Friday, June 26, 2009

Of Real and Virtual People

I was reading an article from last week’s Wall Street Journal titled, “The Myth of Prevention” by Abraham Verghese, MD. The bulk of the article focused on health reform and the specter of phantom savings derived from a greater focus on prevention. Specifically, more screenings find more diseases, get more patients on more drugs and the economics of how, as awful as it might be to say, hundreds of thousands of dollars spent on new care spawned of “prevention” may not really return high numbers of years or lives saved; begging the question, is all that prevention delivering real health system value or will it actually drive costs up with little return?

A fascinating economics-ethics debate for sure. But not today.

For today, however is a discussion that Dr. Verghese sparks near the end of the piece. “[The EMR will] ensure that we doctors, nurses, therapists, particularly in hospitals will be spending more and more time focused on the computer, communicating with each other, ordering and getting tests, buffing and caring for our virtual patient—the iPatient is my term for this phenomenon—while the patient in the bed wonders where everybody is.”

He continues, “I have felt for some time that the patient in the bed has become an icon for the real focus of our attention, the iPatient.”

This intrigues me. Computers are about data, and the “insights” that data can deliver. I am knee deep in a digital project right now, awash in all the conversation/debate about what is measurable and what is trackable – connectable and projectable to some form of real or modeled ROI. The inherent data-collectability of digital activities, be they website clicks, ad views, drugs prescribed, or digital x-rays reviewed very well may be distracting us from the humanity and reality of what we do as providers, planners, marketers, communicators and strategists.

Or to Dr. Verghese’s point, are our tools shifting our focus from the human to the digital representations of the human – their medical data, the data about their behaviors in digital space, their purchase data, their attitudinal data?

An extension of the iPatient is the iConsumer. We’re guilty of this in marketing communications—boiling people down to numerical representations of the larger population’s humanity.

I can’t say that I have a pointed opinion or conclusion to offer here, other than to wonder when the last time was one of us sat down with a real patient and listened to their story. Not for the purpose of collecting data about who they think is “best” or “most preferred” or how they engaged the internet in tackling their health condition or whether a ad made them trust a hospital more or less, but rather just listened to the reality of confronting disease and what’s needed to find peace of mind within a disorganized network of care providers. While your customers should never develop your strategy for you, they certainly inform your planning.

Maybe that’s the difference between “research” and “listening.” In research we have a goal in mind. We ultimately want the target to either confirm our suspicions (brilliance) or report our effectiveness in influencing their rational thinking to our point of view. In listening we should have no agenda for what they are to give us, other than connecting in real, human terms. Sure, compile enough connections and the inquisitive mind can craft correlations, conclusions and relations. Even insights.

As we rush forward, in policy around reform, in strategy responding to changing technologies, economies and care delivery models, in communications marshalling the unrivaled power of digital mediums, tools and all the data they can spew at us, perhaps we should all make a concentrated effort to talk to, and listen to humans.


  1. That’s a very debatable subject to raise especially when the machines are taking over everything in return for efficiency.
    I tend to disagree though with Dr. Verghese’s argument. I don’t think that EMR will result in less time with the patients. Let’s look at it from the concept of spending “quality time” with patients. Instead of wasting time taking the same information (medical and non-medical) from the patients, providers will be focused on what is the presenting medical problem. In other words, focusing on patients’ problems instead of fact finding. How many patients spent enormous amounts of time trying to make sure that their provider understood completely their entire medical history? And what if that patient cannot remember a name of a procedure or a drug he/she undertook?

    Also, we can talk about EMR’s effect on reducing medical errors which is a “hot topic” in healthcare right now and which eventually will have its effects on healthcare costs. However, further research must take place before fully judging EMR, but historically technology has always won its battles.

    To your point of listening to patients, I completely strongly agree. Research to me is an obsession to find what you think is there, or not. Sometimes, we just have to pay attention to what patients say. Let’s learn a listen from our marketing colleagues and listen to our customers without imposing our products (in this case our research objective). After all, a non-benefit research is time, money and effort wasted on nothing.

  2. Too many people are relying on computers or technologies to do their job instead of using it as a tool to help them. When used as a proper tool, technology can increase medical personal's abilty to serve their patients in a more humane manner by not wasting time lookng for information.

