Two physicians enter the same hospital room to see patients. One immediately turns and goes to the nurses' station to look for the patient's chart; the other uses a computer terminal next to the patient's bed and calls up the chart. When it is time to write a prescription for the patient to take home at discharge, one physician needs to go to the library to check drug interactions in the PDR and find a prescription pad. Meanwhile, the other physician takes a handheld computer from his pocket and obtains drug information, calculates dosage and sends a prescription to the patient's pharmacy.
As the two physicians leave to check on orthopedic cases, one calls to ask someone to locate his patient's X-ray films and bring them to him at the nearest light box, while the other uses a computer terminal to view high-resolution digital images.
From the Stone Age to the present, the history of medicine has been told in terms of new instruments and procedures, new diagnostic techniques and treatments. However, the latest chapter in the history of medicine is being written in zeroes and ones, the language of computers, as rapid changes occur in the way information is processed and moved from one site to another.
Physicians as a group have been slow to embrace computers, often preferring to stick with paper-based techniques rather than invest precious time in learning a method whose worth has yet to be proven. Whether they are at the forefront of the movement or not, the digital revolution is affecting direct patient care and the ways in which physicians interact with patients and manage their business.
Physicians must become computer-savvy because the balance of power between them and their patients is shifting based on knowledge and knowledge acquisition, says Subhas Gupta, M.D., a professor of surgery at Loma Linda (Calif.) University Medical School. Gupta also heads I-Med, a company he started to design and host Web sites for physicians and now has turned to providing telemedicine services.
"Patients are more empowered, with access to information and to ratings of health professionals," he says. "They understand disease processes, are more informed about their own health and are more demanding of their doctors.
Physicians have no control over the patient information revolution. But we need to be part of a framework with our patients to obtain data together."
Several companies are competing to offer software and services for physicians who use personal digital assistants (PDAs). Many practicing physicians receive them free from pharmaceutical companies and other vendors that cut deals with the PDA software companies to include special information relevant to their companies on the PDAs they hand out.
Michelle Snyder, vice president for marketing of ePocrates, which says it is the "largest handheld physician network," says her company has surpassed 100,000 users, with more than 65,000 physicians and more than 25,000 other health professionals. She says the company is working toward the time when pharmaceutical or other companies sponsor nearly all of its users, providing them with their PDA
"Although the service varies from physician to physician, it includes a variety of customized applications as well as the handheld device," she says. For those who are not yet sponsored, there is no cost to download ePocrates applications, and future updates also are free.
Typical software applications include a PDR or other drug database; patient scheduling and record-keeping; Internet access for medical journals and other information sources; electronic prescribing, charting, and billing; and a medical calculator.
Among the major players in addition to ePocrates are eMD, MDeverywhere, Medscape, and WirelessMD. These companies predict success in their efforts because the PDA can be used at the point of care, overcoming a problem physicians have had with desktop computers that can be used only in the office.
While no one knows how many physicians use PDAs regularly, this year's Modern Physician/PricewaterhouseCoopers technology survey found that 26.2% of the physicians surveyed said they use handheld devices. Most companies say they have several thousand registered users for their software, but it is impossible to tell how much overlap there is and whether the units actually are being used.
Duke University Health System orthopedic spine surgeon Lloyd Hey, M.D., who founded MDeverywhere, says doctors need better tools at the point of care and that his company is a "bridge between the trenches of clinical care and the corporate world that can create the tools." The company recently signed a contract with Shared Medical Systems, a Malvern, Pa.-based company that provides information solutions and services such as clinical, financial, and administrative applications; technologies; and consulting, network, desktop, and outsourcing services to more than 5,000 customers worldwide. Under the agreement, MDeverywhere will gain access to the 25,000 physicians who use SMS software for scheduling and billing. There is no charge to the end user for integration with the SMS software, MDeverywhere says.
As is typical of fast-moving revolutions, the use and functionality of PDAs is going to change as more physicians decide to use them. Most analysts believe PDAs will evolve into a device that combines the functions of a pager, cell phone and wireless handheld computer.
Physicians who use their PDAs for patient encounter information at the hospital or clinic can transfer that information to their office computer system when they return. The ability to transfer information from PDA to office computer becomes more important as an increasing number of practices automate many of their back office functions in an attempt to become more efficient in dealing with health plans.
One hospital that has employed the digital revolution for all of its medical imaging is Arrowhead Regional Medical Center, which opened on March 30, 1999, as a ground-up replacement for San Bernadino County Medical Center in Colton, Calif.
