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IT and Health Care
Punk CPA writes "Technology Review has some thoughts about why the health care industry has been so slow to adopt IT, while quick to embrace high technology in care and diagnosis. Hypothesis: making medical records available for data analysis might expose redundancy, over-testing, and other methods of extracting profits from the fee-for-service model. My take is that it might also make it much easier to gather and evaluate quality of care information. That would be chum in the water for malpractice suits."
Is not very surgical, but probably will be the right tool to diagnose this problem.
Having worked in development of EMRs, it was an extremely challenging area to work in. Trying to get 3 highly paid doctors to agree on a single thing was very difficult, and it was harder still to convince them to enter the same data the same way. In a particular area, such as diabetic care, it was possible to templatize the intake notes. But when dealing with general care, it became a very difficult data input issue, and meaningful data extraction was messy.
A very large HMO has spent Billions on an EMR, with major IT consulting involved, and little to show for it. The benefits were very clear over 15 years ago. The medical community wants it to save money, and also to document against malpractice suits. The OP's take on why it has not been adopted was definitely not the view at the VP levels of the HMOs...
Hold the conspiracy theories. It's relatively easy to install a stand-alone diagnostic device. It's a thousand times harder to migrate a system that's ingrained into how everybody does their work from moment to moment throughout the day. It requires conformity, and that means resistance (sometimes well justified!)
Were your hypothesis correct then there should be a visibly greater level of non-clinical IT adoption in tolerably resourced, state-funded healthcare schemes - eg the UK.
OMG!!! Ponies!!!
I work for a company that makes ophthalmic ultrasound machines.
1. They cost roughly $30000USD per system, plus a couple grand for training. Most large hospitals and HMOs are run by bean counters who refuse to spend any more than they absolutely have to, and they could care less if everything is still paper records. Smaller organizations are just so cash-strapped that they CAN'T spend money on non-essentials. Government hospitals (like VA hospitals) have NO money to even fix aging equipment, let alone buy new or have fancy things like IT.
2. Quite a few medical people are, frankly, pretty average intelligence, if that. Some are complete doorknobs and barely know how to use a PC let alone deal with using a network. Almost all of them are so damned busy that they don't have the TIME to learn non-essential skills like computer and network use, let alone having time during the day to actually USE the stuff, unless it's absolutely necessary to do their jobs.
"making medical records available for data analysis" will also lead to easier abuse and leakage of said data.
All your medical data managed by one IT service provider ('cause that's where IT in healthcare usually leads to)? There's no way this could go wrong.
Incidentally what was the name of the social website that tries to sell its users' data after going out of business?
The nugget of this is not explained really in the article:
Cost is *NOT* the barrier, but "lucrative business model hidden" what they mean is the intrinsic structure of how medical care is delivered and who gets to be responsible for care delivery.
In my opinion, refusal to openly adopt electronic medical records is a direct result of overt protectionism by physicians and surgeons. For good reason, society has left medical care in the hands of competent, trained people. However, competency and training has been industrialized to only 1 kind of person, with one kind of standardized training: the MD, and basically no one else, regardless of training or ability is allowed by license to practice medicine, or reap the financial rewards of such extreme responsibility. NPs have wiggled their way in a bit and DOs are close, but basically no one else.
When physicians are required to interact in electronic, shared systems, they can't lord over all the responsibility in care environments, and then they won't be the only ones who run all the medical care and take home most all the money. They will lose their self-created and maintained monopoly on responsibility for care.
Anyone who has worked a hospital environment learns in the first few weeks exactly what the MD care delivery scheme is all about.
Am I alone in thinking that some systems are better off with a buffer of redundancy rather than streamlined efficiency?
Graduate of the LeRoy Funkified Badass School of Soul.
While liability is a concern, the medical industry needs to see that there is a real bright side to analysis of medical data as well.
There are no karma whores, only moderation johns
I suppose engineering approach i.e based on merits would not work here and the reason is simple: this is one of t he two remaining guilds in modern world (the other one being lawyers) and thus any change has t o come from within. If the change is perceived as a cost and burned or even threat then it is not going to happen. Unless that is the system collapses under its weight of its own fat.
The amount of unnecessary spending is huge. In a project that analyzed 4,000 hospitals, the Dartmouth College Institute for Health Policy and Clinical Practice estimated that eliminating 30 percent of Medicare spending would not change either access to health care or the quality of the care itself.
