Paging Dr. Dotcom
From PDAs to online disease management, doctors go digital.
By Neil Osterweil
Reviewed By Charlotte Grayson
Prowl the corridors of any teaching hospital at any time of day and it's easy to spot the medical residents: they're the ones with the deer in-the-headlights expressions and dark circles under their bloodshot eyes.
Another way to tell you've sighted freshly minted MDs is by the PDAs (personal digital assistants) they carry.
Residents used to be walking libraries, the pockets of their white coats crammed with diagnostic manuals, drug guides, and reference charts.
"We had wheelbarrows full of manuals," says Donald Girard, MD, associate dean for graduate and continuing medical education at the Oregon Health Sciences University (OHSU) in Portland, recalling his residency way back in the mists of history -- the early 1970s.
PDAs for Info PDQ
Today, OHSU has 600 medical residents, virtually all of whom use PDAs in their daily rounds, Girard tells WebMD. In contrast, many, but not by no means all, of the senior physicians have adopted PDAs in their day-to-day practice. "They're definitely behind," he says of his benighted colleagues.
The major advantage of PDAs is that they allow instantaneous, easy retrieval of information on a broad range of subjects limited only by the software and the amount of memory in the device, Girard says. The most frequently used programs are drug guides (pharmacopoeias), which list drug types, doses, interactions, and prescribing information on demand.
Residents (and attending physicians who aren't digitally challenged) can also thumb electronically through such classics as the Merck Manual of Diagnosis and Therapy, medical dictionaries, and the 5-minute Clinical Consult, as well as programs customized to specialties such as pediatrics, emergency medicine, gastroenterology, and just about every other clinical discipline you can name.
PDAs can also help doctors calculate drug conversions and equivalencies (for example, when a patient is switched from one narcotic to another), and provide interpretation of critical information such as blood gases.
"I don't mean to denigrate the usefulness of hard copy," Girard says, "but the PDA has such readily and easily accessible, standardized information that it's used by nearly everybody."
But in one area, at least, the technology still hasn't caught up with demand: "We had a study group where we tried to see if we could take the PDA and make it useable for order entry and with pull-down windows to do notes so that you could do them on the fly while making rounds, and then send by wireless technology to a computer for making hard copies," Girard says. "We actually abandoned it, because it was too hard to do. The information retrieval is easy, but the input side of this thing is too complicated. But I'm sure that it's going to happen."
PDAs are also finding their way into the operating room, says Stephen Schwaitzberg, MD, director of the Minimally Invasive Surgery Center and Associate Professor of Surgery at Tufts-University School of Medicine in Boston.
Schwaitzberg tells WebMD that's he's working with a leading computer maker to develop voice-recognition systems for use with handheld devices. The idea is that "you could dictate on your [PDA], bring up somebody's medical record, and shoot it right into the electronic medical record."
Doctors could use the devices to record simple notes or specific orders to be included in the patient's care plan without ever picking up a pen or pecking away at a keyboard.
But the idea is still not ready for prime OR time, Schwaitzberg acknowledges. "There are a lot of voice recognition systems out there, but the details of getting it to interface with Dr. Joe Blow when he's standing there in his clinic is hard work. The 'last-mile' interface is a real challenge."
He adds, however, that he has recently tested a voice-recognition dictation system for use in the operating room that requires little or no training on the part of the surgeon, and works well with a wide range of speaker for limited applications.
For today's physicians-in-training, poking away with an electronic stylus at a handheld computer comes as naturally as blasting away at invading aliens with a Nintendo Game Boy.
In fact, doctors often have been quick to embrace technology when it improves patient care. For example, the first use of X-rays in medicine was reported in February of 1896 in Dartmouth, Mass., within two months of the formal announcement of the discovery of "a new kind of rays" by German-born physicist Wilhelm Conrad Roentgen.
Similarly, doctors were among the first to appreciate the advantages of the telephone. In the late 1800s, if someone in a rural farm family fell sick or had an accident, they either had to treat the problem at home, haul themselves in the wagon into town, or dispatch a messenger to fetch the nearest doctor. With the advent of the telephone, however, doctors could be summoned at a moment's notice.
"Nevertheless," writes Alissa R. Spielberg, JD, MPH, in an 1998 Journal of the American Medical Association article about at the historic roots of online medicine, in the early days of the telephone, "many practitioners believed that practicing medicine over the telephone compromised the moral integrity of the profession and promoted substandard care, with patients forgoing necessary physical examinations and misinterpreting muffled prescriptions."
Spielberg says that in contrast to their colleagues of a century ago, "contemporary practitioners have been reluctant to use electronic communication in their practices. Partly because the telephone has satisfied the need for immediate communication, particularly during emergencies, email and Internet interaction may not seem critical to medical practice."
