Edward Peskin,MD Visiting Professor University of Tokyo School of Medicine New uses for the computer in medical education and clinical practice in the USA • Associate Professor, Department of Obstetrics and Gynecology University of Massachusetts Medical School, USA • Clerkship Director and Quality Officer • Member of Steering Committee, U.S. Association of Professors of Gynecology and Obstetrics Disclosure of Conflict of Interest (now required for US lectures) • Dr. Peskin has no financial connection and does not get any financial gain related to any of the products discussed in this lecture Computers in medicine rapid expansion in USA • Uses: – Medical education at all levels – Point of service medical information (especially diagnostic, treatment, and medications) – Medical research Computers in medicine in USA uses (continued) • • • • Electronic medical record Electronic billing Electronic prescribing Collection of data to determine quality of care and quality of medical education Why is use of computers in medicine increasing rapidly in USA – Availability of high speed connections 高速インターネット接続の利用が可能になった – Availability of personal digital assistants(=PDAs) Cell phone-PDA combinations will be available soon 個人用携帯情報端末（PDA）が出現した まもなく（PDA）と携帯電話の一体化が実現する – Availability of wireless connections ワイヤレス接続が可能になった – Decreasing cost of hardware and software ハードウェアとソフトウェアのコストが低下した Why is use of computers in medicine increasing rapidly in USA • The public and government are demanding increased quality of care and documentation of this quality 医療の質向上とその記録を残すことが政府と社会から 強く求められている • computers can help in these areas コンピュータにはこの分野をサポートできる Why is use of computers in medicine increasing rapidly in USA – Amount of medical information needed to practice medicine is become too great to access without computers 医療に必要な情報量が増え、コンピュータなしでは もはやカバーしきれなくなった Example of too much information -- 40,000 new English language medical journal articles published monthly -- 1-2 new drugs approved on average each week in USA “A physician who reads all day long for 6 weeks will already be a century behind.” (Criswell, JAIA 2002) How can computers improve quality of care and document that quality? • Mistakes in communication are less likely with typewritten word than handwritten word 意思伝達ミスは手書きよりもタイプ文書のほうが起こりにくい • Computers can be programmed to find errors in dosage, name of medication, medication interactions, and in preventing medicines getting to allergic patients or the wrong patient 用量、薬品名、相互作用、アレルギー、患者の取り違えなど のミスを発見するようコンピュータをプログラムできる How can computers improve quality of care and document that quality? • Computerized records are less likely to get lost or be unavailable than paper records 電子化した記録は紙の記録よりも紛失しにくい • Computerized patient information can be electronically transmitted from one desktop computer or personal digital assistant to other very rapidly with little chance of error. 電子化した患者の記録はPDAに瞬時に転送可能 • Information can be transmitted between hospitals even over long distances. 病院間で情報の転送が可能 How can computers improve quality of care and document that quality? • Computer programs can easily collect data such as: – Mortality (required by US regulators) 病院別の患者死亡率 （米国では報告が義務付けられている） – Number of patients seen 医学生と研修医が診療した患者の数 – Number of patients with certain diagnoses seen (required by US medical school and residency regulators) 疾患別の患者数（米国では医学部と研修施設に報告が 義務づけられている） How can computers improve medical education • Decrease the amount of class time where the professor is giving information that could be better learned through computer programs コンピュータを介するほうが学びやすい情報があれば、教室 での授業で教員が割く時間を短縮できる • Increase the amount of time in class available to answer questions and concentrate on confusing or difficult topics 質疑応答や難しいトピックの検討に、より多くの時間を割く ことができる How can computers improve medical education • Teach medical students and residents how to efficiently get the most accurate and useful data through computer programs