April 11, 2039, 9 a.m.

Siri says it’s a rainy morning as I clamber out of bed to see my first patient. It’s amazing to do this from home!

I open iDOCTR. Fifty new messages with requests for emergency appointments today! It’s a brisk morning at the virtual emergency department. A minute or two per patient and then another five for charting and billing. I can do this.

9:02 a.m.:

Tommy, 19

6’4″, loves to hike, stab wound to the chest

Active today! Now about 21 miles away.

9:03 a.m.:

I message Tommy, but it’s no use as he bleeds out.

<SWIPE LEFT>

9:11 a.m.:

Sandi, 52

Blood type: O+, proud mom to Tommy

Active today! Now about 21 miles away.

I begin, “Ma’am, we did all we could, but we could not save Tommy—”

Her screams and tears are familiar, yet somehow not as chilling as those I remember from when we did this in person. And 48 messages await…

<SWIPE LEFT>

If the horror of swiping left to reject a human being isn’t enough for you in dating, try it in medicine. On the front lines, we see how medical care continues to be shaped by our technologically driven, service-oriented economy. Most New Yorkers could tell you that every day the subway pulls up to the platform full of new ads hawking startups that promise less time spent in the company of actual people as we plan weddings, find business collaborators, buy apartments, order food, care for our pets, or shop for mattresses. Why bother asserting yourself in a social setting when you can order up a real, live human on a dating app?

Charm, it seems, is obsolete, but what about bedside manner? Medicine is about human contact at one’s most vulnerable moments—or, at least, it was. The health care delivery landscape has shifted dramatically with declining reimbursement, large-scale electronic health record (EHR) adoption, new delivery models, and increasing administrative burdens. Physicians are faced with the conflicting and unattainable pressure to care for patients faster and faster while being nicer. Something’s got to give.

As we scan our patient lists, it is still routine to refer to them as “that chest pain in room 7” or “you know, the one with lung cancer.” You can argue that we do so to avoid revealing personal information, but during daily practice, we may find ourselves engrossed in the computer screen and the endless boxes that need to be checked to the point that we feel we are treating the computer, not the patient.¹

EHRs are jeopardizing the sanctity of the doctor-patient relationship by distracting clinicians and obstructing their access to patients.² The 4,000 mouse clicks that each emergency physician makes during every shift they work require time, attention, and emotional energy that could be spent on patient care.³ Why are we here? Well, the Health Information Technology for Economic and Clinical Health Act incentivized physicians and hospitals to rapidly adopt EHRs. In the rush to get systems up and running to qualify for incentive dollars, vendors developed safe, functional, reliable, yet clunky platforms in which physicians’ and patients’ needs have been forgotten.

Social media may have altered how we interact with our world and one another, but we cannot allow it to violate the doctor-patient relationship. The big EHR vendors—Epic, Allscripts, and Cerner—are fairly independent of Silicon Valley, but mobile health startups are seeking to disrupt the industry. Wired has written about patients who, as social media influencers, are compensated by pharmaceutical firms, medical device manufacturers, hospitals, and insurers.⁴ TechCrunch has described the influx of Silicon Valley venture capital cash into the medical sector as a “funding frenzy,” and Allure has addressed the “ethically questionable” phenomenon of “Snapchat doctors,” who advertise their services on social media.^5,6

Surely, there must be another way to improve the patient experience. If you can measure it, you can manage it, right? Let’s look at another case of a well-meaning federal incentive structure gone awry. The Affordable Care Act established the Hospital Value-Based Purchasing Program, which has tied an increasing percentage of hospital reimbursement to the patient experience. Similar to the well-known Press Ganey patient experience scores in emergency medicine, patient experience in this program is measured using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). These surveys are rewarding etiquette while hoping for empathy.⁷ HCAHPS measures communication and responsiveness of staff, how staff behaved, and how they cared for the patient. To be clear, in this incentive structure, empathy—caring about the patient—is not part of the deal. In a perverse Hawthorne effect, piling additional measurement and expectations on overburdened physicians may be driving health care delivery that lacks both etiquette and empathy.

As the service economy tightens its grip on our society, we must consider that when these moments become transactional, we lose the human connection that makes them tolerable. The Wall Street Journal recently reported about an emergency department telehealth initiative at NewYork-Presbyterian/Weill Cornell Medical Center that provides remote urgent care.⁸ We applaud them for this initiative that strives to make health care more efficient, accessible, and innovative. However, let’s take a moment to pause and consider the unintended downstream dehumanizing consequences that such a program could have. Health technology design must focus first and foremost on the human side of medicine.⁹ Social media itself was intended to bring us together in more efficient ways, not drive us apart. If systems are designed for patients’ and physicians’ needs, there is no reason we cannot have efficient and accessible care that is also kind, compassionate, and deeply human. As emergency physicians, we have a deep understanding, appreciation, and knowledge for health care needs at the individual, departmental, and system level. Indeed, emergency physicians are uniquely poised to train and lead the health IT workforce of the future.¹⁰ Please join us!

References

1. Verghese A. Culture shock—patient as icon, icon as patient. N Engl J Med. 2008;359(26):2748-2751.
2. Gellert GA, Webster L, Gillean J, et al. Should US doctors embrace electronic health records? 2017;356:j242.
3. Hill RG Jr, Sears LM, Melanson SW. 4000 clicks: a productivity analysis of electronic medical records in a community hospital ED. Am J Emerg Med. 2013;31(11):1591-1594.
4. Molteni M. Social media influencers finally come to … medicine. Wired Available at: www.wired.com/2017/03/social-media-influencers-finally-come-medicine/. Accessed Dec. 13, 2017.
5. Magee C. Venture capital is trying to heal the healthcare system. TechCrunch Available at: https://techcrunch.com/2015/04/09/venture-capital-is-trying-to-heal-the-healthcare-system. Accessed Dec. 13, 2017.
6. Savini L. Snapchat doctors: how plastic surgeons have gained an ethically questionable following. Allure Available at: www.allure.com/story/plastic-surgeons-on-snapchat. Accessed Dec. 13, 2017.
7. Melnick ER, Powsner SM. Empathy in the time of burnout. Mayo Clin Proc. 2016;91(12):1678-1679.
8. Reddy S. Can tech speed up emergency room care? The Wall Street Journal Available at www.wsj.com/amp/articles/can-tech-speed-up-emergency-room-care-1490629118. Accessed Dec. 13, 2017.
9. Melnick ER, Hess EP, Guo G, et al. Patient-centered decision support: formative usability evaluation of integrated clinical decision support with a patient decision aid for minor head injury in the emergency department. J Med Internet Res. 2017;19(5):e174.

Dr. Melnick is program director for the new Yale/VA Clinical Informatics Fellowship Program and assistant professor in the department of emergency medicine at Yale University.

Ms. Sheffler is a freelance writer and translator who edits Works & Days, an arts quarterly. Her writing has most recently appeared in The Guardian.