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Fast access to data aids decisions THE PROFESSIONAL


Dr. William C. Dooley's bedside manner is distinctly modern. He makes his rounds at Johns Hopkins Hospital with a computer under his arm.

A quick tap on the keyboard and he can call up the medical records of his patients. It is part of the effort at the Baltimore hospital, an institution drowning in records, accounts and bills, to become paperless by the year 2000. More importantly, it enables Dr. Dooley, a surgical oncologist, to do a better job.

Eventually, he predicts, he will be able to look not only at his own patients' histories but at similar cases across the country, consult doctors in other hospitals and search through any medical library -- all within seconds, all at the bedside.

The trend carries enormous implications for the cost and quality of medical care -- a major national concern. It also may intensify troubling ethical issues about whether to prolong life when "the numbers" suggest otherwise.

Right now, Dr. Dooley's vision is missing only the portable communications link between the bedside and a host computer, but this gap is likely to be filled in a year or two at most.

The American Medical Association is preparing to issue the first computer disk giving doctors access to a synthesis of the best literature, expertise and advice on 200 ailments. Guidelines to diagnosing and treating another 1,300 ailments will eventually be available electronically to doctors.

Easier, more timely access to information, the American Medical Association reports, has already been linked to a drop in the number of Caesarean sections recommended by doctors without any increase in fetal or maternal illness or deaths; a 50 percent decrease in deep postoperative wound infection (apparently related to better-timed antibiotic use); and a decline in the use of cardiac pacemakers.

According to Dr. John T. Kelly, director of the AMA's Office of Quality Assurance and Medical Review, more than 1,000 items are added daily to the literature of the National Library of Medicine and 5,000 medical articles are published every day.

"One of the major challenges is to try to help physicians see through that [amount of information], figure out what is relevant, what is important, what is new, what is generally accepted and provide that in a practical way," Dr. Kelly said.

Enabling this information to reach a portable computer carried by a doctor at the bedside will give doctors the power to make increasingly speedy and accurate diagnoses and prognoses.

Once the computer has a read on your condition, your chances of life and death can be calculated electronically, promptly and more confidently, based on all appropriate precedents and expertise.

Within 24 hours of surgery, for example, doctors at Johns Hopkins can use a small number of measures -- less than 20, ranging from heart rate to stiffness of the lungs, from oxygen levels in the blood to fluid shifts in the body -- to enable them to predict who will survive to go home, how much time a patient will need in intensive care, and how much the treatment will cost.

Also, immediate bedside access to patient records would prevent duplication of tests. Currently, more than one in three lab tests is redundant, says Dr. Dooley, but is ordered because the bedside doctor is simply unaware of previous tests. The savings here could be substantial.

On a more profound level, the computer's ability to assemble information on similar cases from across the nation or world can point immediately toward the likeliest cause of illness and the most appropriate response.

Finally, the accurate prediction of the likely time of death could eventually enable doctors to decide with near-certainty when further treatment becomes a waste of money.

Dr. Dooley says half of all health-care spending occurs in the last 90 days of life. If it can be ascertained through technology when a patient actually enters the last 90 days of life, the appropriate treatment outlays can be assessed.

But whatever advances technology allows, the AMA's Dr. Kelly cautioned against presuming it would provide absolute certainty prognosis.

TH "If there is one uncertainty in medicine, it is certainty," he says.

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