I read with great interest the white paper by Greenes and Lorenzi, “Audacious Goals for Health and Biomedical Informatics in the New Millennium.”1 As a primary care physician (PCP) I was particularly excited about their vision for the personal clinical health record (as if we need yet another descriptive term for the EMR, CPR, etc). In conjunction with Schoolman's viewpoint article, “Then and Now and When,” in the same issue,2 it appears that I, along with the 49 percent of physicians practicing primary care, will be gone in the next ten years. This is fascinating!
Although they refer to providers, Greenes and Lorenzi allude to them as a “new generation of intelligent agents to assemble, record, and update individuals' data.” Schoolman insists that PCPs are already extinct, having been replaced by physician assistants. On the contrary, PCPs have hired and worked with physician's assistants and nurse practitioners for years. They have their roles, and PCPs have theirs.
As implied by Dr. Schoolman, anyone can ask a question. The value of a history of present illness, however, increases with the training and experience of the person who obtains it. There is a notable jump in responsibility and training between the physician's assistant, nurse practitioner, and PCP. All are valuable, and all have their role. Patients recognize this and are able to choose. To attempt to re-engineer the primary care system to fit the informatician's EMR formats is foolish. Primary care physicians have interacted with patients for thousands of years. The system has undergone change through natural selection. An attempt to change this artificially would meet with predictable resistance from the general population.
The real problem is not that the primary care base is ineffective in gathering data but that the informatics community has failed to give PCPs the necessary tools. No more than 4.5 percent of PCPs utilize the EMR.3 This number has not changed since the AMIA proposal of 1993.4 Wouldn't it be easier to develop software and hardware more suitable to the ways PCPs interact with patients in every possible setting? The present-day PCP and practice owner deals with problems to which medical informaticians have been oblivious.
There are some benefits to the 30,000-ft., global view of medicine expressed in the articles by Greenes and Lorenzi and by Schoolman. None of these benefits applies to the microenvironment of the PCP office and patient encounter. Heavy cloud cover mars their view of these critical areas.
References
- 1.Greenes RA, Lorenzi NM. Audacious goals for health and biomedical informatics in the new millenium. J Am Med Inform Assoc. 1998;5(5):395-400. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Schoolman HM. Then and now and when. J Am Med Inform Assoc. 1998;5(5):401-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Family Practice Statistics. Fam Pract Manage. 1997:4.6.
- 4.Board of Directors of the American Medical Informatics Association (AMIA). The standards for medical identifiers, codes and messages needed to create an efficient computerstored medical record. J Am Med Inform Assoc. 1993;1(1):1-7. [DOI] [PMC free article] [PubMed] [Google Scholar]