Photo from Biometric Devices: Current Attitudes and Trends, a collaboration with Phil Balagtas
“These don’t work.” Dr. Bradley Monash, a young doctor said as he walked briskly towards three COWs in a hallway at the UCSF Medical Center. He’s not talking about animals grazing in the hospital. COWs are an acronym for Computers On Wheels, rolling desktop computers enclosed in plastic housing. The day I visited, three of these big beige units were parked unused, against a wall, around the corner from the nurses station. They can be wheeled into patients rooms, but if patients are contagious, the doctor takes notes on paper, or leaves the patient room to update the terminal. Perhaps their most lovable quality is their non-medical name, but it’s also their barnyard name that expresses their awkwardness in the hospital setting. As an interaction designer, I am trained to look for broken things, to investigate behavior, and to question improvised workarounds to problems. As I watched Dr. Monash sit down at a working COW, I realize he’s speaking hyperbolically about his diagnoses. The outdated computers are perceived to have little remaining function compared to newer, faster mobile device alternatives, which leads me to question, what are the current information technology needs of clinicians? Looking at a current information vehicle, the Apple iPad, I realize we are just beginning to understand its possibilities. The iPad is changing the way we live our lives and how doctors care for patients.
I follow Dr. Monash through his account of a typical day at UCSF. He logs into a desktop computer to check lab results, find information on a particular illness, record information from his rounds, communicate with staff, and to stay informed about new developments in medical practice. He uses several different databases. In all, he spends a lot more time using a computer than I thought he would. I infer too, that it’s even more time than he imagined he would spend when he attended medical school and later when he chose to specialize in care for very sick patients. As we pass the nurses station, he points to binders containing paper forms and records, evidence that digitized workflows in modern medicine have not fully been realized.
One reason is that the hospital’s information systems have changed faster than the hospital’s floor plans. Even if the COW units were able to keep up with the fast pace of Dr. Monash, and they did not rely on humans to remember to plug them back in (another one of his complaints), they still would not be close enough to a telephone, to the nurses station, or to the social comfort of other people. I empathize with his frustrations. Hospital staff are often hurriedly computing, but it must feel lonely to work in the hallway– a makeshift work space.
Dr. Monash takes his iPhone out of his pocket. He has over 20 medical applications, he says but he hasn’t used them all yet. I take a moment to ponder this. When else in the history of human civilization have we kept tools in out pants, without the full knowledge of what these objects can do, or how they can help us? These devices are not really even tools. They are toolboxes of unlimited size. With mobile technology, he’s hoping to ease his burdensome workload. The efficiency of a digital device could keep needed information literally at his fingertips. As I discuss the iPad with him, I can sense his excitement. It has the promise to make his job easier and to change the way he cares for patients.
Dr. Monash specializes in Hospital Medicine, the discipline that focuses on the site of intervention–the hospital, rather than the age of the patient, or a particular organ of the body. It’s a field which balances both patient care and systemic problem-solving. In addition to seeing patients, these physicians, called hospitalists often manage quality initiatives. His supervisor, Dr. Watcher helped coin the hospitalist term. Dr. Monash explained all of this to me by typing “hospitalist” into Wikipedia and clicking on a blue link to show me Dr. Watchler’s blog. It’s the first time that I’ve surfed the internet in a doctor’s office and I’m struck by how ubiquitous medical information is influencing hospital care.
When Steve Jobs, the late CEO of Apple unveiled the new computer tablet in April 2010 called the iPad, he referred to it as a “magical” device. Several people in the crowd snickered, but by magical perhaps he meant that this object has surpassed a person’s ability to understand how it function. Sure, it is essentially a larger version of a pre-existing Apple product. We know that the iPad was designed in-house by Apple’s rather secretive design team. It relies on many different technologies, such as a nano-technology computer chip design, a multi-touch user interface, a liquid crystal display, individually precision-machined aluminum unibody enclosures. The interactive surface, the part of the object that people can feel and control with their fingertips, appears to be just a piece of glass. Jony Ive, Senior Vice President of Industrial Design describes the way that the object has been reduced to its bare essentials. “There’s no pointing device and there isn’t even a single orientation. There’s no up. There’s no down. There’s no even right or wrong way of holding it. I don’t have to change myself to fit the product. It fits me.” Ive argues that the iPad is one of the first interactive objects created in which a person is not customizing the object, but that the physical object is customizing itself.
