Fran Lowry is a freelance writer living in Toronto.
Canadian Medical Association Journal 1995; 153: 1636-1639
[résumé]
Computers are poised to become full-fledged partners in the health care delivery system, but they'll have to find greater acceptance from Canadian physicians first.
A panel of physicians gathered for a recent conference on medical communication in the electronic era said computers have the potential to facilitate diagnosis, keep doctors informed about research findings and make practice management simpler and more efficient.
But this dazzling potential will not be realized until physicians overcome their reluctance to use computers daily in their practices, or until the older generation is replaced by young physicians raised on computers.
Delegates attending the recent conference of the Canadian chapter of the American Medical Writers Association (AMWA) heard that most doctors appear a little hesitant about increased computerization because it is costly and finding the right back-up support is often difficult.
Dr. Robert Hayward, director of the Health Information Research Unit at McMaster University in Hamilton, said computers can and should be used to help clinicians make diagnostic decisions. "I'm deeply troubled," he said. "I look to the future and see myself having even less time than I have now for trying to attain and retain a massive amount of knowledge that my patients and my colleagues expect me to have. [And] I see my students, interns and residents growing more and more disappointed with the amount of knowledge that I demand. It's a pretty desperate feeling."
Hayward, like most Canadian physicians, is inundated by publications, videos and free items, all vying for his attention. He said the big problem for physicians is separating the wheat from the chaff, and this is where computers come into their own. "What I need is a refinery of information. I need the most potent distillate possible of the most pertinent, important and valid information, presented in a way that I can apply it to my own patients' problems -- to the people I see, not necessarily the people in the study. Computers -- health informatics -- can do this."
Computers would be an important cornerstone of evidence-based care, which means that physicians are aware of all evidence available to support their therapeutic decisions and are also able to evaluate the strength of that evidence.
The approach has "caught on like wildfire," Hayward said. "Evidence-based care calls for a change in the way we think about and practise medicine, where we move from a heavy reliance on clinical intuition . . . and where we explain our actions and make our choices based upon what we think the basic science is telling us and our own, unsystematic experience based on the last 10 times that we dealt with a particular problem, to using evidence from controlled studies, in man, moderated by clinical circumstances."
But evidence doesn't come only from randomized, controlled trials. It also comes from the histories physicians take from their patients and observations made during physical examinations. This means that the best treatment decisions are also based on the validity of the evidence, its importance and its applicability to a particular patient's situation.
"Is there a high density of validated information in the resource or information tool that the clinician is interacting with?" Hayward asked. "Is it important information? And did the information provide you with, or make accessible to you, the details needed in order to decide whether the information can be applied in that particular clinical environment?" In other words, did the computer really help you treat your patient better?
Hayward cited the following "typical scenario" in which educated use of a computer could help a clinician cope with a time-consuming problem. "Imagine that you are a busy clinician. It's the end of a terribly busy morning, you're already late for an important meeting, and so it's with relief that you note your last patient is a healthy female well known to you who is complaining of a acute dysuria. You find that she does indeed have a lower urinary tract infection, prescribe antibiotics and make arrangements for a follow-up visit. End of story -- it's been a nice, short visit.
"On her way out, she says, `By the way, doctor, my friends have started taking estrogen, and I've been reading some really good things about it in Reader's Digest. Should I be taking this hormone?' It turns out that her mother got postmenopausal breast cancer at age 55 and died from her disease. Now, you have a very big problem that you can't even begin to address in 5 minutes.
"What you tell your patient requires information, not only about how that hormone will affect cardiovascular disease, osteoporosis, breast and endometrial cancer, but also such things as facial wrinkles, mood, sexual function. There's a lot of information you require in order to make the best decision that will reflect your patient's unique risks and circumstances."
Hayward said that if physicians have a well-designed health informatics or computer set-up, they could simply punch the right keys.
This is not yet practical for most physicians because it takes too much time and too much expertise to set up a system that will provide the information, let alone let the clinician gain easy access to it.
But Hayward insists that physicians need the tools to make this style of practice possible. For the last 10 years, he and others have been researching ways to cull research information from bibliographic databases and deliver it to clinicians. The Health Information Research Unit at McMaster has done Medline studies to improve the recovery of valid and pertinent studies on the effects of health interventions in man. For a time, Medline searches were provided free on wards at Chedoke-McMaster Hospital in Hamilton, with computers placed in special areas so any clinician could do a search. Those who chose to participate became proficient at doing searches quickly. "In fact, after about eight searches they got as many relevant citations from the literature as the experienced librarians." Participants also reported that they felt it had enhanced the care they provided.
The right computer program or health-informatics system can deliver the best studies concerning a particular topic and serve them up with the tapping of the right computer keys. In fact, the prototype of such a system already exists in print. The American College of Physicians [ACP] Journal Club, a "knowledge refinery," screens all medical literature pertaining to internal medicine to ensure that it is of general importance to practising internists, and the highest quality articles are selected for its database. The articles are then summarized in a standard one-page format in which the objectives, data sources, results and conclusions are all clearly marked. A commentary places the study in context.
The research unit is developing an electronic version of the Journal Club, although copyright and proprietary concerns are blocking availability, something Hayward calls "a very great shame. We have all of the ACP Journal Club available on the Internet, but we have to keep it locked away. We can't disseminate it."
The Journal Club abstracts "the guts" of an article so that all information needed to make an informed therapeutic decision is "staring [physicians] in the face. When we make this available on the wards, it's the most popular software tool that our clinicians use [because they] don't have to sift through a lot of information. A clinical-informatics network is ready to bring together all the different types of information in a single computer desktop on the wards."
However, Dr. Richard Handfield-Jones, manager of continuing medical education (CME) for the College of Family Physicians of Canada, said the reality is that most doctors are not going to rush to use computers this way. "I practise in an office in Oakville with three other physicians and there is not a computer anywhere. The receptionist doesn't have one, the secretary doesn't have one. It's pure paper and it works just fine, thank you very much. And it's probably going to stay that way for some time. My partner is the senior person there, and although I haven't asked him, I assume that if I did, he would say he's been there for 10 years, and [he would] challenge me to prove that computerizing his office and his CME is worth his while."
Many questions arise in the day-to-day practice of medicine, not only regarding treatment but also issues such as prevention and health maintenance. It is a challenge for doctors to keep current, and the quality of care they provide depends in part on the kind of information available. This is where computers will come into their own, said Handfield-Jones. "Helping physicians gain access to information at the moment of care is going to be one of the real opportunities for computers in the practice of medicine."
Practice management, the nuts and bolts of the business of medicine, is where computers currently find the most use. Today most provinces accept only computerized billing, and even when it is not required many physicians bill that way. Most practices have at least one computer for billing, not clinical, reasons.
For use to grow, said Handfield-Jones, physicians are going to have to become comfortable with them earlier in their training. "What computers can really offer is information you need in a digested and distilled fashion. Plus you don't have to go anywhere, it costs less, you can do it in your home, your office, the hospital library. You can do cardiovascular, dermatology, prevention, whatever you want. When you sign up for a conference, you don't really have a lot of choices."
But -- and it's a big but -- even though computers can do so much, very few family physicians actually use them personally. "Most practices probably do have a computer, but it's used by the support staff," said Handfield-Jones. "[There are] only a very small number of practices in which the physician actually uses the computer in his or her practice. It's going to take a long time, I believe, before practices can be computerized enough."