Slashdot Mirror
Why Digital Medical Records Are No Panacea
theodp writes "As GE, Google, Intel, IBM, Microsoft and others pile into the business of computerized medical files in a stimulus-fueled frenzy, BusinessWeek reminds us that electronic health records have a dubious history. Under the federal stimulus program, hospitals can get several million dollars apiece for tech purchases over the next five years, and individual doctors can receive up to $44,000. There's also a stick: The feds will cut Medicare reimbursement for hospitals and practices that don't go electronic by 2015. But does the high cost and questionable quality of products currently on the market explain why barely 1 in 50 hospitals have a comprehensive electronic records system, and why only 17% of physicians use any type of electronic records? Joe Bugajski's chilling The Data Model That Nearly Killed Me suggests that may be the case."
Everyone knows that everything should be computerized, since everyone knows that big, REALLY COMPLICATED data systems always work and always come in under budget.
Like the redesigned FBI data system that works so perfectly!
"I don't know, therefore Aliens" Wafflebox1
Digital Medical Records Are No Panacea... but they are pancreas!
Be relentless!
Interesting, for certain - and raises some good points for discussion in the how the system is implemented.
But it's anecdotal evidence, as much as it may affect the author, doesn't necessarily prove the point.
Major credit card companies either can't or won;t take the necessary precautions to protect credit card information. So what if there is a breach, identify theft, headaches, etc?
Now what makes you think hospitals, private doctors, etc. are going to be able to protect their data any better? They have less money then the credit card companies.
Can you imagine a million patient digital medical record breach? The black mail or power that could be leveraged over people?
Is this a US-only situation?
Or is it also true for other developing nations?
There's also a stick: The feds will cut Medicare reimbursement for hospitals and practices that don't go electronic by 2015.
I know that might seem like a really bad thing at first, but consider this. Wal-Mart, Supermarkets, and any retailer with shelf space to "sell" to companies trying to get their product sold to the end user have major pull. Most all of these stores require some form of electronic invoicing. Many will require you to pay fees if you do not, and some will simply not carry your product.
That isn't much different from Medicare. If you want to accept patients with medicare, and get paid for the service you provide, you need to use *insert desired service here*. The government is the one with the pull (they have the cash), and so they can require you to do this. All I am saying is this might not be a case of the Big Brother, but just simple market forces.
No comprende? Let me type that a little slower for you...
Wouldn't it be better to spend that money on diagnostic equipment, and outfitting small town clinics. I would rather have a piece of paper that says "repaired cerebral aneurysm" than to have an electronic file that says "died waiting for MRI".
When our name is on the back of your car, we're behind you all the way!
When my wife was in the hospital with a broken ankle I tried to get a copy of the X-ray, because it was on a big monitor out of view of the patient. The user interface of the DICOM viewer did not provide a way to print or save the image... presumably to protect patient confidentiality.
The next day I went in to the hospital to pick up the "films" for her doctor, and they gave me a copy of the same files on a CD, completely uncontrolled, and I used OsiriX to convert them from DICOM to JPEG so my wife could see them.
Having the files in digital format is great, but let's have some appropriate level of controls. If the patient wants the images on a flash stick, it's THEIR records, let them have it!
The real need is not multiple, most likely incompatible, electronics records systems. What is needed is a standard for securely storing medical records while allowing for transfer of this information to authorized parties who need it for medical purposes.
With the money, $$$, being thrown around, you know several big companies are already working on making these systems. And I am sure their accountants are already counting the monthly support contracts and other associated profits from these mega systems.
I only look human.
My mother is a halfling and my dad is an ogre, so that makes me an Ogreling
I currently work in healthcare IT (past 5 years). I used to work in food proccessing (3 years) and for a IT provider for various industries (banking, manufacturing, advertising) for 3 years. Of all the industries, I have to say that Healthcare is the worse. The software that hospitals purchase is extremely buggy. Software providers for IT, bank on the fact that the person making the final decision doesn't have any idea about IT. In other words, the doctors and administrators. Every vendor offers an EMR (Electronic Medical Record) in their software and they are different by company. Government oversight of this industry is desperately needed. If people knew the truth, they would be VERY afraid to go to a hospital.
This article reads like a lifetime made for TV movie. Heavy on emotion devoid of logic.
The author was repeated asked for his medical information, his doctor's written instructions were ignored and different departments within the hospital did not communicate. Therefore the problem is Obama's computerized data record system that doesn't exist yet.
The whole time I was reading it I was waiting for the author to tie his experience to how computerized medical records are bad. He never did, his experiences were caused by humans that did not care enough about patients to read computerized records OR paper records.
The author fails to explain how his experience proves anything other than that particular hospital is terrible and that the health professionals employed there are less than friendly.
I know this is slashdot, but hey... I really encourage you all to RTFA. It's a near-death experience plus an in-depth analysis of the issue, with lots of links to additional information (not on wikipedia...). Worth the read.
If you take a ride in an ambulance in many states, the government already knows the details of your treatment. Not meant to scare anyone - just be advised.
More doctors. Break the back of the AMA, double the seats in medical school and let the market do more of the talking.
The tired old argument of "fewer, but better doctors" is bullshit. You know what they call the guy who barely got through medical school the day he graduates? "Doctor!"
All of the regulations miss the point entirely. There are not enough doctors, not enough competition. Even the "evidence-based medicine" advocates miss the point about mandating "best practices" when you have people like the orthopedic surgeon who treated my mother. The man was 15-20 years out of date on certain techniques, and did them according to the way he was trained, and screwed the pooch big time. A doctor at UVA medical school had to intervene to get her back to normal.
People like that couldn't exist in other professions that are less regulated and coddled. Imagine someone only knowing C/C++/Ada circa 1995 today and trying to compete in the mainstream software development market for new development work. It's laughable here, but doctors get away with that.
In a perfect and honest world this would be a good tool.
However I dont trust the governemnt being able to pull anything off on such a scale without a) making non functional, and b) winding up writing legislation that allowis insureres and pharmeceuical agencies datamine to screw us.
Why not start cutting costs by reducing the 30% overhead provate insurance has!?
the article did point out a lot of problems, but HIPAA is the culprit. It was passed in 1996 and took effect a few years ago. it says medical info has to be controlled so that only the people who need to know, get to know about your condition.
Any electronic data model has to be built around this. and medial people are as scared of HIPAA as other people are scared of SOX and everyone goes overboard
... and here we have just a single anecdote about how the system did not work in one instance. If we are playing the anecdote game, I'm sure I can find a similar example where non-computerized health records lead to bad care. Of course, while the anecdote game is very effective at playing at human emotional response (we tend to assign more weight to a story that we can associate with a single person versus aggregate statistics), it's useless as an actual policy question.
Since every complicated system has failures, even the critical ones like hospitals and air traffic control, the important policy question is not whether it works in all instances, it's whether it produces overall better care than the system it's replacing and whether that improvement is worth the difference in price. If the new system actually reduces costs, then it's a good idea so long as it doesn't degrade care (since, ultimately, reduced cost means either more health care or more dollars to satisfy other wants).
I'm not going to comment on the data myself, since you should read the studies for yourself and draw your own conclusions.
http://journals.cambridge.org/action/displayAbstract;jsessionid=7C274D08947B0625B3B540BEF2E70367.tomcat1?fromPage=online&aid=416400
http://content.nejm.org/cgi/content/abstract/348/22/2218
(PDF)
http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1421388
PS. Of course there's no panacea for our medical problem. The question is whether EHR are better than the system we've got, not whether they represent the best possible system. The perfect is not the enemy of the good.
PPS. I have a sneaking suspicion, reading my post (yeah, some /.ers actually read their own posts before hitting submit :-P) that I will be accused of not having the proper sympathy for the guy in TFA. That's not true. I have sympathy for him as an individual, but I'm not going to let that sympathy for him cloud my judgment on the merits of a system.