コンピュータプログラムを通じていかに正確で便利な データを効率よく収集するかを伝授する • This will reduce the amount of information that they need to memorize and reduce the chance of an error due to faulty memory 記憶する情報量を減らし、記憶違いによるミスを減少させる How can computers improve medical education • The current system of reading journals and books after medical school and residency requires a large amount of time. This same information can be more efficiently obtained via computer programs that have collected the most useful information 医学雑誌・書籍の情報は、最も有用な情報だけを集めたプログラム を通じて閲覧することが可能 • Give medical students and residents computer knowledge that they will use for all of their life in order to stay up to date in their specialty 医学生や研修医に、各自の専門分野の最新情報に精通するために 生涯使えるコンピュータの知識を与える What are the disadvantages of computer use in medicine? • Requirement that anyone using computers know how to type quickly コンピュータを使いこなすには速くタイプすることが要求さ れる • Extra time and effort needed to get familiar with a new system 新しいシステムに慣れるのに余分な時間と労力を要する • Discomfort with a new way of practicing medicine 診療に新しい方法を取り入れることに抵抗を感じる What are the disadvantages of computer use in medicine? • Fear that data will be permanently lost due to computer malfunction PCの故障による永久的なデータ消失の恐れ • Fear of computer problems that the user cannot solve ユーザが解決できないコンピュータの問題発生の恐れ • Fear of violation of patient confidentiality 患者の機密情報が侵害される恐れ • Some computer uses can increase the amount of time needed to get work done コンピュータの使用により、かえって仕事が増える場合も What are the disadvantages of computer use in medicine? • Fear that computerized data can be used by the legal system against doctors and hospitals パソコン上の情報が医療者の意思に反し、裁判などで使わ れる場合も • Fear of making the interaction between the patient and doctor more impersonal because the computer gets in the way コンピュータの介入で、医師と患者の関係が人間的感情を 交えないものになる恐れがある • Initial cost to introduce a new system 新システムの導入に初期費用がかかる When you first start using computers for medical information • It will feel like a struggle and it can be painful! After the initial struggle You will feel accomplished You will wonder how you were able to function without computerized medical information How do we decide if the benefits of medical computer use are greater than the disadvantages? コンピュータの使用で生じるプラスがマイナスを上回るかどうかを どう見極めればよいか？ • Lets look at some computer programs so you can decide if they are worthwhile いくつかのプログラムの利用価値を検証 してみましょう The use of mobile technology in medical practice and education 医療と医学教育での携帯技術の利用 • This is the major difference Dr. Peskin has noticed between the practice of medicine in the USA and in Japan • Mobile computer technology is widely used in the USA. Currently, the most common device used is the Personal Digital Assistant which is commonly called a PDA. PDAs are one type of mobile computing 携帯型パソコン技術は米国では広く用いられている。もっ とも一般的なタイプはPDAである。 Other examples of mobile computing • Clipboard size computers ノートサイズのパソコン • Cell Phone Personal Digital Assistant Combinations 携帯電話とPDAが一体化したもの Use of Mobile Technology in USA: • Approximately 40% of U.S. doctors use Personal Digital Assistants 米国の医師のおよそ40％がPDAを使用している。 An increase of 50% since 2001 (Forrester Research 2003) -- • This is projected to grow to >50% by end of 2004 and >75% by 2007 (Gartner Research 2002) • 2004年末には50%に、2007年末には75%に達する見込み Usage high for all specialties すべての専門医が高頻度で使用。 -- American College of Physicians (US Internal Medicine Physicians) found nearly half of members using Personal Digital Assistants in 2001 2001年、米国の内科医のほぼ半数がPDAを使用。 -- Specialist use high among cardiologists, anesthesiologists, psychiatrists, oncologists (Rowan Group, 2001) 心臓外科、麻酔科、精神科、腫瘍外科の医師は頻繁に利用している。 