@emergency.doc
David Schriger
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Mention "computers" and "doctors" in the same sentence, especially given the heated debate over HMOs and individual health care, and people tend to conjure Orwellian images of huge clinical bed labs manned by faceless technicians diagnosing patients by the number. Not David Schriger. To the contrary, the associate professor of medicine in the Division of Emergency Medicine has devised a computer program for UCLA's emergency room he believes will restore the personal touch to medicine. By prompting physicians to ask the right questions, order the proper tests and then prescribe the correct medications and procedures, Schriger's program will unburden ER doctors from some of the vast memorization otherwise required, thus giving them more time to practice their bedside manners. "Patients still want the Marcus Welby-model plus the technical knowledge," says Schriger, who came to UCLA as a fellow in 1987 and has been working on the computer programs since 1989. "Maybe we can use the technology to do some of the latter so that the doctor can concentrate on the former. The technology is like a stethoscope or other tool; it's a means, not an end." Schriger's software comes out of a larger movement in this country toward developing clinical guidelines for everything from depression to bed- sores. But it was also motivated by his own interest in determining and modifying how doctors make decisions. The problem, he has found, is encouraging doctors to implement standardized recommendations. "Even if you get them to read the guidelines, they may not use them," says Schriger. Nowhere is this more apt to occur than in the chaotic environment of the emergency room, where it's doubtful a doctor will stop to read a standardized protocol for dealing with, say, cardiac arrest. The computer, though, offers a carrot: If the doctor works on a case through Schriger's software, he or she won't have to write out prescriptions, test orders, discharge instructions or even medical-chart reports. The computer will do it for them - and legibly. It will also document their decision-making for later analysis. So far, Schriger has developed programs to handle five frequent complaints encountered in the emergency room. If a patient comes in complaining of needle sticks, lower-back pain, seizures in known epileptics, fever in healthy children under 3 or male urogenital problems, then his or her chart is flagged as a computer case. The physician can then choose to look up the complaint on the computer and answer a series of diagnostic questions. The program suggests which tests to run, marking some optional (in blue) and some required (in red). The suggestions are strictly advisory, but if the physician ignores a "red" test, he or she has to type out an explanation. |
After the chosen tests are conducted, the physician returns to the computer and enters the results. The program then recommends treatment options or more tests. Those suggestions are also color-coded, and again the physician must explain any deviations from red recommendations. Since 1992, more than 1,000 ER patients have been treated with computer assistance, and Schriger is pleased with the results. In the case of needle sticks (the first complaint for which he's fully analyzed the data), 96 percent of all cases were computer-aided, physician documentation increased substantially and the quality of treatment improved. (A Web site funded by the Centers for Disease Control will make the needle-stick diagnostic available on-line in early 2000.) In addition, charges for care have dropped 28 percent. But those remarkable savings may not hold for all complaints. "My suspicion is that we're going to see variance across the specific complaints," says Schriger. "The drop in costs, for example, may be true for needle sticks more than for other complaints." Eventually, Schriger wants the computer to catalog protocols for 20 chief complaints, covering 80 percent of all emergency room patients. And he expects the human interface with the computer to become less and less obtrusive. Theoretically, with advances like voice-recognition software, physicians will one day be able to simply record a conversation with a patient and have the computer parse it out. There are still drawbacks, though. "One of the challenges here is that it's based on having one chief complaint," says Schriger. "How do you write the program to cover more than one complaint? Also, there may be a whole class of complaints for which this isn't very good." As for those who worry that the computer will put the doctors out of work, Schriger isn't concerned. "Fundamentally, I'm a humanist. I do this computer stuff as a way to free the doctor to focus more on the art of medicine," he says. "Anyway, if you got rid of the doctor, who would you complain to?" - Michele Kort
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