William Cayley: Systems wisdom

bill_cayley_2In a recent BMJ blog Steve Ruffenach made some excellent points on the importance of balancing “accept” and “except” in approaching “Tech” in medicine.

However, as we continue to feel the pressure of realizing “meaningful use” of electronic medical records (often with attendant requirements for documentation, reporting, and ad-nauseam clicks of different buttons in each patient’s chart), I’ve been intrigued by growing evidence suggesting we need rather to focus on “wise use.”

Some seem to feel that the more systems (usually supported by “tech”) that we implement in medicine, the better and safer our patient care will be . . . but I am not so sure:

Just this month, a study in the Journal of the American Board of Family Medicine documented an association between implementation of a web based patient portal and increased patient phone calls to the office. So much for using web based platforms to streamline patient communication.

Another study earlier this summer in the Annals of Family Medicine found that asking patients to address their “Quality of Life Goals” in pre-visit paper questionnaires (no electronics here) led to reduced expressions of physician empathy during the office visit.

• And when it comes to the process of care itself, a Cochrane review found that opportunistic risk assessment and case finding of cardiovascular disease (CVD) and associated risk factors may be associated with the same reduction in all-cause and cardiovascular mortality as systematic screening. All those “preventive” outreaches may not prevent much after all.

I’ve posted before my thoughts on whether we are “getting too systematic for our own good”—and these bits of evidence shed more light on the picture. We need to be attentive to those instances in which efforts to systematize healthcare not only seem to add no benefit (as may be the case with CVD screening), but may in fact lead to poorer patient care (quality of life questionnaires?), or unwittingly add to our already heavy workload (patient portals).

Systems have their place, but that place is not everywhere. We need to think clearly, study carefully, and implement wisely those systems that may help improve care—and learn to abandon those that add nothing or make things worse.

William E Cayley Jr practices at the Augusta Family Medicine Clinic; teaches at the Eau Claire Family Medicine Residency; and is a professor at the University of Wisconsin, Department of Family Medicine.

Competing interests: “I declare that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare.”