For example, suppose there was a highway by you that had no center divider, just a grassy median. Suppose also, for the sake of argument, that installing a jersey barrier (http://en.wikipedia.org/wiki/Jersey_barrier will lower the injury/fatality rate in accidents by a statistically significant amount by preventing out-of-control cars from going into oncoming traffic. Now, hypothetically, someone could be in an accident where the jersey barrier caused him serious injury or death (say, by flipping his car even though they are designed to minimize that chance) where the old system would have been just fine (say, because there was no oncoming traffic at the time of the accident). Does someone that still says we have jersey barriers not have sympathy for that guy? No. His death is regrettable but because we can't make a perfect road, we have to settle for the best road we can make.
The problem is that you can point to someone that's injured (and provoke an emotional response related to his regrettable accident) but the only thing the jersey barrier proponent can do is point to the statistics that say there are fewer serious injuries since they've been installed. There's no emotional resonance to the thousands of people that travel without incident each day because they don't make a good story. "Man drives to work safely" isn't news, but because it happens much more often that "Man killed in car wreck", it's actually much more important in the grand scheme of things.
We aren't privy to all the stories where EHR made things smoother, cheaper or helped prevent calamity. Largely, these will be small victories, unsung
it's really not that expensive. it's the retraining doctors and staff. an office that works with paper has to be efficient and highly conditioned. when you take away the paper and reorganize the whole flow of data, it can cripple what was a working system.
it's totally worth it, though. survival of the fittest. I won't go to a doctors office that doesn't use EMR.
Computers are great but the likes of IBM and Accenture and all the other d**khead system integrators can't design and build a business system with a UI for toffee.
Let's keep them, and by extension, computers, out of important things like healthcare...
Internet informed patients help solve this problem. Of course the Internet also helps people go off half-cocked about the dangers of vaccines and such.
All ideas^H^H^H^H^Hprocesses in this post are Patent Pending. (as well as the process of patenting all postings)
Prior to bashing an entire industry due to the fact that GE, Google, Intel, IBM, Microsoft have not put their own software into the frenzy is bull IMO.
Look at some of the offerings from leading companies, and look (or contact) hospitals that use them for EMR. You'll find a rather productive and happy group. The issues with EMR are:
1) often these hospitals/private practices are coming from a proprietary EMR solution (COBALT ftw) and are stuck in an outdated inefficient work flow (that is hard to change b/c doctors are so busy)
2) sales is eager to make a sale, and can promise delivery a bit early in relation to the amount of customizations that the CUSTOMER requests (requires) in this market highly specialized offerings are commonplace.
3) Legacy EMR systems have endless duplicates and junk records put in them to get around various insurance/billing problems forced upon the provider due to lack of insurance regulation.
To say you want to have a doctor keep everything in a paper file is the dumbest thing I've ever heard. Clearly you don't live in an area where a natural disaster could ever occur. I've moved 4 times in 5 years and am most thankful my records are highly portable and the fact that if I'm ever in need of urgent care in an area outside my town/state I'm confidant my records and medical history can be quickly and easily retrieved (and read by anyone versed in the English language.
for info on a solid EMR solution check out http://www.allscripts.com/
I've looked through the VA's code for VISTA. What unreadable garbage. MUMPS has supported functions and variables with names longer than a few characters for years now. The spaghetti-code logic is terrible. It's pretty apparent that the software was developed by multiple contract agencies over several decades when, quite literally, the left hand didn't know what the right was doing.
Also, VISTA is basically useless outside of the government-run healthcare system. Why? Two reasons: because there's no Pediatrics module, and because there's virtually no facility for capturing patient charges, since the VA is it's own payor. Unless we switch to single-payor universal healthcare in this country, VISTA is going to remain a niche product, since no one is going to develop financial modules for it. (Are there any FOSS MUMPS developers?)
Finally, my understanding was that the DoJ and the VA forked the VISTA code base a while back, with the end result that our veterans receive a brand-spanking-new, completely blank medical record when their discharged, as the systems were incompatible. That may have changed with the NHIN, but not drastically. The amount of information contained in a Continuity of Care Document isn't really comprehensive.
ObDisc: I work for the vendor of the OTHER major MUMPS-based EMR-- think Kaiser.
Nobody should think that EMR is a cure-all, but that's no reason to not use it. It will save a tremendous amount of our money and be a major health benefit once implemented in a "good-enough" way. In IT we discredit the serurity by obscurity model, and that's exactly the kind of privacy/security we have with paper records. The government can't and shouldn't guarantee privacy, but they can sure as hell make people or companies pay dearly for their privacy crimes regardless of how they stole or used the information. We should be talking about privacy laws and standards, not nonsense about meaningless what-ifs and paranoid hysteria about misuse.
Greed is the root of all evil.
To prevent this problem, you might try contacting your regular health-care provider right away. Assuming they fall under HIPAA, you usually have the right to make requests to the provider regarding how they will handle your medical records, and who can access them. Make a request that your records not be stored in a shared electronic database.
The provider can refuse the request, but few do.
(Of course, 15 years from now, when your new doctor at General Hospital does not realize that you're the ONLY patient who still has paper records in that filing cabinet at the back of the server room, there could be a problem...)
Trying to use sarcasm in text-based forums does not work.
The problem with medical records is, essentially, that our present ways of representing data lack sufficient abstraction to let us manage all of the complexity.
I've worked on systems that track what goes into just -buildings- for insurance and those have enormous interoperability problems compounded by terrible standards. Just imagine what a field like "building type" could mean across vendors. I can't even imagine what a medical records system might look like, and, it probably doesn't help that the taxonomy of medical data is not well aligned for computerization, and, doctors would probably be resistant to encoding their knowledge into an information schema of some sort. But, in fairness, the domain expertise is so well, intense that one wonders if the programmer as a generationalist of information actually fails in this case.
Bottom line is, its going to take more than a push from any administration before we really get this right. We're going to need better technology, and more progressive doctors. I think what it really means is probably some funding for academic programs that examine the fusion of medical training for IT people and vice versa.. like, maybe you could be a programmer with a specialty in medicine such that you aren't a doctor per se, but you know enough about how medical information is organized so that you can represent things.
This is my sig.
I saw my doctor last week and was presented with a new form to sign to opt-in or opt-out of putting my records into an electronic format. Being a paranoid, tinfoil-hat wearing, "I remember Diebold voting machines" kind of nerd, I opted out. The form explained what EHR's are and espoused the benefits of them. I'll continue to rely on good old fashioned paper records for now, thank you. This is very new because I lost saw this doctor four weeks before then. They also mentioned that psychiatric information will not be stored in the EHR.
In other related news:
This 2-page PDF from the Nebraska Medical Association and Creighton University Medical Center dated June 27th, 2007 gives some numbers on offices that have adopted or thinking about adopting an EHRs.
If you are a Nebraska health professional or just have too much time on your hands from hiding from the pending Swine flu pandemic, you can go to this website whose tag-line is, "Enhancing clinical practices through the adoption of health information technology in Nebraska".
Here is a letter (blog entry?) from the office of the Governor of Nebraska posted on April 10, 2009 talking about the pilot EHR project in Nebraska.
Enjoy!
Veritas patesco per quaestio questio. Truth is revealed through questions.
I've used electronic medical records in both the NHS (UK) and the United States. Cerner is the big player here and it is one of the most ugly, inefficient, and convoluted interfaces I've ever used. It makes some more famous UI messes discussed on Slashdot look line the Mona Lisa. For those of you who don't understand how electronic systems work and why there is so much resistance let me explain how a basic patient encounter works for me:
1. Do a history and physical (H&P) on the patient and record the results on paper.
2. Enter in pertinent information into the computer system about the type of management I want started.
3. Dictate my history and physical for transcription.
4. Wait several hours for the dictation to show up in the EMR. Until which time all other doctors and nurses must refer to my hand written notes.
5. Heaven forbid I have to call in a consultation from cardiology, GI, or some other specialty in the hospital. If I do, then we use our text-based pagers to figure out when the hand-written note has been dropped off because every specialty has to go through steps 1-4. As they follow these patients, they too have to physically recheck the chart since dictated H&Ps and progress notes take time to show up.
6. I can very easily see how a mistake could be made in drug dosing because computers are another step in the way. Plus dosages are selected via a regular dropdown box. All dosages of compounds are rechecked by pharmacy anyway. We can get quite a few calls from pharmacy if something is non-standard or rare.
