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Editorial
editorial
August 2010
Mayo Clinic
Proceedings
Volume 85
Number 8
Patient-Computer Dialogue: A Hope for the Future
D
ialogue between physician and patient continues to be
the mainstay of clinical medicine. During the clinical
visit, the physician endeavors to establish rapport, develop
bonds of mutual respect and trust, obtain information relevant to the patient’s medical problems and general health,
and communicate information for the patient’s immediate
and long-range use. In turn, the patient can communicate
personal preferences to the physician, and the two can
work together to develop an approach to treatment that
is consistent with both the patient’s wishes and the dictates of medical science. However, a detailed, thoughtful
clinical interview requires a great deal of time, and too
often medical histories are inadequate and counseling
is insufficient because of limitations of time beyond the
physician’s control.1-4
Physicians are pressured to see more and more patients
in shorter and shorter intervals. Indeed, since World War
II, advances in medical care have outstripped our ability to apply them primarily because of time pressures on
clinicians and health care systems worldwide. There is an
urgent need for new ways to enhance medical communication and thereby supplement the interpersonal relationship between physician and patient. New approaches to
communication between physician and patient could also
help to alleviate another serious problem—the rising cost
of medical care—by reducing the need for expensive inperson office visits.
One answer may lie in interactive computer-based dialogue with the patient, both to obtain the patient’s medical
history5-7 and to offer advice and suggestions to the patient
about the prevention, diagnosis, and management of common, important medical and psychological problems.1,3,8,9
Address correspondence to Warner V. Slack, MD, Division of Clinical Informatics, Department of Medicine, Beth Israel Deaconess Medical Center, 330
Brookline Ave, Boston MA 02215 ([email protected]).
© 2010 Mayo Foundation for Medical Education and Research
Mayo Clin Proc.
• August 2010;85(8):701-703
•
Although controversial when first reported during the
1960s,5,6 patient-computer dialogue has been studied with
increasing interest as our societal comfort with computers
in general has increased. In a recent, comprehensive review of the literature, BachSee also
man10 reported that a number of studies over
page 704
the years have demonstrated the potential of
dialogue between patient and computer for obtaining accurate, comprehensive medical histories on a wide variety
of medical problems and in a manner that is well received
by both physician and patient.
However, despite favorable reports, the computer-based
medical interview has yet to be widely adopted in clinical
practice. Before the advent of the Internet, one limiting factor was space. More often than not, the physician’s office
was too crowded and too busy to have a computer available
for each new patient. The Internet offers a new opportunity
as a medium to deliver computer-based medical interviews
to the patient in the privacy and comfort of the home at a
time and place of convenience.4,11
A small but growing number of patients already use the
Internet to obtain information from their electronic medical
records located in their medical centers. Although the idea
of sharing the medical record was controversial when first
suggested,12 there is now an increasing interest in providing patients with ready access to their medical records4;
in places where electronic medical records are available,
clinical facilities have begun to implement secure patient
portals to enable access to these records. With Web-based
portal systems such as PatientSite at Beth Israel Deaconess Medical Center in Boston, patients with access to the
Internet can view results of laboratory tests, interpretations
of radiographs, and lists of medications, as well as view upcoming appointments, request new appointments, request
prescription refills, and, by means of a secure electronic
messaging system, ask questions and receive explanations
about their medical care.13 Furthermore, such portals can be
doi:10.4065/mcp.2010.0412 •
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Editorial
used to conduct computer-based medical interviews over
the Internet.4,11
In this issue of Mayo Clinic Proceedings, Adamson and
Bachman14 present the results of a pilot study with a commercially available patient portal and clinical office management system, programmed in turn with a link to a commercially available, computer-based medical history system and
designed to function as an electronic office visit (e-visit).
With each e-visit, patients first enter their primary problems in free text, together with their vital signs and any
medications currently being taken. Patients then respond to
a series of structured medical history questions to qualify
the presenting problems in detail. The e-visit program then
applies diagnostic codes to the presenting problems, initiates procedures for billing, and sends a message to inform
the responsible physician that a summary of the patient’s
history is available for clinical assessment. Within 24
hours, the physician reviews the e-visit summary and responds in both free text and preformatted statements, with
medical recommendations as well as prescriptions that may
be indicated.
During their 2-year study period, Adamson and Bachman offered their e-visit program to 4282 patients under the
care of physicians in the Department of Family Medicine
at Mayo Clinic. Of these, 1159 signed on for a total of 2531
e-visits. The results of this study are impressive, both for
the quality of care provided and for the cost-effectiveness of
the approach. The results are particularly encouraging as we
look for solutions to the problems of health care delivery.
As with all clinical trials of this type, Adamson and
Bachman faced a selection bias. Physicians and patients
who were already favorably inclined toward computers
were more likely to volunteer and to respond favorably to
the e-visits. However, experience thus far with computers
in medicine indicates strongly that clinicians and patients
alike will use computing regardless of preconceived aversion, if the computing is helpful to them3,15,16; it seems clear
from the results of this pilot study that the e-visit protocol
was sufficiently helpful to the participants to diminish the
importance of selection bias.
The study had no control group with which the investigators could compare the results. Nonetheless, the physicians and patients participating in the study had a wealth
of experience with ambulatory care visits in the traditional
setting, and therefore they had a basis for comparison with
their new experience with the e-visits.
Effect modifiers, such as the “Hawthorne effect,” might
also have influenced the results. The physicians and patients were informed participants, and their enthusiasm
for the study may have favored the successful outcome.