The first thing I did was go looking for who funds the Dartmouth College Institute for Health Policy and Clinical Practice. Following the second search result was just too damn funny - excellence.php needs a bit of work, I guess.
[17] Leary, T., White, C., Wood, P. R., Bhabha, W. D., and Wirth, N. Lambda calculus considered harmful. In Proceedings
However, the biggest stop to systems like this is the medical staff. Doctors seem to think they're above having to enter medical details - as it's mere clerical work (I've heard: "I didn't spend years at med. school, just to be a secretary") and they, personally, don't gain anything from a system such as this. Until somoeone gieves the profession as a whole a kick up the rear, this kind of prima-donna attitude will prevail.
In the end, it's a people problem - not a tech. problem.
politicians are like babies' nappies: they should both be changed regularly and for the same reasons
When physicians are required to interact in electronic, shared systems, they can't lord over all the responsibility in care environments
As patients, we often forget that most diagnoses are really just a SWAG. A doctor usually can't be 100% confident that his diagnosis is correct, but does his best based on his expertise and the training he has. If I were a doctor, my daily concern would be malpractice suits. I don't even want to know how many incorrect engineering decisions I make in a year. If I had to be concerned about being sued for every one of those incorrect decisions, I would be lording over the data as well because I know there is always multiple ways to interpret the same data set.
A much simpler explanation for why IT is not strong in your local doctor's office is because they don't know enough about it to trust it, or understand why and how it could help.
Some older doctors might even be scarred for life from their encounters with IT in medical school. I have a case like that in my own family - for his dissertation, he did a statistical evaluation of certain accidents (probably trivial today, just punch the data into a spreadsheet and you're done in less than five minute) ... with punch cards.
He'd only touch any kind of computer with a ten-foot pole ... if the twenty-foot pole is broken. Heck, most electronical devices that come with more than one button and don't read minds drive him bonkers, unless he learned how to operate them thirty years ago. Navigating a menu (like that of a cellphone) is a completely alien concept to him.
Some people just relate to computers like geeks relate to people, really. ;)
We're tired of waiting for docs to adopt EMRs, so we're about to roll out a claims-based PHR for our members to keep track of basic things like physician encounters, vaccinations, drug lists and interactions, etc -- basically anything you can get from an insurance claim. I'm not looking forward to the switchboard lighting up on day one when they discover they've been diagnosed (a.k.a up-coded) with conditions for re-reimbursement reasons rather than actual diagnostic reasons.
Parent either is full of it or lives in a parallel universe.
1. Cost is not a barrier? Our EMR costs each physician many tens of thousands a dollar a year in application support, licensing, databases, and for a phalanx of IS personnel in various departments (local, regional, EMR, hospital IS).
2. MD's have a monopoly? What planet are you on? DO's have had precisely equivalent standing for decades in medical practice in the United States, and NP's are far from being "wiggled in." As a primary care physician, when I send a patient to the cardiologist or pulmonologist, half the time the entire consult is done by a PA or NP.
3. Please direct me to the land you describe where I can have control over my care environment and take home most of the money. I can't get a contracting pregnant lady into labor and delivery without asking for permission from two nurses, and I'm not aware that the balance of power in any health system I've worked in has been any different before and after transition from paper records. Medical care in most locales in the US has long been collaborative, team-based system, even if you've met a few physicians who are jerks or drive nice cars. (I am looking forward to upgrading my '94 Corolla by 2014.)
EMR systems have poor market penetration, in my direct experience over the last 9 years, because:
1. Many, if not most, suck in a medium to large way;
2. They are incredibly expensive;
3. They can often be hard to use, and are typically more labor-intensive than paper charts for most physicians in the US;
4. They don't inter-operate. (When I request old records from other physicians with electronic charts, I enter the pertinent data into my electronic chart by typing it in.)
If any skilled group of software engineers were to write a decent, usable EMR that was extensible, and didn't cost an arm and a leg, with an eye to being excellent first and profitable as a consequence, they could be up for a Nobel prize.
TFA refers to cardiac CT to prevent heart attacks. The author, too, lives in a dream world - contrary to her thesis, this test has been shown to help with the boat payments of radiologists and equipment manufacturers, but there is no evidence it helps prevent heart attacks.
When physicians are required to interact in electronic, shared systems, they can't lord over all the responsibility in care environments, and then they won't be the only ones who run all the medical care and take home most all the money.