The EMR is a few extra steps in the management of a patient and does not guarantee that mistakes won't be made. Management plans are checked and rechecked as are drug dosages.
The places where EMR is helpful is getting lab results, radiology results, and study-based information on a computer. However, we have several different systems for viewing different sorts of radiology films that can't be viewed in some types of EMR. Then there is the problem of making sure the COW (computer-on-wheels) we take on rounds has a working battery back and the Cerner database hasn't taken a dive into the deep end. If its all working then it's very helpful that old notes can be looked up without giving medical records a call to haul up a 10 volume chart on a chronic COPD patient we see every other week. Unfortunately, coding for billing is still a pain. The system is so complicated that professional medical coders are needed to maximize profits through proper billing to insurance companies and government agencies.
Another problem not addressed by EMR is the fact that every hospital and practice uses a different system. If I need records from an admission at another hospital then I still have to get a Release of Information form filled out and then hope to god the other hospital can fax over copies of the chart to me. These faxes are huge sometimes, completely disorganized, and at times illegible because notes are hand written. There is no electronic transmission. If I need radiological studies then I better pray the patient or ambulance brought copies on a DVD for us to view. Then we better hope a computer system with sufficient privileges and the right Microsoft Service Pack can run the disk. The NHS system tries to address this but I left long before the system was full operational.
The current crop of EMR systems aren't fitting in with our workflow and our IT teams aren't drawing up a way for us to deal with all the variety of systems we may need to deal with in a streamlined fashion. If a consulting company could come up with a system that worked from point of admission through discharge and follow-up (and billing) of a patient with "it just works" simplicity without forcing me to add tons of different steps then we'd have a reason for EMR. Until then, its just a disaster.
This is one place where a computer alone isn't a solution. We need a solution from start to finish that works with us. A government deadline won't solve this problem. However, if a consulting team made up of a group of doctors, programmers, UI designers, and device integrators/manufacturers got together to attack this problem in an Apple-esque way they'd be billionaires.
I suppose electronic records are inevitable.
I wonder how it will be done do capture useful info. ... its not very useful. But a list of every drug you have ever taken with dates and times could be useful. For detecting side effects.
If its just a PDF of a doctor's hardcopy scribbling
Almost universally, the development model for the major EMR vendors has been to acquire smaller companies with "the best" niche product, and then try to stick them all together with magic glue to make a full-scale enterprise EMR. They call themselves "best-of-breed", and, frankly, it's amazing that they work at all.
But they don't work well. Since most of the components of the system started out as seperate, independent software packages, they're all reliant on seperate database backends, or they don't structure data the same way. For instance, in one major vendor's product, your primary care doc has to enter your allergies in the ambulatory module, and then if you go to the ER, they'll ask you and enter it again in their Emergency Department module. Being admitted to inpatient? It won't pull in-- they ask you yet again. It's ridiculous.
Here's the shameless plug part: there is an EMR vendor out there that built their own product from the ground up in the past 30 years, so it doesn't suffer this problem. KLAS (an industry rating agency) consistently ranks it #1. Plus, really amazing corporate culture. Obligatory disclosure: yeah, I work there.
I think all Slashdot users can agree it would be terrible if Microsoft got in this game.
If this might happen, show me where to protest!
This guys rant about the medical system is more just a problem with over-worked health care professionals, and physicians who are used to doing it their own way, and has very little to do with the electronic records system in use.
One we have physicians in place that have used computers their entire lives, and are comfortable with their electronic systems then we will start to see the benefits provided by automation.
There are already organizations that are planning complete open-spec systems, it's just a matter of ensuring that the proprietary systems comply with the specifications (hl7.org)
Like all software, digital medical records can be done badly. But they can also be done right. Joe Bugajski's story is gripping, but I want to compare it with the story of my mother.
My mom was in her mid-50s when she became ill, apparently healthy but in fact hiding a serious alcoholism problem. I'll skip the details, but suffice to say that a lifetime of drinking can destroy your body's natural blood-clotting system, leading to internal bleeding. So don't drink, kiddies.
Anyway, once she was medevaced to Queen's Hospital in Honolulu, we never saw a single obvious piece of paper. Everything was recorded digitally. But the key difference between my Mom's story and Joe Bugajski's is that the data was *available* once entered. I got a chance to look over the doctor's shoulder as he reviewed her chart. He was able to look at blood tests, x-rays, up-to-the-minute vitals, every piece of data the hospital recorded, at his fingertips in seconds. And he drove the software like a pro.
In the end, my mother died, but it definitely wasn't because of bad recordkeeping software.
Just look at what it did for our favorite cooking recipes! We now manage our kitchens more efficiently as a result.
As someone who works in the medical information technology industry, I have to say that placing the blame on the software is very misleading. Software is a tool that enables doctors and nurses to better communicate by removing the cause of common errors and making patient data more readily available. The issue in the article appears to be that doctor's refused to look for the patient records, either electronic or paper.
If that hospital's CIO was uninformed enough to purchase software that does not allow different departments to communicate, then shame on the CIO of that hospital for purchasing that software and shame on the doctor's that did not go down the hall to get the records from the other department.
Having worked with Doctor's, I know that they DO make mistakes. Whether this is because they are under huge workloads (which they are, most of the time), they just do not care (I hope this is not the case), or they are lacking in training, I cannot say. However, it has been my experience that whenever a doctor does not understand a process or makes a mistake in a process, they automatically blame the software and then they do not tell anyone. This is not to say that all doctors are like this, but these are the cause of the serious errors.
The issue is not the software alone. Even if the software has bugs (and it always will) the users are ultimately responsible for the patient's care, just like when records were on paper. The software can be improved to prevent errors, but it cannot prevent the doctor from ignoring error and warning messages or from taking an ice-pick to the platters of the hard-disk.
I'm a resident physician, and so I've used various EMRs in different hospital and clinic settings, and they pretty much all suck in different ways. EPIC, which is based in Internet Explorer of all things, is the worst, but seems to the the one that's being adopted at the most hospitals.
The UI design is just horrible, but beyond that I had a hard time putting my concerns into words until I read an article somewhere that talked about something called "cognitive support to the physician." That is what most EMRs lack.
As a physician, I want an EMR that lets me rapidly get at important clinical information and give me targeted alerts that I need to make a decision. Instead, the systems are centered around billing and cover-your-ass medicolegal documentation. In the paper chart word, these issues had already diluted the meaningfulness of the chart. (Ever see a hospital chart - maybe 10-20% of it has meaningful clinical data in it, the rest is full of useless legal/billing/redundant crap.) Many EMRs just translate the same troubled paper chart system into electronic format, but then the ease of electronic data entry means that even more useless information is included/required, making it that much harder to find the info you really need to make a clinical decision.
I have to say that the best EMR I have used is still good ol' CRPS at the VA. It's not as slick looking as the newer ones, but the data is easily accessible and I have never had to waste my time looking up a billing code. It's been chugging along for over a decade, sharing data between hundreds of sites across the country. (And the issue in the first article about the EMR causing more deaths because you can't put in orders while the patient is en route - not an issue in CPRS, we do this all the time at our VA.)
My understanding is that the code for CPRS is open and free to anyone who wants it. I would gladly choose CRPS over the ability to type my notes with colored fonts in EPIC. They were considering adapting it for the large county hospital system where I work now, but in the end went with EPIC because... wait for it... it was easier for billing.
Here's how an admission would go in the middle of a typical call night: I'd get called at, say, midnight to admit a patient from the ER. I'd go down there to examine the patient and admit them, which means find out what's wrong, formulate a plan of action, and stabilize them for the night.
We actually did have a primitive EMR, which held any recently (within a year or so) dictated discharge summaries -- those are a lengthy summary of what brought the patient in last time, how it was handled, what meds the patient was sent home with. Those were available to us about 1/4 of the time, and were a goldmine of information.
The remaining 3/4 of the time, we had nothing except the patient's memory (they're ill, it's the middle of the night, majority of patients don't keep track of their long lists of meds and dosages). So I'd request the patient's chart to be found. Usually, I'd hear the following from medical records:
A) The chart will be here in the morning: they're understaffed right now (they'd have 1 clerk in there at night)
B) The chart is off to some doctor's clinic from a recent visit, and hasn't come back yet. It'll be a couple of days
C) We have no idea where the chart is.
