Doctors didn’t study it in medical school, but this revolution will constitute a major share of their work in the near future. The melding of computers, digital patient records and videoconferencing with the practice of medicine will change the profession for the better – and maybe for worse – around the world.
As physicians’ physical examinations of patients took a back seat to lab test results and sophisticated scanning, will the day come when they see more patients on video screens than in their office? How will that affect the doctor-patient relationship, doctors’ and nurses’ responsibility, liability and status, access by the disadvantaged and residents of the periphery, and patients’ right to privacy? Will the revolution result in better, more equitable and less-expensive healthcare?
All these issues were discussed in depth at the 11th annual Dead Sea conference of the Israel National Institute for Health Policy Research. For nearly two days, over 100 leaders of the health system, economists and experts in telemedicine and electronic medical records converged on the Royal Hotel in Ein Bokek to discuss them and make recommendations.
THE PROCEEDINGS consisted of three plenary sessions for all participants, who also divided themselves into separate teams to discuss the change in the medical professional’s status and relationship with patients; economic and social implications; and national electronic medical records.
Conference chairman Dr. Yair Birnbaum, deputy director-general of the Hadassah Medical Organization (HMO), began by presenting just a few of the changes that have already resulted from healthcare’s digital revolution: The Human Genome Project, carried out with computers, has made it possible to determine according to one’s personal genetic makeup which drugs will be useful against certain diseases and which useless; home tests have been developed to predict if one is predisposed to numerous chronic illnesses; a blood test at birth might even predict what a baby will eventually die of; robots assist surgeons in performing operations, not always with improved results; electronic patient records could conflict with privacy laws; and computer keyboards that can be used by observant Jewish staffers on Shabbat.
HMO director-general Shlomo Mor-Yosef, board chairman of the national institute, added that the four public health funds are way ahead of the hospitals in using computerized patient records. “And technological advances in the field run ahead of decisionmakers in the health system. If the decisionmakers wanted to do something organized, it would take them 10 years. Discussions of ethics fall behind.”
Dr. Varda Shalev, chief of medical informatics at the second-largest health fund, Maccabi Health Services, said it has come to the point that if she leaves her stethoscope at home one day, “it’s not terrible. But if the computer in my clinic doesn’t work, I can’t. All the patients’ records and the ability to prescribe medications and lab tests are there.”
Each health fund has its own electronic patient record system, which cannot interact with the others or with the hospitals’, except that the largest one, Clalit Health Services, owns medical centers and uses the same system in both clinics and hospitals, she said. The systems give the generic and commercial drug names and show contraindications, while the patient can see what the file contains along with the physician. They list risk levels for various diseases and warn about tests that have not been done.
Then telemedicine appeared, enabling patients in areas never or hardly ever visited by top specialists to consult with them via videoconference. Cameras can even make it possible for people to be monitored at home rather than remain in a hospital, said Shalev. The progress of wound healing or how well a patient can walk can be seen over the screen. Electronic signatures could be used to prescribe medications, freeing patients from having to go to clinics to get them. But how will doctors be compensated financially for answering patients’ questions over e-mail or doing other work via computer? This has not yet been determined.
In 2004, the Health Ministry gave the go-ahead for a national electronic patient record system to unite those in all the health funds and hospitals; it was supposed to be implemented in 2006, but has not yet arrived because of opposition from the Justice Ministry and civil rights groups, said Prof. Avinoam Reches, a senior HMO neurologist who heads the Israel Medical Association’s ethics bureau.
Ben-Gurion University Prof. Avi Porath, who headed the group studying change in the medical professional’s status and relationship with the patient, said the use of electronic patient records is very high in countries like the Netherlands and New Zealand and low in places like Canada. This phenomenon is pushed by the financial and human cost of medical errors (even though electronic medical records are only as accurate as the person who enters the data), the lack of manpower, rising healthcare costs and the reduced attractiveness of the medical profession, he said. Patients, going to doctors with long Internet printouts on their condition, want more involvement in their care, said Porath. Alzheimer’s patients are monitored by GPS so they can always be located; surgeons perform surgery from another hospital, city, country or continent; patients with the same condition consult with each other online; and wearable health-monitoring systems are on the horizon.
Foreign studies “have shown that control of diabetes from afar produces just as good results as being there. Germany, for example, saved 1.5 billion euro by sending hospital patients home early and monitoring them from home,” said Porath.
WHERE THERE are too few medical specialists, such as in alcoholism, very rare genetic disorders or type 2 diabetes in children, those experts working in the big cities can “see” patients virtually and advise them, said Porath. This is clearly a boon.
“Most things develop from the bottom up,” said the BGU physician, but “we need national strategies, multi-year plans and integration of community institutions and hospitals. Will a doctor be sued for negligence if the advice he gave a patient [he didn’t know] by videoconference at night caused the person to take a turn for the worse? How do you train professionals to use telemedicine efficiently and cope with the ethical and legal problems?”
The doctor’s role used to be paternalistic, telling patients what to do, said Prof. Gil Siegal, who combines teaching in the University of Virginia law school and working as a physician who directs the Center for Health Law and Bioethics at Kiryat Ono College in Israel. Then the focus switched to the doctor becoming the patient’s chief informant about his condition, helping him decide what options to choose. But today, information on any disease is a mouse click away, and some patients know as much or even more about their condition, said Siegal. This has changed the doctor’s role to being a commentator on information and also a debater of alternatives and coordinator. The Israeli-born physician/lawyer predicted that in the future, the patient – instead of his health fund – will control his medical records and decide whether to give medical professionals access.
The digital revolution is already here, said Prof. Amir Shmueli, a health management and economy expert at the Hebrew University-Hadassah Braun School of Public Health who headed the team on economic implications. “We can’t predict the pace of development. The question is how to design it so we can produce the maximum. Telemedicine is not suited to all services provided by the health funds, and they must be chosen carefully. Competition about the insurers and marketing considerations are the main reason that pushes them to offer such services, not what is most efficient and needed. We must be careful to ensure that advertising about telemedicine will not be used to steal members from competitors. Regulations must be suited to the new digital era.”
Shmueli warned of the “danger of anonymous call centers, in which doctors who have no connection with patients they see over their computers will be overused instead of the personal physician. Telemedicine can reduce socioeconomic gaps in access to health care, but it has to be assessed in terms of costs, health improvements, accessibility and the influences of incentive payments.”
Dr. Nicky Lieberman, an internal medicine specialist who heads Clalit
Health Service’s medical services and headed the electronic patient
records team, announced its recommendations that safeguards be set in
place, with such files tiered so that medical information it accessed
by professionals according to their need to know, with data transferred
to other institutions only if it benefits the patient.
The doctor-patient interaction team recommended a new assessment of the
Patients’ Rights Law in view of technological realities and the setting
of required standards for technologies.
Finally, the economic team called for suiting digital medical services
to various sectors of the population and conducting research to examine
the change in costs (to the country, health funds and insured Israeli),
state of health, gaps in healthcare and accessibility and influence in
compensation for such services. Clearly, as technologies expand and
change so rapidly, periodic examinations of the digital revolution in
medicine will have to be performed.