Today’s web-based entertainment was courtesy of Nuance and its Dragon Ambient eXperience product. I’ve been keeping an eye on it since seeing it at HIMSS19.
Their demo at the time involved an orthopedic visit, which tends to be a lot more straightforward than most of the visits we have in primary care. I was hoping they would show a truly complicated visit and how the system could handle it. It was encouraging the host said they would be doing an “unscripted” demo based on attendee input through a Zoom poll with randomly generated options.
However, it quickly turned into the same old orthopedic visit that they typically show. They asked the audience to have input via poll on past medical history elements, but many of what we were given to choose from were just standard conditions like hypertension or an ACL repair.
I have yet to see a demo where the system can manage the real-world things we see in practice. Where is the history of “heart surgery” where the patient has no idea what was done or what the underlying diagnosis might have been? What about the problems that were more complex than injuring your ankle while walking your dog Lucky, which was the demo they actually showed? They showed the voice recognition streaming during the demo, and there were a number of elements where it wasn’t capturing exactly, so I was curious to see what the process would be to resolve those.
The command “Hey, Dragon, show me the x-ray” brought up an x-ray example with no patient identifiers, which failed my realism test. The physician also interpreted the x-ray before examining the patient, which is a no-no for many of us. The physician used a fair number of medical words, but didn’t really explain to the patient what those meant, including the anatomical names for the affected areas.
I wasn’t impressed by their simulated assessment and plan, which didn’t entirely follow the standard of care in that the patient was given a scheduled controlled substance for her ankle sprain, which most of us wouldn’t do until the patient failed other pain management strategies such as anti-inflammatories or acetaminophen, neither of which she said she had taken.
I know I tend to be critical since I’m a practicing physician, but it’s all part of credibility. It’s hard to find the messaging to be credible when they missed the clinical mark. Was it intentional, or did they not find it important to be clinically credible? Interestingly during the interview, the clinician ordered tramadol, but when the host reviewed the medication orders, the canned display on the back wall showed Tylenol, which maybe was an indicator that it was a little more unscripted than they planned. The final note did mention both Tylenol and tramadol, however.
They cut away to videos from physicians, including family physicians and orthopedic physicians, but they didn’t really show what this would look like in family medicine. I asked a pointed question via the Q&A chat about how the system would manage vague elements like I mentioned above. Not surprisingly, it was skipped. They did mention that they have a four-hour service level agreement for note turnaround, although they noted it can be shorter in the real world. As a physician who likes to have my notes done when I walk out of the room, that would take some getting used to. They did demonstrate how the system could filter out the conversational parts of the visit in order to create a concise note, which is promising. Still, I’d love to see how it handles a complex primary care visit.
Today’s patient-side entertainment was courtesy of my local hospital, which continued to underwhelm. I’m living the nightmare shared by a number of female healthcare providers who received the early rounds of the COVID-19 vaccines. Since it’s been two months, and statistics do what statistics do, one-sixth of us over a certain age have been due for an annual mammogram since receiving their vaccines. Both of the current vaccines tend to cause swollen lymph nodes, usually in the neck or underarm, and sometimes those nodes turn up on a mammogram. It’s a widespread enough issue that mammography centers are adding questions to their intake forms asking about vaccine status and which arm was used for the administration. The Society of Breast Imaging sees this as a big enough issue that it has recommended women delay screening mammograms until at least 4-6 weeks after receiving their last vaccination. However, for those of us who were due for screening prior to the recommendation, we are now chasing down rogue lymph nodes that could be due to the vaccine or to something more sinister, such as breast cancer or lymphoma.
I had a difficult enough time scheduling my follow-up ultrasound due to my clinical schedule and the limited appointment slots. Today’s actual appointment could have served as a case study of what not to do from a technology, operational, and clinical standpoint.
It started with patients reporting 15 minutes before their appointments as instructed, only to find that they had a single registrar who was taking names and instructing people to be seated until called. The problem: six patients and five chairs in a waiting room that had been stripped of furniture for social distancing. Patients were slowly called to the desk, where they were forced to fill out the usual clinical history form (completely from scratch, once again not pre-populated from the Epic system as it could have been) standing there in front of the registrar. This delayed additional check-ins and I’m sure was frustrating to patients.
Despite arriving early, I wasn’t called back until 10 minutes after my appointment time, where I was taken to a changing room that fed a sub-waiting room with an additional four patients (although there were five chairs, but this time we got to sit around with each other in flimsy gowns). Plus, instead of watching HGTV in the main waiting room, we were treated to a screen displaying a version of the imaging center’s tracking board, showing all the patients and their appointments and how backlogged they were. Although the names were truncated like we were flying standby, it felt like an invasion of privacy since we could see all the procedures scheduled for the day. There was a Windows popup on the screen that looked like an error or alert message, and although I couldn’t see the details, I wondered if we were really supposed to be seeing it.
After finally reaching the exam room, I was treated to a brusque sonographer who acted like I hadn’t followed appropriate prep instructions (despite having received none). I felt like reminding her that even though she does this a dozen times a day, each patient was enduring the harrowing experience of wondering if they have cancer or not, so they don’t need her attitude. It was clear she was having trouble getting the images she wanted, but she finally went to review them with the radiologist while leaving me draped on the table.
When the radiologist came in, she started spouting medical terminology and I’m hoping it was because somewhere my chart was flagged as a physician because as a “regular” patient I would have had no idea what she was talking about. I guess I’m also more sensitive to the patient’s comfort than she was, because I rarely have conversations with patients while they are draped and lying on the table. At a minimum, it would have been nice to sit up and have a conversation at eye level.
I don’t think I have unreasonably high expectations. They have been shaped by the way I was trained and how I’ve seen medicine practiced for the last two decades. But it seems they’ve substantially diverged from the post-COVID reality of healthcare in my city. Patient advocacy and patient empowerment are supposed to be major factors influencing how healthcare organizations operate, but apparently for some they’re little more than buzzwords.
The perfect cap on the day was when the sonographer walked me back to the changing room, where she told me to “enjoy the rest of your day.” As I looked at the faces of the other women in the sub-waiting room, knowing that their lives might be changed dramatically today, it didn’t seem like what patients might want to hear, especially knowing that some of them would go home to sit and wait for results. Perhaps “take care and thank you for choosing us as your healthcare team” might have been a better option.
Have you experienced a decline in patient services in the COVID era? Leave a comment or email me.
Email Dr. Jayne.