Mobile technology like the iPad is offloading responsibilities from the doctor and it’s likely that its succeeding technology will continue to do so. The ability and memory of the machine to retain data has eclipsed the memory of the human and the need to remember medical information independently. I begin to think, at what point, will the iPad become the doctor? It is already increasingly common to not see a doctor when one visits the doctor’s office because expert medical care is becoming less common. A growing shortage of physicians has increased the need for less-skilled doctors, like nurse practitioners. Medicine is moving from diseased-based treatments to symptom-based treatments, as says Richard Thayler whose small Californian company, the Catalysis Foundation aims to treat tuberculosis more effectively by harnessing mobile technology in third world countries to assist low-skilled doctors in making more accurate diagnoses. Telemedicine, the field of providing healthcare remotely through technology is a growing field. Admittedly, the far away doctor is less ideal than a visit to one’s doctor in person, but the introduction and implication of virtual practices means that more people in more areas have access to doctors.
Looking at the iPad through the lens of a medical device, there is extraordinary potential. With Apple’s open-source software initiative, developers have created hundreds of applications for the device. Epic, the major electronic record developer, has released an iPad application. There is a demand for compatible peripherals to be designed that could help automate, record, and communicate procedural tasks such as measured blood pressure, heart rate, and other vital signs. As with the introduction of any of technology, there is also the potential for safety concerns. Like the COWs, the iPad will have to withstand hospital disinfection procedures and theft.
Design philosopher Vilém Flusser argues that the problem with technology (which he calls non-things) is that it is not able to emote. If we apply Flusser’s critique of technology, to the COWS at UCSF we realize their sense of coldness- these machines are not able to feel, to express those feelings, to live or to die in an environment that cares for the living. Dr. Monash describes the current inabilities of the iPad. He tried to reassure me, “It can not provide empathy or the healing power of the human touch.” The object to person relationship can not yet replace an interpersonal relationship, but I realize we’ve only seen the first two models of the device. With the agglomeration of interconnected technologies contained in a specific device, technology is changing at an unfathomable pace. This pace not only exceeds our ability to understand how the complex object functions, but it also threatens to break our distinction between things and non-things. The futurist Ray Kurzweil predicts that this transcendence where the thing and non-thing become one will be called “The Singularity”. He writes, “The Singularity will allow us to transcend these limitations of our biological bodies and brains … There will be no distinction, post-Singularity, between human and machine.” One could ask, can we stop ourselves from reaching this point? (Kurzweil, 9)
Throughout my visit at UCSF, I kept needing to interrupt the sharp and speedy Dr. Monash with questions to translate his doctor-speak into my medically-untrained lexicon. He seemed well-adapted to my type of questioning and patiently gave explanations for me, the non-expert. He preemptively answered some of my questions and I wonder, how does he know what I don’t know? For example, does he as a doctor know that most people understand what a hospital is, but not a hospitalist? While the iPad can access Wikipedia and find the definition of what a hospitalist is, it’s not yet as intuitive as the doctor to assume what I don’t know. The computer is not yet able to use the same kind of advanced reasoning to guide patients through medicine that websites like Google and Amazon are just beginning to do with search and e-commerce optimization. So, if the iPad knows more than Dr. Monash why am I interviewing him? Could I not just google my questions? I acknowledge that the iPad knows more about medicine, but perhaps it knows too much. With the amount of medical information it has, I also realize when seeking council of a medical professional, I am not necessarily looking for the aggregate opinion, I am looking for a subjective view. Medicine is somewhat quantitative, but it is also qualitative in its prescriptive advice. However flawed the current human perspective can be, perhaps what I was looking for was that confident, humanistic point of view that he has. I prefer talking to people than to things, but I realize that this preference might be beyond my control.
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