Picture 1There’s a big discussion going on in the health tech community about a controversial keynote speech given by Vinod Khosla at the Health Innovation Summit (HIS), in which he stated that 80% of what doctors do could be replaced by machines.

If you’re a doc like me who has no idea who the heck Vinod Khosla is (he’s a venture capitalist and co-founder of Sun Microsystems), why he’d be a keynote speaker at a healthcare event and what the heck HIS is, well, that’s the point of this post. You see, there are a whole lot of folks like Khosla out there – investors, entrepreneurs, tech types – who are attempting to redefine healthcare according to their own personal vision. Where we see a healthcare system in crisis, they see opportunity – just another problem with a technological solution. Computer-driven algorithms are the answer to mis-diagnosis and medical error, IPhone apps can replace physician visits, video connectivity can increase access.

Where we see illness and distress, they see a market.

And what business folks like to call disruption in the marketplace. Think about what happened to downtown small town USA after the first shopping mall opened. Or what happened to movie houses when Netflix started offering DVD rentals online. Or where all the independent bookstores went when the first Borders opened up, and what happened to Borders when the Kindle hit the market.

Out with the old, in with the new.

If Khosla is right, the we docs in our offices and hospitals are the old downtown department stores, the bookstores and the bricks and mortar businesses in an online revolution. We’re replaceable. At least most of us.

Is Khosla right?

Maybe.

The therapeutic relationship between a doctor and a patient can never be replicated by an IPhone app. Not when so many of my patients leave my office on a daily basis telling me how much better they feel just having spoken to me. It’s a powerful and sacred relationship that is irreplaceable.

These days, however, almost all of my patients have googled their symptoms, and many have done a over the counter diagnostic test or treatment before coming in to see me. I’ll never see the ones who got their questions answered online or their symptoms cured by that over the counter med – I see what’s left after self-diagnosis and self-treatment has failed, or google told them to see me.

That’s disruption, isn’t it?

One day very soon, women will be able to screen themselves for cervical cancer and std’s using a self-administered vaginal swab. No need to see me unless the test is abnormal, or there are symptoms.

Disruption.

Of course, computer driven diagnostic algorithms, apps and programs can create a whole new set of problems in over-diagnosis, since “there’s nothing seriously wrong with you” is rarely an output. In my office, that’s a very frequent clinical assessment. Functional ovarian pain. The occasional errant menstrual cycle or missed period. Anxiety. Stress. Depression. Lack of sleep. Over-eating, over-drinking, over-medicating. What computer is going to pick that up?

Not to mention trauma care, surgery, childbirth, respiratory distress and any one of thousands of health emergencies that you can’t treat with an IPad. I don’t see any of that work going away for docs anytime soon, do you? Some of it, of course, is being shared with trained non-physicians, and even robots. But docs are still an indispensable part of the healthcare mix.

So while the mix is changing, we docs are still in it. And I don’t see that changing. At least for here and for now. But the future?

I don’t know.

Docs need to be part of the digital revolution

I do know that if this is the new revolution in healthcare, we docs better get in on it.

Take the EMR as an example of what happens when docs let non-docs innovate in healthcare without significant physician input. We become typists, not physicians. Clerical work that used to be done by lower paid staff – entering lab and radiology orders – becomes ours to do. We spend the majority of a patient visit looking at a computer screen and not the patient. Retrieving relevant clinical information is like searching for a needle in the haystack of required fields of entry, most of which are not necessary to provide care.

Indeed, we have not yet shown definitively that EMR’s improve outcomes.

And yet we’re all using them, aren’t we?

If we are not part of the digital revolution and leave it to the venture capitalists and entrepreneurs, they will develop products that may sell, but if they don’t improve outcomes, all that will have been accomplished is a disruption in a marketplace.

Wouldn’t it be so much better if we could disrupt disease?

The real opportunity in Healthcare Innovation

There are millions upon millions of folks – some in American, but most in the undeveloped world – who have never had, and will never have the opportunity for a patient-physician therapeutic relationship such as that I’ve described above. They have no one to call when Google tells them to “talk to your doctor”.

But the overwhelming majority of the do have cell phones. Amazing, really. We can’t get indoor plumbing modern contraception or malaria tents to those in need, but 80% of folks in the developing word have cellphones. If that’s not an opportunity and a potential market for healthcare innovation, then nothing is. If we can get any healthcare into the hands of these folks, even if it’s healthcare delivered by a mobile app, we have the potential to improve their lives.