This all sounds good, but how exactly does charting via PC (instead of by hand) somehow change the rules that Doctors (regardless of if they are DOs or MDs) are the ones who write the orders that all the other practitioners follow? Granted, FNPs (Family Nurse Practitioners) and PAs (Physician Assistants) can now write orders and scripts, but thats because they are now filling in the position of general practitioner that most MDs have abandoned in pursuit of more lucrative specializations. Plus, there is currently a push to make it mandatory that by 2015 all nursing practitioner programs are based on DNPs (doctorate of nursing practice), and not masters....so they are still all docs...
There's another good reason.
In the IT Healthcare Sector, teams have to perform intense amounts of testing on all aspects of the system (right from the specs, to the product, to the docs, to the training - the whole deal). Some of the testing can be done in house, some has to be signed off on by external bodies.
This kind of process is expensive, long and inflexible. None of these things is conducive to rapid development or innovation.
Replying to my own post is in horrific bad taste, so I expect to get the bejesus mod'd out of me, but ...
I don't know how the dollars add up, and it also smacks of conspiracy theorism, but advocating automation in health care as a cost saving measure, with a side benefit of data-ming the hell out of electronic medical record systems looks like enlightened self-interest for health insurers
And when the Dartmouth College Institute for Health Policy and Clinical Practice (author of one of TFA's cited sources) looks to be financed by health care suppliers (J and J), and really large health insurers (Wellpoint, United Health) through their charitable foundations, my spidey sense really starts tingling.
None of which means that there isn't any merit in the article. Maybe I'm just being too cynical at 4:00 a.m.
[17] Leary, T., White, C., Wood, P. R., Bhabha, W. D., and Wirth, N. Lambda calculus considered harmful. In Proceedings
ironically, lording over the data is a large reason why care providers often still have to make SWAG diagnoses, instead of having a long progression of better medical knowledge fueled by accessible research and outcomes data.
is it some sort of real problem, or just the expected difficulties? is it the curmudgeons in bureaucratic positions that are afraid of "new", or is there something else at work here, like mentioned above (easily finding extra charges, etc)?
for a while, i sold insurance for AFLAC. around my area, there is a HUGE hospital system, Meritcare; the last time i checked, they had around 20k employees (that's 10-15% of the working population, depending on the radius used for calculating).
they will not permit AFLAC to come in and offer their products because of the perceived difficulty of presenting and making it available to everyone.
maybe it's just me, but if wal-mart can find a way to share something with all of their employees, i'm pretty sure a relatively small hospital system can.
I agree. I think there is a lot of fear and apprehension of putting data "on the record", particularly in a litigious society. It is as likely to work against you as in your favor. If on the one hand that information limits privacy or insurance policy coverage for patients, it may also be implemented in exposing incompetence, neglect, and greed. Its a double edged sword, since in truth, people behave like there is an angle on one shoulder and a devil on the other. We only want to reveal the good stuff, so the diploma is on the wall, and the malpractice settlement remains undisclosed. Information Technology won't do a thing to change human nature, but it sure as heck will make our medical process more efficient. Lets move forward then, in spite of the perceived cultural drawbacks and fears.
...there are multiple reasons and road blocks (natural and artificial):
1) Healthcare is about making profit. It is not about caring for health. I have seen many IT companies bite the dust during proposals by stating their systems could help caring for health quicker and much better. That's the last thing Blue Cross or anyone else wants.
The idea for IT companies is to open a presentation with how to increase profits. That, as far as i know, is the only presentation which interests the healthcare company.
2) There are combinational factors; for instance doctors and software don't go well together psychologically except in times of peace, which is rare. Instead of adopting touch screen systems and throw-away laptops small enough and tough enough, most companies insist on producing massive software run in PCs and Servers in a serene a/c room. Excuse me, which doctor has sanguinely traversed through a maze of Visual Basic or PowerBuilder application menus?
3) IT companies should seriously stop considering "integrated" systems which connect doctors with nurses with patients with pharmacies. No, for the last fcuking time, no we don't need integrated crap. All we need is a simple system that can be accessed with a max of three clicks and accepts voice input.
4) Record management: HIPAA is not exactly an easy job. Any standard created by a committee is, by definition, an as$ to work with.
5) Changes in systems result in changes in behavior and processes: something hated by surgeons, doctors and hospitals.
Don't attribute to malice what can be explained by stupidity.
"Doing what i can, with what i have." ~ Burt Gummer
Quite simply it is that Doctors believe they are the most intelligent people in the room whenever they walk in. They will accept no management advice, no time allocation advice, no parking advice, no dietary advice . . . no advice.
