Often in medicine there is an invisible pendulum that swings in wide arcs.
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When ransomware hits a medical system, providers must scramble to learn how to generate orders and doses without a computer to prompt them. It took years to get our own system to stop giving lactation warnings for my 90-year-old female patients. The computer provides (often inaccurate) proposals at each click for dosing, drug options, and diagnostic testing. Moreover, the young providers of today know nothing of generating orders in their mind and then putting them to paper. Electronic medical record systems were built not for patient care but for billing and mitigating legal risk. We have a system that values a database that can be mined for profit and publication. We no longer have a system that values attention to the person.
All that matters is you put her on the approved diabetes medications and her hemoglobin a1c is at target. Smith's emotional eating is driven by her grief for her son's addiction problem and her 14-year-old cat who she recently put down. Proponents will point to "best practice advisories" and "metrics" that our electronic medical records blip across the screen with dizzying speed. We have paid a heavy price for medicine that is at once "at your finger tips" as well as broken and fragmented. A separate corporate system has sprouted like a weed, and has taken over as the remote "medical director of record" for nursing homes where there are too few staff, and where "standing orders" are an automated way of caring for any particular problem that may arise so as to minimize any thought or analysis of the problem. Now, many nursing home facilities have no on-site provider, and for some, the facility's medical director is in another state altogether. Nursing home care was also under the purview of the primary physician, who would do rounds and take phone calls, write orders, and talk with the family. If more than one or two organ systems are affected then subspecialists will come and pore over the computer (rarely over the human) to see if the numbers in the electronic medical record are within their wheelhouse. If the risk is too high, then they hand you off to the hospitalist who will admit you, but if your condition worsens, there is often another handoff to an intensivist who manages the ICU. There, staff need only to verify that you will not expire within 24 hours, and out you go. Pretend for a moment you're a patient and you go to the emergency room for an acute issue. Patients have become a conglomeration of body systems and body parts to be fixed or addressed in a fragmented fashion, reminiscent of an assembly line. Medicine has become the great handoff, with no one seeing the whole picture of the person in front of them. What is the most substantial impact of this fragmented care? No one provider is the sole caregiver with total responsibility. "Care" has now become a fragmented web of hospitalists, intensivists, and mid-level care that only remotely reflects the relationships that were the bedrock of the American medical system just 20 years ago.
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