Now, imagine that we docs were able to free ourselves from the 80% of our work that can be replaced by technology, and then redistributed ourselves (virtually and personally) across the globe where we were truly needed, so that we could provide needed healthcare to the entire planet?

Now that’s disruption.

Margaret Polaneczky is a board certified obstetrician-gynecologist and Associate Professor of Clinical Obstetrics and Gynecology at Weill Medical College of Cornell University. You can follow her at The Blog That Ate Manhattan where this post first appeared.

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29 Responses for “The Day the Electronic Medical Record Tried to Kill Me”

  1. john says:

    @ Nice post. Doc. Great response to Khosla!

    “Now, imagine that we docs were able to free ourselves from the 80% of our work that can be replaced by technology, and then redistributed ourselves (virtually and personally) across the globe where we were truly needed, so that we could provide needed healthcare to the entire planet? Now that’s disruption.”

  2. coriolanus says:

    “And yet we’re all using them, aren’t we?”

    No, we’re not all using them.

    There are many of us who have looked at the evidence, and made the decision to stick with paper FOR NOW.

    It’s been a huge practice builder for us, as was indicated by the recent survey showing that only 28% of patients (and dropping) want their medical records in electronic form.

    Those doctors who whine about EMRs should look very closely at why they are continuing to use them.

    • Coriolanus –

      Once someone makes the switch to EMR there’s really no going back. The disruption in workflows, staffing, patient care would be prohibitive.
      BTW, I had no choice in the decision to go to EMR. Neither do most docs these days, since most are employed in large group practices.

      But to see how one solo practitioner who was resistant for a long time has embraced the EMR, check out this post –

      http://dinosaurmusings.wordpress.com/2011/08/04/the-year-of-going-paperless-or-embracing-the-electron/

      • coriolanus says:

        Yes, I read Dr. Dino regularly. She’s one who made the switch to EMRs when it was right for her and her patients, not on someone else’s schedule. I wonder how she’s doing with MU.

        Contrast her experience with Dr. Lamberts, who had a long-term love affair with his EMR until the relationship was broken up by MU.

        Every doctor and every practice is different.

        I didn’t mean to be rude, but I just think that doctors need to realize that when they decide to become an employee, they’re . . . an employee.

  3. DeterminedMD says:

    People who look to control health care fairly much do so for one or both the following reasons: money and power.

    And physicians who care are complicit for letting these non physicians control the process just because they do not want to compromise their empathy and compassion. Traits that people who crave money and power have no idea what those traits mean.

    So either rationalize or just turn a blind eye to what unregulated EMR will do if left unchallenged and to be regulated by those focused on money and power. As we seem to be doing so pathetically well of late.

    Because in the end, people in control for other reasons than providing care will be fairly much ruthless and compassionless in removing those who will rock their boat. As the PPACA lobby continues to voice.

    • Determined MD –
      I truly think the reason docs have been so silent are that we are all just too busy taking care of patients. In addition, we exist in silos of subspecialties that compete with one another for patients, resources and dollars.

      The takeover of healthcare by “the suits” started over two decades ago – I remember those early days as a time of frustration and anger as those who never laid a hand on a patient began dictating the care I was giving. If I though that it has made health outcomes better, I’d be more than happy to let the suits run the show. But outcomes if anything remain less than we want them to be. And while the pockets of entrepeneurs, consultants , pharma and the device manufacturers, and now the IT sector, become lined with healthcare dollars, doctors (with a few exceptions) continue to bear the responsibility in the end for the care of the patient. And the healthcare costs continue to climb.

      Peggy

  4. Quintin Adamis says:

    Let’s be realistic here and not over exaggerate what most doctors do these days. This applies to family doctors as well as those in hospitals. The patient doctor spending time with patients is few and far between. The amount of patients increase and the amount of time spent decreases drastically. In most family practices and hospitals patients are seen by everyone but the doctor if possible. The work is distributed more to every other position and doctors are rarely seen by patients. Typically seen only for several minutes because they are responsible for diagnosis and even that job in recent years, has more nurse practioners doing it.