They believe that they are already operating in the most efficient manner and that any change will put patient lives at risk. Well . . . actually they don't believe this, but this excuse is used every time they don't like something. A quick "OOooooo - patient lives at risk" and any progressive idea is already on the back foot.
This ideology permeates through the health care system with consultants at the top right down through the chain to the nurses.
Getting these people to agree on ANYTHING is a Herculean task.
A friend of mine (a Doctor) was on a committee trying to bring more IT into the healthcare system in Scotland. He is very IT minded (read geek) and was keen as mustard to help push things along. Within a handful of months, he was at the end of his tether due to the sheer deluge of nonsensical crap that was being floated purely to waste the committee's time and ensure that nothing got done.
There's ample room for conspiracy in the murky world of health care, but I don't think it is in IT - instead, look at medical companies and the way medicine is prescribed and used, if you are looking fopr conspiracies.
There are many good reasons why computers aren't used universally in health care. Two of the biggest are education and resources - doctors and nurses aren't really taught to use computers in their work. And while having a well designed computer system can be a huge advantage in any line of work, that is actually only true once everybody is fully trained; until that has been done, it is actually less efficient. And the situation in most countries is that there are too few medical staff anywhere, so where would one find the resources to make it happen?
On top of that comes concerns with incompatible, existing systems, privacy issues etc. Not to mention the fact that nearly all public IT projects so far have been hugely over budget and behind schedule. I think that perhaps the only realistic way this can be solved is by creating a good, open source health care system and let it mature and grow into general use from the grassroot up.
I think there has always been a serious barrier to the uptake of new information technologies among the medical profession. Most HATE taking notes which is why note taking is left to the junior medical staff on ward rounds. Most clinicians take very brief notes, especially surgeons and only verbose when practicing defensive medicine. Most have a personal way to annotate their notes which cannot fit into any template (eg. unconventitional acronyms, stylized diagrams etc) and are loath to learn new ways of doing things. Sometimes surgical notes only make sense to that particular surgeon or surgeons of that sub-specialty (eg. ophthalmic vitreal surgery... very difficult to decipher...pain in the arse reading their notes.. ) Why? I think some of you guys need to see the amount of stuff medical specialists have to learn and the years of training (at least five here in Australia for specialty training, ( that is after 5-6 years medical school and another 1-3 years as general intern and resident) and then another 2-3 years for sub-specialty training which can involve 2-5 exams and possibly a PHD during the training). There is an incredible amount of stress on the person and their families. (Yes, I think the high standard of medical training IS necessary and not just economic gate-keeping by the medical colleges). During all that training before you are a qualified specialist, your hourly rate can be lower than the hospital cleaners or even not allowed to claim paid overtime at all, as the public hospitals here in Australia frequently runs out of money.
At the end of all that, I don't think many like to be told how to take their notes.
I don't think you need conspiracy theories to explain poor uptake of EMRs. In NZ where basically doctors can't get sued (generally speaking), doctors STILL hate EMRs and do poor job of entering data into systems. I once worked for an older surgeon and we got called for an emergency laparotomy on a drunk 19 yo male who lacerated his spleen in a car accident. The surgeon hated taking notes and hated talking to patients but was one hell of a surgeon. All his patient notes consisted of scribbles on flashcards. The young guy's abdomen was full of blood. We had no idea at the time where the bleeding was coming from. The surgeon was clamping major arteries by feel blindly as the suckers couldn't keep up. After five hours the surgery was over and the young guy lived. I tell ya, I had a new found respect for the "old school" surgeon. There are times when you REALLY don't care whether a surgeon is good at filling out forms or has polished bed-side manners.
I had an interesting experience in China. In 1996, when I received treatment, I kept my own records (they gave me a little paper booklet). This eliminates all the record keeping costs of the doctors and hospitals.
It might be an interesting model to look into here.
Fight Spammers!
As patients, we often forget that most diagnoses are really just a SWAG. A doctor usually can't be 100% confident that his diagnosis is correct, but does his best based on his expertise and the training he has. If I were a doctor, my daily concern would be malpractice suits. I don't even want to know how many incorrect engineering decisions I make in a year. If I had to be concerned about being sued for every one of those incorrect decisions, I would be lording over the data as well because I know there is always multiple ways to interpret the same data set.
