Peter Brindley: The greatest healthcare change in a generation?

If the British media are to be believed then the only thing that matters is Brexit. Regardless, as a Canadian expat, I am distracted by a different, but similarly all-consuming, issue. I don’t want to trivialize Britain’s political fate by over comparing it to the future of the medical chart, but, as I write this, my provincial Canadian healthcare system is palliating paper and going “full digital”. This (likely) irrevocable change will significantly alter how we interact, prioritize, and “get work done.” In time, UK hospitals are likely to face the same decision, and you may or may not get a vote. Regardless, our electronic chart was rolled out as the greatest change in a generation. Sound familiar? Sound scary?

My province’s healthcare system serves approximately four and a half million souls: more than Wales and less than Scotland. Mirroring your Brexit, it is safe to say that many of the medical staff were justifiably anxious, just as they are understandably exhausted by yet more change. Our “remainers” fear we are giving up on something that, while imperfect, is “good enough.” They also fear that average patients and frontliners, rather than politicians, will feel the brunt. In contrast, “leavers” are convinced that this will offer “broad sunlit uplands,” a safer future, and better decision making. The software company has stated that, after a period of adjustment, things will run smoothly and we will never want to go back. Others believe we will collectively find a way to prevail; we always do. Moreover, if we get it right then other jurisdictions will surely follow. If I haven’t overdone this Brexit-equals-medicine analogy, some have argued that we simply need the courage of our convictions, while others fear it is all about control. 

Fortunately, there is one thing that all agree upon. Unfortunately, that “thing” is that both change and inertia are scary, and always have been. Confucius summed this up two millennia ago when he posited that “only the wisest and stupidest of men never change.” I certainly share the desire to live alongside legible doctors’ notes. After all, my profession’s indecipherable handwriting has been a punchline for too long. It is similarly enticing if we no longer have to be like a pig searching for elusive truffles in order to find important results. I want meaningful information (not just data) at my literal fingertips. I also want to share meaning (not just data) while ensuring confidentiality. I need to be able to objectively challenge whether we are good, rather than just claiming that we are. The danger is, in exchange, that we may spend a disproportionate amount of time satisfying the illogical demands of a computer, rather than the understandable concerns of patients. I want to be tired at the end of my day because I fought for a flesh and blood human, not exhausted because the “computer says no.”  

I accept that relying upon paper and pen is likely yesterday’s news. However, I don’t want to dismiss those who are less convinced by the move to digital. After all, change usually includes loss as well as gain. Moreover, any major transition requires collective hard graft, and we already have a system that needs more, rather than less, of its workers to be engaged. In order to “deliver” we all need to get stuck in and this means the freedom to advocate as we see fit. This means allowing skeptics and supporters of all shades the time and space to challenge, respectfully disagree, and constantly refine. It is important to emphasize that those who support the status quo are not luddites. Moreover, the best administrators and frontliners are flexible and open to constructive criticism. As such, I’ll tactfully outline what I believe are justifiable concerns. Given that the great medical safety advocate, Atul Gawande, was not shy in doing so in his New Yorker essay Why doctors hate computers, I will add a Canadian two cents.   

I work in a great system, but one that (justifiably) claims “there’s no more money” at every turn. When we pitched for an outdoor patio for long stay patients, I was told, “no, it’s just not in the budget.” “What about money for beds and showers for sleep deprived family members?” “No,” was the understandable reply, “we have to do more with less.” We all get the need for economy. Accordingly, it is understandable that people are questioning how we found a billion dollars in the sofa cushions in order to implement a province-wide electronic health record. It’s not that people are suggesting that there won’t be a return on investment; it’s just that the average citizen will find it difficult to combine words like “patient centered” and “computer data entry” and “fiscally prudent” in the same sentence. The messaging could have been better, even if nobody went as far as to post anything on the side of a bus. Moreover, I have yet to meet a commercial program that didn’t overpromise and underdeliver. 

Presumably, what matters most to both patients and healthcare professionals is connecting on a personal level, not just reliable internet connectivity. There is justifiable fear that a disproportionate amount of time will be spent facing a screen that could be used to engage with a fellow human. In the short term, at least, healthcare professionals are likely to devote a lot of time muttering under their collective breathes, and this time could have been spent communicating empathically. Patients are scared enough when they come into the hospital. They need to see that their healthcare providers are confident and in control, not looking frustrated at screens. Doctors and nurses are skilled at reaching out to other humans, but are generally far less adept in the dark arts of attending to a computer’s needs.

Healthcare workers have impressive knowledge and wisdom, but very few understand the computer lexicon. New fangled words like “navigator” and “smart phrases” seem foreign, even threatening. My colleagues are not intolerant; they are, like me, bewildered by the pace of change in their world. Everybody deserves time and space to share valid concerns and forthright opinions. The move towards full electronic medical charting is clearly not the end of the world, but with everything that is going on, I understand that it can feel that way.  I think it’s worth a gentle (non-partisan) reminder that healthcare is about the people, for the people, and by the people. 

Peter Brindley, Professor of Critical Care Medicine, Medical Ethics, Anesthesiology at University of Alberta, Canada. He is on twitter @docpgb

Competing interests: None declared