A 'doctor' in your pocket

Digital technology and computer communications promise to revolutionize medical care.

hand gesture 224 88 (photo credit: Courtesy)
hand gesture 224 88
(photo credit: Courtesy)
Imagine - some day in the not-too-distant future - that you have fallen and broken your leg on a deserted sidewalk in a strange city - with only a cellular phone in your pocket. Don't worry! Digital medicine will come to your rescue. Press a button to call your health organization, which will know with pinpoint accuracy, via GPS, exactly where you're located. Perhaps it will also be able to transmit your blood pressure, heartrate and other vital signs. A representative will assure you, find an urgent-care clinic nearby, arrange for coverage, call an ambulance and ask for permission to give the doctor there access to your digitized medical file. Although the infrastructure for such a revolution is not yet in place in the Western world, the technology to make it - and much more - possible already exists. The question is whether the Health Ministry, hospitals, insurers and medical schools are ready for it. Those in Israel and abroad will have to decide soon whether they're interested in investing large sums in the software, hardware and infrastructure that will undoubtedly improve care and save lives. ONE OF the few people keeping their finger on the pulse of these amazing developments is not at the Health or Science and Technology Ministries but at TEREM, the network of private urgent-care clinics based in Jerusalem. Dr. Nahum Kovalski, a Canadian-born and trained urological surgeon who earned a degree in computers even before he thought of going into medicine, is monitoring these developments on a daily basis from TEREM's headquarters in the capital's Romema quarter. Kovalski, the deputy to TEREM director Dr. Joe Djemal, says in an interview with The Jerusalem Post that he spends at least an hour daily combing the Internet for the latest information on technology that can be applied to the digital medical revolution. At a recent three-day convention in Eilat on communications, Kovalski wowed the 250 participants with a lecture and PowerPoint presentation on what's ahead, and Dr. Brendon Stewart-Freedman, a family medicine specialist and director of TEREM's Tayalet (Arnona) clinic, spoke about how this technology - which scares many people - could affect the doctor-patient relationship. The issue of uniform digital medical files - which would greatly simplify the treatment of patients in both urgent-care centers and hospitals and provide vital medical information such as allergies to antibiotics or previous X-rays and medical charts - is very controversial, notes Kovalski. "Medical systems in the UK and Canada are investing a fortune in these, but there is much resistance among some doctors and patients, and there is still a way to go before we get it here, as there are technical and privacy issues." Kovalski and his TEREM colleagues have already introduced a bit of this technology into their clinics, including digitized X-rays and a system that automatically informs doctors when the images are ready. "In our previous clinic in the Magen David Adom station, when an X-ray was ready, the film was put on a table and the relevant doctor looked at it. But our new main clinic has long corridors, so doctors wouldn't know an X-ray is ready to examine," he says. "We set up a system with a computer screen, so when the digital X-ray is ready, the name of the doctor who ordered it pops up. If it isn't examined within 15 minutes, it changes to one color and then later to red." IN HIS OFFICE, Kovalski uses a thin touch-screen tablet computer to which he attaches a rubber keyboard. The modern Orthodox physician also has a special Nokia phone costing NIS 4,500 and called the HTC Tytan2 Tilt that he uses even on Shabbat. It loads digital X-rays and electrocardiograms that TEREM personnel send him for an urgent consultation. "I was one of the first in Israel to get this model," he says. "It has a keyboard, a large screen that tilts like a mini-laptop, wi-fi connectivity, Hebrew, a built-in camera, and image manipulation at a touch of the screen." Fellow congregants in his synagogue are no longer surprised to see him fiddle with it in an emergency. Stewart-Freedman, with his less-tekkie approach and work as an independent Clalit Health Services clinic physician, doesn't like the fact that many doctors are so busy plugging text into files on their PCs during consultations that they barely look their patients in the eye. "This causes a lot of resentment among patients, who feel they have become almost invisible. They think the doctor isn't interested in them." To change this in his office, he cut a rectangular hole in his desk, installed a glass window and sank a tilted computer screen below it so he can look at his patients while entering data via a keyboard pulled out from under the desk. "I haven't seen such a thing anywhere, but I think it can bring about a revolution in patient communications," stressed the British-born family medicine specialist. "You can miss the forest for the trees with technology," adds Kovalski, "but you can make minor changes to transform the use. Technology should not get in medicine's way. STEWART-FREEDMAN is concerned about the incompatability of medical files. Paper records going back decades can't be digitized even with scanning, and are left decaying