    Every spend time in a hospital, whether working there or being hospitalized and you will realize this to be the truth. As far as diagnosis goes, it is always a doctors best “educated guess” based on a variety of factors. This is similar to the way algorithms work and also vert similar to them, Doctors can often be wrong for the same reasons. Not enough info from the patient, disinformation from them, looking at the wrong contributing factors.

  5. ThePatient says:

    Wow. Remove 80% of your workload and you’d be OK? Most of the rest of the world doesn’t have the option of removing 80% of their workload. But, really… I think I’d like a job where I can close my office between 12-2, earn the money that is currently being earned by physicians, and require everybody to schedule their lives around me. As a patient with a serious medical condition, I’m tired of having to take off work without pay to be see on your schedule. I’m tired of being told I can’t have my medical records or that I have to sign a form saying the X-rays, CT images, etc belong to the physician’s office. I’ve successfully gotten records from hospitals, and one physician, and I’m amazed at mistakes contained therein. It wasn’t the electronic medical record that killed the patient, it was the doctor not reading the electronic medical record and not listening to the patient.
    I’m tired of doctors not communicating with me, and of them telling me I don’t understand. They do not take time to explain or listen. I have doctors who turn away from me when I am speaking. I find this kind of doctor to be more common than the kind that take the time to hear what I am saying. Most doctors take one look at me, and decide they know the problem. I have doctors who give my lab results to other doctors treating me, but cannot be bothered to call and give me the results. I’ve experienced doctors who tell me I should listen to them because they have all this training from Harvard, Hopkins, Yale.
    I’m also tired of having a serious medical condition, because until a surgeon didn’t do his job with follow up care, I did not have the medical condition. Now, my life is irrevocably changed. All I ask is that you treat me with the respect you want me to give you because of your title. I don’t give respect because of initials after your name. I have plenty of initials after my name, and I have just as many years of training as you do… and from the same institutions you revere: Hopkins, Harvard and Yale. Look at me when you talk, do not decide the conversation is over while I am thinking (or if it must be give me a way to write down my questions–email is fine), return my phone calls in a reasonable time frame, do not expect me to change my entire life because of your schedule. Understand that not everybody can take off work without consequences, not even professionals with sick leave.

    • The Patient –

      So sorry to hear you’ve suffered at the hands of the medical system. It’s a system that in many ways is not working as well as it could. And it’s not just the healthcare system – it’s our working system that does not give workers time off to see a doctor during the day. As convenient as it would be for everyone to get their healthcare after hours and on weekends, I’m not sure that is feasible. But make it international, give you a doc in a time zone where your night is their day, and maybe its possible. Spread us docs around the globe in a way that makes us accessible to the most people at the most time. Unfortunately, if what is required is the laying on of hands, then maybe not so. Although with remote robotics, who knows what we’ll be doing from afar someday?

      Brave new world this is…

      Thank you for your comments.

      Peggy

  6. mike says:

    Non-medical “business folk” guy here. First, thanks to all docs for doing what u do. Second, the closing paragraph of your article basically sums up what I think Khosla really meant. I.e. that 80% of what docs do can be done by machines instead. Forget the shopping malls and think pilots instead. Just like 50 years ago, every plane has a pilot. But now he or she is assisted by 1 copilot instead of a copilot a navigator and an engineer. And the pilot generally only hand-flies the jet for the first few minutes of a flight, instead devoting his or her efforts to monitoring radios and instruments.

    • southern doc says:

      Mike:

      To stick with your airline analogy, our current medical system requires the pilot to go back in the cabin and take drink orders during take off. Meaningful Use 2 is comparable to making her load and unload the baggage.

      Our medical airline is energetically striving to maximize the distractions and obstacles that prevent the doctor-pilot from doing what she is trained to do. To paraphrase Peter Arno, “It’s a hell of a way to run an airline!”

  7. mike says:

    , watching for traffic conflicts, etc. I.e. the real work of flying, the mental stuff. Stuff that’s better suited to a human than a machine.

  8. Peter1 says:

    One care giver does not need EHRs -e.g. Marcus Welby. Multiple caregivers do need EHRs to coordinate care, and by the way, stop doctor shopping for meds.

    Docs won’t get replaced if they’re good/great diagnosticians. The proper diagnosis makes the rest easy.

  9. MD as HELL says:

    The three EHRs I have used this year in three different settings are full of errors and computer gibberish. Anyone who puts his/her life in the hands of doctors relying on the information in them is going to get hurt.