It stands that You make considerably smaller amount of false engineering decisions. When did You have default value range 1-100 out of possible 0-300 units? It is common thing in medicine.
If You put voltmeter at test point number 321, you measure exact that voltage, while in medicine, blood sample can literally be different because the room walls were of different color or because nurse said something or it was not taken in the morning but after the lunch.
It seems to me that considerable number of problems comes from the fact that engineers are used to work with models, while medicine is done in the real conditions. I agree that science part of medicine makes difference, but the ground is still shaky.
Just remember, if something is done in one hospital/county/state one way, there is no way that all of it will be the same in next hospital/county/state.
Doing a good job is like spilling coffee on a dark suit, you feel warm all over, but nobody notices.
In most healthcare systems, staff are very busy, and computer illiteracy is rife. To get good with these electronic systems you've got to use them constantly, and when half the staff or more don't understand why they're doing a particular thing in a particular way. There's also a workplace culture of written notes, and often a limited number of computer terminals per staff member. So with queuing for terminals, fairly high friction processes for retrieving data and so on and so forth, there are quite high barriers to entry from a human point of view.
Don't get me wrong, EHRs have potential, and can reap benifits (especially for management - they can also make floor staff's job harder). Some kind of robust iphone-like device which is a secure platform for data entry and retrieval, might make it sufficiently easy and efficient from an end-user's perspective to decrease implementation barriers.
No really, Doctors hate technology for the most part from what I've seen, as they see it as intrusive and contradictory to their long history of practice. The number one concern I hear voiced is that having to deal with electronic records, especially with the patient present takes the doctor's attention away from the patient and that's a big no for most physicians. The other one I hear alot is that from the patient's viewpoint it looks a whole lot less intimidating and polite to have a doctor staring at a paper chart than a hand-held device. Something about a person staring into a screen as they attempt to hold a conversation with you is still a bit unnerving and something that we haven't fully gotten used to for the most part, I guess.
The eternal struggle of good vs. evil begins within one's self.
Those points about EMRs look to me like a stagnated market, rather than inherent difficulty. In particular point 4, isn't HL7 precisely what solves that?
True confidence comes not from realising you are as good as your peers, but that your peers are as bad as you are.
etc.
Oh, and there's no such thing as an "exact" measurement. Not even in engineering.
Sorry, but as a physician, you come to the table with a prior of zero credibility in a discussion of financial matters.
Most physicians ought to try working in any other profession besides the guaranteed-high-salary-MD-world before commenting on who it is that lives in a parallel universe.
Physicians in the US have created a closed system that requires a *state license* to enter, and then they earn 3-10+ times the median salary:
http://www.payscale.com/research/US/People_with_Jobs_as_Physicians_%2F_Doctors/Salary
commensurate with remarkably low unemployment (while the rest of the US are now around 9.4% and rising).
I'm a strong supporter of anyone who creates high value earning as much as possible. When one builds value or manages high responsibility, they get the money.
Unfortunately, physicians in the US are not creating significant value despite the costs and their salaries. The costs to the US society have gone now above 17% of the nation`s Gross Domestic Product (GDP), and rising at rising four times faster on average than workers` earnings since 1999. That means more than 1 in 6 of *EVERY* dollar of value created in the US goes to this racket (sic). High cost, by itself, not a problem: health is extremely important BUT, health results in the US are not very good, on a cost comparison basis with other 1st world countries:
http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2006/Sep/Why-Not-the-Best--Results-from-a-National-Scorecard-on-U-S--Health-System-Performance.aspx
For all this expense, and all those salaries, US health is not as good. Why?
Becuase care providing is a controlled, state-sponsored monopoly. In any other industry physicians would all have been fired and improved long ago for such a horrible financial mess coupled with such poor comparative results. As a physician you and your peers created and profit directly from the high costs in the system.
I agree with any of your assessment of EMRs. They are dead on - but interested physicians driving this technology forward with a sincere interest in human health and not solely on protecting their business and on profits would have made EMRs a priority more then 30 years ago when research in this area first started, and solved all those issues.
And as for "Medical care in most locales in the US has long been collaborative, team-based system" - that`s comic. A physician`s definition of "team" and what everyone else in the work world means with that word are miles apart.
This might be news to you, but it's pretty much the same as in the other first world countries, which are getting better medical outcomes at lower overall costs.
I find it interesting how huge pressure from law practitioners changed medicine in united states. All this segmentation parent is talking about can be traced to increased liability pressure, long and expensive education and some other things.
