Note: This section is from The House Officer's Survival Guide: Rules, Laws, Lists and Other
Medical Musings, by Lawrence Martin, M.D. It is written for doctors in training, but will be of interest
to anyone who works, or has worked, in a hospital or outpatient clinic. Please address any feedback to
martin@lightstream.net
Musings on the Hospital Room and Outpatient Clinic of the Future. Is This Science Fiction or What?
Rounds are conducted at the bedside. The patient is in a private room and the room is quiet. Hallway noise and conversation are obliterated by sound-nullifying technology. In two corners of the room's ceiling are unobtrusive video cameras used to observe the patient from the nursing station. One side wall of the room can be converted into a giant display panel at the touch of a palm.
The house officer presses her palm against the wall and the display panel comes to life, showing all recent laboratory data, including x-rays, MRI scans and sound wave tests done within the past 24 hours. All are digitized, and contrast can be adjusted with the twist of a knob. Any test result more than 24 hours old can be retrieved by a simple voice command, e.g., "x-rays, please; liver studies, please." Displayed are the data (all digitalized, including x-rays) and printed interpretations. (The same information can also be obtained by touching an on-screen menu.)
In fact everything about this patient that, in the 20th century, was printed on paper, is now retrievable easily and fast on any of a dozen flat panel screens situated throughout the ward, as well as in each patient's room. There are no paper records to search through, no x-ray films to find, no labs to call. All data are available through simple oral commands, or by touching a screen menu. Because of developments in storage technology and built-in computer redundancy, there is little danger of data loss. Every 12 hours a permanent record of the patient's data is engraved onto a tiny chip which cannot be erased, and can be read by any personal, hand held scanner. The capacity of each chip is enormous, equal to the amount of data that would be generated after 10,000 hospital days. The chips, costing pennies each, are replaced each 12 hours; old ones are re-cycled. On discharge the patient is given one copy of the final chip, and another is deposited in the hospital's patient record vault.
The patient has an intravenous line in his right arm. Connected to the tubing is an external coil leading to a small grey box. The box is a mass spectrophotometer; it chemically analyzes every substance entering through the intravenous line.
The list of oral medications is entered via voice activation by the nurse. All medications are distributed from the central pharmacy directly to a bedside vestibule in the patient's room. The nurse retrieves the drugs by entering a simple code and on removal the drug and dosage are entered into the data base. If for some reason the nurse handles the drug but does not give it to the patient, she can correct the entry easily. All drugs the patient is receiving are displayed as soon as the panel is activated. To the voice command, "previous drug therapy, please," a list of all previously-administered drugs is instantly displayed.
The house officer spends no time looking for data; it's all there and it's all accurate. Now the house officer has time to talk with the patient, and can examine him while scanning for any relevant information.
The hospital bed is cantilevered out over the floor, attached only at the wall. Unlike beds of the late 20th century, this one can be ergonomically contoured to fit any posture, at any angle, from 45 degrees head up to 45 degrees head down. It can also be converted into a chair with the push of a button. For transport purposes, wheels float down from hidden recesses underneath, and the bed disconnects from the wall. The mattress is water consistency, with constantly shifting pressure points, so subtle they are not noticed by the patient. This "electronic bed" makes no noise: no hum, no whine, no buzz.
Before leaving the room the house officer notes the daily fluid intake and output and the patient's weight. Weights have long since changed over to the capillary flow scale. Only organic material that receives capillary flow is weighed by the bed scale. Living matter is easily separated from inanimate objects - the sheets, the pillows, the patient's clothes. A detailed outline of the patient's anatomy can be displayed, showing the weight. Adjustments can be made for any area that has no capillary flow, such as an area of necrosis. Weights are thus true body weights, and not the inaccurate and often fluctuating numbers common in the 20th century with human-operated bed scales.
Data are constantly analyzed by "expert doctor" programs. Suggested diagnoses and remedies are offered by the computer, based on the accumulated data. Diagnoses are listed in a probability format, based on clinical data the physician enters as important, plus all available laboratory and radiologic tests. In this patient the house officer is concerned about a facial rash, joint pains and fever. To the simple oral query: "What is the likely diagnosis or diagnoses?" the screen brings up the following display:
___________________________________________________
PATIENT: XXX
HOSPITAL NO. 12345
DATE: NOVEMBER 15, 20--
Considered Diagnoses Probability
Systemic Lupus 96%
Drug reaction 24%
Polymyositis 15%
Bacteremia without endocarditis 12%
Bacterial endocarditis 03%
____________________________________________________
The high probability of lupus is consistent with the house officer's own assessment. She then asks the display panel: "What are the skin manifestations of Lupus?" Instantly a short list of skin signs is displayed. The house officer touches the word "butterfly facial rash" and several pictures are shown of patients with a classic lupus rash, along with a photo of her patient's face.