However, the physicians (like most) were pressed for time,
and the patients (like most) wanted the best possible care.
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Mayo Clin Proc.
• August 2010;85(8):701-703 •
It seems unlikely that they would offer favorable reviews of
an experience that offered little or no benefit.
The study is limited to people with access to the Internet
and, as with all Internet-based studies, is subject to the criticism of fostering a “digital divide.” However, the number
of people with access to the Internet is growing at a rapid
rate; according to a recent survey, more than 150 million
Americans go online for health-related information.17 If
e-visits such as these can be demonstrated to be helpful to
patients and physicians, this will be another good reason
that the Internet should be made even more widely available for health-related purposes.
In the early days of digital computers, thoughtful observers had considerable concern about the appropriateness of the computer in medicine in any circumstances.3,15
Would the computer dehumanize the clinical encounter?
Would the computer destroy the art of medicine? Today, of
course, the computer and the physician coexist, although in
an often uneasy relationship, and the current concern has
less to do with whether the computer will replace the physician than with whether the computer will fulfill its potential
to help both the physician and the patient in the practice of
medicine.16 With such widespread use of the computer by
the general public, there are of course real dangers with
misuse and overuse, such as depersonalization, true dehumanization, and breach of privacy, and we must be vigilant.
With the computer in medicine, however, the problem is
not so much overuse as underuse—or, at least, too little
good use. In medicine, the computer is still only slowly
finding its way, and doing so often along disparate and
competing paths.
The results of Adamson and Bachman’s study are therefore most heartening. If e-visits such as theirs can be demonstrated to be generally applicable and cost-effective, and
if they can be demonstrated to improve the efficiency and,
most importantly, the quality of the services provided, this
will be an important step forward as we move to improve
the quality of medical care. Furthermore, the availability of
such e-visits could actually increase the likelihood that a
patient would seek medical care. A patient busy with work
and family-related activities might go online for help with
a medical problem that he or she might otherwise have left
untreated if treatment involved a costly, time-consuming,
and routine-disrupting office visit. The idea is not to replace
the physician; the idea is to fill a void.
doi:10.4065/mcp.2010.0412
Warner V. Slack, MD
Division of Clinical Informatics,
Department of Medicine
Harvard Medical School and
Beth Israel Deaconess Medical Center
Boston, MA
•
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo
a Clinic Proceedings.
editorial
1. Slack WV, Slack CW. Talking to a computer about emotional problems:
a comparative study. Psychother Theory Res Pract. 1977;14:156-164.
2. Slack WV. The computer and the doctor-patient relationship. MD Comput. 1989;6:320-321.
3. Slack WV. Cybermedicine: How Computing Empowers Doctors and
Patients for Better Health Care. Revised and updated edition. San Francisco,
CA: Jossey-Bass, 2001.
4. Slack WV. A 67-year-old man who e-mails his physician [published
correction appears in JAMA. 2005;293(4):425]. JAMA. 2004;292(18):22552261.
5. Slack WV, Hicks GP, Reed CE, Van Cura LJ. A computer-based medical
history system. N Engl J Med. 1966;274:194-198.
6. Mayne JG, Weksel W, Sholtz PN. Toward automating the medical history. Mayo Clin Proc. 1968;43(1):1-25.
7. Slack WV. Patient-computer dialogue: a review. In: van Bemmel JH,
McCray AT, eds. Yearbook of Medical Informatics 2000: Patient-Centered
Systems. Stuttgart, Germany: Schattauer; 2000:71-78.
8. Slack WV, Slack CW. Patient-computer dialogue. N Engl J Med. 1972;
286:1304-1309.
9. Witschi J, Porter D, Vogel S, Buxbaum R, Stare FJ, Slack WV. A computer-based dietary counseling system. J Am Diet Assoc. 1976;69:385-388.
Mayo Clin Proc.
• August 2010;85(8):701-703
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10. Bachman JW. The patient-computer interview: a neglected tool that can
aid the clinician. Mayo Clin Proc. 2003;78(1):67-78.
11. Slack WV. Cybermedicine for the patient. Am J Prev Med. 2007;32(5S):
S135-S136.
12. Slack WV. Patient power: a patient-oriented value system. In: Jacques
JA, ed. Computer Diagnosis and Diagnostic Methods. Springfield, IL: Charles
Thomas, 1972:3-7.
13. Sands DZ, Halamka JD. PatientSite: patient centered communication,
services, and access to information. In: Nelson R, Ball MJ, eds. Consumer
Informatics: Applications and Strategies in Cyber Health Care. New York, NY:
Springer-Verlag; 2004:20-31.
14. Adamson SC, Bachman JW. Pilot study of providing online care in a
primary care setting. Mayo Clin Proc. 2010;85(8):704-709.
15. Bleich HL, Beckley RF, Horowitz G, et al. Clinical computing in a teaching hospital. N Engl J Med. 1985;312:756-764.
16. Bleich HL, Slack WV. Reflections on electronic medical records: when
doctors will use them and when they will not. Int J Med Inform. 2010;79:1-4.
17. Harris Poll Shows Number of “Cyberchondriacs”­­—Adults Who Have
Ever Gone Online for Health Information—Increases to an Estimated 160 Million Nationwide. The Harris Poll #76, July 31, 2007. http://www.harrisinteractive
.com/Insights/HarrisVault8482.aspx?PID=792. Accessed July 7, 2010.
doi:10.4065/mcp.2010.0412 •
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo
a Clinic Proceedings.
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