Personal Tech

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My 87 year-old father broke his hip this past weekend.  He was in Michigan for a party for his 101 year-old sister, and fell as he tried to put away her wheelchair.  The good news is that he’s otherwise pretty healthy, so he should do fine.

Still, getting old sucks.

During the whole situation around his injury, surgery, and upcoming recovery, one thing became very clear: technology can really make things much easier:

  • I communicated with all of my siblings about what was going on and gave my “doctor’s perspective” to them via email.
  • I updated friends and other family members via Facebook.
  • I have used social media to communicate cousins about what is going to happen after he’s discharged from the hospital and coordinate our plans.

All in all, tech has really made things much easier.

This reality is in stark contrast to the recent headline I read on Medscape: “Doctors are Talking: EHRs Destroy the Patient Encounter.”  The article talks about the use of scribes (a clerical person in the exam room, not a pal of the Pharisee) to compensate for the inefficiencies of the computer in the exam room.  Physician reaction is predictable: most see electronic records as an intrusion of “big brother” into the exam room.

To me, the suggestion to use a scribe (increasing overhead by one FTE) to make the system profitable is ample evidence of EMR being anti-efficient.

Despite this, I continue to beat the drum for the use of technology as a positive force for health care improvement.  In fact, I think that an increased use of tech is needed to truly make care better.  Why do I do so, in face of the mounting frustrations of physicians with computerized records?  Am I wrong, or are they?

Neither.  The problem with electronic records is not with the tech itself, it is with the purpose of the medical record.  Records are not for patient care or communication, they are the goods doctors give to the payors in exchange for money.  They are the end-product of patient care, the product we sell.  Doctors aren’t paid to give care, they are paid to document it.  Electronic records simply make it so doctors can produce more documents in less time, complying with ever-increasingly complex rules for documentation.

When I say we need more tech, I am not saying we need more computerization so we can produce a higher volume of medically irrelevant word garbage.  I am not saying we need to gather more points of data that can measure physicians and “reward” them if they input data well enough.  The tech I am referring to is like that I used regarding my father.  I want technology that does two things: connects and organizes.  I want to be able to coordinate care with specialists and to reach out to my patients.  I want my patients to be able to reach me when they need my help.  Technology can do this; it sure did for my dad.

Yet people are incredibly reluctant to adopt this.  They fear that using technology will inevitably make things less personal.  I have patients who are still reluctant to use computers for this reason, and I definitely see this in my colleagues, who reject my pleas to communicate with me electronically.

My main communication tool, Twistle, allows me to communicate quickly and securely with my patients.  Using it has greatly improved the efficiency of care and makes my patients feel more connected with me.  Here are some examples:

  • Patients routinely send me pictures of rashes/lesions.  Sometimes I end up bringing them in to the office to get a personal view of them, but often I can give care based on the computer.  One mother was out of state with her child and I could successfully diagnose and treat a yeast diaper rash.  She was thrilled.
  • I send actual copies of lab, x-ray, and procedure reports to the patients along with my explanation of their significance.  Now the patient has a copy with them at all times (as long as they have a smartphone) and so can share the reports with any specialists they visit.
  • One patient was having bad problems with an intestinal infection and was in the ER for the 3rd time in a week.  The ER doc was not taking her seriously and so she sent me a Twistle message asking for help.  I replied with a run-down of what had been done and the reasons I felt she needed to be admitted for a work-up.  She showed it to the doctor in the ER who grinned, nodded, and admitted her without any more questions.
  • I often have a back-and-foth conversation using Twistle regarding symptoms and/or concerns a patient is having.  This sometimes resolves the problem, but sometimes it results in an office visit.  These visits, however, usually take less than 10 minutes of the patient’s time (from when they come in to when they leave) because I’ve already gotten the history on Twistle.  This is normal in my practice, but is almost unheard of in the “real world.”

There are other examples, but clearly my patients who use this tool think it makes their care better.  But what about those who are still reluctant?  What about those who worry that this will push their care toward impersonal electronic communication?  I finally figured out an answer to this: my daughter.

My daughter is in college in upstate NY (where I grew up, and where my parents live).  She loves it up there (although has realized why few people retire and move up north), but the distance has been hard on us.  We don’t get to see her nearly enough.  The one thing that has helped us deal with this long distance has been technology.  We use text messages, email, FaceTime, and other technology to stay close to her.  Does the technology replace seeing her in person?  Absolutely not.  But it does enhance our communication and connects us when we couldn’t otherwise do it.

This is what technology should do: it should enhance connection and improve relationship.  Technology doesn’t have to add a layer of complexity or push people apart, in can simplify and connect.  Technology doesn’t bring my dad or my daughter down to Georgia, but it can make the distance feel much shorter.

So I roll my eyes when people suggest paper medical records.  Really??  I wouldn’t give up the ways in which tech has improved my communication and has brought me closer to the people who really matter.  I think most of my patients would agree.

Rob Lamberts, MD (@doc_rob) is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind), where this post first appeared. 

17 replies »

  1. As you say when technology connects and organises then it can only be good for everyone – doctors and patients alike. As with most technology, some take longer to adopt it, but realise in the end the value it gives.