  3. I also tend to disagree with Dr. Verghese's argument. EMR is not perfect; there are inherent issues like what type of information should it contain, the never ending question is the information in the computer correct, etc. But as imperfect as EMR is, it allows the doctor to spend more time with their patient; in certain cases EMR may contribute to saving someone's life. Of course there will be physicians who prefer to have a relationship with the computer rather than a patient but that is their choice.

  4. Dan,

    I feel sheepish in responding to your plea for more human interaction by commenting to your blog through my computer keyboard. I want you to know that I am looking at your picture (every single pixel) in order to make this communication seem more “human.” I promise to buy you a cup of coffee the next time we meet and to rehash in person the same thoughts that I present below, unless I see your eyes glaze over from boredom (another benefit of human interaction).

    I am intrigued by Dr. Verghese’s comments. He highlights for me the extent to which we lack good statistical data to prove or disprove his concerns about the impact of an EMR on the physician-patient interaction. The nation is about to embark on a massive investment in computer technology under the assumption that care will be improved and (more importantly to some) costs will be reduced. While one would hope that the care physicians render will be enhanced by the new technology and human interactions between the physician and patient will not suffer, it is not hard to understand Dr. Verghese’s concerns about the unintended consequences of asking care givers to interact with a computer during an office visit.

    Regardless, my response to Dr. Verghese would be “that train left the station.” There will be an EMR. The focus should be on how to engineer the computer-physician interface in a way that improves human interaction between patient and physician, or at least limits the damage to it.

  5. I tend to agree with the comments that EMR is a tool; a tool with a specific use that is superior to the previous paper records that are still being kept today by many health care organizations. It cannot take the place of the human side of listening and "laying hands on the patient."

    Technology is not a replacement for human interaction. We should focus our efforts in continuing to provide excellent quality care for our patients and use this tool to its fullest potential. There is no reason why we cannot achieve excellent results and improve the quality of medical care.

  6. Even though a well engineered and implemented EMR can provide healthcare providers with several short-term and long-term benefits, as a patient I still look forward to the quality time invested in my patient care by my provider. An EMR should be designed to capture a patient's medical history, treatments and procedures in order for a physician to make the best decisions regarding one's health regardless of location, urgency or provider. As more businesses have and continue to transition into computer-based systems for responding to consumers and their concerns, the potential risk is a decrease in patient satisfaction and an increase in motivation to seek out a new physician who is committed to adapting to new technology and improving human interaction.


  7. Many of the comments I have read have great arguments. As a non healthcare provider, I suspect that an EMR would be a tool to help document and track a patient's care. This should allow the Physician to spend more time with a patient. As health systems move to become more efficient, my hope is the time savings will be used to focus more on the patient and not the numbers of patients a physican can see inside of an hour.


  8. I think its also important to recognize that while EMR is a useful tool, it would be even more efficient if healthcare providers and payers could all utilize the same centralized EMR system or at least have the capability to communicate with one another easily.

    Most patients do not obtain all of their healthcare from one single provider within the same network. It would save the patient and healthcare professional significant amounts of time if they did not have to recapture the same health history over and over again. If a patient moves for example from one state to another, their EMR could be accessed by their new healthcare providers - everyone from their new physicians, nurses, pharmacists, and insurance company would be able to access their history, saving time and decreasing the possibility of serious medical errors from occurring, or even the duplication of tests/treatments. This is especially important for the elderly patient population. The extra time saved would give the healthcare provider the chance spend more time really listening to the patient and providing quality care.


  9. Please do not misunderstand me, I understand and support the value of computerization in improving health care delivery. Paul, you are correct in saying that train left the station. A marvel to me is the size of the gulf between what we as insiders know needs to happen in EMR and interoperability and what the consumer/patient thinks is already in place. They see computers everywhere in hospitals, physician offices, waiting rooms, et. al. And we need billions in new spending to make all these things better?

    Sometimes, I take off my "wonk" hat and put on my "health care marketer" hat and wonder about best practices and future steps. The good Doctor's concerns connected with me on that level. In research and planning we see people as so many numbers or suspicions to verify that I wonder if we need to be more intentional about humanity as we become more digital.

    Great points all. Thank you all for reading and contributing.