So I'd have to rely on the patient's recollection of what meds they are taking, what their medical history is, what their allergies are, etc, etc. If you've ever had to go to the ER in the middle of the night, you know how hard it is to remember that stuff about yourself, and how annoying it is to be asked the same questions by the clueless medical staff over and over again.
When I saw patients in my own clinic, it was just as bad. The records were often gone -- to the hospital for a recent admission and still being processed, to another doc or clinic, etc.
I bought a Vaio subnotebook and as an intern kept my own notes on my patients, and carried the notebook with me everywhere. I was ridiculed a lot, but I always had critical info about my patients at my fingertips.
Then I went to another hospital system for residency, and spent some time at the VA, which had an early EMR called VISTA. It was just fantastic! It had usability problems, and required a lot of typing, but it was amazing to see a patient's current medications, list of major problems, past history, etc, all instantly, integrated over hospital and clinic visits, and even across different VA systems across the country if the patient recently moved. It revolutionized care, in my opinion.
So no, it's not a panacea, but a damn sight better than what we have now in many instances!
But does the high cost and questionable quality of products currently on the market explain why barely 1 in 50 hospitals have a comprehensive electronic records system, and why only 17% of physicians use any type of electronic records?
Yea, right. The Veterans Health Administration has a computerized record system called VistA that is quite successful. The U.S. Department of Veterans Affairs (VA), the largest integrated health care network in the country and has been using VistA successfully for at least 10 years.
The software, being developed by the United States Government, is in both the public domain and open source versions.
I read part of the Newsweek article I and I don't have a clue what they where talking about, except wasting taxpayers money. VistA or any of the Supporters of variants of VistA software are not mentioned.
When I worked in a hospital records department the computer systems for keeping records digitally were available.
I asked the boss why the hospital has not bought a system and was told "the doctors like to use paper and would not use the computers".
Different generation maybe ?
Most EMR systems are terrible. As a post above pointed out, they're driven by accountants, not physicians. And what works for, say, a family practice doctor may not work for a physical therapist.
There's an opportunity here for two programmers, two people with medical experience, and a lawyer to create a system that will capture the entire market just by because usable by all interested parties.
Anybody want to quite whining and start fixing it?
Every other business in the world uses computers to track its business. Healthcare has used it for the financial portion of the business but has been slow to track its most important function. Healthcare at its heart is information communication. You tell the doctor what is happening, he or she makes a diagnosis and a plan of care, others in the system help carry out that plan. Electronic health records aid that communication. They also facilitate the bigger job of analysis of patient problems, care, and outcomes with larger groups of patients. With a paper system it is nearly impossible to do a retrospective analysis of care. The issue of privacy is cited but the biggest issue for the general practitioner is cost. It can be hard to see a ROI in the short term for the large investment in hardware and software. We need flexible open source xml-type language that can be then used by developers to create applications that meet the needs of individual practitioners.
I agree that medical records should be electronic for the most part. However, there are some big challenges that our current IT business model can't solve:
1. How do you prevent Oracle, IBM, SAP or some other large vendor from getting a permanent lock on the market for EMRs? If this happens, a closed standard will develop and mo one will ever be able to make changes without paying mullions of dollars.
2. Opposite problem -- if there is no standard, or it's so loose that it might as well not exist, what's to prevent a million small companies from developing EMR, EMR 2.0, OpenEMR, StarEMR, YetAnotherCoolEMR 3.2.10.23alpha8, and so on? How do you get providers using different standards to share? (The answer, I think, is open protocols, but that way lies 800 MB XML files and crappy J2EE applications written by developers who don't understand optimization.)
3. Privacy. In the US, healthcare and insurance are for-profit businesses. How much do you think a life insurance company would love it if they were able to see your entire birth-to-present health history? Insurance would be even less affordable than it is now. In countries where everyone's on the hook for medical costs, privacy is much less of an issue. But when it can cost you the ability to get treatment that doesn't bankrupt you, it's a big problem!
4. The huge "obfuscated mess" problem -- Go look at the system the Veterans' Administration uses for EMRs. It was written years and years ago in a language called M, and the source code (publically available) looks like line noise. It works fine from the front-end, but I can imagine it's a disaster to administer, make improvements, etc. How do you prevent a system from getting so stale that no one knows how to modify it anymore?
From what I've read, EMRs work well for the VA, precisely because they have to keep costs lower than for-profit hospital systems. Their patients are also ex-military. When you join the military, you give up the right to privacy.
Brazil seem to have an amazing electronic healthcare system using Java. Maybe that pushed oracle to buy sun. http://java.sun.com/developer/technicalArticles /xml/brazil/index.html
The author loses a lot of credibility by starting off the article with snarky remarks about President Obama. ("The law makes a job for yet another bureaucrat to oversee the vast program - is this change we can believe in?") He initially attacks the creation of a standards-creating body for electronic health records ("It defines rules for health information standards by designating a new standards board - everyone desires more data standards and standards groups"), but concludes that we need to create a uniform standard for the development of an electronic health record infrastructure. It seems as though his bias overwhelms his sense.
He blames Obama's proposal before it even started because he had a bad experience. It makes no sense. His anecdote only shows that his doctors were ignoring him. That had nothing to do with the electronic health record system. His allergist wrote a memo that no one at the hospital read. That is not a failure of the EHR.
A NYC lawyer blogs. http://www.chuangblog.com/
I worked for about 20 years writing EMR systems of one sort or another. There are about 6000 hospitals in the US. The company I worked for had systems in at 1500 of them. That's 25% right there. Users generally seemed to consider their EMR's to be essential and to contribute significantly to doctor productivity and patient safety. For instance, an electronic prescription is easier to produce, much more legible than a handwritten one and checks automatically for allergies and drug interactions, rather than relying on the doctor's sometimes fallible memory. There are usable data interchange standards for medical information: HL7 for text, DICOM for images plus various specialty coding standards (pathology, etc). It is true that the standards are not perfect and also, not every vendor's information is 100% standards-compliant. Still, systems are relatively easy to integrate and are usually able to talk to one another without too much difficulty. More and better automation in medicine can only be a good thing, as far as I can tell. I call BS on TFA.
In Oregon, the number of new nurses accepted every year is severely limited to "ensure only the best candidates" are accepted. This is decided upon by a panel of nurses, who benefit from the shortage driving up wages. I know of people with 3.8GPA's, that were not selected for the nursing program, and told to apply next year, two years in a row. Yet the state screams about how much more it needs to pay nurses, to attract more, while it is turning them away.. Talk about either a scam, or just plain stupidity.. (or both)
What are we going to do tonight Brain?
AAAAAAHHHHHH! swine flu!!!!!!!
I worked on a medical informatics product that was in production more that ten years ago. I have been on more complex non-medical data systems since then. There's not a lot of reason for the fear.
However, we should be aware that the current paper-run filing systems are already complex and full of errors. Patient charts are lost all the time, even disappear in the mail. Doing statistical analysis of the paper charts is a huge, complicated, expensive logistical mess. It isn't good enough, and humanity can do better.
If done right, computer medical records have the potential to enable general improvement in the field of medicine.
Although having more doctors would help, the problem is insurance. Because it's a tax-free benefit, we press our employers to provide the best possible health insurance. When we need health care, we have no incentive whatsoever to shop for price. It's an all-you-can-eat buffet and we have season tickets.
The insurers have the system rigged so that uninsured people get screwed. They negotiate price very effectively, to the extent that non-insured people are expected to subsidize the discounts that the insurers demand in exchange for a steady flow of patients that keep utilization rates high. The government plays the same game with Medicare and Medicaid.
Example: 10 years ago, I had inpatient surgery that resulted in an overnight stay in the hospital. The bill was $5800, of which insurance covered all except the initial doctor's visit co-pay of $10. But the hospital accepted $1500 from the insurance company as payment in full. If I could get the same type of pricing, I would be thoroughly tempted to go self-insured.