    The realtime generation of these documents coupled with the time it takes for the other misadventure, CPOE, and you have people waiting much longer for real care. People do die in ED lobbies. The more patients out there and the longer they wait…

    After 30 years of this I believe I am qualified to determine what works for the patient and what does not. EHR does not. (Paper records are also full of crap, but they do not move forward like EHR.)

  10. dr s says:

    Mike and Southern Doc – I think you’re both right. The idea is to use machines for the rote, algorithm, easy work and people for the subtle or more nuanced thinking that requires experience and the intuition that comes with years and skill. The challenge is how to separate which one is which and how to address them appropriately.

    ThePatient – I feel for you. You’ve obviously had something happen at the hands of a physician and it has left you physically harmed with all of the emotional hurts that come with it. I am a physician. And I have done things that were imperfect. I have also been a patient and been unhappy with the care that I have had at times (2 prior surgeries).

    I have also been the doctor who is sincerely frustrated and struggling because I’ve been overbooked with patients (in a capitated system, no profit motive to me) and barely have time to talk with them and spend the time needed to do a good job.

    I have struggled in frustration with having to turn my back to a patient because I’m trying to type in a note. It makes me crazy when the room is arranged so that I cannot look at someone and really connect with them without the barrier of technology between us.

    And absolutely nothing makes me crazier than not being able to really listen and have a genuine conversation with someone to hear the subtleties of what may be going on for them. There have been times when I need to do a lot more with a particular person, but I know that for each 5minutes I spend with them, I am backing up the entire rest of my day. And that may mean 20 really angry people who are complaining about how doctors don’t listen, just care about money, are arrogant and just sit and type into computers.

    There are days when the volume of people, paperwork, insurance issues, and technology minutae makes me feel like a factor worker. This is a a part of what separates us further from the empathy and desire to care that we usually entered the profession with.

    There is a real inhumanity to the system as it stands right now, both for doctors and patients. Some of what may seem like whining on the part of docs, is sometimes an expression of frustration without a sense of any way to make change. My fear is that the increase in demand without the corresponding rise in supply is only going to make this – and frustration for both patients and doctors – much worse.

  11. Anonymous says:

    Quintin, I wonder if you’ve ever been really sick. NP’s are great, as are many other mid-level providers. Some are better than some doctors I know. But the number of things that I’ve seen them do wrong is also scary (this includes delays in cancer care because they didn’t know that the problem wasn’t a generic routine issue). There’s a reason doctors go to school and train for as long as they do. And It’s not for the fancy letters and a claim to specialness.

    We are already seeing the decrease in ability even in residents with work hour regulations because they are getting less experience. The problem with calling physicians relatively irrelevant is that when you really need one, you really need their often specialized experience and expertise. Suddenly the differences between the ‘best guess’ of a very well trained physician with experience and years of skill, and other providers becomes very apparent.

  12. Tarun says:

    Greatly written Dr MARGARET.

    This is reminder to the IT guys like me involved in healthcare about the limitations of using technology. It is easy for technology people to get deviated from what the actual healthcare deliver is. I have great respect for Mr Khosla, but I guess as a technology entrepreneur, he is bound to think in that angle.

    I wish in the future that a great synergy with technology usage will come into healthcare but only as a means to enable it, not replace the current model.

  13. Mighty Casey says:

    Terrific post. The issue that I see w/HIT in its current form is that it was built with traditional IT systems-think. The real promise of EHR is facilitating better comms between doc and patient – yes, so far we’ve got #epicfail, because of that legacy-think. Which has been enabled by the ACA/ARRA gold rush, giving us 800+ EHR vendors and an equal number of new data silos. Wot larks!

    How disruptive would it be to unleash a gaggle of MIT coding whiz kids on the APIs of the top 10 EHR vendors, and actually got them talking to each other? Including giving records access to patients via Blue Button? It’s possible, but no one would make a killing on it …

    Fee for service. Meh.

  14. J.T. says:

    When I read the line “powerful and sacred relationship” I quit reading…

    Tell the people speaking in tongues and praying to the great sky fairy to save them hello for me. That ethos has no place in this century for the practice of medicine. You are a producer of a product/service; they are a consumer. You are the auto mechanic for the human vessel.

