Abstract
Patient-centered care has always made use of information technology. In particular, the support of decision making by doctors and therapists is a principle that has been leading since information technology has been applied—from first stand-alone electronic databases in the 1950s to modern integrated decision support systems. 1
Already much earlier in 1832 the very first (nonelectronic) example of a digital decision support system in medicine was invented in St. Petersburg. Driven by the Asiatic cholera pandemic from 1826 to 1837 Semen Nikolaevich Korsakov developed his so-called Homeoscope to give the physician an instrument to find a homeopathic remedy for patients quickly and efficiently. 2,3 To do so, characteristic symptoms of a disease were stored “digitally” as a hole in the columns of a wooden plate with every symptom placed in a characteristic raw. When a patient entered a physician's office describing their symptoms, pins were placed in a respective bar. When the bar was moved over the plate it snapped if and only if all symptoms corresponded to a certain disease.
Although the digital age was far away, Korsakov's machine can be regarded as a first binary storage with an algorithm to read out the information needed by the physician. However, it failed in the judgment of the panel of the Russian Academy of Science at that time, especially because the statistician involved abstained from commenting on Korsakov's invention, and in the course of time was forgotten for almost 150 years. 4
With the advent of “real” computers in science in the late 1950s, integrative medicine also made use of this new technology. In 1966, an IBM 1401 computer with a 16k memory was programmed for homeopathic case taking by entering coded symptoms through magnetic tape transmission. 5 Pirtkien, who led this study, suggested that the physicians' knowledge will increase when using a computer by forcing them to deal with a greater number of possibilities in diagnostics—including that of drugs. To prove this statement, he proposed a double-blind randomized trial where “a group of patients with similar diseases should be divided into two equal sections. For one section the remedy should be determined by hand, and for the other section by a computer, and the results compared” and stated: “Investigations of this kind, however, have not yet been carried out.” 5 I am not sure if this statement does not still apply today.
The author at that time as well concluded that the computer will not replace the physician and decisions are not taken away from him. In particular, he proposed that “in fact it gives the doctor more time to talk to the patient.” 5 This, however, only holds if communication between physician and patient does not suffer from using a computer. Modern technologies such as Extensible Markup Language (XML) or ontologies such as SNOMED CT indeed have eased the development of user-friendly digital applications, such as full text repositories or electronic health records (EHR) in the field of integrative medicine. 6,7 Unfortunately, due to a still existing lack of a standardized nomenclature for Integrative Medicine automated ontology-based coding compared with other medical areas needs improvement. 8
To cut this knot, physicians and practitioners not only in the field of integrative medicine, according to recent study results should be encouraged to use modern information technology in a balanced and patient-centered manner. 9,10 Under which conditions free-text data in EHRs should also be available for research is currently a highly debated topic. According to a recent study, patients might refuse to make their data available to research, if they believe that their data are unsafe. Moreover, this also might afflict the communication between practitioner and patients as information is being withheld from the practitioner. 11
In this respect, the idea of sharing the practitioner's notes might be a promising and patient-centered way of solving this information gap. But again this idea of “Open Notes,” which already is implemented in the context of integrative medicine, 12 also has ethical implications that have to be taken into consideration carefully: according to a recent summary of research, inviting patients to read their clinical notes could have the potential of a treatment that might “augment placebo and nocebo effects” by communicating the clinician's expectations. 13 Even more interesting, the content of the notes might also change to a more easier patient-oriented language. 14 Although this is a benefit for the patient, it can also result in valuable information being lost in transition.
So, after more than half a century after Pirtkien's computer experiment, where are we now? Well, again at the very beginning, I suppose! But let us hear what Lang in the same issue in 1968 stated: “With the computer […] we have an instrument which […] opens up a wide avenue of education […]. Not only will the ‘old hands' be continually re-educated and intellectually stimulated, but when this new frontier […] is created the virgin lands thereby opened up will almost certainly attract new ‘settlers’.” 15 That not only sounds quite actual but also promising, does it not?