Market forces are the ONLY way to reduce cost. But we have to be careful to avoid a system as dysfunctional as the airlines.
For starters, health care expenses (except insurance premiums) should be 100% tax-deductible. There are some tax breaks available, but the government tries really hard to make this more difficult than it needs to be. It should be as simple as the mortgage interest deduction. Every dollar that is spent outside the insurance industry is helpful to the system and should be encouraged. Current policy does the opposite.
Next, there should be a universal price policy for health care providers. Let them charge whatever they want, but they should offer the same price to all. Individuals should be able to pay the same price as the insurance company. They might have to require payment upfront to avoid collection hassles, but it would be cheaper than playing the reimbursement game with "managed" care providers.
Insurance should be mandatory, but limited to big-ticket expenses with high deductibles.
Getting prescription prices under control is as easy as opening the door to Canada, India, or wherever. God knows, the pharmaceutical companies are quick to go with offshore outsourcing when it serves THEM. Why should the customers think differently?
Any solution that leaves the insurance and pharmaceutical industries unscathed is not a solution at all.
The administration either has an undisclosed agenda or no idea what is really wrong with the health care industry. I work for a large medical institution in their IS department and I spend most of my time moving medical data around. In the short time I've been here, I have run across several roadblocks to providing efficient, safe and effective medical treatment.
The most detrimental entity in all of health care has to be the private health insurance industry. Insurance companies have spent a great deal of time and money developing strategies to MAKE MONEY. They are not in the business of making people well, they are constructed to make profits and protect those profits at all costs. They have nearly perfected the art of delaying or denying treatment for sick people all in the name of the almighty dollar.
The lack of standards is truly astonishing as well. There are dozens of large companies vying for stimulus money to develop electronic medical records. Do you really think they'll be working together to provide a single solution that can be transported all over the country? These companies are also out to make a buck and it better serves their interests to develop the one standard format and be the holders of the golden goose than to work collaboratively on a solution that fits all (or most) needs. See: Blue Ray vs. HD-DVD or VHS vs. Beta-max. I would estimate that 9/10s of the stimulus money directed to these companies will be an utter waste, and the remaining 10th will got to produce fortune for a single organization.
Whenever a format *is* declared the winner, it will likely be so inadequate that it will be routinely altered and hacked to fit the specific needs of each institution. It will be rendered nearly useless. HL7 is great example of this. It's designed as the de facto format for transmitting health care information from one site to another, however, I have yet to see two institutions or vendors do it alike.
Pricing and billing are two other concerns. Both are seemingly completely arbitrary and vary widely from one facility and/or patient to the next. A simple lab procedure, let's say a white blood cell count (literally counting white blood cells), could be done in one location for X while in another location for 6X. The worst part, you have no way of knowing what that charge will be until you are billed. Then, if you have insurance, they get to choose whether to pay all, part or none of the bill based on what loopholes are available to them.
My personal opinion, I represent no one other than myself, is that the single most effective action that any government can do to help solve the health care problems is to do away with privatized health insurance as we Americans know it today and replace it with a system that is much more socially responsible. A standardized digital medical record will be a good thing, but it will likely show very little impact on patient care.
There are not enough doctors, not enough competition.
So, what exactly are they to compete on? My wife's a doctor, and she can't fit any more patients into a day without sacrificing quality of care. She can't compete on price because Medica{re,id} and insurance companies effectively set her prices. All she can do is try to keep her patients happy so that they come back when they need to see someone, and she's apparently doing that pretty well (judging by her appointment schedule). If you doubled the number of practitioners in her specialty in our city, the only long-term effect would be that half of them would go out of business.
Dewey, what part of this looks like authorities should be involved?
You make a good point that simply making charts digital is not enough. A good system detects errors, supports reporting after-the fact, and allows for good auditing. Our healthcare system has had an EMR for nearly a decade, and I've had a chance to see the growing pains and thrills over that time. Here are a few benefits that come to mind.
Auditing. I help an audit team look at who's pulling up whose records. With paper, this would be nearly impossible, but with electronic records it's quite easy to see that user X is pulling up the medical records of their ex-wife or the visiting famous person. Though this has been hard for some, I think it's made our organization much more respectful of a patient's privacy.
Moves. We moved our hospital recently and I got to write the system that tracked each patient as they went through the various staging areas to their new bed across town. Our EMR made this like tracking packages in FedEx and it worked great.
Widespread Communication. On a more practical note, this is the big one. It used to be very difficult to move charts and images around town or even to other cities. Now people anywhere in the sprawling healthcare system can see the latest on your medical condition.
Reporting. We have a massive data warehouse that lets us see the effect of our various health improvement efforts and gives us the ability to more accurately report quality data (e.g. are we giving asprin to everyone who comes in with chest pain?). Evidence based medicine is big in our organization, and it requires good data to support it.
Fixing Errors Before They Happen. This is the most challenging one, and I think we're still in our infancy. I helped make a lab cross-reference system whose purpose is to make sure nurses know what lab a doctor really ordered. If they ordered something vaguely cryptic, they can key in the lab name and it will give them the different names in different electronic systems, in addition to hand-entered names that some doctors use.
EMRs alone aren't going to improve healthcare greatly, but they open up a lot of other options that most certainly will.
Lowering standards might lower the costs, but it would also be immensely stupid. Sure, people who barely make it through medical school are doctors, but that's still quite an achievement given the rigours of medical school. You're talking about opening the door to the yahoos who haven't managed much at all - people who have achieved much less than that out-of-date surgeon.
We can and should demand solutions that are better than what the market provides. They may not be perfect, and they may not be as cheap as your neighbourhood voodoo woman, but the quality will be higher.
For every problem, there is at least one solution that is simple, neat, and wrong.
"Clearly, the networked monitors with alarms sounding so frequently no one believed they meant anything is a serious design problem"
This isn't just applicable to this system. I can't tell you how many places I've been were network and system alarms were ignored and the answer was "that's one that we don't worry about". It leads to a really bad place. It always ends up that a real problem got missed because "app02 always has an alarm".
"Fighting the underpants gnomes since 1998!" "Bruce Schneier knows the state of schroedinger's cat"
But does the high cost and questionable quality of products currently on the market explain why barely 1 in 50 hospitals have a comprehensive electronic records system, and why only 17% of physicians use any type of electronic records?
Well, I know from personal experience in my region that many doctors and medical facilities have been moving to digital record systems for some time, even before the stimulus package was conceived. What I found from discussions with my oncologist and others is that the adoption has been slow partially because of cost (not just installation and initial costs, but support and maintenance costs), but also because they and their staff are not all that computer literate and there is quite an on-ramp for them to clear before they get used to and comfortable working with an electronic system.
Don't get me wrong. There are tons of doctors that are computer and gadget freaks, but there are tons more that rarely touch a computer except for basic Internet and MS Office services and have to be guided through the intricacies of an electronic records system and how to use it. It is similar to what academia has been going through for the last ten to fifteen years as more technology gets used in a classroom and for administrative purposes. This is going to take time and will certainly be dependent on younger doctors and newer medical facilities driving the change and bringing the older, less computer literate generation of professionals along.
Oh, I should mention that all the folks I've talked to prefer the electronic systems to the older paper systems. Better access, ease of use (once trained), etc. are all cited as why they like it. Of course, there are also the cons of the software stability and other, typical support issues one encounters with technology. I look forward to being able to have my complete medical records on a secured storage device so I never lose any again like I did a few years back when an old family doctor destroyed my records without contacting me!
Put on some scrubs, don a white lab coat, and walk around with a clip board and see how long it takes for someone to notice you at a big hospital. Answer: they won't.
We had a reporter try to do this after a school shooting. They were caught and I'm not sure if charges were filed.
Everyone wears badge photos at our hospital and if you wandered into a patient area without one and no one recognized you, security would likely be called.
You mean there is some other way to develop software than C/C++/Ada?
How it breaks down is this:
HIPAA is very specific about how data is to be handled and audited from end-to-end, and includes specifics on how data can be properly de-identified. As a systems and network administrator at a major trauma center, HIPAA has been a nightmare to implement and a security officer's dream come true. That said, the focus on personal accountability and the high level of monitoring and enforcement leads to an environment much different than a credit card processor or company.
