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Computer technology in the workplace is becoming increasingly common. US medicine was initially slow in adoption of information technology, but acceptance has accelerated significantly over the past few years. There are four areas in which rapid advances have been made: computerised order entry; electronic medical records (EMRs); e-mail communication; and hand-held devices. These four technologies are destined to revolutionise the way medicine is practiced in the US.
Reducing medical errors has become a national priority in the US. Specifically adverse drug events are an important source of injuries in hospitalised patients. In response to the need to improve patient safety, computer physician order entry (CPOE) systems have become increasingly more common. In general, CPOE systems force physicians to write all orders online. These systems have the capacity to verify that written orders are correct, that is, based on a patient profile, they can automatically check the dose and contraindications of a specific drug. They have been shown to dramatically reduce serious medication errors. Unlike EMRs (see below), I believe that most hospitals in the US will have CPOEs within five years. From both a financial and publicity standpoint, hospitals will be unable to afford the consequences of a medical error that was preventable. Whether CPOEs are mandated by US hospital licensing bodies is less clear.
EMRs hold great promise in the clinical arena. The ability to care for patients with a record that is integrated with laboratory and pharmacy information, and provides point of service information regarding preventive services, diagnosis, treatment, and follow up represents a dramatic advance in patient care. Improving and measuring quality would be instantly improved if all clinicians used EMRs. For example, it would be easy to prompt clinicians that their patient with diabetes needs an eye examination or a haemoglobin A1c level. Drug prescribing patterns of individual clinicians could be carefully evaluated and compared to established standards. In fact, computer based clinical support as part of an EMR has been shown to improve physician performance and patient outcomes. Unfortunately, in the US, with its cottage industry approach to care and payment, it is not clear who will support this dramatic advance. Currently, a number of staff model health maintenance organisations and academic medical centres have EMRs. But most physicians that I speak with, who are in private practice or work at community health centres, cannot afford the change to EMRs. Not only are they concerned about the cost, but daily maintenance and upkeep is of concern. Of note, one approach that may speed the introduction of EMRs is the use of systems with specified functions. Hence EMRs would be introduced in a more gradual fashion. Nevertheless, I believe we are more than a decade away from a time when a substantial number of Americans will have the majority of their care provided by a clinician sitting at a computer terminal or holding a computer screen.
E-mail communication has been compared to the telephone—a new form of communication that will transform the practice of medicine. “You've got mail” is a common refrain heard by 32 million America Online subscribers around the world. The benefits of e-mail include: (1) communication that is dyssynchronous—that is, the two parties do not both need to be “home” to communicate; (2) it is inexpensive, convenient, and available in many places; (3) it can provide a permanent record of the transaction; (4) it affords a certain level of anonymity that is not available on the telephone; and (5) it may make practice far more efficient. There are many potential liabilities, including threats to confidentiality and privacy, inappropriate use, and the possible workload that it may create for clinicians. Nevertheless, many patients in the US are requesting e-mail communication with their physicians, and more importantly, the office of their physicians. Just like the telephone, e-mail communication should be established with an office, rather than an individual, so that requests can be appropriately categorised, distributed, and answered. I predict that e-mail communication between physician and patient will become more common, more quickly, than EMRs. We tend to be responsive to patients in the US, particularly since they are increasingly seen as consumers, and few patients are clamouring for an EMR, but many are requesting access to e-mail communication.
I have been impressed with the numerous software packages now available for hand-held devices. Growth charts, books, pharmacy databases, and other important patient related information is now available. The recently released US guidelines for management of cholesterol were available for hand-held devices soon after they were published. Hand-helds will soon have as much memory as desktop computers did 3–5 years ago. Where I practice, virtually every physician, and certainly every resident, has a hand-held and is making good use of it in the clinical arena. Combined with EMRs, and advances in e-mail communication, it is quite imaginable that every physician will be able to literally “carry” the medical record of every patient they care for and communicate with them instantaneously. The uses of hand-helds will continue to evolve, but I suspect that every physician in the US will be using them in the next few years.
Information technology is advancing rapidly. Translation by head sets, distant surgery by telecommunication, and consultation by video and computer, are examples that I have not discussed. However, unlike those advances, EMRs, e-mail communication, hand-held devices, and computer order entry are likely to touch the lives of everyone of us and our patients.