The center, which cost $474 million to build, won a Computerworld Smithsonian Award this spring for innovative application of technology. The center's medical imaging infrastructure consists of a multivendor collection of computerized radiography, digital fluoroscopy, MRI, CT, ultrasound, nuclear medicine and angiography equipment. The devices are linked via a Siemens picture archiving and communication system (PACS) network.
Medical staff can view images on high-resolution monitors located in patient units, operating rooms, the trauma center, outpatient areas and consultation rooms. The PACS system enables integration of images with electronic reports, eliminating the traditional jacket of forms, notes and films that would follow a patient throughout the center.
Arrowhead says that since electronic files are stored online, they are instantly accessible to authorized medical staff members. Images can be shared among users, never get lost in transit and don't require development time in a darkroom. Images and patient records can be sent to doctors in outlying offices and for consultation without having to be physically delivered.
Carl Jansen, M.D., Arrowhead's medical director and chairman of the Department of Medical Imaging, says that when work to design a new medical center began in 1991, doctors wanted to have the option to use film or go filmless. However, the architects said there was not enough space and a decision to go one way or the other would have to be made. Jansen and the CEO persuaded staffers "to take the risk and make a commitment not to open a new hospital with old technology."
Because he had been talking about the benefits of new technology for several years, Jansen says, it was not that hard to persuade the medical staff and administration to adopt the filmless technology, and "now, everyone loves it and no one would want to go back to the old way."
The big advantage to the system, Jansen says, is its ability to provide information that physicians need when and where they need it. "You don't have to get a file clerk to get the images you want. You have the images plus the report wherever you need it. It takes just a few seconds to call up an old case and review it."
As a result, he says, radiologists now are able to read many more examinations per year than they did with the old film system. Reports are available more readily because transcribing runs only an hour or two behind dictation and the reports are automatically linked to their images.
Jansen admits that the system was "significantly more costly" when it was installed, but he is convinced that it will ultimately be less expensive over the long haul. He says it cost $10 million to install but probably would cost half as much today. The savings, while real, can be intangible--"how do you measure a delay in a patient's surgery because you can't find the films," he asks.
The keys to success with the filmless technology have been the availability of 80 stations throughout Arrowhead at which images can be accessed, good training for the staff and a customer service attitude dedicated to solving any problems that might arise. Arrowhead now is moving its system over to the Internet, an option that wasn't available when it was installed.
Jansen says the local business community has responded positively because executives are used to technology that increases efficiency and don't understand why others in healthcare aren't doing the same thing. "Health plans don't know what's been going on, however, and don't realize what a help this has been."
"You simply can't be efficient with a manual system," Jansen says. "Can you imagine a bank today that doesn't have all your account information available online for instant access? Hospitals have to change, and those that don't are going to go under."
Although the interest in digital imaging undoubtedly will grow, many physicians still take comfort in having a paper copy of something, whether it is an e-mail or an X-ray.
And there have been advances in printing technology for them. In the past tw1tal practitioners have approached International Paper Co. looking for high-quality paper that could be used to print medical images on a low-end inkjet printer.
Chih-her Suen, new business development manager for International Paper, says the company responded with Jet-Print Imaging, a high-definition imaging paper with a glossy finish that dries instantly, is water-resistant and produces a high photographic quality image.
Suen says the "improvement in the quality of low-end printers is amazing" and predicts they will eliminate all but the most expensive specialty printers in the next few years. "People will use just one printer but will change paper depending on the work they are doing."
Since launching its product this summer, Suen says, International Paper has brought in 20 clients and expects that next year the market for medical inkjet paper can grow to the range of $3 million to $5 million and then maintain a growth rate of more than 50% per year for several years.
There still are connectivity problems between printers and medical imaging equipment, Suen says, since most inkjets are designed to work with Windows systems while other operating systems are still standard in the medical field.
But the images' low cost and high quality are encouraging manufacturers to find a solution.
Modern computer technology also is providing continuing education courses online, readily updated medical texts, secure channels for transmission of e-mail and Web sites with information for healthcare professionals and patients.
The changes are in their infancy, but one thing seems clear: There can be no turning back from this latest evolution in medical care. Other industries already have reaped the many benefits of the computer age, and medicine is poised to catch up.
John G. Hope is based in Harrisburg, Pa., and is a frequent contributor to Modern Physician.