Electronic Medical Records (EMR) WILL BE A PANACEA... IF ...
1. There is a national (world) standard format. It doesn't have to be the best, it just has to be good. Without this, it will be an EDI (Electronic Data Interchange) nightmare.
2. It is relatively secure.
EMR would be a good candidate for cloud computing if the security issues can be addressed. If cloud computing is used, medical organizations need only purchase any device that can attach to the web.
Why haven't hospitals and medical offices done this already? Look at many hospital accounting systems. They were written in the 60s, in COBOL. Every couple of years another layer of ineffective crap is plopped on top to âoeimproveâ the human interface. The systems have not been replaced because the medical industry HATES to spend money on OVERHEAD.
Remember, most hospitals consider NURSES to be overhead, not production staff. Consider: the main reason for hospital existence is for advanced nursing care.
Another reason EMR have not been adopted is related to administration costs. By adopting EMR, insurance companies will no longer to justify siphoning off over 25% of health care dollars. Consider what we could do if the cost of medicine went down by 25%.
My wife just had a baby and I had a discussion about the hospitals electronic records system with a nurse there. While it sounds like a great idea, and saves them a bunch of time in some cases. The hospitals system sounds really buggy, and its secured to the point where bugs which would normally just be annoying turn out to be 1/2 hour long calls to help desk/security to reset machines/user id's.
None of this is a surprise to anyone familiar with the services provided by IBM or similar companies. What gets me is the amount of money being spent on dozens of system which in the end are just going to be a mismatch of partially communicating systems. There are only about a half dozen "standards" for record exchange. None of which are complete enough to actually build a system. Its like the SNMP protocol. It gives you warm fuzzies, but completely useless without standard MIB's for device classes.
So, you have the government spending $19B and its not really going to do shit. You will see more computers, but if you are out of state and get sick its likely your medical history still isn't going to be available to the ER doctor treating you. What the government should do, is form an independent foundation and hire a couple systems engineers, nurses etc, to go around and look for example installs of some small companies product which appears to be mostly functional, scalable and has a decent core architecture that supports some kind of application specific plugins and record exchange. Ideally the system has not only a client application, but a standalone web interface, and runs on fairly standard hardware.
The smaller the company/product the better. Then they need to take a few hundred million of the 19B and purchase the company and make that product the standard system available to any hospital or doctors office for free. A reference hardware/software stack should be setup. It should then be documented such that 3rd parties can write plug-ins for their baby monitors, CT scanners, etc. The resulting data from the plug-ins should be represented in a standard way in the system. The government could then setup a couple of server farms to act as information brokers/backup agents for the larger doctors offices or hospitals and provide web interfaces for the smaller doctors offices.
That system could then be the reference system and doctors/hospitals are given the remainder of the 19B to implement local versions of the same software stack. If the office is to small to implement the whole stack they can use the government servers over a secure connection. Even accounting for massive waste and corruption, with ~300k doctors in the US, 19B works out to 63K each, which should be more than enough to provide and maintain the system for a couple of years. The cost savings from having a single reference implementation should be huge, compared with the current method of giveaways to big IT companies for what is 30 year old records management technology.
All these comments and nobody mentioned OpenEMR?
http://openemr.sourceforge.net/
Long story about how the Veterans Heath Administration became the best health care system in the country. They even used open sourced software.
http://www.washingtonmonthly.com/features/2005/0501.longman.html
There is a story that surfaced last about the DVLA in the UK. When modifying the address on their licence, a number of people in the UK have lost the fact that they are licenced to drive motorbikes. The DVLA requires them to send in their original test certificate, but that is sent in when they first get their licence. The DVLA destroy all copies after 10 years - a WTF! However, what is going to happen to medical records with dodgy systems!! I leave you to imagine this.
I've had loved ones in the hospital with fairly serious conditions. They do NOT get much attention from doctors. Maybe their charts get a little more attention, but the patients are lucky to see them for more than 5 minutes a day except when they're in surgery.
I think that the solution is they need more tiers of medical care. Right now you have mostly just doctors and nurses (I do realize there is some graduation in-between right now, but in a typical hospital those two categories will cover 90% of everybody who cares for a patient).
Hospitals could use everything from volunteers, to aides, to basic-intermediate-advanced nurses, to basic-intermediate-advanced doctors. Go ahead and put limits on what that guy who currently couldn't pass medical school can do, but chances are they're qualified to do quite a bit. Having more people will lower costs (start paying doctors less).
Also - I'm not convinced that doubling the size of medical school admissions would lower quality at all. Go ahead and have the same standards - right now the problem isn't people not graduating, but people not getting admitted. Also - if you had 10X as many medical schools out there then tuition costs would go down (more competition). Doctors should be well-paid, but not to the extreme they are today.
Also - doctors should have limited hours - certainly no more than 50 per week and no shift longer than 12 hours (with at most one 12 hour shift in a week). Why is it that we can regulate how many hours a truck driver can spend behind the wheel and yet we have interns working 100 hour weeks as some kind of way to weed out anybody who has a shred of humanity in them?
I've worked in the Medical Records environment at two separate hospitals for nearly six years combined. The first hospital I worked in was half way through the transition to electronic filing at the time of my departure. During that time we saw a decrease in paper, work load and general inconveniences. I still keep in touch with those at that facility and though the transition process was equal to that of the seventh level of hell; the final result appears to be a very sound and very well implemented program.
The hospital I worked for following that was still merely toying around with the idea; their filing system was prehistoric at best. I worked in the medical records department at that facility for three years, that amount of paper is nearly unmaintainable. This is no fault on the department but rather a lack of initiative on the facilities part to understand the necessity of technological advancement in an industry that is become more dependent on technology to run. The medical field grows every year. Insurances require more paperwork than you can imagine. There is so much that has to be done on a patient to patient basis that tangibility (regarding documentation, not patient care) becomes more of hindrance than anything else.
Following the post at that hospital's medical records department I transferred to their storage facility for the retention and eventual destruction of those records. I worked alone. I retained thousands upon thousands of boxes of records at any given time; going as far back as the 1940's They came in faster than they would go out; and overcrowding became a regular problem. They still as of yet have made the step toward transitioning.
I don't think the average person is fully aware of the amount of documentation that is necessary in order to provide "quality patient care". Too many physicians are forced to spend too much time filling out paper work instead of caring for patients.
But then again... this is only one side of the argument; as long as I've been doing this I have heard my fair share of dissenters as well. And their points are valid. The only question is how long is an archaic system sustainable in a society where technology has become so dominant? The world is changing; it has been weather we have noticed it or not. And it will continue to do so despite whatever disagreements we may have with that progression; we have to figure out how to change with it or we will fall behind. And I think that the accuracy of our health care depends on our ability to do so.
sudo apt-get lost
How would they compete? Oh, I don't know... maybe by keeping more up to date than the next guy, some would forego insurance altogether in favor of buying all services in cash (works well for many who do that) because those offices are cheaper to run, among other things.
One of the things you haven't accounted for is the fact that doctors can go anywhere in the US. Right now, there are a lot of areas of the country which have so few doctors and specialists that you could probably increase the supply by 300% and still not run into a glut of labor. Florida and Massachusetts are great examples of that, especially considering the former's persecution of pediatricians and pediatric surgeons (among other professions) in the past which has resulted in the vast majority of child health care specialists leaving or retiring.
IT vendors and insurance companies will be the main beneficiaries. It vendors will make money selling systems. Insurance companies will be able to deny more claims.
Kiss privacy goodbye. Once these records are accessible, they will be accessed.
Bottom line: Taxpayers are being forced to fund a boondoggle at best, big brother at worst.
Wansu, th' chinese sailor
I work at a large clinic in Illinois. We use Allscripts for our EHR management, which includes everything from prescriptions, med history, dictation of doctor's notes, every single scanned sheet of medical information that exists about the patient (including from outside sources), task list for nurses and receptionists, you name it. It doesn't always work exactly like you want it to (that's what our systems analyst are for), but it works pretty damn well, and I for one would prefer a doctor or nurse to look me up this way, rather than wait for my doctor from ten years ago to fax or snail over my history. That scares me a lot more.
ubi dubium ibi libertas.