The house officer, through the display screen, also has access to the entire medical literature. She can research any topic by voice request, and download the information to her personal portable reader for later perusal.
(Access to the data bases does not have to be in the patient's room. The information is retrievable on any of several panels situated throughout the ward. But it is a pleasure to make bedside rounds and use the computer without having to leave the room.)
Back in the hallway, the house officer decides to dictate her chart note. She does this in about four minutes; a typed draft will be waiting for her at the nurse's station in another five minutes. She can edit it with a pen and, since the computer recognizes her handwriting, a revised version can be created and stored instantly.
On teaching rounds, the typed, dictated notes are scanned by the
attending physician and used to follow both the patient's progress
and the house officer's understanding of the problems.
Return to Top of Page
Two great advances in the early 21st century particularly improved outpatient management. The first was a revolution in information collection and processing. Primitive 20th-century methods of handling outpatient clinic information were literally outlawed by the 2015 Omnibus Outpatient Information Management Bill, which stipulated an OOMPH system for any facility seeing patients with government-subsidized insurance (VA, Medicare, Medicaid).
OOMPH, which stands for Optimal Outpatient Management for Patients and Hospitals, was designed by MIT scientists in the first decade of the century, as a way of managing medical information, particularly in the outpatient setting where contact is apt to be brief and focused on a specific problem. It was created from the ground up based on three simple assumptions: 1) to be effective for both patient and caregiver, a non-emergency outpatient encounter should be able to be completed in less than 30 minutes; 2) without proper information a physician cannot efficiently arrive at a diagnosis and treatment plan in the best interest of the patient; 3) the cost of providing this information quickly and in a useful format, although high, would be recouped by preventing medication and diagnostic errors, no show' appointments, unnecessary repeat visits, hospitalizations, etc. Based partly on the landmark MIT Report on OOMPH, Congress passed the Omnibus Outpatient Bill on March 15, 2015.
Now, when the patient enters an outpatient facility his social security number is entered into the computer and all extant medical information is instantly accessed, going back to birth if desired; this includes all previously-printed data, radiologic and histologic images of any type, and DNA codes.
The ability to store and retrieve mountains of information is, of course, not so special. (The technology was long there, but it required federal law mandating linkage via the social security number to make the project feasible.) The true advance of OOMPH comes from its ability to choose and then display, from gigabytes of information, the data that will be most useful to the physician on each outpatient visit.
Using methods of artificial intelligence, OOMPH extracts what will likely be the most useful and important information for the particular clinic encounter, and then prints out (or displays on a flat screen - whatever method the physician chooses) the best format for quickly grasping the problem at hand. For example, the printout (or screen display) may be: a graph of blood pressures vs. medications prescribed over one year for a patient with hypertension; a flow diagram showing the patient's last four outpatient visits (from three different clinics, including two the current physician doesn't know about) and from which the diagnoses and therapy appear to conflict; a display of all MRI scans taken over the past year with all abnormal findings highlighted; or a list of all pap smear and pelvic ultrasound findings in the preceding 10 years.
The information chosen for printout or screen display is predicated on several factors, including: the nature of the clinic, initial lab results (see below), abnormal values from previous encounters, the patient's complaint or reason for coming to the clinic, clinical condition on most recent hospital discharge, etc. From this initial input, OOMPH prioritizes what information should be extracted, and how best to display it.
Of course, all the medical information is available to the physician if requested. Both the format and the nature of the information can be easily changed by voice request (as in the inpatient setting). However, a study published in 2017 showed that in less than 5% of outpatient encounters (from a variety of clinics) did the physician find the initial OOMPH display not helpful to the point it had to be reconfigured. (Other studies have showed the large amount of time saved compared to more traditional methods of managing outpatient information.)
Full implementation of OOMPH was held up for a while because lawsuits claimed it would be an invasion of privacy. The argument was that if medical data were so easily available, anyone could get it, that its very availablity infringed on all sorts of freedoms. The issue went to the U.S. Supreme court, where the judges ruled 9 to 0 in favor of the principle behind OOMPH, i.e., that physicians should have uninhibited access to a patient's medical record, unless specifically prohibited by the patient. (A medical encounter can still be kept off the system if requested by the patient or the patient's guardian; however, except in some psychiatry and adolescent encounters, such a request is rare. Most patients want their doctors to know all their problems.)
The judges pointed out that in the 20th century, when institution-dependent paper charts were the norm, anyone with a little determination could pick up a patient's chart and read it. The only real chart privacy patients had then was the inherent inefficiency of the records-keeping systems. Records were often lost, misplaced or hidden in a myriad of offices, generally unavailable even to most doctors and caregivers, let alone someone who might want to invade a patient's privacy. Thus, OOMPH was deemed not to represent a change from a secure to an unsecure system, but rather to be an inherently new technology for improving patient care, and in that sense decidedly not unconstitutional.
