight broke their backs...

Paul Krugman, the Nobel economist and NYT columnist wrote again about the saving glut - the easy money that fueled the bubble - and how we must deal with that before we can get the global economy stable. He ends his column by saying we're still looking for the way out of the mess we're in. The implication in that line is that we don't know how to fix the economy. I'm not as sharp as Krugman, nor as educated, or knowledgable in economics and finance. But I have come to one conclusion. Average folks get ahead in the long haul by saving more than they spend.

The average person should not be trying to build great wealth by inclusion in a "culture of ownership" as Bush expressed it. Owning some equities is a good thing. But the average Joe isn't going to build financial security through the appreciating value of the assets he's holding. Assets gain value, but they also lose value. And their is no magic economy that can protect everyone from the effects of lost value. So when we all sunk our savings into equity heavy vehicles and watched our paper wealth soar, we also needed to remember that just as that value can go up, so too, it can go down. Or basing our financial stability in the value of our housing. I got wiped out completely in the 80's when the housing market bubble in Texas burst into little pieces.

There are some folks who aren't being clobbered by the latest economic follies. They're folks who know first-hand the effects of the Great Depression. They're homeowners, but they don't consider their houses as part of their investment portfolio. It just made sense to get something back on the money they've spent on housing through the years. So if you have to pay for a place to live, why not own it?

These folks do own some stocks; mostly staid old companies whose stock price has been pretty stable over the years, rising no faster than the Dow, and often not even keeping pace. But they're stocks in companies that have paid a decent dividend year in and year out - that make money even if they're not flashy. But most of their money is in various savings instruments. A solid nest egg in savings accounts/cd's. And the rest in various holdings of bonds and other simple, basic financial instruments.

I found it interesting that the CEO of AIG said yesterday that his company's core business, its insurance operations, was solid and profitable. What was ripping the largest corporation in the financial sector into shreds was all the other instruments they were involved with such as the CDO's or whatever they're called. It was all those fancy investments that the big brains had developed that were responsible for the collapse of the giant. And which I'm stuck paying for.

No, I'll never travel in Krugman's circle. But I do see the way out. For us little guys to save more than we spend over the long haul. To make simple low risk investments. And to let the high fliers soar when the wind is favorable, and let them crash when it's not. Because if Main Street isn't counting on Wall Street for its wealth then we can survive ok when things come crashing down in the financial sectors. When our wealth is centered in real transactions involving actual commodities, not speculation, then the rise and fall of the speculators doesn't hold us hostage. It's what Fred Allen wrote about in 1930. It's what we need to remember in 2009.