  10. I enjoyed reading the thoughtful article by Abraham Verghese and off course your comments. In spite of the many advantages of an EMR, it takes away from the face to face, eye to eye contact with a Physician as already mentioned. An example might tell the story better. I experienced it first hand visiting a doctor with a love one recently. The 30 minute visit consisted of less than 5 minutes of face to face contact with the patient, the rest of the time the doctor was glued to a laptop filling in an office visit template, occasionally asking a question, eyes still fixed to the screen. At that moment, a thought crossed my mind; I like it the old fashioned way. I assume this is the new way across the country as EMR supposedly increases the productivity of physicians. Those on the train have a great responsibility in preventing a derailment.

  11. I have read all of your comments and to some extent agree in part with all. However, I agree with Dr. Verghese's point of view. As a caregiver, the EMR was supposed to reduce time wasted documenting, decrease medical error, and provide a system for accessing patient information quickly and easier for multiple disciplines. While it does this in some fashion and the EMR is here to stay, it is not perfect by any stretch of the imagination and it does not deliver the outcomes once expected. Caregivers actually spend more time documenting or looking up information in the system, every human interacts with technology differently, others are not techno-savvy thus struggle with even the basic programs within the EMR and there is the group who is resistent to change and attempt to circumvent the system. The other challenge of the EMR, as someone else mentioned is the ability of multiple systems to interface. There is no common language that is utilized by all as a standard nor benchmarking data or research that supports best practice that should be adopted by all. All this being said, the patients still don't get the face time they deserve nor expect. Consumerism is rampant and expectations very high.Yet one has to remember that the elderly population is not very techno-savvy and aren't very articulate with the benefits the EMR has to offer them. Caregivers are busier than ever trying to meet the demands of documentation required by all of the regulators, government entities and accreditors as well as third party payers. Therefore, they spend their time making sure they have documented accurately so that reimbursement is ensured. In my humble opinion, we have a ways to go with the EMR from its current state.


  12. The idea of using preventative medicine to reduce costs needs to be looked at in the same manner we look at investing in any other capital good. Using indicators like Return on Investment (ROI) and Net Present Value (NPV), among others, can help us determine where, and how much to invest. I partly agree with Dr. Verghese in that a lot of the preventative medicine efforts thus far have been shots in the dark without fully understanding their ROI. Unfortunately, healthcare is very complex and identifying where to invest in preventative medicine is difficult.
    The prevalence of technology in our healthcare system is not going away, in fact, I believe that we need to put a national EMR system in place as soon as possible. Providers need to treat patients like people, not like numbers, or dollars for that matter. A fully integrated EMR system can help us identify where to invest in preventative medicine and will allow us to pin point what is working and what we need to do differently with regards to clinical pathways. Most importantly, physicians need to be physicians and need to balance listening to EMR data and listening to their patients.


  13. The fact that the use of the EMR and its functionality is still in its nascent stages lends support to Dr. Verghese’s point. The introduction of an Electronic system over the past several years has led clinicians to ineffectively balance their time with patients and incorporate the use of the EMR in their daily work processes. There are realized benefits in having a complete accessible medical history on a single platform that supports better clinical decision making and this will greatly impact the efficiency of our overall health care system going forward. At the present time, however, the EMR is comparable to the Personal Computer of the 1980s. There are a multitude of possibilities of how it can be used and incorporated into daily practices yet it is not fully understood and the technology is not exactly where it could be. I believe once the interface of an EMR becomes more user-friendly and can be better assimilated into the interaction between doctor and patient can we say technology has truly made a positive impact on health care and not taken away from the doctor-patient relationship.

  14. From an administrative perspective, the EMR assists patients tremendously by allowing the physician to have complete access to all of your medical records thus allowing them to make better decisions for the patient. Although you may not have as much 'face time' with your provider, it allows you immediate access to your records when they are needed. For example, we have many older patients who have several providers with each needing to know what was prescribed, how much, for how long, etc. The EMR allows the physicians office to quickly send that information (typically within 24 hours) so that there are no additional meds given and future treatment plans are discussed. Without an EMR, it would typically take 4+ days for this information to be forwarded to referring physicians. I do believe that we have a long way to go with EMR interacting with other systems effectively and physicians figuring out how to appropriately and effectively use this tool, but if I had to choose between more 'face time' with my physician versus adequate record keeping and being able to access my records in a timely manner, I would choose the latter.