Have you seen how much money it takes to become an MD? Did you see how much hospital spend on liability? Ant to top that all, what are the profits (holy grail of capitalism, I agree) of health insurance and pharmaceutical companies?
the US has just enough regulation to maintain the monopoly, but not enough control to ensure central planning for good outcomes - that would be... horrors, "socialism"
the same is true for the cell phone market - state supported companies given permission to monopolize and provide crappy service here.
it's the worst of all possible cases - either getting out completely and allowing the market to work would be better services, or stepping in all the way and providing centrally planned services would be better too, than this.
Some things people fail to account for: ...
A) Cost. Some of these data entry systems are pricey! Some physicians who only have 5-10 years of practice time left and with private practices do NOT want to invest the time or the money to adopt such a system. The software runs thousands of dollars. You assume each and every physician is just REAPING in the cash and has 30,000 to invest in a computer system. Plus the cost of inputing old records into the data system on top of that. Granted its a system of healing people and what not, but everyone is out there to make a good living for themselves as well. You invest a lot of time and money to have an opportunity to treat people. A lot of delayed gratification as well. Most of ya'll probably went to work right after college/masters, assuming you did one at all. Some doctors don't get out and make money till they turn 30. Some even later than that. A neurosurgeon has 9 years of residency training at least.
B) Time of entry. Having used some of these systems. They are a pain in the butt and not that quick. In private practice. Its much easier to write out a note than spend 15-25 mins trying to write an electronic note. Time is limited and using these data systems are not efficient for most physicians! Especially with all the overhead costs of providing care, most doctors do not have the time to spend more than 10? mins per patient. Anything more and they can't pay the rent or the staff, etc.
C) None of the systems are compatible with each other. For these savings to be realized, Every doctor and point of medical care would require the same software and access. That is not going to happen without any intervention from a big brother.
D) HIPAA sucks. Adds a lot of overhead, headache and costs.
E) DOs are MDs, just a different philosophical background on the cause of the disease. But in the end they are physicians. Nurse practioners are not doctors and will never be. They do not receive the same amount of knowledge and training. Average primary care physician spends 4 years in college, 4 years in medical school and 3 years in residency. NP does what? 2 or 4 years max? BIG difference.
F) Doctors are not the big problem here. Granted some do over order exams. Some do it to protect themselves legally. You know its not there,but you need a way to document that its not there when you get sued.
G) HMOs and insurance... can't be sued for making business decisions. Setup a lot of roadblocks to not cover patients and create as many road blocks to keep from paying doctors for service. I worked with a urologist. HMO basically said we think this procedure was worth $150 (used to be he got $1500 for it 10 years ago). Its a take it or leave it proposal. Then if he wants to take it, HMO requires that he personally call in and go through a convoluted phone system that costs him/her time and money. They want to make it as long as possible so that the person calling in will just give up that money and move on. Like a mail-in-rebate essentially
I can't speak for the US or private medicine but I've seen numerous electronic record systems piloted in the NHS.
My colleagues would love to have fast access to up-to-date clinical notes rather than play pass-the-parcel (or more often, hide & seek) with a patient's paper case-file(s), but wards tend to have one or two computers per ward and community services may have one computer between three to five staff. So at the end of a shift, when ward staff would be writing their notes, there'd be a queue for the computer. Similarly, before setting out on their visits at the start of the day and after returning from their visits at the end of the day, all community staff want access to the computer at the same time. Also, security dictates that as little information as possible is stored on the user's machine, so the intranet is swamped at these times and users face frustrating lags (I've been unable to access records in time for an appointment as the system was "oversubscribed").
To increase computer access to usable levels in my former service would have required a 3-400% increase in the number of computers provided to healthcare staff. I have no idea what the resource implications would have been for the service's intranet, but I imagine that a commensurate increase in server capacity (and in the IT department staffing, to take care of all of this) wouldn't be cheap. As a health service manager, having to decide between enough hospital beds or enough computers, which do you suppose is more likely to keep you in your job?
As a medical interpreter, I see health-care IT up close all the time. (I'm writing this in an ER, on an overnight shift.) TFA has a lot of good points, but think the biggest single reason the IT sucks is the sheer complexity of medical information, but also of our byzantine and baffling health system in general.
