We live inundated with promises that technology will solve our most challenging problems, yet we are regularly disappointed when it does not. New technological solutions seem to appear daily, and we feel like we are falling behind if we do not jump to join the people who are implementing, selling, or imposing new solutions. Often these solutions are offered before the problem is even fully understood, and no assessment has been made to determine if the solution actually helps to solve the challenge identified. With 80% of us now having transitioned to EHRs, we know full well their benefits as well as their pitfalls. While we have mostly accommodated to electronic documentation, we are now at the point where we are beginning to explore some of the most exciting potential benefits of our EHRs – population health, enhanced data on medication adherence, and improved patient communication. As we look at this next stage of growth, we are reminded of a lesson from an old joke:
A rabbi dies and goes to heaven. When he gets there he is given an old robe and a wooden walking stick and is told to get in line to the entrance to heaven. While the rabbi waits in the long line, a taxi driver walks up and is greeted by a group of angels blowing their horns announcing his arrival. One of the angels walks over to the driver and gives him a flowing white satin robe and a golden walking stick. Another angel then escorts him to the front of the line.
The angel turned toward him, smiled, and shook his head. “Yes, yes,” the angel replied, “We know all that. But, here in heaven we care about results, not intent. While you gave your sermons, people slept. When the cab driver drove, people prayed.”
As we look ahead to the next generation of electronic health records, there are going to be many creative ideas of how to use them to help patients improve their health and take care of their diseases. One of the more notable new technologies over the last 5 years is the development of wearable health devices. Innovations like the Apple Watch, Fitbit, and other wearables allow us to track our activity and diet, and encourage us to behave better. They do this by providing constant feedback on how we are doing, and they offer the ability to use social groups to encourage sustained behavioral change. Some devices tell us regularly how far we have walked while others let us know when we have been sitting too long. As we input information about diet, the devices and their associated apps give us feedback on how we are adhering to our dietary goals. Some even allow data to be funneled into the EHR so that physicians can review the behavioral changes and track patient progress. The challenge that arises is that the technology itself is so fascinating and so filled with promise that it is easy to forget what is most important: ensuring it works not just to keep us engaged and busy but also to help us accomplish the real goals we have defined for its use.
Wearable technology is now the most recent and dramatic example of how the excitement over technology may be outpacing its utility. Most of us have tried (or have patients, friends and family who have tried) wearable technology solutions to track and encourage behavioral change. A recent article published in JAMA looked at more than 400 individuals randomized to a standard behavioral weight-loss intervention vs. a technology-enhanced weight loss intervention using a wearable device over 24 months. It was fairly obvious that the group with the wearable device would do better, and have improved fitness and more weight loss. It was obvious … except that is not what happened. Both groups improved equally in fitness, and the standard intervention group lost significantly more weight over 24 months than did the wearable technology group.
There are many reasons that this might have happened. It may be that the idea of this quick feedback loop is in itself flawed, or it may be that the devices and/or the dietary input is simply imprecise, causing people to think that they are doing better than they really are (and then modifying their behavior in the wrong direction). Whatever the explanation, seeing those results, I think again of the moral handed down though generations by that old joke – that here on earth we need to care less about intent and more about results.