  15. I think the introduction of EMR is a great advance for the purpose of decreasing errors and documentation purposes. However, the nature of my clinical work requires in depth discussion with patients to figure out what is actually wrong with them (90% of my diagnoses come from the history). There is little doubt that the introduction of EMR has left me with two divergent alternatives-spend less time with the patient or less time with my family. This conflict is real for most physicians I know, with most choosing the latter (as I do). That, unfortunately, adds up to >2 hours per day after clinic for some docs to document in the record, plus the time you spend during the visit ordering all of the tests (after you can find them), and correspond ing with referring physicians. To top that off, sitting at a computer during a visit puts your back to the patient, most rude to be sure and not conducive to eliciting a good history.

    Solution-sorry, I don't have one short of very sophisticated voice recognition OR a scribe. There is a drum beat about how EMR is going to save health care and decrease costs. Improving health care by decreasing errors and availability of an electronic record is good, how it saves money is beyond me. It certainly is less efficient for the providers and will likely increase the divorce rate for some.

  16. I have to agree with Paul. As I read this post I could not help but think how ironic it is that this conversation is taking place over the internet and not at a coffee shop or in a park or at a meeting. Heck, most of us see each other on a weekly basis but we choose to communicate on a blog. I guess that is just the way society is progressing.

    I also agree with the many comments that is EMR is here to stay. It is an improvement to healthcare. I think the point is or should be that we recognize that it does or could take away from face time with patients. Are we okay with that? If not clinicians need to find a fix. I like David's idea of the scribe. Every doctor needs a court reporter to follow them when they round on patients and take notes. Who new court reporting would be the solve for our unemployment crisis?

    I have not seen any data that supports the notion that EMR takes away from personal interaction with patients. Anecdotally, the emergency room that I work in as a nurse has recently gone from paper to EMR. I find that I spend far more time at the computer than I ever did at the paper chart. In triage I stare at the computer screen most of the time and type while I ask questions. Very little face time. On the other hand, many patients come into the triage booth texting or talking on their cellphone and don't want to hang up to talk to me. It seems many human interactions are becoming depersonalized. I guess that it just the way society is progressing.

  17. From my experiences being with patients in the emergency room the need for immediate care is utmost on their mind. A physician or nurse using a computer isn't noticed as much as the feeling that you've been forgotten. That's were the personal attention is needed. The patient needs feedback reaffirming their being attended to.

    The comments highlight an important issue in the EMR implemention. Having your back to a patient is bad but why can't it be relocated? Or I've seen PDA uses in a doctor's office so technological solutions are there.

    I'm hearing that timeconsuming EMR entry is a barrier in acceptance. Are workarounds and shortcuts done reducing the EMR effeciency? EMR is here to stay but as an efficient time saving tool there is room for improvement. I have a neighbor who is a court reporter maybe she could moonlight doing EMR input.

  18. When I hear that electronic medical records are dehumanizing the patient experience I can't help but think of the naysayers who cried that the telephone would ruin face to face relationships forever. I can assure people that human interactions inside hospital walls are alive and well albeit much different than the interactions of the pre-technology era. It's time to stop living in 'how it used to be' and understand what patient care looks like in the 21st century.

    What's changing how healthcare providers interact with patients? How about the myriad CMS/JCAHO standards, the threat of lawsuits that often lead to over documentation, and life-saving diagnostic tools that pervade a patient's hospital experience.

    The EMR absolutely has the potential to improve healthcare and reduce costs. One example of the EMR improving care is automatic orders for influenza and pnuemovax vaccines. Another is how an EMR can facilitate a more accurate medication reconciliation on a patient's admission and discharge reducing the incidence of missed medications and interactions.

    A more testy problem is the possible adverse effects of electronic decision support on healthcare providers' critical thinking skills. Now that is something to worry about...

  19. EMRs don't dehumanize healthcare, humans dehumanize healthcare. From what I've seen of physicians adopting EMR technology it is more of a learning curve issue that will fade away as the EMR becomes ubiquitous.

  20. I agree with most of the posts. EMRs have their positives and negatives. We have talked about this IT technology for many of our other courses and the focus was mainly on how it improves efficiency and prevent medical errors which can result in reduced costs (positives). However, we should not go over broad and heavily rely on technology. I remember watching this video during one of our classes, and this Robot Doctor (InTouch Health) was cruising down the hall and checking up on his patients that were recuperating from surgery. This is a pretty innovative and interesting idea and I can understand why this sort of technology can be helpful (its allows the physician to see his patients without actually being there), but I do not think it is entirely necessary. Perhaps, the dollars invested in this technology could have helped another aspect of cancer research.

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