The Call of the Wired
So are email and Internet access critical to medicine? Probably not. Are they pretty darn useful? You bet, say doctors interviewed by WebMD.
When doctors use email to keep in touch with patients, "we lose information but there's still plenty of information that's communicated; that's why email is driving this economy, it's driving the business world. Where would we be without email?" says Daniel Z. Sands, MD, MPH, professor of medicine at Harvard Medical School, and clinical systems integration architect at Beth Israel Deaconess Medical Center in Boston.
"I think the biggest advantage is the asynchronous communication," says William E. Davis, MD, a family physician in Winona, Minnesota, and chief medical information officer for Winona Health Online.
"I spend a lot of time calling, and calling, and calling trying to reach patients, and they're not home and I'm not here and we can do that phone-tag business for days. So when you have the ability to respond either to an email from the patient or to send lab results or test results of some kind along with an interpretation, that can save an enormous amount of time."
Both Sands and Davis caution that email and online records can't substitute for direct doctor-patient contact, either in person or on the phone.
"You have to understand the limitations of that technology, just like we've all learned the limitations of the telephone," Sands tells WebMD. "We all use the telephone a hell of a lot in our practices, but we know that it's not perfect and sometimes we just have to tell patients to come in.
"As long as we understand the place of this technology and what its limitations are, and we don't feel uncomfortable saying to a patient, 'look, this isn't going to work through email; you're going to have to come in,' then its OK."
Davis says email is often a good way to initiate an office visit, allowing patients to fill out some of the inevitable forms and questionnaires online beforehand, so that the patient isn't a blank slate when he or she first crosses the office threshold.
Patients can use online health logs to enter daily measurements such as blood sugar readings (for diabetics), or blood pressure and weight measurements (for people with heart failure).
"That way, they can be tracked by the providers rather than waiting for them to show up in the emergency room. If they're in severe heart failure, for example, you can notice that they're gradually gaining weight and that's a sign that they're retaining fluids [a symptom of serious heart failure]," Davis says.
In the Know
The Internet has also produced a rapid shift in the balance of power between doctors and their patients, a change that some older and/or more traditional physicians find troubling.
In a report on Internet Health Resources published by the Pew Internet & American Life Project, one patient tells what can happen when an empowered patient matches wits with a deeply entrenched doctor:
"Every time I visited with the neurosurgeons," the patient wrote, "I was well-equipped with an incredible amount of information retrieved from countless hours of scanning sources on the Internet. Many times, they became irritated with me for having knowledge of the condition beyond what they chose to share with me. Many times they became defensive and short with me when I would question different aspects of either the information they were giving me, or what I had found out on my own on the Internet."
Once patients had (via the Internet) easy access to the same kind of health-care information that doctors always had, physicians were no longer uniformly seen as wise, all-knowing guardians of the mysteries of medicine, and instead became, in the eyes of patients, what they have always been in real life: well-educated, well-trained, compassionate people who know a lot, and know how to look it up when they don't. And fortunately, many doctors aren't threatened by well-informed patients.
"The old model of health care is one of information asymmetry: The doctor knows everything, the patient knows nothing," Sand says. "Those days are gone, Information symmetry is the rule now because you have access now to the same information through the web that I do. You can look at The New England Journal of Medicine on the web and do literature searches."
Sands tells WebMD that about one-third of all searches of the medical literature performed at the National Library of Medicine are performed by lay people.
"All of this information is available to you. What you don't have is the experience and some of the knowledge necessary to interpret some of that, and you don't have the clinical judgment, so I think patients should go out and look for stuff," Sands says.
"I think it's a burden personally to have to know everything or to have a patient who expects you to know everything, because physicians who say they know everything are just lying -- you can't know everything. So if I can't know everything, why do I have to keep up this impression that I do? If I don't know something I'm going to tell you I don't know something, and either I'll look it up or I'll tell you to look it up or we'll look it up together in the office."
Back to Wired Health -- At Your Fingertips.
Published September 2003.
SOURCES: Donald Girard, MD, Associate Dean for Graduate and Continuing Medical Education, the Oregon Health Sciences University, Portland. Stephen Schwaitzberg, MD, director of the Minimally Invasive Surgery Center and Associate Professor of Surgery,Tufts-University School of Medicine, Boston. Daniel Z. Sands, MD, MPH, professor of medicine, Harvard Medical School, and clinical systems integration architect, Beth Israel Deaconess Medical Center, Boston. William E. Davis, MD, family physician, Winona, Minnesota, chief medical information officer , Winona Health Online; Spielberg, AR. On Call and Online, Journal of the American Medical Association, Oct. 21, 1998. American Physical Society. Pew Internet & American Life Project.
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