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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."
Major credit card companies depend on thousands of small merchants who use swipe machines. To improve security, these would have to be replaced. It'd be a big headache. Besides, the credit card companies have been quite successful at pushing fraud and "identity theft" onto the victims (merchants and purchasers). They are fairly protected against data breach, in a sick kind of way. Their problem has become your problem.
But medical offices aren't like that. They have computers (that are re-programmable). There are fewer doctors than general merchants who take credit cards. And medical data is more difficult to turn into revenue than credit card numbers.
I don't think that the money is the dominant part of what makes a good system. Very capable, secure systems can be built on the cheap. The basic things that need to be used are available in open source software (image manipulation, cryptography, databases).
"Can you imagine a million patient digital medical record breach? The black mail or power that could be leveraged over people?"
Yes, I can imagine such a breach. It'll probably happen eventually. Good use of cryptography can mitigate the damage. But the idea of filtering through a million records looking for good blackmail candidates, then conducting said blackmail ... for that effort, you could start a legal business.
Digital records make sense: they should be more secure and easier to transfer. There will be pain switching, but the new system will be more efficient in the long run. There were pains moving from horses to cars, from gas to electricity, from wood to coal. But they all got ironed out.
Use the Firehose to mod down Second Life stories!
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'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.
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?
[T]he VA is run entirely by the government. What the rest of the US is going to wind up with is a huge train wreck of competing standards and products by proprietary vendors who don't want to interoperate.
Once again it's probably worthwhile to note that this was a major part of the motivation behind the original ARPAnet project which grew into the Internet. The US Dept of Defense was trying to deal with a growing problem. They were collecting all sorts of fancy electronic gadgets that generated and consumed data, but most of them would only talk to other gadgets from the same vendor. It was clear that this wasn't an accident. Every vendor wanted a to be the sole supplier, and one way they all saw to do this was via proprietary data formats.
The ARPA gang's solution was to build what they called Interface Message Processors (IMPs), whose job was to talk to a proprietary gadget in its native language, translate the gadget's messages into a standard format, and transmit that to another IMP, which would translate it into the native language of another recipient gadget. They knew from long experience that their vendors wouldn't cooperate with this, and would do everything in their power to sabotage the ability of other vendors' gadgets with their own. So the ARPA people farmed out the task of building the IMPs to people who had a history of successful communication with their competitors, the people in academia.
That was about 40 years ago. Now, with four more decades of experience, we can clearly see that the problem hasn't gone away. There is no prospect that gadgets or data systems built by different corporations will ever interoperate sanely. Private companies have a strong motive to sabotage such communication whenever they can get away with it. So, as in the past, the only way we can get useful medical data systems is the same was we've done it with the Internet. We need government-run projects to develop and enforce the standards. Building the low-level gadgets can be a job for the corporate world. But if we ever want to be able to use the data for any meaningful purpose, we must make sure that the corporate world can't control it.
Actually, of course, we have no guarantee that government agencies will do the job right, either. There's no shortage of incompatible data formats in government databases. Unless the job is handled by people as competent as ARPA was back in the 1960s and 70s, it'll still be a huge, expensive failure. Sorta like the medical data systems we have now, which were mostly developed in-house at hospitals, and even the nonprofit hospitals have a poor record of interoperability. (Yes, I've worked on some of their systems, and it's not a pretty sight.) So we should be watching how the governments deal with the problem, and be quick to criticise the crappy standards that we know they'll design.
Otherwise we'll end up with medical records based on a standard similar to the Avian Carrier Protocol, but it won't have been published on April 1. You should also read the wikipedia article to read of a real implementation. But most managers in both corporate and government circles don't have a sense of humor good enough to prevent such things from becoming actual standards.
Those who do study history are doomed to stand helplessly by while everyone else repeats it.
It's pretty well-written. I suspect a professional writer may have had a hand in writing this.
Not to mention the telltale "I'm a $PERSON supporter, but this is why $PERSON sucks" disclaimer, beloved of underhanded $PERSON-bashers all over. This smells so much like propaganda, as is getting the political slant in while the reader is still interested in the story. Just on internal evidence, I'd call it a right-wing hack job.
It also reminds me of some experiences a friend of mine had, back when hospitals were run on paper. The writer could well have had the exact same problems in a hospital without electronic records.
"When you have eliminated the unacceptable, whatever is left, however improbable, must be the truthiness" - Holmes