‘Between the NHS and social care, there must be total commitment to ensuring that interaction is paperless, and that, with a patient’s consent, their full medical history can follow them around the system seamlessly.‘ So said Jeremy Hunt,the Health Secretary, on 16 January 2013. And NHS England say that: ‘Our vision is for a fully integrated digital patient record across all care settings by 2018’.
It sounds like a good idea. It’s not. Or not in its present form. Many of the concerns that have been expressed relate to privacy/confidentiality. Those concerns are real. But even if they can be satisfactorily addressed, electronic health records have the potential to do great harm. They divert attention from the patient to the screen, and they cause clinical skills to atrophy.
David Loxterkamp recently observed that the computer in the consulting room is a Frankenstein-like creature: ‘….we have created a place in our exam rooms for a computer that needs our care and feeding. It now directs the flow and purpose of an encounter that once unfolded organically according to the particular needs of the patient.’ The electronic servant becomes the master.
What might it tell doctors to do? Well, says Loxterkamp, it might prompt doctors to tick the boxes that must be ticked in order to meet various national standards, instead of concentrating on the patient’s problems. ‘Increasingly, we are graded on our performance on meeting national guidelines for the control of weight, blood pressure, smoking cessation, cholesterol levels, and diabetes, and the results are reported on consumer websites. It is possible, even likely, that such data will change our approach to patient are. They are already inexorably shaping to what and to whom we listen.’
There’s precious little time in a typical medical consultation. If a computer directs a doctor to tick boxes (a direction strengthened, as it will be, by a financial incentive), there’s even less time.
But there are deeper concerns than this. The tick-box culture tends to turn an individual patient into a member of a cohort. It turns medicine into epidemiology. It dehumanizes the patient, and hence the consultation, the practitioner and the profession. And to dehumanize – to de-individualise – the clinical encounter is, eventually, to de-skill.
This de-skilling may happen in obvious ways. If you deduce what’s wrong with a patient by applying an actual or metaphorical algorithm based on the electronic clinical record, you’ll palpate, percuss and listen sympathetically less than you otherwise would. And, slowly, you’ll lose the ability to do so.
Less obvious but crucially important skills will be lost too. There’s a fascinating paper entitled Clinicians’ gut feeling about serious infections in children: observational study. In a primary care setting in Belgium, 3369 children and young people were assessed clinically as having a non-severe illness. Of these, 6 (0.2%) were later admitted to hospital with a serious infection. Two of those six cases would not have been missed had the clinicians acted on their gut feelings and said, in effect: ‘I don’t care what the assessment says: my intuition is screaming out that there’s something serious going on.’ This gut feeling isn’t just another label for clinical experience. The authors state: ‘The diagnostic value of a gut feeling changed little with clinical experience, although the more senior the doctors the less likely they were to experience a gut feeling in addition to forming a clinical impression.’
Intuition, so derided by the reductionists who are the masters of modern medicine, can save lives. But it speaks with a still, small voice: a voice that’s likely to be missed if the doctor’s chasing her mouse round her desk.
Of course an electronic patient record has some very valuable uses. It’s important to know, for instance, about allergies and major clinical episodes. But in seeking to give doctors all, e-records result in them having less.
My wife, who’s a GP, read through this piece. ‘Nonsense’, she said. ‘E-records are wonderful. You can’t practice modern medicine without them’. Which is, of course, precisely the point. Doctors shouldn’t be practising modern medicine at all.
Another great concern is that medical e-records will make it impossible for patients to get an unbiased second opinion.
Isn’t that rather like saying that an appeal court will be biased by having read the transcript of the original hearing ?
I agree that if any tool becomes master we should be concerned. But surely the answer is to train the user rather than blame the tool and throw it away ?
Charles and his wife both have important points, but are they really so incompatible ?
Anita: thank you. Yes. Perhaps the danger is best generalised as a sort of sclerosis – of which the hardening of presumptions about a patient’s condition is one of the most dangerous symptoms.
Anthony: many thanks, as ever.
As to your first point: it’s not really like saying that there’s a bias inherent in reading the transcript of the original hearing. Many medical consultations will not be appeals from earlier hearings at all: they will be unconnected with earlier medical events. If all the details of earlier medical events are available, there will be an inevitable bias towards assuming that the new is part of the old. That can be a dangerous bias. There’s not a correspondingly dangerous bias in the other direction: clinicians are unlikely to assume inappropriately that everything that has gone before is irrelevant.
As to to your second: yours is a counsel of unattainable perfection. Our cognitive biases, coupled with the exigencies of hurried consultations, mean that we’ll be very easily mastered. Accordingly the mid-point that you describe between the two extreme positions is likely to be inaccessible.
Thank you Charles. You’re probably right : perfection is always unattainable.
PS : I think you might enjoy Winckler’s “La Maladie de Sachs” – translated as The Case of Dr Sachs……if you haven’t already read it.
Anthony: many thanks. I haven’t read it, and I will.
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