Use of Mobile Technology in USA Drug Reference Scheduling Charge Capture Dictation ePrescribing Clinical Notes EMR Hospital Interface Download Labs Other 0 20 40 60 % MDs Using the Function Source: Health Information and Management Systems Society, 2002 80 Why US physicians like Personal Digital Assistants アメリカの医師はなぜ個人用携帯情報端末が好きなのか • • • • MAJOR REASONS Improves patient safety 患者の安全性を高める Improves efficiency 効率を良くする Keeps the physician up to date 医師自身が最新情報に精通できる US Physicians Were Asked If Mobile Technology is Useful • Consensus among users that PDAs have potential to improve patient safety and streamline care 医療の安全性と能率的治療に役 立つ潜在的な力があるとユーザ は理解している •Even nonusers recognize these potential benefits Strongly Agree Users Nonusers Agree Neutral Disagree ユーザでなくてもこうした利点を 認めている Strongly Disagree Source: Carroll, Pediatrics 2004 Decrease Medical Errors Improve Efficiency Improve Information Access Improve Reimbursement “Physicians reported that use of Personal Digital Assistant-based applications prevented an average of 2 adverse drug events” Bates, JAMA 2001 Why do Personal Digital Assistants Improve Safety? なぜPDAは安全性を高められるのか The reason why safety is improved with mobile computing •Insufficient drug and drug interaction information are the most common causes of serious errors and is easy to obtain with mobile computing 薬品と薬品の相互作用に関する情報不足は重大な医療 ミスを引き起こす一番の原因。しかもこうした情報は携帯 パソコンで簡単に入手可能。 • Even if your pharmacy has a computer program to warn about drug incompatibility: 薬局側で、飲み合わせの危険性を警告するソフトウェア を持っていても・・・ • They have to call the physician about an error 医師に報告し、判断を仰がなければならない。 • The physician has to review the chart, and the patient has to wait for an answer 医師がカルテを調べる間、患者は回答を待つことに。 • The patient may be at risk if the pharmacy does not catch the error or if the patient goes to more than one pharmacy. 薬局がミスを発見できない場合、また、患者が複数の薬局 に行った場合、患者は危険にさらされる。 What is the proof that Personal Digital Assistants Improve Patient Safety? PDAが患者の安全を守ることの証明とは This is a new field research is limited. Initial studies are encouraging Clinical Utility of Mobile Technology: • Numerous reports suggest that use of mobile or wireless technology can improve patient tracking and exchange of patient information among medical staff 携帯／ワイヤレス技術により医療者間での患者に関する情報の特定と 共有が改善される • Applications include: -- Sending wireless alerts for physiologic, laboratory and medication data 検査結果や処方について緊急の警告を無線で送る -- Managing transition between house staff 医療スタッフ間の情報伝達 -- Reducing handwriting error by handheld data entry 手のひらサイズのデータ入力で手書き文書のミスを減らす Research on Mobile Technology in the treatment of asthma Compliance to US national asthma guidelines was measured before and after introduction of PDAs containing the guidelines 米国喘息ｶﾞｲﾄﾞﾗｲﾝを収めたPDAを導入する前と後で、そのｶﾞｲﾄﾞﾗｲﾝに準拠 する割合の変化を調査 • Use of PDAs was associated with increased use of the asthma guidelines in patient evaluation and drug therapy PDAの使用は喘息患者の評価と薬物治療に使われる喘息ｶﾞｲﾄﾞﾗｲﾝの利用 増加と関連する Source: Shiffman, Pediatrics 2000 More research on Mobile Technology in Medicine: • Use of Personal Digital Assistants has been found to improve documentation and patient follow ups by emergency medicine residents (Bird, Academic Emerg Med, 2001) PDAを使用することで救急の研修医による診療記録と患者の経過観察が改 善した • Use of personal digital assistants by patients awaiting transplant surgery has been shown to improve admission condition (Szynal, Health Data Management 2001) 移植手術を待つ患者がPDAを使用することにより、入院中のコンディ ションが改善される Why Many US Physicians Think that Mobile Computing Improves Efficiency アメリカではなぜ多くの医師が携帯端末を使 うと効率が向上すると考えるのか Mobile Technologies Effect on Efficiency in the Office: -Helpful in the office where patients are seen quickly and desktop computer availability can be limited. デスクトップPCでは利用できる場所が限られるが、携帯端末ならば 患者を診ながらすばやく検索できる -When desktop computers are shared, it requires that each doctor have password access to the computer. This extra step can get in the way of efficiency. デスクトップPCを共用する環境では、各医師がパスワードでア クセスするが、PDAならばその必要がなく効率的である -PDAs do not have this same problem since they are inexpensive and small enough that each physician can carry their own. PDAにはこうした問題がなく、手ごろな価格で小型であり、 医師一人一人が自分用に持ち歩ける Mobile Technologies Effect on Efficiency in the Hospital: In both the hospital and the office, diagnostic and treatment help is often needed quickly for efficiency, and sometimes for emergencies where finding a book would be too late. 