in archives, he notes. Digitized medical files assembled in recent years are stored separately by each health fund, and are not accessible by hospitals that are not owned by the health fund or by clinics owned by other insurers. "The Health Ministry didn't insist on this. You can easily change your cellphone company, but if you change your health fund or go to a medical facility outside the fund, you can't automatically transfer your chart. It would be best for the Knesset to pass a law." Many doctors are already encouraging patients to save their personal health records on a computer. Google and Microsoft are investing huge amounts to provide Web-based medical file services for the world's population. Privacy is a major issue, but Kovalski declares that "a decade ago, it was said that online banking wouldn't succeed because nobody would trust it. Look at it now. You can learn more about a person's habits and conditions from financial records than you can from medical records. Financial records are a window into the soul. If you learn that a person used his credit card to purchase a specific antibiotic, you can pretty much conclude that he contracted a sexually transmitted disease. The danger exists that somebody will break into your electronic records and find things out. But we face such dangers every day." Not only the storage, but also the manipulation of visual and textual data will be revolutionized by computers, the TEREM doctors predict. Already, industrial engineering and management researchers at Ben-Gurion University of the Negev have developed a hand-gesture recognition system that enables doctors to manipulate digital images during medical procedures, including surgery, by motioning instead of touching a screen, keyboard or mouse. Tested recently at a hospital in Washington, D.C., the Gestix system can reduce the spread of deadly infections. The lead researcher, Dr. Juan Wachs, noted: "A sterile human-machine interface is of supreme importance because it is the means by which the surgeon controls medical information, avoiding contamination [of patients], the operating room and the other surgeons. This could replace touch screens now used in many operating rooms that must be sealed to prevent the spread of contaminants and require smooth surfaces that must be thoroughly cleaned after each procedure - but sometimes aren't. With infection rates at US hospitals now at unacceptably high levels, our system offers a possible alternative." Kovalski predicts that in the foreseeable future, patients will be given a cheap electronic "bracelet" packed digitally with their names and medical records, and everywhere they go in a clinic or hospital, screens will open and present medical staff with information needed to treat them, including existing medical conditions, medications taken for chronic conditions and allergies to antibiotics. This, he says, will considerably reduce medical errors. Prescriptions will increasingly become digital. Even today, Terem-Tayelet doctors can click on a diagnosis and be offered the pertinent medications available. "At our urgent-care clinic, we have 50 basic medications we use all the time," says Kovalski. "As doctors' handwriting is a big problem, digital prescriptions are much better.We print out a sticker, glue it to paper, and then the doctor signs his name over both of them." Elaborate instruction sheets can be given to patients on how to take care of themselves after discharge, what problems to look for and when to return - an improvement over the few sentences scrawled by doctors on discharge reports. High-powered, hand-held computers taken everywhere by doctors and nurses that are cleaned regularly with alcohol to prevent the spread of infection will undoubtedly be used routinely. "The doctor will go around with it and not have to ask who a patient is, because the radio-frequency identifier in the wrist bracelet will provide instant identification," says Kovalski. Consulting with your primary physician or getting followup information via e-mail is already taking place, but Stewart-Freedman thinks most physicians "don't like it, because they don't get paid to do it. Nevertheless, if payment is arranged through the health funds, this could become very popular." An important British study has shown that patients presented with various scenarios are most willing to pay more if they receive continuity of care from one physician; they are also prepared to pay extra to undergo a total physical exam," says Stewart-Freedman, who notes that Israelis may be somewhat different, so such a study should be carried out here. A more advanced step in the digital medical revolution would be automatic notification via cellphones that tell you when your blood pressure or sugar level is too high and remind you of your next appointment for a colonoscopy or mammography. Health funds and the Health Ministry will easily be able to trace medical utilization and notice whether, for example, too many chest X-rays or too few baby vaccinations are being carried out in a certain place. This will save money and lives. "We have finished learning how to collect data," Kovalski concludes, "and are now entering the era of learning from this data. With advanced data analysis, we'll be able to see medical trends that were simply invisible before. We will then finally be able to start planning health services based on facts rather than on personal impressions."