Big brother is watching. Just as in George Orwell’s futuristic novel 1984, the advent of big data has brought with it the ability for organizations to track our every move. Smartphone applications track your children’s habits when they are playing games on their devices. Government crooks such as those managing the Internal Revenue Service are able to tap into your private conversations and business dealings and create a special tax code for “non conformists” and those who disagree with the current administration. Your GPS navigation system can track your location and analyse your travel habits. Internet search engines compile profiles of your search history and display advertisements based on your determined interests. Now, physicians are being tracked and rewarded (or penalized) based on their net cost to hospital systems. Ultimately, patients, and our helathcare system in general, will suffer. Linking economics too closely with the physicians providing patient care may be similar to allowing “church and state” to dance to closely on Capitol Hill. As physicians, we are trained to work hard and to make decisions that are in the best interest of our patients. Hospital administrators, CEOs and “bean counters” are trained to do what is in the best interest of the hospital system and ultimately their own pocketbooks.
This weekend in the Wall Street Journal, author Anna Mathews discusses the issues surrounding “Big Data” and healthcare systems. In a California healthcare system, physicians are tracked through the use of massive data collection systems. Their cost to the system is analysed as well as their patient outcomes. The Electronic Medical Record (EMR) mandate has now begun to allow hospital systems to better track physician behavior and clinical habits. EMR databases can be easily queried and the data “mined” for easy analysis. In this particular California based system, Big Brother is now watching every time you order a CBC, a chest X-ray or a CAT scan. If those who administrate the system and evaluate cost do not agree with your clinical decision, you may be penalized. The most frightening thing about the entire story is that it is unclear WHO sets the standards and exactly WHAT data these standards are derived from.
This article has left me with more questions than answers. Just as referenced in the WSJ piece, many physicians are angry and feel as though they cannot practice medicine any longer but must learn to follow a checklist and move carefully through disease specific and symptom specific algorithms.
What’s the fallout of big data and how will it impact patients? Are physicians no longer treating patients and practicing medicine? Or are administrators and data analysts now going to mandate how medicine is practiced? What happens to the ART of medicine and gut instinct?
As I contemplate these questions, I am feeling a bit depressed. The future of medicine is not as I imagined it when I was in training. Here are my thoughts on some of these questions:
These types of practices may very well end the need for lengthy residency and fellowship training–rather than learn how to make decisions and respond to clinical scenarios at 3am, physicians in training may be better served learning how to read flowcharts and algorithms and negotiate with hospital executives. I worry that many physicians will not want to treat the elderly, sicker patients with multiple medical problems as these patients often have poorer outcomes and may bring down an individual physician’s performance rating. Unfortunately, these patients are the ones who often need the most help–these patients benefit from a doctor who understands complex illnesses and treats them with instinct and compassion. I am frightened by the prospect of having my clinical decision making and practice habits evaluated by an MBA executive for a healthcare system with absolutely NO clinical training and NO medical degree. I am afraid that with government mandates, greedy healthcare systems and administrators with egos as large as oceans, we are in for a dark period in medicine. In medical school and residency we are taught to think critically about patients and their problems….in the future we will be taught to think carefully about our clinical decisions because…Big Brother is watching….
Dr. Kevin Campbell, MD 
You bring up some great points. I don’t have firsthand experience since I’m just starting medical school, but I have made an effort to be well-informed on medicine and healthcare policy. Inexperience may detract from my argument but nonetheless, here it is.
Delegating physician compensation based on performance reminds me of the same issues that are ruining the education system (my wife is a teacher). Teacher compensation based on performance leaves little incentive to educate inner-city youth or even rural community school systems for that matter. Instead, they’re inclined to educate the best and brightest in order to be considered a quality educator in the eyes of the system. Furthermore, teachers are being asked to follow strict educational guidelines with little room for innovative teaching. School systems are producing cookie cutter students capable of solving straight-forward problems in various subjects, but neglecting to instill critical-thinking skills in our youth. Now, physicians are at risk of experiencing the same situation.
The public fails to realize that medicine is by no means a perfect science. Physicians are fallible just like any other professions and having big brother watching isn’t going to remedy the situation. I think physicians need some form of accountability, but it should be maintained by other physicians (or at least medical personnel). Furthermore, critical-thinking is what saves lives in many situations. Medicine isn’t an exact science and disease presentation isn’t always straightforward. Someone must treat these difficult cases and shouldn’t be punished for their efforts.
Thanks so much for reading my blog and leaving a thoughtful commentary. We are at a crossroads in medicine today. IF we do not step up and begin to lead as healthcare professionals, the government agencies, insurance companies, hospital systems and litigators are going to determine the path we take FOR us.
Best
Kevin
Kevin, I find that not only scary but so true. I saw it when my husband was dying. He was four months in hospitals and I am well aware of the bean counters. It ties your hands. I am glad you sent this out. I watched as the nurse advocate I hired, hashed out coding strategies trying to work around the systems and Medicare, just to give him the care and facilities he needed. After like 26 days in a rehab and on a vent, being told, ok you have to move him today, have a check or credit card for the ambulance ride. Because he was no longer making them money. Big brother watching.
Sent from my iPad
Nancy
Thanks so much for your reply. It is certainly a sad day when we can no longer do what is right and just for a patient like your husband because of administrators who sit behind a desk (and NEVER see a patient or a family) and make decisions that impact our ability to provide indicated care
Best
Kevin
Kevin/Dr. Campbell-I just started reading your blog, and find it well-thought, well-written and stimulating. Thanks. Your concerns in this regard are mine, as well. Removing docs from the decision-making process will also significantly reduce professional satisfaction, and will expose docs to greater liability. Imagine that-losing the power to make decisions, but being held responsible for enacting the decisions of others (who are not in a position to make such decisions)! Baffling situation, to say the least.
Thanks so much for reading my blog and taking the time to respond. It is very scary to think what might become of our healthcare system if we do not make significant changes soon!
Best
Kevin