診断と治療には効率が求められ、時には緊急を要するもの。本を探す余裕 などない。 PDAs are easily updated either by attaching to your computer or by wireless so that you have access to the latest warnings concerning drugs and treatments, and to the latest advances in your field. PDAはパソコンに接続するだけで簡単に情報をアップデートでき、薬品・治 療に関する最新の警告、専門分野の最新情報を入手可能。 Does Mobile Technology Get In The Way of the Doctor-Patient Relationship? 携帯端末は 患者と医師のつながりに影響するか Patient Satisfaction with Mobile Technology: •Personal experience in the USA indicates that patients accept -- and view positively -- use of handhelds in the physician encounter 米国での個人的経験から患者は医師が携帯端末を 持つことには好意的である • They appreciate that the doctor is being careful and precise and getting the latest information 患者は医師が治療に正確さを期し、最新情報の入手を怠 らない姿勢を歓迎する Patient Satisfaction with Mobile Technology: • PDAs are an important opportunity for patient education PDAは患者の教育に重要な機会を与える • Use technology to engage patient in discussion of disease management 病気の管理に患者自身を参加させるのにこの技術は使える • Interactivity makes patient a partner in treatment plan -- E.g., Epocrates Framingham Risk Calculator 相互にやりとりすることが患者に治療計画のパートナーとしての 自覚を促す Involving the Patient with Mobile Technology: An Example Framingham Risk Calculator Demonstration Effect of Mobile Technology on Medical Education 医学教育における携帯技術の効果 Up to date information is available instantly when needed. 最新情報が必要なときにすぐ使える Studies have shown that learning occurs best when there is an immediate need to know 研究結果が示すとおり、最良の学習効果が出る のは知りたいときに学ぶこと Research on the Effect of Mobile Technology on Medical Education Use of PDAs improved learning of evidence-based medicine PDAの利用によりEBM（症例に基づく医療）の学習が改善 (Leung, British Medical Journal 2003) The Future of Mobile Technology in the USA: New Developments •electronic prescribing •Wireless alerts 無線の警告 •Allow doctors to do continuing medical education どこにいても医学の学習の継続が可能 anywhere •Combination of the PDA and Cellular Phone in one device will increase convenience PDAと携帯電話の一体型ツールでより便利に Adoption of Mobile Technology: • Many users quickly find personal digital assistants an invaluable addition to clinical practice 多くのユーザがPDAを使ってみてすぐ臨床に不可欠な道具 であると認識する -- “Several American Association of Family Practice members reported that the purchase of their first Personal Digital Assistant was the most significant practice enhancement they made all year” (Reider, Medscape 2002) 複数の米国家庭医療学会会員が、PDAは年間で診療の質を向上さ せたものとしてもっとも重要なものと報告した -- “I’d rather be without my stethoscope than my PDA” 「私はPDAよりむしろ聴診器のほうを必要としない」 Now I will give you a Mobile Computing Demonstration Hardware is PalmPilot Software is Epocrates Information on Epocrates • Epocrates is not available in Japanese at this time • Medications are updated weekly • It is available for either desktop or personal digital assistant • Unlike “up to date,” drug companies help pay for this product which makes conflict of interest possible • This is the most popular US PDA program Information on Epocrates • EpocratesOnLine is for desktop or laptop computers and is free for first month and then costs US$60 each year • Epocrates for Personal Digital Assistants has two versions • Free version-more limited • Complete version-US$60 each year If you want to try the free month of the desktop/laptop version • It is very easy to sign up • Go to – Epocratesonline Thank you • Any Questions? NEXT PRESENTATION BY DR. PESKIN Dr. ペスキン次回講演会のお知らせ TOPICS for the Next Presentation • INTEGRATION OF THE BASIC SCIENCES WITH BEDSIDE LEARNING: 基礎医学教育と臨床医学教育の統合： • • • • EXAMPLES FROM THE U.S. 米国の事例 HOW TO DO THIS 実行するには WHAT ARE THE PROBLEMS 問題点 CAN IT REALLY WORK? 実際にうまくいく？ TOPICS for the Next Presentation • FEEDBACK FROM MEDICAL STUDENTS ON FACULTY TEACHING 医学生からのフィードバック • EXAMPLES FROM THE US 米国の事例 • DOES THE USE OF STUDENT FEEDBACK FOR FACULTY PROMOTION IMPROVE THE QUALITY OF MEDICAL EDUCATION? 学生による教員評価を教員の昇進に利用することは 医学教育の質の改善につながるだろうか
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