Eric Topol wrote a post recently put up on The Health Care Blog where he looks to a future enabled by emerging technology.
Just as the little mobile wireless devices radically transformed our day-to-day lives, so will such devices have a seismic impact on the future of health care. It’s already taking off at a pace that parallels the explosion of another unanticipated digital force — social networks.
Take your electrocardiogram on your smartphone and send it to your doctor. Or to pre-empt the need for a consult, opt for the computer-read version with a rapid text response. Having trouble with your vision? Get the $2 add-on to your smartphone and get your eyes refracted with a text to get your new eyeglasses or contact lenses made. Have a suspicious skin lesion that might be cancer? Just take a picture with your smartphone and you can get a quick text back in minutes with a determination of whether you need to get a biopsy or not. Does your child have an ear infection? Just get the scope attachment to your smartphone and get a 10x magnified high-resolution view of your child’s eardrums and send them for automatic detection of whether antibiotics will be needed.
Now, I am the first to confess my infatuation with technology. I am also a very big believer in patient empowerment, which could be the one force strong enough to overcome the partisan politicians and corporate lobbyists resisting any positive change. But there are several problems I see with this kind of empowerment with technology.
First off, the goal is not to find technologies that simply transform, but ones that move care to a better place. Right n0w our system is running aground for one reason: we spend too much money. Patient empowerment that improves efficiency of care is good, while empowerment that increases consumption or decreases efficiency is to be avoided if at all possible. The technology mentioned in the article is predominantly data-gathering technology, increasing the amount of information moving from patient to physician. The hope is that this will enable faster and better informed decisions, and perhaps some of it will. But I can see harm coming out of this as well.
The example of parents checking their children's ears is a good one for me, as it hits close to home. I am certain that by giving this tool to parents we will diagnose many more ear infections than we do now, but for what end? Most ear infections will go away if left untreated, and the push has been (for quite a long time, actually) to resist the urge to give antibiotics for ear infections in children. Doctors have had a very hard time resisting this, as it is in our medical DNA to intervene when we find a problem, but we have caused many problems because of this addiction to intervention. A large number, if not the majority, of ear infections are undiagnosed and clear on their own at home without intervention. Now add to this a technology which gives us the ability to see all of those undiagnosed ear infections, and we have to muster even more willpower to resist the urge to treat them all. This is the same problem as we have encountered with PSA testing: be careful gathering data you don't know how to handle.
But even without considering this important objection to improved data-gathering, there is another problem which stands in the way of this type of technology: reimbursement. It sounds great to enable people to avoid visits to the doctor's office by having tools that previously were only accessible at an office visit. It sounds like a very good way to save money and wasted time spent in waiting rooms with outdated magazines. But this technology presumes that doctors will be willing to act on this information without seeing the patient in the office. It presumes we will be willing to offer free care. If the time I spend sifting through patient-collected data rises exponentially, the payment I get for that time cannot remain at the present level: zero.
If our goal (as it should be) is to spend less money on unnecessary care, we will get to it much faster if we somehow give proper incentive. Our encounter-based payment system stands in the way of any progress in this area. The only way most of us get paid is to see people and deal with problems. This makes doctors reluctant to offer any care outside of this setting, and puts undue pressure on intervention (to justify the encounter to the payors). Until our system puts more value on avoiding unnecessary treatment and keeping people well we will be stuck in this struggle between patients who want to avoid seeing the doctor and doctors who can't afford to let patients do that.
This is a major pity, as life would be much better for my patients if they could stay out of the office, and life would be much better for me if I could encourage them to do so. The "transformative technologies" are hobbled before they get out of the gate by these obstacles, ones that must be addressed if we really want things to change.