Sunday, January 25, 2009

Its Rightful Place

Some pundits have commented that President Obama's inaugural address lacked the catch phrase or memorable line that JFK or FDR offered us in "Ask not what your country can do for you, ask what you can do for your country" or "We have nothing to fear but fear itself."

Perhaps this is true, but what I remember is:
We will restore science to its rightful place, and wield technology's wonders to raise health care's quality and lower its cost.
Let's focus on that first part:
We will restore science to its rightful place.
Does that mean the science adviser's office will be moving back into the West Wing???

Of course the inaugural address has the potential to be all talk. In his weekly address, he indicated that he will triple the number of fellowships in science. Initially, I wondered if this was at the graduate student, post-doctoral fellow or some other level. But then I found a report on with more details about the recovery plan.

With regard to the science in its rightful place goal, it looks like one step is
tripling the number of undergraduate and graduate fellowships in science, to help spur the next generation of home grown scientific innovation.
I wonder where all of those students will go after they have their science degrees? Will industry support them? Because I'm pretty sure academia won't. What about those young scientists who are finding it difficult to get their first grants?

Moving on, I think we should talk about the inaugural promise to wield technology's wonders to raise health care's quality and lower its cost. How exactly will we wield the wonders? According to the same Recovery Metrics document, the US government hopes to
computerize every American’s health record in five years, reducing medical errors and saving billions of dollars in health care costs.
Riiiiiggght... This one needs a little talking about.

I recently finished interviewing at 12 emergency medicine residency programs. As part of this, I toured some of the country's busiest emergency rooms; in many places I donned scrubs and saw how things worked 'on the inside.' Many places do have an electronic medical record (EMR), but some hospitals said that they probably wouldn't have a system in place by the time I finished residency (that's in four years). So that's a first strike against this goal. If the emergency departments - who provide primary care for more than 50 million Americans and are the first access point for unscheduled medical problems for everyone else - don't have an EMR, how will everyone's record be computerized?

This problem aside, there are additional barriers that need to be overcome if a 5 year goal is to be achieved.
  1. A standard computer laguage that all EMR platforms use, so when patients move from one office to another or from one system to another, their info can be brought up in the same interface. As it stands now, this is not even standardized in the same hospital. In many places the emergency room's EMR is different from and cannot communicate with the hospital's!
  2. For patient safety to be increased, more time and/or staff needs to be allowed for computer entry. In emergency rooms with medical records, I was amazed by the amount of time residents and attendings spend in front of computer monitors instead of with patients. In place of noting information on a clipboard while talking with patients, doctors have an extra hugely time-intensive step of data entry. Technology needs to improve. What about notebook style touch screen terminals? Except that would increase cost...
  3. Is computerized care better? This seems to be a moot question, because everyone's headed in the digital direction. I'm probably just not well enough read on this topic, as the VA health system and large HMOs like Kaiser are all computerized. Are improvements to care there because of computers, or because everything's in the same system?
I see the computerized record as one of the important first steps in developing a single-payer model of health care, but the biggest impediment I see is getting the companies who make EMRs to talk to each other.

I applaud both of these goals of training more scientists and making health care safer, but want some more details, too.

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