This is the 75th #WILTW
At some point in the future…
It is late at night. A doctor in an Emergency Department has just reviewed a nine month old infant. He clicks “discharge” as a final instruction into the hospital’s electronic medical record (EMR) system. An algorithm kicks into life and compares the initial observations of the child with its most recent set. It highlights a persistence of a slight tachycardia for age (calculated against a perpetually updated data set of all the children presenting to the hospital over the last 5 years) despite a lowering of the child’s temperature. A voice analysis device, installed into all cubicles, detects hesitancy and doubt in the mother. Finally it notes a cousin of the child (the EMR matches against all possible genetic records) died secondary to pneumonia when only 6 months old.
This combination of findings prompts an alert. A video of the child (all patients are monitored in real time) is sent directly to the audio-visual doctor arbitrator (ADA) who cancels the discharge and alerts a senior clinician to review the child.
While this may seem Orwellian it is not an inconceivable possibility. Hospitals already have the ability to constantly record patient observation data and some have explored the use of constant video recording. It is possible to undertake sentiment analysis on people’s speech and there is no current reason why third parties (especially if not human) would not be able to match patient records looking for risk factors for immunodeficiency or genetic disease if it would be in a patient’s best interest.
So if we accept the technology is possible when should an ADA be called? In the dying seconds of the Australia vs Scotland Rugby World Cup Quarter Finals Australia were awarded a controversial penalty. The conversion of the penalty resulted in Australia stealing victory from Scotland. Had it been reviewed by the Television Match Official (TMO) it probably would not have been given. However rugby laws did not give the referee the option of seeking TMO assistance in this case. But should all decision be reviewed by a third party? The sporting community would wince at such an infringement of the rapid, spontaneous nature of contact games.
What of medicine when patient safety is stake? Clearly capacity is a obvious obstruction – not all patients can be directly reviewed by someone more senior (although currently certain high risk groups are afforded this in emergency medicine.) So who chooses?
The Doctor – well useful if they are not sure but most mistakes will be unconscious error i.e. you can’t predict when you are going to make a mistake or otherwise you wouldn’t make the mistake….
The Patient – Could lead to a paradigm shift. We know parents may be as good, if not better, than health care professionals at detecting serious deterioration. In Australia there is a system called Ryan’s rule enabling the public to ring a hotline if they think a bad decision has been made about a family member.
A Computer – As in the example there is no reason why algorithm based technology could not be used to identify those patients who have management plans that might go against standard practice (which could be to discharge or admit).
A Watcher – Could there be a permanent virtual referee as an ADA? Observing from a distance and picking patients at random, or perhaps by gestalt and experience, for closer inspection.
So will ADA’s transform medicine or as in the Rugby World Cup just create another mechanism for potential system failure. And do we know what the conditions are for when they should be used? Given that almost anyone would agree a third party opinion is useful when a difficult medical decision has to be made is it now a question of when rather than if?
What have you learnt this week? #WILTW
…entirely randomly during the writing of this piece @natalieblencowe drew my attention to this:
— The BMJ (@bmj_latest) October 22, 2015