Opinion: Reflections of a general practitioner on carbon versus silicon-based IT
I may be one of the last of a disappearing generation of working GPs. I graduated in 1970, having taught myself to touch type in my sixth year of medical school (which may have been the most useful thing I learned that year.)
I observed the growth of medical computing from that perspective: typed letters, dictated hospital admission notes, the birth of the personal computer, the use of computers to write scripts, then with increasing sophistication to take over clinical recording.
There was a stage where, for safety’s sake, one had to maintain both computer and handwritten records. A personal computer on the doctor’s desk, another on the reception desk – if connected – that was a ‘network’. There were 10 clinical systems available, all with frequent upgrades, all competing against each other, all ‘buggy’.
Solo practice was unworkable. One needed at least six doctors in a clinic to justify the cost of prompt, competent IT network support. But as things settled down, I felt increasing annoyance at the attempts of some to substitute complex, convoluted, algorithmic IT processes for the well-established, competent, human intellectual routines of medical assessment and clinical care.
What I hear today in IT is a belief that magnified complexity, fuzzy logic and artificial neural networks will competently – ultimately completely – surpass the human intellect. We are still blinded by the computer chip, and still have not fully tested and extended the capabilities of the human brain. I first learned to use my ‘neural network’ at home, then in school, in medical school, and still, even now, in clinical practice.
I concede it is an ancient ‘carbon based’ system. Its neurons nevertheless are miniscule, when compared to the size of a transistor. They require much less power. Sourced from a much wider gamut of energy sources. And, importantly, clinical care functions on a person to person basis.
Who pays the piper?
Reading Adam Powick's opinion piece in Pulse+IT recently, I found myself deeply disturbed. I am concerned at his expectations of clinical responsibility, and of the ‘clinical technology’ he considers should be available for his care.
I am intrigued by and question his list of expectations. Mr Powick states:
- I want access to a complete, secure and up-to-date electronic record of my health conditions and interactions with the health sector
- I want to own and share this dataset, not have parts of it hidden from me by my service providers
- I want to have my key health indicators proactively and remotely monitored and I want to be alerted when there is a discrepancy that needs attention
- I want to access first-level diagnosis electronically from my home at a time that is convenient to me (and this is rarely during normal working hours)
- I want my drug prescriptions to be automatically fulfilled and delivered to my home
- I want to have transparent access to consumer ratings of doctors, drugs, treatments and clinical facilities (i.e. a ’tripadvisor’ for health)
- I want to book all of my healthcare appointments online
- I never want to fill out another paper form again or repeat my details as I navigate the health system
- I want access to reputable, best practice healthcare information
- I want periodic, tailored, full-service health check-ups – if it is good enough for my car, it should be good enough for me.
I ask the following questions in response:
- Will the ‘doctor-shopping’ narcotic addict have the right to massage and curate their ‘electronic record of their health conditions’ and the list of past prescriptions in that record? What an easy way to present oneself to the next doctor as ’squeaky clean’. Would Mr Powick ‘share’ information about circumstances of mental illness, or of a diagnosis of a sexually transmitted disease, that properly is part of his clinical record? Would he leave this information in his eHealth record indefinitely? But once there, who has the right to expunge it?
- How will ‘key health indicators be proactively, remotely monitored’? Which ‘indicators’ is he talking about?
- What is ‘first level diagnosis’? Before any diagnosis necessarily comes a specification or indication of an anomaly, then sequential assessment by patient history, examination, then pathology and imaging tests. Is Mr Powick expecting that this service will be provided – at a full level of competence – by practitioners and diagnostic services working after hours? Just for his convenience?
- Who will pay for the delivery of his ‘drug prescriptions’? How will they be delivered? What safety and security concerns must be met in this ‘delivery’?
- What are and who determines the ‘consumer ratings’ of doctors, drugs, treatments and clinical facilities? Who determines what is ‘reputable, best practice healthcare information’? Will this be an enormous expansion of the TGA? Or will it be done in a less professional, objective and impartial manner, by assessors paid, one way or another, in kickbacks?
- The last periodic, tailored, full service check-up on my car cost me over $400, and cars commonly do not require pathology tests, nor imaging. Would Mr Powick pay $400 for the clinical part of his assessment, in addition to the price of the panel of pathology tests he would consider appropriate and whatever the cost of a total body MRI (best resolution, no radiation) to detect any dangerous anomaly at the earliest possible stage? How frequently? If not, for how much of this should Medicare pay?
For those who, like Mr Powick, admit to being “a little on the portly side”, what is the financial obligation of Medicare to care for him? His health is, and always has been, his responsibility. Does Mr Powick expect Medicare – the taxpayer – to carry the costs of increasing medications, doctors’ visits, expensive technologies, procedures and operations?
Is it impertinent for Mr Powick now to be taking 'a more personal interest in how well our health system really supports consumer needs’ when his health system has needed him to have taken a more personal interest in optimising his own health?
This is an achievement that has not required, and still does not require, any great or sophisticated technology of eHealth.
About the author:
Dr Glenn Rosendahl is a GP who has practised in Australia, Canada, the US, Norfolk Island and the Solomon Islands, and has worked with Aboriginal people in Queensland and the Northern Territory. He has also been a prison medical officer and cared for patients in immigration detention. He currently works as a locum on the Gold Coast.