Fixing the Technological Fix

Perhaps like many of my age, I am not captivated by a number of much-touted technological innovations, increasing choices I don’t desire, and fulfilling needs I didn’t realize I had. I am not sure that having a cell phone at the ready every minute of the day and night to bring messages, pictures, and apps to busy and not-so-busy people (who will become busy because of that phone), is a great human benefit. I watched a father recently in a restaurant who had brought his three young children to lunch, spending at least 45 of his 60 minutes looking at his smartphone screen and not exchanging a single word with them.

Everyone seems happy to send me emails but hard to lure into a (landline) phone conversation. Then I think of the difficulty of getting hold of a human voice in calling almost any institution these days. My family physician, once a good talker with eye contact, now looks more at his screen when I visit him than at me, thanks to the spread of the medical IT romance.

I brought that confessedly dyspeptic attitude, doubtless something genetic, to my encounter recently with some enthusiastic writings on Personal Health System Technology (PHST). A white paper by Care Innovations, a joint commercial venture between the Intel Corporation and GE, noted our aging population and the rising chronic disease that goes with it. That combination, and particularly the widespread desire to age in place, to want or need care at home, is the impetus for the company. It will support and encourage “productive interactions between informed activated caregivers on the one hand and a team of prepared proactive clinicians on the other.” Above all it will “provide autonomy and comfort to patients and keep medical costs down.”

A longer paper by the nonprofit NEHI that winnowed out, from a list of 88, 11 of the most promising emerging technologies. Each of them is carefully described and accompanied by a detailed discussion of their benefits and obstacles to their use. They are Extended Care eVisits (for physicians to confer with nursing home patients); HomeTelehealth (for patients to transmit health data from home to physicians); Tele-Stroke Care (designed to bring the expertise of stroke centers to rural and community hospitals); Mobile Clinical Decision Support (smartphone apps that provide information on appropriate treatment and on reducing medical errors and adverse drug events); Virtual Visits (allows doctor-patient interactions in real time); Mobile Diabetes Management Tools (enables patients to monitor their disease using mobile phones); Medication Adherence Tools (reminds patients to take their medications and monitors adherence); Mobile Asthma Management Tools (provides information to help patients avoid asthma attacks and to help them manage their condition); In Car Telehealth (offers patients a safe and effective way to utilize mobile telehealth technology while driving); Social Media Promoting Health (promoting healthy actions and knowledge that is free); Mobile Cardiovascular Tools (monitors cardiac patients and shares their vital signs with caregivers and providers).

What’s not to like about that list? What brings out the technological curmudgeon in me?

On the face of it, nothing. Each of the 11 sounds useful and will be beneficial to thousands.

But I can’t help noting the claim about reducing health care costs. Save for $200,000 cancer drugs for which no cost savings have been claimed, it is hard to think of any new technologies in recent years that were not advertised as saving money. The counterargument is that the typical downstream outcome is an increase in the number of users, raising the aggregate costs. And whatever a technology’s other benefits, what makes money for companies is what ordinarily drives up patient costs. Someone has to pay for them.

That issue aside, my more nervous reaction to PSHT is that of the distancing of patients from doctors, adding still another barrier between doctors and patients, and in the seductive name of their medical welfare. When that possibility is paired with another strong trend–chronically ill patients in hospitals being treated by teams of doctors–the overall synergy may be harmful, widening the gap between individual doctors and patients.

Human in-person contact matters between doctors and patients, and possibly most of all for patients with chronic illness of long endurance, whose suffering is often as much psychological and emotional as it is physical. Boutique doctors understand that need. It is just too bad that one must pay extra these days to get what was taken for granted in the pre-technology medicine 100 years ago. I have not heard of any boutique medical teams and maybe the very idea is an oxymoron: a single doctor can make a house call, but a team? And who needs either if technology can do it better?

Possibly all of my musing is just a kind of free-floating anxiety, and medicine will be the better for PSHT. But the rising speculation, with some evidence of late, about the harm being done to interpersonal relationships by smartphones and tablets should at least alert us to some negative possibilities. Can some direct and reliable (not just virtual) human contact be integrated into the use of these technologies? I hope so.

Daniel Callahan, 83, an organizer of Over 65, is cofounder and President Emeritus of The Hastings Center.





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