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Physicians won't be replaced by robots in the foreseeable future, but technological advances in recent years are significantly changing the way doctors work. There are physicians who welcome the fact that patients come with reams of Internet printouts, while others see this as an affront. Some argue that these shifts are speeding up the depersonalization of medicine, replacing physical examinations with scans and lab tests and even computerized "suggested diagnoses," while others note that the increased digitalization minimizes the risk of human error.
THIS SUBJECT was the theme of the third annual Hadassah Medical Conference organized recently by the Hadassah Medical Organization (HMO) and attended by over 800 participants - doctors and laymen - at Jerusalem's Pavillion hall. Comprising eight hours of lectures and panel discussions, the event was titled "Looking Forward: The Medical World Examines Itself in View of Technological Developments and the Information Revolution."
HMO director-general Prof. Shlomo Mor-Yosef, who chaired the event, said the rate of medical computerization is not uniform. The four health funds have fully computerized their members' medical files in systems that are among the best in the world, he said, but they are not compatible or linked to hospital computer systems. "Should all the health funds' systems be connected? What about privacy? How much should they know?" Mor-Yosef called on the Health Ministry to invest more effort in reaching policy decisions in these matters.
"There isn't a single physician who isn't affected by these revolutions," noted Dr. Yoram Blachar, chairman of the Israel Medical Association (IMA). "Every doctor has to update himself on the latest developments, and be able to communicate with more-informed patients."
Israelis, he added, are often overwhelmed by news reports about diseases - some irrelevant to them or false - but they have a right to know. "There are challenges to privacy. These issues must be discussed. Perhaps the swine flu outbreak gives doctors an opportunity to improve communications with their patients, but the dialogue should not end after the outbreak has ended."
Prof. Eran Leitersdorf, director of Hadassah University Medical Center's internal medicine B department in Jerusalem's Ein Kerem and newly installed dean of the Hebrew University's Medical Faculty, said that while computerization of many facets of Israeli hospital administration and medical communications is very advanced, there is a gap among functions, and when it comes to the use of computers at the bedside, "we are the last in the queue; there are still many handwritten files" that can lead to errors.
THE EARLIEST computerized communications among hospital departments and units began in 1981, but in 2002, it was decided to unify all of them. "We toured all the hospitals in the country, but didn't find the technology we needed in Israel," recalled Leitersdorf. A privacy-protected, Internet-based system named Machar (from Machar International, a strategic alliance of hospitals and software companies) was developed and purchased for both Hadassah hospitals. The interactivity enables Leitersdorf and other department heads to go on the Internet at a medical conference in Boston, for example, and find out exactly what is going on in real time in his department. "My staff feel I am there all the time, even when I am physically away."
Surprisingly, just 1.5 percent of all US hospitals have the technological abilities of HMO's Jerusalem medical centers. Only a few months ago, President Barack Obama allocated $19 billion for computerization of medical facilities, and those that do not implement it within four years will be fined, said the medical faculty dean.
Leitersdorf presented a video showing showing a woman "patient" (in fact, a former Hadassah nurse) in a hospital bed, being shown her X-rays and test results on a nearby computer screen. The doctor explains and answers questions. "We don't want the computer to be a barrier between physician and patient," said Leitersdorf.
The doctor in the film also enters medical data into the bedside computer to replace paper files that are sometimes unreadable by nurses who could give the wrong medication or dosage. If a doctor makes a typing error, explained Leitersdorf, he can correct it, but the original remains on file to prevent medical staffers from "doctoring" things after the fact. "Younger staff members learn very fast, because they grew up with computers, but even older doctors and nurses get used used to them very quickly. Hadassah is supplying bedside computers to new departments gradually, as budget is provided."
He urged that the country's entire hospital system be computerized, even though some institutions are owned by the government and others by health funds, voluntary organizations (such as Hadassah) and private companies. The health funds and their community clinics should be linked as well. This, he said, would minimize duplication of expensive tests, speed up care and even catch cases of abuse of children, women and the elderly. The "translation" of preclinical research to bedside use would be speeded up, while information on patients would be protected.
"These systems and electronic medical records including scanning and lab test results can save lives and money, shorten hospitalization and make everything more efficient," Leitersdorf said. The next step at Hadassah will be using computers to suggest various diagnoses based on stored information. This will not make doctors obsolete, he declared, but can help them reach conclusions.
DR. SHLOMO KODISH, deputy director-general of Soroka University Medical Center in Beersheba, said accessing Web sites for medical information is one of the most popular uses of the Internet. "Patients have difficulty understanding data. They go to friends, relatives, people with the same illness, and get the nurse next door to explain it to them. Some may go to medical journals; over 670,000 new journal articles appear every year, and the US government site PubMed has over 18 million articles."
