Dr Schuman, section editor for Peds v2.0, is clinical assistant professor of Pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, and editorial advisory board member of Contemporary Pediatrics.
Every few years I like to speculate about the future of medical technology as well as the future of pediatric practice. Both, you see, are very much intertwined, and in my view the future of pediatric practice looks very good indeed.
One needs to consider that we practice medicine at a time when innovation is progressing at an amazing pace. In the tech sector, experts speak frequently of “disruptive technologies” that create entirely new ways of doing things, or shake up an industry entirely. For example, personal computers replaced the typewriter decades ago, and downloadable media is replacing compact disc media, just as compact discs replaced videocassette tapes and vinyl records. Let’s take a look at some current medical technologies that are “begging” for disruption, and other technologies that may prove to be “game changers” over the next few years.
To help improve pediatric practice, physicians must remain nimble, optimistic, and ever willing to try new things. We also must be innovators ourselves, to challenge the status quo and to aggressively confront government or insurance reforms when they are not in our patients’ best interest or ours. It is important to remember that innovation is not limited to keeping an open mind toward new office technologies. It also involves being creative when it means implementing new models of care or new workflows, and utilizing improved methods of educating parents to keep our patients healthy.
Yep, I have just identified a new medical condition-one that is not yet listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition! Medical documentation stress disorder (MDSD) unfortunately affects many physicians who have been forced by the government to prematurely adopt expensive and inefficient electronic health record (EHR) systems. I discussed improving medical documentation (ie, avoiding “note bloat”), in the January 2016 issue of Contemporary Pediatrics.
If you are unfamiliar with this condition, let me enlighten you. Medical documentation stress disorder is a “click”-related disorder, caused by the inability of providers to expedite completion of office notes, therefore requiring taking an hour or more of one’s personal time to complete notes at home. Symptoms include staring into space or yelling at one’s computer screen, as well as a compulsion to frequently check one’s retirement funds, and chronic pain in one’s dominant hand.
Fortunately, MDSD is a treatable condition. Management modalities include scribes, virtual scribes (see Contemporary Pediatrics, November 2015), and my favorite, voice recognition software (see Contemporary Pediatrics, June 2014). Using new Dragon for Mac Medical software from Nuance Communications (Burlington, Massachusetts), notes that used to take me 10 minutes now take less than 3. I also use Dragon for Mac Medical to navigate from one screen in my EHR to another, using voice-directed macros. I rarely leave work with notes left to be done, and I no longer suffer from MDSD!
There are other innovations yet to be introduced that will assist with our utilization of EHRs and reduce the number of providers succumbing to MDSD. It is one issue to write a note, yet another to quickly review the note to use it as a “handoff” to assist in ongoing care. In my view, one merely needs the ability to press a button that collapses or folds a previous note to reveal just the chief complaint, history of present illness (HPI), assessment, and plan. This would expedite handoffs as it would facilitate chart review. The note, of course, could be expanded just as easily.
Tasks are “to-do” lists that are an extreme annoyance in most EHRs because they are a dumping ground for staff who prefer to message providers to resolve patient concerns. It is not unusual for physicians to have dozens upon dozens of tasks that accumulate every day. Physical forms to be signed, lab orders, and prescriptions to write are examples of items that accumulate on our task lists every day. The solution is straightforward. First, the simplest and lowest tech solution is merely to print out all the tasks and hand them to staff with instructions on how to complete them! If you prefer an electronic solution, redesign the EHR task interface so that a task can be easily reassigned into piles associated with default instructions to staff members.
My last suggested EHR innovation involves correcting a situation that is commonplace. Not infrequently, a patient is seen and tests ordered and the note completed before diagnostics become available. To ensure adequate follow-up, one subsequently needs to enter various sections of the chart (ie, lab, imaging, outside studies, etc) to gather information relating to the original visit. Electronic health records should include the ability to “breadcrumb” all tests, telephone calls, and tasks related to a specific visit or medical problem, and organize and present all information as an “episode of care.” This would improve care coordination tremendously while making EHRs more efficient.
