Do you trust your doctor?
That question is the cornerstone of the doctor-patient relationship, a relationship which has long been the basis for all medical care. But answering that question is becoming complicated by the changing role of the primary care provider with respect to technology, EHRs, modern care teams, and what is expected from “primary care” in the first place.
Technology is redefining not only what skills and functions are expected of doctors, but the role of trust in care delivery.
Traditional patient-physician relationships relied heavily on trust: patients deferred to the judgement and expertise of their physicians, and in the event of any doubt (or sometimes, denial) could seek a second opinion. These 1:1 relationships were protected by confidentiality privileges and held sacred by both members.
That old doctor-patient relationship may not be capable of all the things that the developing doctor-patient-computer system is (or, rather, is expected to be). Adding this third, sometimes automated and in time, interoperable component into every stage of care and every encounter does more than enable analytics and population health to piggy-back on individual care.
The doctor-patient relationship we talk so much about preserving is already long gone Click To Tweet
Interoperable EHR platforms and data exchanges by their nature disrupt the doctor-patient relationship; they bring a third party to every stage of care. They add new layers of digital visibility and accessibility to all of the sensitive, personal information that arises in healthcare settings. This enables automation, and the integration of artificial intelligence (AI) as, at minimum, a supplement to the human caregiver’s decision making.
It is hard to argue against the use of AI in, for example, reading slides, interpreting charts, or performing genomic analysis. The savings in time, and the increases in accuracy, are already impressive and only set to improve through further tinkering and refinement. Then the question, besides how to better integrate this technology and make it more accessible, is:
What should the future role of the human caregiver be in medicine?
For a rural or remote community the choice may already be between WebMD and a telemedicine consultation with a nurse practitioner; sure, the latter comes with a live human, but in both cases it is a new technology defining and facilitating access. Regardless of the prejudices or professional qualms people have regarding which credentials ought to be requisite for a primary care role, they have to confront their feelings about having this electronic third party facilitating the delivery of care.
That third party, by the way, may become increasingly savvy about what is going on behind the formerly closed doors of the consultation space, even if patients opt for the human element, rather than going straight to the internet.
“This could be kind of a sleeping dragon, where, if the tools that we use every day were to become smarter with knowing who we [users] are,” explained Dr. Farzad Mostashari during an interview at the HIMSS 16 conference. “So when I do a search for a hospital, or ‘Knee pain,’ maybe Google … maybe they should know my medical history already. Maybe they should know who my doctors are. Maybe they should know who my insurance company is.”
When artificial intelligence is responsible for test results, diagnosis, genetic risk calculations and correlating health history, behavior, and preventative opportunities, the critical trust element is not between patient and physician, but between patient and…AI program architecture? EHR platform developer? Interoperability infrastructure? Google? And if some digital component becomes the trust lynchpin for care delivery, where does that leave the human caregiver?
Trust is relative to perceived or to expected benefit. The big thing in marketing today is getting consumers to “opt-in” to the surveillance, data collection, and persistent third-party tracking that goes on virtually everywhere online.
“The question is, if you track me, what are you offering in return?” said Fareena Sultan, professor of marketing at Northeastern University. “Consumers also have privacy concerns and want to know, who is getting that information and how many solicitations am I going to get? Where is this data going?”
The thing that tips the scales is the value-add that comes from compromising on privacy or security. Again, if the tracking makes it easier to find answers to personal questions, or even supports some broader goal of humanitarian goodwill, people generally are willing to consent.
So the smarter a EHR/AI system becomes, the more tolerant patients will likely be of its ubiquity, its depth of personal, intimate knowledge, and its availability across the continuum of care.
“…we get smarter and smarter about you over time, just like Google and Amazon and so on–it’s just kind of marketing, isn’t it?” said Dr. Danny Sands, also at HIMSS16. “We want to really engage you about your health and we want to educate you, so we have to know you.”
To know you, it seems, is to track you.
As with driverless cars, the question of accountability in a health system that offloads the heavy lifting to robots and algorithms is a fuzzy one. If something should go wrong in treatment, is it the fault of the programmer who helped construct the AI system? The hospital that acquired this technology and employed it clinically? The insurer, for driving its patients to seek the statistically safer AI-driven care? The doctor, who collaborated with the digital system to shepherd the patient through a flawed, automated system? The patient himself, for failing to recognize and correct for machine error?
We talk about ownership of EHRs as though it solves something important. But if our decision making with respect to privacy, security, and access is primarily based on convenience – even the perception of convenience – should we, as patients, even be responsible for our own data? That same question is popping up in other industries where record ownership historically has been less ambiguous, like finance. Again, the question is one of trust, and how trust changes when relationships and communication go digital.
For patients, healthcare begins with insurance, not a doctor. Actual care pivots around data entry and encounter documentation; patients may never see the notes their visits generate, but those notes will go on to define how they are billed, how their insurers quantify them, how their doctor is evaluated and compensated, the overall status of the practice or hospital at which the visit occurred, and possibly how future encounters are handled by partners or referred specialists.
The doctor-patient relationship we talk so much about preserving or compromising is already long gone.