講演スライド

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