More Unrealistic Expectations From the Public, This Time Involving CDS

Yet again, someone needs to educate the general public about healthcare in general and health IT in particular.

HealthLeaders last week asked the question, “Does Decision Support Make Docs Look Dumb?” The story, apparently based on a 2007 study (not 2008, as HealthLeaders reported) in the journal Medical Decision Making, says: “Most clinicians would agree that evidence-based decision support tools have the potential to improve clinical quality. But patients’ perception of the tools—and the physicians who use them—might be yet another barrier to their adoption. The problem is twofold: Some patients are skeptical of docs who need a computer to help them make a diagnosis. And some physicians don’t want to be seen as being too reliant on technology.”

We’ve long known that physicians have resisted clinical decision support, for a variety of reasons. They trust their professional judgment. When they only have a few minutes with each patient, they believe it simply takes too long to look up information that might help reach a more accurate diagnosis or devise a better care plan. The technology simply isn’t up to snuff. Or there isn’t enough electronic data available on each patient for CDS to have a positive effect.

But to read the conclusion of that Medical Decision Making study is to see an entirely different excuse for shunning clinical decision support: “Patients may surmise that a physician who uses a [decision support system] is not as capable as a physician who makes the diagnosis with no assistance from a DSS.”

HealthLeaders interviews other clinicians and researchers who have found similar sentiments. “Patients object when they ask their doctor a question and then she or he immediately types in the question into their laptop and then reads back the answer. It gives patients the feeling that they just paid a $25 copay to have someone Google something for them,” Illinois State University information systems professor James Wolf tells the publication.

“Physicians are reluctant to adopt computer-based diagnostic decision aids, in part due to the fear of losing the respect of patients and colleagues,” Wolf adds.

If this is true, it represents failures on many levels. IT systems designers haven’t made their technology easy to use. Physicians and healthcare entities haven’t done a good job educating patients and journalists like myself have truly failed the public by continuing to feed them false expectations about healthcare.

First off, Wolf’s statement that patients feel like they wasted only a $25 copay perpetuates the myth that a physician office visit only costs $25. If patients think they may have wasted $25, how do you think insurance companies and employers must feel that another $150 of their money went out the window?

The part about losing respect is perhaps more troubling. Physicians need to put their fragile egos away and do whatever they need to do to provide better care. The status quo just isn’t cutting it.

I’ve had the distinct honor of interviewing Dr. Larry Weed on several occasions. Weed, the octogenarian inventor of the problem-oriented medical record and the SOAP note, has been calling for CDS and other IT for more than half a century. Yes, more than half a century. He’s been actively working on such technology since the early 1970s. In a 2009 interview with the Permanente Journal, Weed said:

Computer technology maximized access to voluminous data and knowledge, thereby exposing the limited information processing capacity of the human mind. Scientists cope with this limitation by controlling the research environment, defining the variables involved, and limiting the scope of their investigations. Practicing physicians do not have that luxury. The time constraints of practice and the enormous scope of information implicated by multiple problems in unique patients make it impossible for the human mind to function with scientific rigor. Physicians inevitably resort to dangerous cognitive shortcuts.

I realized that medicine must transition from an era where knowledge and information processing capacity resides inside a physician’s head to a new day where information technology would provide knowledge and the processing capacity to apply it to detailed patient data. The physicians’ unaided minds are incapable of recalling all the necessary knowledge from the literature and processing it with data from the unique patient. An epidemic of errors and waste is occurring as we persist in trying to do the impossible. Changing this requires that we recognize the crucial distinction between electronic access to information and electronic processing of information. This requires a rational standard of data organization in medical records. Yet, these points are still not recognized in most current discussions of health information technology.

As a result, I have been involved for the last 60 years in trying to design and develop a medical care system in which patients are no longer dependent on the limited, personal knowledge their caregivers happen to possess. The medical care system must resemble the transportation system, where consumers use knowledge captured in maps, road signs, computerized navigation devices, and the like at the time of need. Patients, like travelers, will be expected from childhood on to develop the necessary skills to navigate the system.

At all times, patients should be supported by caregivers who are highly trained in the necessary hands-on skills, like removing the appendix or listening to heart sounds, just as in the travel system there are pilots, mechanics, air-traffic controllers, and others who perform functions that travelers cannot perform.

Yet, few outside of academic medicine have ever heard of Weed and his pioneering work. Instead, we rely on shoddy reporting and sound bites designed to score political points to shape our opinions. Why do you think the debate around “healthcare reform” focused so much on insurance coverage rather than actual care? And why do you think patients still believe office visits and prescriptions really cost just $10 or $20 or $30? And why do so many people still expect their physicians to know everything?

We must do better.