The man was 15-20 years out of date on certain techniques, and did them according to the way he was trained, and screwed the pooch big time.
I don't want to interrupt your irrational, anti-union rant but doctors are required to keep current with their methods. They have to prove this to the state medical board every year. Perhaps you'd prefer to go back to the pre-AMA days where serial killers like John Brinkley could operate with impunity and make millions while killing people on the operating table through incompetency and neglect.
(-1, Raw and Uncut is the only way to read)
I'm all for bringing up issues that can hurt a new system, but what is with the total hostility to new things lately? Has the economy really made people so depressed that things like increased science funding and electronic medical systems (that Slashdot has been pining over for years!) finally start to happen everyone just craps on them? That is the whole problem people, everyone gets negative, no-one wants to spend anything, nothing gets spent and the whole thing keeps going down in flames.
C'mon, /. overlords?
Where are the cynical
The only reason GOVERNMENT wants digital records is that SOMEONE who stands to benefit monetarily is pumping money into someones campaign.
With easily searchable medical records, I will now be able to exclude you from employment, coverage, or various treatments.
Do you think insurance companies would like that?
Wake up folks.
The difference between the credit card industry and the medical industry (in terms of privacy): HIPAA. The law prescribes very serious penalties for violating the privacy of medical records - accordingly, it's now big news if someone's records are accessed inappropriately. By contrast, the credit card industry has fought off similar laws governing your credit records, so it's fairly routine to hear that hundreds or thousands of credit card numbers have been stolen - there's simply no consequence to the organization with poor credit data security.
It's all about the incentives.
Mike, a beer on me for this post.
Doctors (and AMA, the selfish and hypocritical lobby) are just as big a problem as pharma, insurance, and legal industries in the mess that is our medical industrial complex.
Fuck systemd. Fuck Redhat. Fuck Soylent, too. Wait, scratch the last one.
You raise some interesting points. Although not all of the extra doctors would be superstars, a larger pool of reasonably competent doctors could probably provide better care by increasing the amount of time spent on each patient.
Not everyone has hard-to-treat diseases. In many cases, simple diagnosis, early detection, and standardized treatment will save the day. In fact, many people who really DO need a superstar doc to save them started off with easily treatable conditions that could have been handed by anyone with a prescription pad.
There are some private care doctors working totally outside the world of "managed care". They require payment on the spot and they don't take insurance. In return, they spend more time with each patient and (in theory) provide better care. Some of these people are very pricey, but there are some who are charging $100/visit. Most people spend more than that for routine car maintenance.
As long as the healthcare industry is an third-party payor oligopoly, there will be no meaningful change. Look at education, a government monopoly, they are still giving students the summer off to complete the harvest! As if we were living in the agrarian age.
Until we patients start paying for their own care, and the healthcare industry is a competitive free market, we will not have progress. Look at the finanical sector, I can go to any ATM in the world and get authenticated, and receive cash. It is not hard.
The legal industry successfully converted to digital in the last decade, the healthcare industry can, too.
I think that the real reason that hospitals don't go to electronic records is this: doctors want their notes in the chart handwritten so when something goes wrong they can say that the scribbled notes were read wrong by the nurses. This helps when the doctor is sued. The computer makes all notes legible.
Despite these heroic efforts, I never received correct medications during my stay. Indeed, my wife snuck one of my inhalers into my room. After I used it, I finally began to recover.
Why didn't he just use his inhaler at home and start to recover there?
I'm a surgeon and a former software developer. I would love to see an electronic medical record system that was both functional and portable. I think software can be written to meet both those goals, but the reality is anything written will meet one of those goals but not both. The real problem is that very few physicians have the time or inclination to be involved in something to help remedy the problem. I think part of the problem is that IT people can build anything that we physicians need, but we don't have the time to enumerate the problems to make a system work. The end result would be a system that physicians would be forced to use, but would waste more of our time with documentation that could be handled by a computer. Here's a concrete example: When a patient leaves the hospital I have several things that need to be done for discharge. I have to write out a discharge summary of the patient's hospital course to go with the patient which includes oupatient followup, discharge activites etc. I have to write out all their prescriptions on a prescription pad. I have to reconcile their home medications with new medications they receive from their hospital stay. I have to dictate a report of their hospital stay including outpatient followup, discharge activities, etc. I estimate it takes between 15 and 20 minutes to do all these tasks. Not to bad if you do it once or twice a week, but I have 25 patients on my service at a time with 3-5 discharges a day. As you can see there is already a lot of redundancy in what work I do. A computer could easily fix that and make it safer for a patient (so I don't give them meds they are allergic to, meds that are over or underdosed etc.) Now if we were to have a nationalized electronic medical system, how would this be implemented? Would it be designed to save me time? Would it be designed with patient safety in mind? My gut feeling is that the answer to that is no. Even though I love computers and I see the potential benefits of computer systems, the reality is that no one has built anything that saves me time. I still write orders in the chart with my unintelligible handwriting because it's a lot faster to open the chart write the order and run off to my next operation rather than login into a computer, login into our EMR portal, find the patient, search for the desired order, click the 11 checkboxes needed, click the order, and then e-sign with my password, then logoff. I already work 80-100 hours a week, my feeling is that a computerized EMR will just increase my time spent in the hospital.
Break the back of the AMA, double the seats in medical school and let the market do more of the talking.
It's obvious to me that a shortage of medical doctors is one of the main problems with health care in the USA. What I don't understand is why other people don't seem to see it that way.
For example, I've got a fair amount of respect for Obama. He seems like a reasonably bright guy with the right set of priorities. But when Obama talks about fixing health care, why isn't the shortage of medical doctors front and center?
It seems unlikely that Obama is just too dumb to figure this out. Maybe Obama is so busy with other things that he really hasn't had time to mull it over. Or, maybe Obama recognizes the problem but figures that an explicit showdown with the AMA would drain resources from other endeavors.
The one thing I worry is that Obama is so committed to compromise and hope that he isn't cynical enough to "tell it like it is" and confront the underlying causes of the problems that the USA faces.
What's wrong with nurses as an intermediate step? They're often quite clued at what they do.
I'm not sure if doubling admissions would be productive - in theory it could just burden the schools more, but I don't know enough to do more than guess on that.
I agree with you on the hours. However, interns are not doctors yet - I don't think too many full doctors have a work week that resembles the itnernship.
For every problem, there is at least one solution that is simple, neat, and wrong.
...Medica{re,id} and insurance companies effectively set her prices.
So then why aren't her prices down at minimum wage (or even zero)? I'll agree that insurance companies are siphoning off some of the monopoly profits that would otherwise go to medical doctors but they certainly don't set her prices.
If you doubled the number of practitioners in her specialty in our city, the only long-term effect would be that half of them would go out of business.
No. In the simple model the practitioners would all have half as many patients.
In a more complex model, some practitioners would start spending more time with each patient (and reducing the backlog of time spent in the waiting room) while other practitioners would simply take the afternoon off and go golfing.
The patients would then transfer to the practitioners who provided better care (more face time, shorter wait, better outcomes, etc.) and some of the worst practitioners would go out of business.
When the system finally reached equilibrium, each practitioner would have fewer patients and a few of the worst practitioners would go out of business (but not half as you claim).
It's certainly true that practitioners (e.g. your wife) would make less money (and they would also be doing less work - but not half as little work because they would also have to provide better service). I understand that you don't want to get off the doctor monopoly gravy train but you're living in massive denial if you deny that the AMA has engineered as massive shortage of medical doctors.
I'm beginning to suspect the problem is "up-front classification". If everything has to be "properly" classified up-front before data-entry is done, it can slow things down and result in force-fits. Perhaps collect it first in an unstructured or semi-structured kind of way, and then have "categorization experts" clean it up, or classify it, after the fact.
It's very difficult to get schemas and categorization right the first time in large systems. Thus, some kind of "systematic organics" should be tried. If things can belong to multiple categories or departments at the same time, so be it. Link them as needed without worrying about "the Grand Schema or Grand Model". I'm thinking half-wiki (Cunningham-style) and half database. Plus, different orgs can tailor how they link stuff (as long as basic standards are met).