For a simple explanation, they go to Wikipedia or do a Google search. "But Wikipedia articles are not always accurate, though some people will make life-and-death decisions on the basis of this information. Many sites are commercial and only want customers. There are also professional forums with doctors giving online advice, but who do not take responsibility for their advice," Kodish warned. The Soroka physician said researchers can, however, reach conclusions about the epidemiology of illness according to the number of people who visit sites focusing on specific disorders.
Many large software companies provide sites to put personal medical information anonymously into electronic files. But they may not be reliable, and some hospitals will not use them for that reason, he said. There are also online questionnaires that enables people to type in the names of the medications they take to see whether they are compatible with each other, and get a list of dozens of possible side effects.
In the US, said Kodish, "most patients want to read their doctors' file from home; most also want to send e-mail directly to their physicians. But when does he have time to answer, and how reliable is it? When a patient had one paper file of his medical history, everything was in it, but now data may be stored in different places." There are warnings in hospital computer systems that the pharmacy doesn't keep a specific prescription drug any more; a doctor can ask the health fund or hospital lab to send him an SMS if serious results are received, added Kodish, but if these become too frequent they will be ignored. If hospitals buy inappropriate systems, they will waste money. He recalled that the famous California hospital Cedars Sinai spent $34 million on an electronic file system that proved impossible to use. A decade later, it has a successful system.
JUST A FEW days ago, a nonprofit "national medical Internet program" called Shave Bdika (Worth Checking) was launched (at www.shavebdika.org.il) by the IMA and Wolfson Medical Center in Holon. Initiated by the hospital's director-general (and former Health Ministry deputy director-general) Dr. Yitzhak Berlovich, it will enable any Israeli to anonymously enter personal medical data and receive a list of medical tests he should undergo for early detection of disease, vaccinations and other activities to protect his health and quality of life. All the information - based on guidelines of the Health Ministry, the Israel Task Force for Health Promotion and Disease Prevention as well as American and European authorities - will be determined by his age, gender, height and weight, and will state whether treatment is included in the basket of health services. Prof. Hava Tabenkin of Emek Medical Center's family medicine department in Afula, also a founder of the site, says she hopes it will induce many Israelis to "take responsibility for their health."
Hadassah surgeon Dr. Yoav Mintz discussed minimally invasive surgery conducted with the help of robots that insert tiny scalpels via the navel. The systems are very sophisticated, with the surgeon using joysticks to move instruments around. The same system could make it possible for a surgeon on Earth to perform an operation on an astronaut, he said. At Hadassah, robot-assisted surgery is performed in urology, gynecology, ear-nose-and-throat and internal medicine departments. In the future, Mintz concluded, patients will undergo an MRI or CT scan the day before surgery, generating an anatomical plan that will actually help the surgeon do the cutting.
Dr. Nahum Kovalski, deputy director of the TEREM urgent care clinics, a urological surgeon by profession and one of the country's best-informed doctors in the field of computerized medical technology, attended the Hadassah conference and offered his comments: "Israel continues to see continuing improvement in objective measures of health care. Infant mortality, longevity, rates of immunization, speed of access, medical care options and more are all among the best in the world. The majority of primary care is fully computerized - a goal that the US and the UK can only dream of. Hospitals are increasingly computerized, causing data to be exchanged with fewer errors. Tests are not as readily repeated and patients overall reap the benefits of the digital chart."
He noted that physical examination has lost a great deal of its value. "The doctor who spends a great deal of time listening to a chest may impress a patient, but in fact is unlikely to garner significant information that could not be generated much more quickly and accurately by modern diagnostic tools," Kovalski pointed out. "There is plenty of literature showing that physical examination is limited in identifying many common illnesses. Even the present swine flu can only be distinguished from seasonal flu via a blood test."
It was once thought that the telephone would end community life, he concluded. "People would no longer physically cross the street to speak to a neighbor and thus our world would become a cold and distant place. In fact, the telephone made it possible for people to communicate even more and for families to stay in touch regardless of distance. It's true that a phone call is not the same as a hug, but the reality we live in is that friends and family live far apart, so a phone call can be an emotional lifesaver.
"Equivalently, we no longer live in a reality where it is even appropriate for a doctor to physically examine a patient for half an hour. But the same modern technology that has eliminated this physical contact has made medical miracles possible on a daily basis. My personal opinion is that the nostalgic memories of 'Ol' Doc Smith comin' around next week to check Grandpa' belong on movie screens and in museums."