All the health systems in town use the same medical-records company, because it's local. Its design reminds me of Windows 95, and the nurses know more about the workarounds for the bugs than about the intended use. The thing is, few of the doctors and even fewer of the nurses are interested in computers. They're interested in medicine, and computers are a pain in the neck even *before* they break down. They can't tell when the computer is behaving unpredictably, because as far as they're concerned, the computer always behaves unpredictably.
Am I trying to blame the victims, here? No. I'm saying this is a detailed and ongoing focus group, and they're telling us that the whole IT system is a disaster. And as far as I'm concerned, the most damning critique is that no one I've talked to wants them to change it, because, almost to a person, they're convinced the upgrade will be just as, if not worse.
What if I do the same thing, and I do get different results?
Sure, all those people must be in cahoots. There must be a conspiracy here.
Yes, let's promote a profession with foundations as dubious as baby twisting motherfuckers.
// file: mice.h
#include "frickin_lasers.h"
this is a very touchy subject as medical records are very sensitive information... im sure most would agree that there is no room for sub par implementations in this case. so all in all, they have to get it right, any small mistakes made on the IT level could prove quite disastrous...
as the world has become globalised, the only right way of doing this will be an international database... formed by an international consortium... which can regulate standards, credentials etc...
there is no room for mistakes...
As always this is a relatively simple problem wrapped in layers of -- to a certain extent unnecessary -- complexity.
...).
... not -- I would be quite weary if just about anyone could look at my records. How is this problem solved?
The simple idea is to have a system that records the patients history of illnesses and treatment (including medication, obviously) and which is easily communicated across different places of diagnose and treatment (GP, specialists, consultants, hospitals,
This specific problem could easily be solved with standard software like Lotus Notes, Microsoft SharePoint and similar systems, but that is where the simplicity stops and the layers of complexity start.
Sorry if I am going down a well-travelled trail here.
Firstly, it is very difficult to get people and organisations to standardise on a single system for good and for bad reasons. (Like "We've already got Lotus Notes, why should we get a Microsoft product?" -- plug in whatever conflicting product/system names you can think of.) This means that a single system probably is out of the question, which leaves us with a standardised interchange format instead.
OK, now we have a gazillion systems happily exchanging information in a standardised format, so everybody is happy, right?
Wrong!
Because secondly, who is responsible for the safekeeping of the data? This is two-fold: Who is responsible for storing the data and who is responsible for who has access to the data?
So 2a, Responsibility for storing the data: If every place of diagnose and treatment is responsible for storing own data, how can a patient be sure that any specific institution treating her has access to all the information? This needs some centralised storage or at least "mediating" (much like peer-to-peer systems, e.g. torrents, need a "meeting place", like The Pirate Bay, where they can find the trackers so they know where to find the peers). Either system suffers from the problem of connectivity dependence, i.e. if they cannot get access to either the storage, the "mediator" or the peers, information cannot be retrieved. This is still better than paper-based systems, if you are treated in different places, geographically.
This leads to 2b, Responsibility for who has access to the data: I would obviously like for my GP to send information directly to the hospital and for the nurses, doctors, consultants and surgeons treating me to see my records, but -- being the famous person, I am
Thirdly, who would be responsible for correcting errors and mistakes in the records? This problem is not really an issue relating only to electronic records, but is a general issue, which crops up all the time. Should you, as the patient, be allowed to correct mistakes you know about? If that is the case, how do the professionals make sure that you are not trying to tamper with the system for some ulterior motive (everything from trying to cover medical problems for insurance purposes to hypochondria)? If you are not allowed to correct mistakes, how do you tell them that you did not receive a certain medication two years ago and, in fact, is allergic to it?
Fourthly, a system relying on doctors, specialists and consultants to type would probably be doomed, at least for now. It seems that doctors, etc. at all the hospitals I have seen, rely on dictation, having a pool of secretaries typing it in and updating the records, which introduces unnecessary delays and adds an extra risk of introducing errors.
These are some of the many problems facing such a system and I am sure I have left out many, just as relevant. I honestly do not believe that the fear of transparency regarding the treatment is the major stumbling block for the introduction of electronic medical records, but rather the diverse types of problems facing the system.
"Hypothesis: making medical records available for data analysis might expose redundancy, over-testing, and other methods of extracting profits from the fee-for-service model"
Besides being perhaps the most ignorant thing I have read this morning, this statement reminds me of the irony inherent in listening to tech people whine about how medical caregivers have no trust or knowledge of IT, while the caregivers complain non-stop that IT has no idea how to design a decent medical record system.
