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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."
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.
... 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
I RTFA, and there is a very telling reader comment at the end...
The moral of the story, then, is that no amount of even well-organized information can compensate for a break in the continuity of care. The allergist tossed this guy to the wolves with a post-it note stuck to his forehead. The current system couldn't cope with that, and it's hard to imagine any system that could, because the hospital et. al. can't morally or legally just follow the instructions on the post-it note; they have to start from scratch.
The allergist had to know this, but dropped the ball anyway. Find a new allergist.
FATMOUSE + YOU = FATMOUSE
My wife works at a hospital with digital records, and it seems to work fairly well - no worse than paper charts anyway.
The major issue that I have is that they use it only to a fraction of its potential. They use it just like they did charts, with no real capability increase other than stretchability and speed.
For instance, they could use it to prevent some medical mistakes by requiring an override if a physician changes an order. Right now one doctor (or even a nurse) can simply walk over and change the order given by another doctor. At the very least, another doctor who is on call should okay the change so there are at least two eyes on it.
Another example is medications. A groggy doctor woken up at 4AM can and will make mistakes, sometimes as severe as mixing mg and micrograms. You can bet that a dosage 1000 times higher than indicated will not be good for a patient, and currently they rely on the pharmacist to catch these errors. The computer could be programmed to require an override by a second doctor before allowing such orders.
Also, due to lawsuits, everything at the hospital is a CYA system, and patient care suffers. Computers could be used to help this situation, too - but I'm getting carried away now :)
W..w..W - Willy Waterloo washes Warren Wiggins who is washing Waldo Woo.
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.
Better to get rid of the lawyers first.
If the medical journals say that there is a 0.0001% chance of deadly condition Y being present given the patients symptoms, and a $5k MRI test has a 0.001% chance of detecting Y, then the doctor is going to have to order it. Otherwise when the 1-in-1-million patient dies from undiagnosed Y the jury will be handing money to the plaintiff hand over fist.
The expectation of modern juries is that every patient gets tested with every modern technology available, has access to experimental technologies that are just emerging, and has a board of doctors meeting in a conference room with House to discuss every aspect of the patient's care.
This depends greatly on your threat model.
If the attacker is some guy with some cash and contacts and they want a photocopy of one person's medical record, chances are that paper will be easier to defeat. However, there is a substantial risk of getting caught (if the guy you approach who works in the file room doesn't take your bribe). If you do successfully bribe the clerk, however, nobody else will ever know about it (no access controls, audit trails, etc).
On the other hand, electronic records are vulnerable to some hacker in Indonesia who copies the records of 30 million patients from a NYC hospital without anybody even realizing that it had happened. Most likely the attacker didn't target any one patient or hospital in particular - in fact the security at 99% of all the hospitals was probably completely effective at keeping him out. However, since this was a trawl they will extort anybody of interest whose records they do get, and since somebody will mess up electronic security chances are there is someplace they'll manage to break into. A successful theft might even leave a trail - but most likely beyond the jurisdiction of whoever performed the theft. In fact, the theft victims might just get the guys home phone number when he calls to demand money - and they'll be powerless to do anything but pay it.
Paper and electronic both have strengths and weaknesses. The ways they are likely to fail from a security standpoint are very different.
I was a medic in the USAF during Viet Nam. I had a strong technical background, so I worked on a medical records database project from 1975-77 at the Air Force Rocket Propulsion Lab in the Mojave desert.
We hand coded, on punch cards, for a Control Data host, about 650 records. Took 6 months.
I thought at the time, "there's got to be a better way!"
In the late '80's, I was CEO of a medical software company that created a networked medical transcription application integrated to "ChartChecker", an expert system for ER physicians, that would analyze a patient record and tell the doctor if he had passed or failed the encounter and was therefore at risk of malpractice litigation. We got the chart through the network from the transcriptionist to the analysis engine and had a result in 30-40 SECONDS. With voice-to-text, we actually did near realtime analysis.
Massachusetts approved a statewide 25% malpractice premium reduction for any ER doctor that leased our system. At the time, the minimum annual premium was around $30,000 and our system leased for $5,000. The average ER doctor stood to net $2,500 a year and that doesn't factor in the reduced chance of litigation.
This was 20 years ago. We spent a LOT of time with the VA, BIA, DoD, CHAMPUS, the Navy and Air Force. I saw a WORKING digital dogtag in 1991.
And where have we gone in 2 decades?
Not far. Not far enough by ANY yardstick.
We have sufficient technology; what we need is a national standard medical record that is mandatory for all who deliver medical services in the U.S.
This is a problem that should have been solved 20-30 years ago.
I am my own gestalt.