Sunday, February 25, 2024

Views of Digital Health from the Oregon Trail – MedCity News

I’m too old to be a millennial. I’m too young to be a Gen X-er. Folks like me who were born in the late 1970s are better classified as the Oregon Trail Generation, named after the Apple II computer educational game many of us played in elementary school.

We grew up in the analog world of wall-mounted telephones, printed newspapers, nightly news shows, cassette tapes, and VCRs. We came of age as the internet took off, first through online bulletin boards, then chatrooms, and later AOL, Netscape, and Napster. We’ve lived our adult lives in the increasingly digital, hyper-connected world of smartphones, social media, news feeds, eCommerce, and streaming.

I’m also part of a generation of Oregon Trail doctors who graduated from medical school around “Y2K,” just as healthcare started slowly transitioning from analog to digital. As interns and residents, we carried mini-reference books like the Washington Manual and Sanford Guide. (A few of our tech-forward colleagues used Palm Pilots). We handwrote progress notes that we’d deposit in patients’ physical charts at the end of the day. We regularly trekked to the medical records department and repeatedly scribbled orders for insulin sliding scales and heparin drips.

Later, as newly minted attending physicians, we turned to online tools like UpToDate to review medical literature, dictated our notes using phone-based transcription services, used homegrown electronic health records (EHRs) to review patient records, and placed orders verbally or using paper slips. Our patients increasingly started showing up with information from their Google searches.

Soon, the “Meaningful Use” program pushed our practices to implement certified EHRs. Later, the Covid-19 pandemic temporarily forced us to provide care virtually. Today, artificial intelligence is promising to reshape further how we practice. In total, our experiences give us a unique perspective that blends analog old school and digital new school and points to several key lessons.

Digitization has both positive and negative effects.

Technological advances bring benefits along with unanticipated side effects. The digitization of healthcare is no exception.

For one, far more accessible information both empowers and overwhelms us. Clinical notes are now legible and easy to retrieve but bloated with unnecessary, often duplicative, and, at times, unintelligible content. We’ve traded cumbersome message slips and results printouts for overloaded digital In Boxes, much of it filled with junk and nonsense. We can conveniently access EHRs anywhere, anytime, but we struggle to disconnect from work. Though we can monitor our patients remotely, we fight to sort meaningful signals from noise. And by accessing online content and their own medical records, our patients have better access to information but sometimes still remain misinformed.

Digital technology has also brought us closer together and pushed us further apart. In the hospital, we spend far more time in workrooms glancing at computer screens than rounding at the bedside. We easily communicate with colleagues via rapid-fire text messages at the expense of in-person interactions that foster teamwork and build community. In clinics, obtrusive keyboards and screens sit between our patients and us. And though our patients can more easily reach us through portal messaging and video visits, we are more distracted and less present.

Digital tools also make us both more and less productive. We can quickly notify patients about their test results but strain to keep pace with a barrage of incoming patient messages. We easily prescribe medications electronically but must enter orders for tests that non-clinical staff used to place for us. We use eConsults to obtain specialists’ advice rapidly but suffer through endless clicks and alert fatigue. We spend up to half our days interacting with the EHR during and after hours.

Healthcare has digitized but has not yet digitally transformed.

In the early 1900s, manufacturers started replacing steam-powered motors with electric motors, otherwise leaving their factories unchanged. They did not realize returns on their investment until many years later, when they radically redesigned factories and workers into modular units with smaller production lines, taking advantage of the smaller electrical motors.

Similarly, while healthcare has digitized, few healthcare provider organizations have digitally transformed. Instead, we’ve digitized our old paper-based processes within EHRs without evolving systems needed to manage the digital exhaust. We continue to primarily provide care during intermittent, in-person visits rather than more continually over multiple asynchronous and synchronous channels. Stuck using new digital tools within the confines of old systems, we feel strained and increasingly burned out.

We must shape a better future.

For decades, many have hoped digital technology would solve healthcare’s most vexing challenges. So far, digital technology has not delivered its promise. Still, we should remember Amara’s Law: “We tend to overestimate the effect of a technology in the short run and underestimate the effect in the long run.”

Today, many hope artificial intelligence will be the key that unlocks the value of digitization. Perhaps it will, but the claim that better technology will necessarily improve healthcare is no longer credible.

Historian Melvin Kranzberg famously stated, “Technology is neither good nor bad; nor is it neutral.” In other words, it’s up to us to shape how we use it. New technologies can help us dream of better ways of doing things. But healthcare is complex, the stakes are high, and it is difficult to effect change.

Having lived in both analog and digital worlds, who better than us Oregon Trail doctors to help ensure digital health technologies best serve our workforce, patients, and communities?

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