Hey Doc, where did you get that app?

Technology has changed medicine in at least one way. When we see our doctors, they see less of us. If you ask doctors and patients about the electronic medical record (EMR) most will tell you the exam room computer is disruptive to physician-patient communication. Developing more usable EMR’s might help reduce the disruption, but is that innovative? Instead of fewer clicks, what if our goal was to develop technology to enhance physician-patient communication? How would that work? Well, what if clinicians and patients used the computer together?

I worked on a project where we modified the EMR to help physicians treat children with a particular diagnosis. The application was built to support physician decision making using complex clinical logic. As something of an afterthought we added educational materials thinking they might be useful to medical students. Physicians gave us positive feedback on these materials, but they weren’t using them to teach medical students. Instead, they were using the materials to educate parents about their child’s care in a way that seemed to engage them in making better treatment decisions (measuring this was not part of the study, so I emphasize “seemed”).

Though it may sound obvious, understanding how people make decisions is important. Researchers have developed three models of clinical decision making:

  1. Paternalistic: where clinicians make decisions and communicate them to patients
  2. Informed patient: where patients reach decisions with information from clinicians or other sources
  3. Shared decision making: the exchange of information between clinicians and patients

Our application was designed to support physicians and fit the paternalistic model. However, by adding a few educational images and links the formerly disruptive computer was immediately transformed into a tool that seemed to support shared decision making via a more informed parent. This shouldn’t have been a surprise. More than any research paper, my favorite article on this subject is a NYT opinion piece, The Computer Will See You Now, where a very insightful pediatrician describes how the often ridiculed primitive paper chart supported physician-patient communication in ways the EMR has yet to match (let alone exceed).

Studying and designing clinical decision support systems is my job, but my most interesting observation of decision making took place in my own health care. A few years ago I saw four different surgical oncologists for a diagnosis of kidney cancer. Three of the four doctors performed the same patient-education ritual. While discussing my care each tore a piece of paper off the exam table in order to sketch a diagram of my kidney, tumor, and how it would be removed (Figure 1).

hand drawn diagram of kidney

Figure 1: A hand drawn diagram of my kidney cancer and treatment plan (oddly reminiscent of artist Cy Twombly’s romantic symbolism seen in his Fifty Days at Iliam: Achaeans in Battle and other works).

The fourth doctor was different. Instead of grabbing the table paper he pulled out an iPad. From a palette of objects he selected, dragged, positioned, sized, and labeled little tumors, scopes, catheters, and drains to an anatomical template (Figure 2). He created three diagrams that illustrated my condition, procedure and recovery and used the app to email the files directly to my personal account (the app can also transmit files directly to an EMR).

DrawMD image

Figure 2: Diagram of kidney cancer and treatment created with DrawMD

So, there I was, depressed and facing one of the most important decisions of my life, but my geeky nature took over. Instead of asking about my prognosis, the first thing I said was, “Where did you get that cool app?” Not only was my doctor a savvy user of technology, he serves as a consulting physician for a collection of these applications developed by DrawMD.

A disclaimer. I am the last person who believes the iPad (or any gadget) will magically transform healthcare (or anything). I am highly skeptical of techno-hype, and it seems to me that people often approach new technology as a solution looking for a problem instead of taking the time (and skill) to carefully study how people think, work and use information.

So, beyond the novelty, were the app-generated diagrams superior to the hand drawn versions? Did the app support improved physician-patient communication? Did it help me better understand my disease and treatment options? Did it help me make the best decision on my treatment? Did the emailed files help me explain things to my wife and family? Putting the app aside, was this doctor exceptionally skilled in patient communication and easily the most qualified expert I had seen? The answer is ‘Yes’ to all of the above (FYI, I had my surgery with his colleague, a leading researcher on my disease, but both doctors are the best around).

As with the NYT article referenced above, The Computer Will See You Now, there is a lot we can learn from studying objects and materials most people dismiss as obsolete. There is a long history of using anatomical artifacts to educate patients (as well as clinicians). In fact, many medical education materials were interactive and dynamic well before the invention of the computer. For example, the anatomical models often found on a physician’s desk (Figure 3) or the transparent anatomical overlays from old encyclopedias.

Figure 3: Anatomical model of kidneys and upper abdomen

Figure 3: Anatomical model of kidneys and upper abdomen

Medicine is more than chemistry and biology and relies on social interaction to communicate complex information used in making the most important decisions imaginable. There is no shortage of attention on the development of healthcare apps and/or applying social media to connect patients, clinicians and others. However, it is in the exam room where clinicians and patients often have their most important social interactions, face to face. Unfortunately the exam room is also the place where the latest and most expensive technology, the EMR, has earned a solid reputation for being antisocial (not to mention lacking in media).

DrawMD demonstrates a refreshing and thoughtful approach to innovation in healthcare technology. Instead of designing a healthcare app to showcase the features of the latest gadget, or to be social by posting something, somewhere for someone, the DrawMD apps are designed to enhance what may be the most well established and important form of social interaction in medicine – patient education toward shared decision making.

In my experience, the app was an undeniable success in supporting shared decision making between a physician and a more informed patient. In fact, it was the only truly productive experience I had with any information technology in any part of my cancer care (the rest could be the subject of 20 posts at least).

2 thoughts on “Hey Doc, where did you get that app?

  1. Pingback: Follow Up | Dean Karavite's Blog

  2. Jim Tobias

    Very insightful! It makes me think of how the principles of communication and shared decision-making could be applied to personalized interface design, especially aimed at users with disabilities. Right now we have 2 disengaged and unrealistic models: an AT practitioner ‘prescribes’ some AT or interface settings, or an autonomous consumer makes interface choices, generally on a mainstream platform. Both incorrectly assume perfect (or even adequate) information, and are based at least in part on role anxiety. I’d like to think we can do better.

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