If the cheerleaders including the one in the Oval Office are right, computerized medical records will save us all: save jobs, save money, reduce errors, and transform health care as we know it. In a January speech, President Obama evoked the promise of new technology: This will cut waste, eliminate red tape and reduce the need to repeat expensive medical tests," he said, and he has proposed investing $50 billion over the next five years to help make it happen.
Any doctor will tell you the advantages of having lots of patient data on computers: it helps us avoid redundant tests, gather huge amounts of data for research, screen automatically for drug interactions, all with no problems with our famously illegible handwriting. I would be happy if every patient could hand me a digital file of everything about him; it could really save time on first visits. But against our government's push to get all patients' records computerized we must keep in mind there will be a cost to this far beyond the billions to be spent setting it up. Many of us in medicine are concerned that the greatest cost will be in the quality of medicine that we practice. (Read "The Year in Medicine 2008: From A to Z")
American doctors have not been enemies of the digital revolution. Looking up lab results and x-rays on our computer screens beat out carbon copies and sheet film in an instant. We like e-mail; we shop, take tests and read our journals on line. But the romance, for most of us, began to sour with Computerized Physician Order Entry [CPOE]: entering patients' hospital orders on the computer. This is when we first confronted the downside to uploading our every medical judgment.
The majority of us are forced to use computerized orders or risk losing our hospital privileges. But most of us have found that CPOE is a lot harder than writing out orders on paper, takes far more time and in too many ways is just not as good. We're never quite sure that what we've typed is going to be seen by a real, live, analog nurse, that it isn't just going to disappear. (It does.) We can't order certain things with those buttons and pull-down menus that we could in writing things like "patient may wear her own flannel nightgown and underwear" or "please, please get the x-ray I ordered for yesterday", or "prop up patient's legs with pillows like this" followed by a little stick-figure drawing. (See pictures from an X-Ray studio.)
After CPOE grief and the obvious but very important "what if it breaks?" issue, our immediate concern with putting all that medical data on a nationwide computer network is privacy. Who gets to look? How do you limit access to information and respect privacy when managing a disease, like diabetes or AIDS, that affects many organ systems and so involves many different kinds of doctors and services. Doctor-patient confidentiality seems quite likely to be one of the sacrifices Americans will be required to make to get this project going.
Health care is a labyrinth of insurers, doctors, hospitals, clinics, pharmacies, all using different computer systems; are we really going to create a single comprehensive system that gives everyone access to all the information they need? Or find a way to get the multiple systems already out there to talk to each other? It would be a task to make Reagan's Star Wars plan seem quite manageable. But that is only the beginning; really hard is going to be getting this multi-billion dollar juggernaut to actually save us money. (Read "Faith and Healing: A Forum".)