Table-ized A.I.
My doctor friend recently said he moved back to paper because electronic was slow, useless and typically wrong. He could work faster and more accurately with paper. This isn't just a problem that needs to be solved. It needs to be solved _right_.
Awww, someone didn't get into medical school.
So then why aren't her prices down at minimum wage (or even zero)?
Because the overhead in a medical practice is tremendous and largely irreducible.
I'll agree that insurance companies are siphoning off some of the monopoly profits that would otherwise go to medical doctors but they certainly don't set her prices.
They most certainly do. Insurance decides the customary rates for a given procedure, then pays a fixed percentage of that. If the average price of a elbowectomy is $1,000 where you live, then insurance will typically pay $600 to a doctor that performs one. Since most doctors take insurance "on assignment", they agree to accept whatever rate the insurance company offers as their fee. When you get older and get a job with insurance, look at your explanation of benefits. It'll say something like:
Basically, they say that they think that $600 is a reasonable fee, they'll pay $500 of that, and you only owe $100 ($600 - $500) and not $500 ($1000 - $500). Medicaid is the worst about this; many times their reimbursement doesn't cover the cost of the raw supplies to perform the procedure, let alone other overhead. If a doctor bills $500 for a minor surgery, and Medicaid allows $10 (no, that's not an exaggeration!), and the sterile supplies cost $20, then the doctor actually just paid $10 out of his pocket for the privilege of doing the surgery. That's why so many doctors either flat-out refuse Medicaid, or only accept Medicaid patients on referral from another doctor ("hey, Bob, can you afford to donate work today?").
In a more complex model, some practitioners would start spending more time with each patient (and reducing the backlog of time spent in the waiting room) while other practitioners would simply take the afternoon off and go golfing.
Those are the two categories that would go out of business. Particularly for young doctors, medicine isn't exactly the path to riches.
It's certainly true that practitioners (e.g. your wife) would make less money (and they would also be doing less work - but not half as little work because they would also have to provide better service).
Um, no. You have rent, malpractice insurance, professional certifications, and student loans. I'd say that a 75% overhead is a reasonable estimate of overhead for new doctors. If such a doctor dropped back to 75% of their current workload, their take home income would drop to zero. Since doctors typically enjoy food and shelter, that's extremely unlikely to happen.
I understand that you don't want to get off the doctor monopoly gravy train but you're living in massive denial if you deny that the AMA has engineered as massive shortage of medical doctors.
Uh-huh. Back in reality, I'm enjoying my paid-off Oldsmobile and hoping to have the mortgage and student loans paid off before the kids start college.
Dewey, what part of this looks like authorities should be involved?
For example, I've got a fair amount of respect for Obama. He seems like a reasonably bright guy with the right set of priorities. But when Obama talks about fixing health care, why isn't the shortage of medical doctors front and center?
Because a big part of the problem is that doctors have insanely high liability for things outside their control. Have a bad reaction to anesthesia? Sue the anesthesiologist and let the courts sort it out! Never mind that his insurance premiums will triple even if he wins. Why would any bright young student want to get themselves into that mess when business school is easier and more profitable?
When Obama shakes the unions off his back and does something about tort reform, you'll know he actually cares about the problem. Anything short of that is just posturing.
Dewey, what part of this looks like authorities should be involved?
I know of people with 3.8GPA's, that were not selected for the nursing program, and told to apply next year, two years in a row. Yet the state screams about how much more it needs to pay nurses, to attract more, while it is turning them away.. Talk about either a scam, or just plain stupidity.. (or both)
I know teachers that tell similar tales. The state is always complaining that it can't find teachers. However, the only jobs are at the very worst inner city schools. There is a law that requires teachers to live in the district they teach in. No person in their right mind would live in those areas. Let alone for the peanuts they get paid.
I think it's just stupidity.
But really with all the crap, legacy systems held together presently by silly string...you really almost need to start OVER.
There is a logical approach, one that's worked quite well for the electricity industry in Australia. Take a hundred or so electricity authorities and try to get them to agree on anything is difficult; getting them to agree on a commonly interoperable software plan nigh on impossible.
What they did do was to agree on a standard set of transactions written in XML. If you agree on the transaction format, it doesn't matter much whether you're sending them via Windows, J2EE or some truly wonderful DCL running on an old 8550. If you agree on the transactions and you have an organisation that can own the transaction test suite you can achieve total interoperability without forcing people into a single hardware or software platform. It works, it's not too hard to achieve, and it's a relatively inexpensive process to achieve a result. The transaction set is called aseXML, if you're curious.
Yes, I was involved in this.
Do not mock my vision of impractical footwear
Might as well burn some karma for a cause.
If you see that you have to bust your balls for 4 years in med school, 2 years in internship, another 2 years in residency, more for specialty, on top of all this accruing 6-figure debt, it's only natural that doctors do its best to protect their investment.
The question to ask is how we came to have such a physician-training system, and who's protecting it? AMA. This is the same AMA that conspired with tobacco industries back in the 60's in their attempt to prevent Medicaid and Medicare. When it comes to interest of physicians and patients, it knows which one comes first. A related NYT piece today here: ahref=http://www.nytimes.com/2009/04/29/health/policy/29drug.html?ref=healthrel=url2html-20281http://www.nytimes.com/2009/04/29/health/policy/29drug.html?ref=health>
AMA is particularly insidious because they pretend to front for doctors, unlike pharma, insurance, and lawyers, whose interests are plainly obvious to us. Many doctors speak against AMAs, and it shows. AMA's membership has been in decline for a while, but being long-standing organized lobby, their political influence remains, keeping a lid on the supply of doctors among other things.
Fuck systemd. Fuck Redhat. Fuck Soylent, too. Wait, scratch the last one.
please spend a day in the life of physician or nurse that has to use one of these systems and you will see how difficult it is to learn about a patient's medical history...this is why doctors are told to ask questions, even if they have read someone else's notes. Think of the "telephone game in kindergarten" if you want to know why.
While the problem really is with the electronic records, the larger problem is that the people who buy them are not the ones who have to use them. And furthermore, the problem is that they are implemented with the goal of increasing re-imbursements, by increasing documentation, not by providing better medical care.
Because Americans have a mentality that they deserve "the best", which includes healthcare. Thus, they demand to take their sniffles and colds and other minor issues to medical doctors. We've systematically devalued any other medical practioner other than the doctor. Physician assistants, paramedics, licensed physicians without medical doctorates.... all of these medical professionals have been removed from the system.
For instance... did you know that in many states you can become a physician with just a Bachelor's of Arts? A physician license is all you need to have to practice medicine. It used to be that a doctorate only indicated that you had extra schooling. Back in the day, physicians without doctorates were common, especially out in the old west. Nowadays, most people can't even conceive of a physician without a doctorate. The military has vestiges of that old practice, though. You can become a medic and practice a much wider range of medicine without a doctoral degree than you can in civilian medicine.
With your point about more doctors being needed, I wholly agree.
"What luck for the rulers that men do not think." - Adolph Hitler
It's strange that this does topic did not trigger anyone to mention the IHE (Integrating the Healthcare Enterprise) This initiative by healthcare professionals AND industry tries to improve the way computer systems in healthcare share information.
As one working for one of the members of IHE I can say it works: the communication in healthcare does improve.
This is achieved by IHE through selecting standards to use (NO new standards are created) and testing that the members comply to these standards.
I agree with you on the nurses - that is what I'm getting at. However, the basic principle is one of triage - there is no reason why somebody with the sniffles needs to be going to see the best respitory therapist on the planet.
I'm not sure if doubling admissions would be productive - in theory it could just burden the schools more, but I don't know enough to do more than guess on that.
I didn't mean doubling the admissions at the existing schools so much as doubling the number of people admitted into a medical school. This would involve creating many more schools to accomodate the demand (and drive down the prices).
If they had to meet the same standards as doctors of today, that sounds fine by me. I also would be ok with having people seeing nurses when today they see doctors. I don't want to dilute the meaning of the title doctor though - keeping it to a high standard is important, I think.
For every problem, there is at least one solution that is simple, neat, and wrong.