A Place for Everything and Everything in its Place

In the last few days, I was doing a review of an online medical service website. This is not the first time I have done such a review. I often get asked the question as to how these medical websites function, what services they provide, does anybody actually use them, and most importantly, do they in fact provide a reasonable service.

I think it goes without saying that I am a big believer in technology and that I personally very strongly believe that technology can solve almost all [if not all] of the medical issues we face on a day-to-day basis. Technology is a way to ensure quality of care. Despite the rumblings of so many physicians who complain that EMRs are inefficient and cumbersome and “get in the way”, there is no question in my mind that these are complaints associated with growing pains.

Initially, when laparoscopic surgery [“buttonhole” surgery where the procedure is done via multiple scopes through small incisions in the belly] was introduced to the surgical world, there were plenty of naysayers. Older surgeons would argue that they could complete the surgery in half the time that it took for the laparoscopic surgeon to do the same. And then there were those who literally scoffed at the idea of removing a diseased organ through a small hole in the belly. I personally remember very well a senior Urologist laughing at the concept of extracting a sick kidney through a tiny hole.

Today laparoscopic surgery  is unquestionably the standard of care. It has dramatically reduced the complication rates from surgeries, especially in patients who are older and/or have multiple medical conditions. Patients who would die as a result of a complication secondary to the incision [not the surgery itself but just the cut on the belly], now leave the hospital in a couple of days at most and continue on with their lives, hopefully for many years to come.

In the same way, when I hear a complaint about EMRs and other newer technologies, I remind the physician who is complaining about these other technologies that were also once thought of as cumbersome and problematic. In 20 years from now, there will not be a physician who knows what it means to write a medical chart by hand, personally request an x-ray from a technician, look for the physical x-rays after they were done, personally ask the nurse to give a patient a medication – all of these interactions will be handled by an efficient and welcomed set of technologies that eliminate wasted time and miscommunications. And as these doctors of the future handle case after case via their mobile phone and bedside tablet, they will simply struggle to believe that once upon a time this was all done on paper and by hand.

By the way, patients will actually get more attention in this new reality. Doctors do not avoid patients on purpose. It is usually the stress of work and pure exhaustion that lead doctors to minimize anything but the most critical activities. When the majority of medical care is efficient and the work gets done without major physical effort, doctors will return to the bedside of the patient to take the five minutes to sit and explain and answer the questions that the patient has. I truly believe that technology will save the kind of medicine that everyone today argues has been lost.

Having said all of this, it still is important to remember that there is a time and place for everything. Just because something is new does not mean it is appropriate for every situation. In my latest review of an online consultation website, the video advertisement for the service attempted to demonstrate how much better things would be if the actor/patient had used the company website’s video consultation tool.

I took a snapshot of the frame in the video where the summary document of the online visit was displayed. With a little bit of magnification, I was able to clearly read the typed comments by the remote doctor, the diagnosis and the advised treatment. To summarize, I was somewhat upset and definitely disappointed.

The creators of the video chose a specific disease, sinusitis, to demonstrate the power of their system. The only real problem with the video is that the diagnosis was wrong. When I looked at the snapshot from the video, what I saw was a chart with two lines of documentation, no apparent validation of various important past medical elements, and a diagnosis that was simply wrong, even based on the sparse documentation on the digital chart. The patient, as he looked in the video and as he described to the actor/doctor, had a flu. The last thing this patient needed was antibiotics. More so, the choice of antibiotics was of a higher end antibiotic that does have some side effects. And perhaps most importantly, any time a patient is inappropriately given an antibiotic, this only adds to the growing problem of reduced bacterial sensitivity, or as often referred to in the media, “superbugs”.

Video consultation definitely is a powerful tool for providing a certain part of healthcare. For example, a patient who has an infection on their arm or finger, does not need to travel halfway across the city and then wait an hour or two, for the doctor to take a quick look and decide that the infection is in fact getting better. This is an ideal case for video consultation. The patient and doctor set a time to virtually meet, the patient shows the doctor his finger via the web cam, the doctor asks a few questions which are documented, a photograph via the web cam is taken which is added to the documentation, and the patient is told that the infection looks better and that at the moment, the patient should continue the present treatment. The doctor can then decide if there is a need to virtually meet on the following day, or not.

Video consultation is ideal for assessing wounds, and even rashes. Also, there are presently a few companies that specialize in remote examination tools. So a parent can place a special device in the ear of their child and the remote physician can see if there are signs of an infection. Another device can be used to listen to the lungs of the patients, and thus the remote consultant can comment on the status of the patient’s asthma or COPD.

Video consultation can be used to diagnose certain neurological disorders. There is a condition called Bell’s palsy which manifests purely on the face. Admittedly, a doctor cannot do an entire neurological exam via a webcam. Nevertheless, as I’ve been told by many a neurologist, watching a patient walk and then sitting down is 90% of the neurological exam. So in this case of Bell’s palsy, i.e. a suspected inflammation of one of the nerves of the face, a diagnosis can be made remotely. The patient can be told that the presentation is not consistent with a stroke, and can be treated with medication. Once again, for the 75-year-old patient who has no one to help him or her make it across town to the doctor’s office, this is a godsend.

In people’s excitement and admittedly their desire to financially succeed, they create a hammer and then try to argue that every problem is a nail. There are enough nails out there without trying to create more. Video consultation is definitely a powerful tool and definitely has its place in the medical armamentarium. But the moment that an individual physician or a company try to apply this technology, or any technology, to uses that are not appropriate, they stand a chance of hurting people and ruining the reputation of the technology itself [which can hurt even more people by denying them access to this technology].

The reason I was approached on these multiple occasions to review these products is specifically because of my understanding of technology and medicine. You really do have to understand both, as well as how they interact, in order to appreciate the benefits and risks of a new medical technology. It is simply far too simple to be overwhelmed by either technological terminology or medical “speak”, and then to find oneself in a situation where one simply can’t decide what has value and what does not. I have no doubt that there are plenty of investors who lost a great deal of money due to a presentation that they simply did not fully understand. I have personally met start up teams who are totally infatuated with their own new technology. But when asked to explain how this will add to the quality of care of patients, they begin to stumble.

It is never easy to blend together two different worlds. And this is definitely true of technology and medicine. But this blending together must be done, and it must be done better and faster than it has been done until now. Otherwise, opportunities will be wasted. And the whole purpose of technology is to create new opportunities, not to waste them.

Thanks for listening

About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.
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