Is 1998 the year for doctors to plunge into computing?
Growth in the field will come from new attitudes and managed care pressure, not technical breakthroughs
From the January 1998 ACP Observer, copyright © 1998 by the American College of Physicians.
By Deborah Gesensway
In the year ahead, general internist Patricia L. Hale, ACP Member, has an office computing plan. It doesn't hinge on buying more and fancier equipment, but instead on getting more of her colleagues in upstate New York to put the technology they already have to greater use.
The strategy may not sound very dramatic, but if it succeeds it could represent a long-awaited breakthrough in medical computing: doctors' real acceptance and use of computers in practice.
The reason for Dr. Hale's strategy is simple. She doesn't see any big technological advancements that would lead her to upgrade or otherwise change the computers she already uses in her practice. In fact, she said, inadequate technology is not the barrier.
Jerome A. Osheroff, FACP, agrees. "I think the news in 1998 is not that there are going to be new things hitting the street," he said. "Rather, things that have been on the street for awhile are going to be introduced into many more clinical practices." In fact, Dr. Osheroff predicts that in the next year, the negatives that have kept doctors from converting en masse to electronic medical records, computerized literature searching and cyber communications will begin to fade.
"It was easy for a doctor to say before that he was not going to fool with this stuff," explained Dr. Osheroff. "Even though the technology was neat and had a lot of promise, the costs in terms of time, energy, learning and inertia gave doctors little incentive to change the way they do business. Now, other forces—most notably managed care and the shifting practice environment—are starting to demand that they change the way they do business. Not changing is no longer an option."
Look at what Dr. Hale is doing with her 300-physician independent practice association (IPA) in New York state's Adirondack Mountains. A few years ago, the IPA set up a central computer to connect all the offices so the doctors can e-mail one another and do literature searches on the Internet. The IPA pays half the cost of any computer the doctor wants; Dr. Hale opted for a laptop.
The group also wrote its own basic computerized patient record program using Microsoft Access software. The program, PatRec, allows the doctors to do as much—or as little—on the computer as they want. They can use templates; forms for hospital histories and physicals, office notes and discharge summaries; drop-down menus; voice recognition dictation or even old-fashioned typing. Some doctors just print out the key information on each patient—the demographic information and active problem and medications lists—and then write notes by hand on that paper during the patient visit. Nurses type new information into the system to update the record.
Convincing more of her colleagues to use computers instead of pens during patient visits is Dr. Hale's goal this year. Already, she is seeing some progress. Some people who have said they would never type are discovering that entering information directly into the system can be efficient and convenient.
The 'next step'
Besides getting doctors to do more themselves, Dr. Hale said, 1998 will be the year she and the other "techies" in the practice try something new themselves.
She has her eye on one piece of new technology that could help take her there: a special card that would allow her computer to communicate with printers and other computers via radio frequency instead of cables and wires. A wireless connection, Dr. Hale said, would allow her to take her computer from room to room and keep it logged on to the practice's network. "When you are seeing patients," she said, "you hate leaving the computer in the exam room when you walk out. There are all sorts of privacy issues. It would be really nice to be able to pick the computer up and move it from place to place."
For the most part, though, Dr. Hale plans to get to "the next step" by working with the practice's existing technology. For instance, she said, she wants to load formulary information into the PatRec system and to arrange with insurance companies to do electronic referrals. She also wants to network the practice's computers to the hospital so the doctors can use the hospital's printers. And—most importantly—she wants to begin to analyze practice patterns and outcomes. She says she'll first try using the office's current software to accomplish these goals. There is no need now to invest in a new commerical system, she said.
And when she decides to, Dr. Hale is likely to find that sorting through the more-than 200 vendors of electronic medical records systems can be a daunting task.
"The big players [in the electronic patient record industry] are just now coming in," said Jerome H. Carter, FACP, a professor of general internal medicine at University of Alabama at Birmingham and director of the Section of Medical Informatics. "I would tell anyone who is considering an installation to wait a few months and start looking at some of the products from the large vendors or some of the more mature products from the smaller vendors. ... You have to be careful that you don't get an orphan product."
But the fact that none of these products are yet perfect shouldn't scare off internists. According to Dr. Osheroff, these programs are improving, particularly as more money is put into research and development.
A boost from technology
While no key breakthrough in the next year is alone likely to inspire physicians to computerize, a number of steady advances promise to draw more physicians to medical computing.
According to Bruce Slater, FACP, a general internist and computer informatics expert with George Washington Medical Faculty Associates in Washington, D.C., the speed of computer processors continues to double roughly every 18 months. (He says a 200 MHz Pentium processor with two gigabytes of hard drive storage space is the entry level he recommends for physicians now.) In addition, modems continue to get faster, and more Americans have access to high-speed Integrated Signal Digital Network (ISDN) telephone lines, which offer online users dramatic improvements in speed.
All this is making the Web more useful, experts agree. Dr. Hale said the Internet has already revolutionized how she keeps up on both medicine and medical computing and on how she communicates with colleagues, something that is critical for rural practitioners. (For more details, see story on electronic curbside consults.) "I read a lot more now than I did before because I'm looking for information so much more," she said. "It's almost as if they should give you CME credit for anytime you are on the Internet."
Watch the pitfalls
Despite these incentives, several barriers remain to medical computing, according to Edward H. Shortliffe, FACP, a College Regent and a professor of medicine and computer science at Stanford University School of Medicine in Palo Alto, Calif.:
- Privacy. Arguably, the biggest issue is privacy and confidentiality of patient records. "There is no question that this is a potential show-stopper," said Dr. Shortliffe. He said that a new report from the National Academy of Sciences (www.nap.edu/read ingroom/books/for/summary.html) spells out the difficulties of creating a system to keep patient records confidential while giving researchers and payers data about doctor-patient interactions.
- Federal regulation. Also hanging over the head of medical computing is the ax of possible governmental regulation of medical software. "The FDA could really ruin this industry by unrealistically applying regulations that are unwieldy," Dr. Shortliffe said.
(For a summary of that debate, see an article in the Nov. 15, 1997 issue of Annals of Internal Medicine; located at ACP Online at http://www.acponline.org/journals/annals/15nov97/currsoft.htm.)
- Standards. If hospitals, insurers, medical groups and even the government could abide by the same standards for collecting and computerizing patient data, it would be easier for everyone to share patient records.
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