Molecular POC diagnostics
I’ve been very impressed by point-of-care (POC) polymerase chain reaction (PCR) testing that recently became available for the primary care office. It is a game-changing technology that may eventually supplant our current POC office-based tests! Companies such as Roche Diagnostics (Indianapolis, Indiana), maker of the Cobas Liat PCR System, and Alere (Orlando, Florida), maker of the Alere i device, have Clinical Laboratory Improvement Amendments of 1988 (CLIA ’88)-waived PCR-based tests available for rapid strep and influenza, with respiratory syncytial virus tests available soon. Polymerase chain reaction POC tests are based on the ability to replicate nucleic acid from a target organism, virus, or bacteria in a matter of minutes, with levels of detection many orders of magnitude better than our current tests. In most situations, PCR is as accurate, if not more accurate, than culture, and in many situations the adoption of PCR POC testing will reduce our dependence on waiting for culture results, therefore expediting treatment.
POC inflammatory markers
Physicians overseas use different POC tools to assist with patient management. Not limited by CLIA requirements as we are in the United States, physicians in Europe have had for decades POC C-reactive protein (CRP) tests that take mere minutes to perform and assist in providing guidance for using an antibiotic in treatment of medical conditions.
As you know, CRP is an inflammatory marker. Pediatricians in this country are most familiar with the CRP measurement in the neonatal intensive care unit environment where its use is helpful in excluding sepsis and guiding the length of antibiotic therapy when a baby undergoes treatment for sepsis. To my knowledge, there is no POC CLIA ’88-waived CRP system available in the United States. There are many POC rapid CRP tests overseas and they have proved helpful in reducing unnecessary antibiotic prescriptions. C-reactive protein is used widely in Denmark, Norway, Sweden, Germany, the Netherlands, Switzerland, and Finland, and many European medical societies have established policies that incorporate CRP tests.
In my opinion, a low-cost POC CRP could be quite the game changer because it may support a limited workup when we suspect a viral infection and perhaps make us look a little further diagnostically when confronted with an ill-appearing child without an obvious source of infection.
I have been involved in a Telehealth project in my clinic for several months. After confronting and resolving many logistical problems, my video visits are quick and very useful for both patient and physician. There is a level of communication one achieves via Telehealth visit that cannot be duplicated in a telephone conversation. I am convinced that pediatricians will slowly adopt Telehealth and learn to integrate this type of visit into their practices.
Although I love gadgets, I think it may be some time before parents universally have a “home medical kit” that will permit remote auscultation as well as otoscopic assessment of ear drums. My project involves management of attention-deficit/hyperactivity disorder medication and is used in conjunction with an online behavior portal. I am now expanding Telehealth service to include management and treatment of rashes, conjunctivitis, and follow-up of acute illnesses seen previously in the office. By providing these services, pediatricians can render care in the context of the medical home and reduce the temptation of parents to take children to emergency departments or retail-based clinics. Best of all, Telehealth visits are easy to perform. Parents download an app on their mobile device or computer and we talk as one would via a FaceTime or Skype video visit.
Clinical decision support systems
Electronic health records are capable of doing so much more for physicians and patients rather than limiting the number of patients that can be seen in a day, and, yes, contributing to dreaded MDSD. In the near future, I expect that our EHRs will evolve to be easier to use, integrate voice dictation and navigation, and provide integrated clinical decision support tools. Today, pediatricians confronted by a complicated patient can either phone a specialist friend or consult UpToDate or a similar resource to assist with workup and management. In the future, we will be able to verbally ask our EHRs questions as we now do with Siri, Alexa, and Cortana, and we will be given recommended diagnosis and workup based on information provided. When our EHRs integrate artificial intelligence-based CDS tools, pediatric practice will be forever changed.
I plan to keep readers informed about the latest and greatest technologies that promise to advance medical practice. Many of these technologies are now being considered by the US Food and Drug Administration and may likely be released in the very near future. Some will improve upon existing devices, while others, well, are likely to be “game changers.”