  2. I think it is great you use technology to stay informed and updated with your patients. As a patient, I found communication to be much smoother via technology. I wish more physicians would come to terms with it. It is the way of the future.

  3. Rob, Twistle is something that is voluntary. Therefore, some will experiment with it, refine it and it may stay or be replaced by something else. The payment system will have a lot to do with Twistle’s effectiveness for if one cannot charge for one’s intellectual property one will have to find another job.

    I would probably like Twistle for some things, but I’ll bet my practice would have had a hard time dealing with it for free as the demands would increase with the patient’s attempts to save money or the copay. It could become a monster.

    I was trained before the CT scan and tests with immediate results for MI’s so I had to rely much more on physical diagnosis. That involved all the senses including smell, taste (no I did not taste urine), looking at the clothing, special emphasis on the hands to know a bit about the person’s lifestyle, speech patterns, gait, family members or friends, etc. It is amazing how much can be learned about the patient and his disease in the first 60 seconds. It is even more amazing how quickly with the proper scans we can get so much more information.

    In the end Twistle is an abbreviated history not as good as the real thing. However, when the patient is able to turn his i phone over and get a type of CT scan anywhere on his body along with a printed readout of his blood components sent via the Internet that will be real progress. 🙂

  4. Having used it for the past year, I haven’t found it a problem. In reality, patients can give a more complete description in writing many times and I can go back and forth with questions. If I am concerned or still not certain, I bring them in for a quick exam (already armed with far more history than I’d usually have when a patient came in my old practice) and I’d round out the information with face-to face. It’s obvious that this tool is not perfect, but neither is the unwillingness to use these tools that forces us into brief encounters where we force patients to limit their complaints to one problem at a time and where I am distracted by the crush of a full office. Been there done that. This is not an incremental improvement, it is a huge jump in my ability to really listen. Refusing to use this would be like refusing to text message with my daughter because it wasn’t as good as face to face visits. It would be stubborn to the point of being stupid.

  5. I think twistle might be a good idea for some, but physicians have multiple senses as do patients and the best diagnostician uses them all.

    A patient complains of pain in writing. Think of how much better one can evaluate the type and intensity of the pain by just hearing the voice. Then think of the information obtained by watching the patient complaining about the pain.

  6. Thanks.

    My concern is what you addressed earlier: that Twistle doesn’t replace anything, it just becomes one more to do. In a small practice like yours, that’s not a big deal; for a doc with 3000 patients, it is.

  7. 1. Secure (HIPAA Compliant)
    2. Multiple formats (pictures, PDF files)
    3. Storage of media within the app.
    4. Asynchronous – patient can send us a message at 2 AM and doesn’t have to pull me out of a conversation.
    5. Portable – the fact that there is an app for the smartphone makes it so that patients can have communication with them at all time (like the woman in the ER).

    In some ways the idea of “more effective” is not right. Twistle is an alternative that patients can choose; we don’t make them use it. The reality is that my patients really like this app, which is probably the best evidence. Most of them are not drawn by technology for technology’s sake, instead using only things that help them out. They not only use it, but brag about it.

  8. What makes communication by Twistle “more effective” than by face-to-face speech, phone, fax, US mail, and so on?

  9. John, do you recall when the fax machine first was available in medical offices. It was of no value if the person on the other side didn’t have one so it grew slowly at first and then suddenly it appeared in everyone’s office.

    Was the fax machine mandated? No. It was a tried and proven product that helped physicians perform their tasks so they voluntarily invested money in a fax machine.

    Do you remember years ago when laboratories were willing to integrate with private offices so that one major portion of the EMR could be accomplished? Who stopped that rapid integration? The federal government. Remember the Stark Laws?

  10. I don’t think it’s entirely about not getting paid; I think it’s the amount of things docs have to do to get paid that has them reflexively rejecting anything new. All new technology becomes “one more thing,” and does not in the end make docs lives easier. I believe that Twistle would actually make specialists’ jobs easier, but they are all jaded by past experiences with technology (AKA meaningful use).

  11. Ok. I think everybody has heard the “I’ll do it when I get paid for it” argument. A lot of people don’t understand the disconnect. It seems obvious that by making our communication with patients and colleagues more effective, we’re working smarter. But as you say, a lot of people don’t feel that way. What’s going on here?

  12. Frustrating. The problem is that they have too much other things to do and see this as “one more thing.” Improving care quality, in my experience, is not as important as improving efficiency of code submission or compliance of notes. Specialists are very skeptical of technology, as their experience with new technology is that it brings more responsibilities to them.

    Interestingly, academic specialists are much quicker to accept it. I guess their not being volume-oriented is reason they are OK with doing something different. I’ve had a couple of specialists do it and they are very happy with it, but acceptance of it is ridiculously difficult.

  13. Very cool. I can see the advantages. I imagine a lot of people will ask about the HIPAA implications of using a technology like Twistle. We’ve added to the queue to review at THCB. Curious what kinds of reactions you’re getting when you approach specialists about this?

  14. Organically grown tech is great, but when it is mandated it turns into fertilizer.