The second great advance was invention of the holographic blood scanner in 2007, the first device to measure both a chemical quantity and a physiologic pressure non-invasively. Placed over a patient's wrist, second generation HBS's provide pulse, blood pressure, cardiac rhythm, hemoglobin, white blood cell count, platelet count, oxygen saturation of hemoglobin, oxygen and carbon dioxide partial pressure, pH, serum electrolyes and blood urea nitrogen - and all with an accuracy that surpasses the old blood-machine technique. (The company making the device went public in 2008, and was bought out by General Electric in 2010; people who bought stock at first offering saw their investment increase 10-fold in two years.)
Now in less than five minutes after a patient has entered the outpatient facility and registered, the physician has available basic lab tests and verifiable medical information pertinent to the problem(s) at hand, and can proceed with a brief and properly directed history and physical exam. The physician has time to talk to the patient, to make sound judgments, to know what is happening and what needs to be done. The physician is empowered as never before.
Unlike the typical outpatient clinic of the 20th century, the modern outpatient clinic is a great place to work. Frustration on the part of physician and patient have been replaced by anticipation of a useful encounter.
(The NEJM is no longer printed for distribution, but is e-mailed at the instant of publication to all subscribers, who may then transfer any part to personal portable readers. Everything is electronically published in hypertext format, so key words can retrieve all relevant information in an extended, virtually infinite search. In addition, for a small additional fee, NEJM makes available on-line all the raw data on which original research papers are based. Note: For an earlier rendition of a future NEJM, see NEJM issue of July 8, 1993, page 142.)
______________________________________________________________________
VOLUME 393 JULY 1, 2025 NUMBER 1
______________________________________________________________________
Original Articles
Nurse Practitioners and the Gemini Computer
Project for Primary Care . . . . . . . . . . . . . 1
B. Asahi, T. Chang, CT Lowrey
Improved Longevity in Spastic Muscle Disorders by Low
Gravity State. Report of the NASA Moon Project. . 7
S. Sanjoori and others
Amelioration of Mid-level Radiation Effects
from the Nevada Blast using Microprobe DNA . . . 16
R. Smith, F. Redstone, C. Riley, M. Mitchell
Microprobe DNA for Downwind Victims of the Nevada Blast . 21
BJ Comroe and others
Prevention of Spinal Cord Transplant Rejection
with Bis-2-4-5 RNA Alternase. . . . . . . . . . . 26
A. Schlomo, T. Peleg, R. Yitzchak
Hepatitis Z2 Outbreak in Antwerp. . . . . . . . . 31
G. Ballate and others
Medical Affairs
Is the National Malpractice Moratorium Working? . 54
M. Mithoefer
Case Records of the Massachusetts General
Health Care Consortium
A 12-year-old "lunar baby" with failure to thrive .32
Reviews
Drugs for Amyotrophic Lateral Sclerosis37
C. Harper
The Portable Artificial Lung46
N. Newton
Editorials
The Nevada Blast 10 Years Later: What have we learned? 57
D. Whitelaw
The Gemini Computer Project for Primary Care: What Role
for Doctors? . . . . . . . . . . . . . . . . . . . 59
R. Harrington
HIV-7: Pathogen or Commensal?. . . . . . . . . . . . . 61
C. Cosgrove
Hepatitis X, Y, and Z: The Alphabet is Full . . . . . 61
D. Rapoport
Medical Intelligence
Mutation of the Cameroon "Chronic Fatigue" Virus by
Reverse Transcription RNA . . . . . . . . . . . . . . . 65
S. Sukhie
Multimedia Reviews
The Decline and Fall of Health Maintenance Organizations 66
Directory of Statistical Methods for Psychiatry - 10th ed. 66
The PDR for Recombinant DNA Products . . . . . . . . . . . 67
Robotic Surgery . . . . . . . . . . . . . . . . . . . . . 68
Correspondence
Side effects of Ridiculifin in pancreatic carcinoma . . . 69
When did dialysis die? . . . 69
Sporadic recurrence of AIDS in rural Africa . . . 70
Occupational illness at 1000 fathoms . . . 70
The electric car safety debate . . . 71
Asthma from pet snakes . . . 73
A simple cure for space shuttle lag . . . 73
More on cryogenics resurrection . . . 74
This is the last page of the book. It is mostly blank so you can
write your own future here. Where do you think you will be, and
what do you think you will be doing professionally, 10, 15, 20
years from now? How do you think the profession of medicine
will change in the next decade or two? Be as specific as you dare.
Predicting the future is impossible, but I promise whatever you
write will be interesting to read when the time comes.