    About 800 billion dollars (larger than the entire defense budget which is already beyond bloated) needs to be hacked out of the global healthcare budget for the U.S. to remain solvent and competitive. Even the strongest labor guilds are not safe from the forces of capital (look at what is happening to the legal industry at the moment). What we are in the midst of is the beginning of the complete industrial reorganization of healthcare. Our current system is grossly fragmented and was initially designed to serve the professional preferences and tastes of physicians rather than the utility, quality, and convenience of their customer/consumer/patients. Physicians will continue to be rounded up and corralled into a variety of integrated delivery systems as salaried employees (like most of the rest of us) until the day when you walk into your local strip mall to a “healthmart” and are greeted by a friendly physician/technician with a big name tag who asks you “How can I heal you today?”

    Khosla is right; it is only a matter of time. All the elitist, paternalistic crap is on its way out exit stage left…it takes a lot of hubris to wave your hand at the spectre of technology when it is eating most of the rest of the world.

    • MD as HELL says:

      Partly true.

      You are the “consumer”, but I decide what services I will provide, not you.

      That makes you a patient.
      And you have chosen to be a patient.
      You may conceal information from me at your peril.
      You may take my advice or not.

      It is your life. You should live it on your terms. Why let a computer share your details with the White House?

      People pick their doctors by chance or reputation, but they keep them for the relationship.

      Sneer all you want. You clearly do not have or want a doctor.

      To your health, sir.

  15. Midwest doc says:

    Wow! The tones tell me of the trouble that is upon us. Breathless I am. You are all correct. Physician, patient, IT guy, victim?
    Flying is skilled. Pilots have an advantage. At take off , in flight, at landing they use a check list. Check it off. The flaps will be set. The degree of climb and landing is set. The skilled pilots are the ones we want when everything goes wrong. Land the plane in the river when you know of no options. Recently done by a beautiful person.
    Back to the land of mortals. Forget the pilot analogy. Over used and over done.
    It is simple. You will give your trust to a computer and a program. Give your information to the EHR. Might be beneficial. I don’t know. Replace me. Fine. I do my best everyday. I have patients who trust me. I get scared. I get help. The patients know. They have my cell number. A few have landed in the river. They are doing great . (Smile). Enough about me.
    I ramble. The time I spend cajoling the ACA mandate is time away from patients and thought. Kholsla is simply an idiot. Let him rest. Yes 80 no 90 % of the time a machine can replace me. That 10 %? Priceless! That is why I became a physician. I love it and no one will take that from me.

    Daniel Jost MD.

  16. MD as HELL says:

    Here ends the lesson.

  17. atlibertytosay says:

    Surely there is a way to make the current EMT better. A way that helps the provider get more time with the patient. And maybe physicians and other care providers can lobby to decrease the amount of paperwork needed. EMT’s SHOULD be what a flat tax would be to the tax code. It should make life easier. They will never help the care giver unless the regulations requiring so many pages, whether electronic pages or paper, are decreased and the care providers are allowed more time with patients and less with a pen…or stylus.

  18. jennifer says:

    I’m also tired of having a serious medical condition, because until a surgeon didn’t do his job with follow up care, I did not have the medical condition. Now, my life is irrevocably changed. All I ask is that you treat me with the respect you want me to give you because of your title. I don’t give respect because of initials after your name. I have plenty of initials after my name, and I have just as many years of training as you do… and from the same institutions you revere: Hopkins, Harvard and Yale. Look at me when you talk, do not decide the conversation is over while I am thinking (or if it must be give me a way to write down my questions–email is fine), return my phone calls in a reasonable time frame, do not expect me to change my entire life because of your schedule. Understand that not everybody can take off work without consequences, not even professionals with sick leave.

  19. Alecia Ogren says:

    How could you think of a machine as an alternative to a human physician or doctor.Machines may assist in several treatments but they can never be an alternative to humans this is insane.

    We both have a mutual feeling Margaret , and I support all the experience you have posted.A machine won’t give you a shoulder to keep your head on if you feel link crying.It wont pamper your kid when he actually needs it while taking medication for the first time.

  20. siddrock says:

    Hi,

    I like this line “The therapeutic relationship between a doctor and a patient can never be replicated by an IPhone app”, its very true. and i also agree with @Alecia, machines never ever can be alternative to humans. each person have their own place in each other life, e.g wife cant take place of mother and vice versa. same thing we can say about this post also.

    looking for more post

    Thanks
    siddrock

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