On Wall Street they say "buy low, sell high" On the pad we say, "buy high, sell high" Isn't that somehow better?
So why not have the ability to "skin" the interface to keep the primadonna clinicians happy? Provide a 'reasonable' default interface and a tool kit that enterprising folk can use to charge the clinicians for making a bespoke interface for that clinician. The clinician then owns his own interface that he can carry around with him (on a thumbdrive maybe).
The system should obviously provide an interface that attempts to provide standard information in a standard way, but should also have the ability to step 'over' the standard way when the clinicians feel it is preventing them from correctly/accurately/fully writing up the patient notes. These occasions should automatically flag themselves up to someone in the "office" who can manaully glean the correct info to fill in the "standard info". It could also notify the writers of the software, providing a feedback loop to help to improve the software for future versions.
My experience of "IT in Healthcare" is the closed shop encouraged by the NHS which means you HAVE to buy from a very small set of approved vendors who then provide last year's hardware at next year's prices!
Eclectic beats from Leeds, UK
handmadehands.co.uk
However, the biggest stop to systems like this is the medical staff. Doctors seem to think they're above having to enter medical details - as it's mere clerical work (I've heard: "I didn't spend years at med. school, just to be a secretary") and they, personally, don't gain anything from a system such as this. Until somoeone gieves the profession as a whole a kick up the rear, this kind of prima-donna attitude will prevail.
I speak as a general practitioner of many decades, and I've been playing with computers since the early 70's. The main reason medical records software is not accepted is that it sucks.
My 24" screen holds far less information than a bunch of scribbled A4 pages. Time is what I lack, and scrolling through pages & sections on a screen is just not very efficient.
Yes, there are some great aspects in most of the software I have used over the last decade, but as far as being a place to store info that I want to easily access & collate later, all too often it is too bloody slow & awkward.
Except for one feature of electronic records, I would go back to pencil & paper.
The only really successful feature was the first; writing scripts & recording the fact that a script was written. In the 'old' days, you would write a script, then the phone would ring, on hanging up, you forgot to record what you had just prescribed, leading to problems down the track. Software to prescribe & automatically store a record of that transaction has been fantastically useful for both myself & the patient.
I have sat here for some 10 minutes, and the only other feature I like is that my notes are more legible to me down the track. As a computer nerd, I want to love these systems, but so far they are not very good.
So why not have the ability to "skin" the interface to keep the primadonna clinicians happy?
Imagine the question "Which button do I have to push?" for each and every necessary function of the system. And more than one button (or, god forbid, navigating a menu) is not accepted.
The reason these systems suck and are expensive is because they are the result of "design by committee". What would be a good approach is that there is an existing system (home-grown perhaps) which gets transferred to another hospital, where a representative group gets together and says "This and that needs to be changed, the rest is OK."
What happens instead is that a committee is formed out of hospital representatives who don't know much about IT, and IT managers who don't know much about hospitals (and, frankly, not about IT either). Since every hospital is absolutely unique and works completely differently from every other hospital (sarcasm intended), a new system needs to be designed from scratch. The hospital representatives list requirements they don't _really_ understand, the IT managers perform CYA tactics because they don't oversee the implications or the _real_ requirements (and they don't actually mind - if the hospital asks for a five-nines system they are more than happy to comply since they can raise the cost tremendously).
Then, there are patient representation groups who interfere because they have privacy concerns, insisting on physically separate ADSL lines going from MD offices to chemists and hospital IT lines because "the internet can be eavesdropped" (I'm not making this up), restrictions get built in so that some kind of card reading device is needed at every desk which the doctor has to sign in on to send prescriptions out (what happens now is that the doctor has more pressing things to do than sign the prescriptions, so their assistants send them out and he signs them in bulk in the evening - what will happen after the card reading devices are installed is that the doctor will simply leave his card in the machine and move on to the more pressing work), etcetera.
Result: The system gets more and more expensive, more and more bloated, and in the end doesn't get implemented.
Oh, and there's no such thing as an "exact" measurement. Not even in engineering.
Especially not in engineering.
Pirate Party UK
I recently saw President Obama make a comment about how FedEx can track every single package everywhere, but we can't even get medical records to follow a patient from one doctor to another.
Well, Fed Ex is a private entity with very little government regulation, while medicine is subject to government involvement all over the place. The government either pays for medical care (medicade, medicare), determines how it will be paid for (tax incentives) or mandates that it doesn't need to be paid for (get wheeled into any emergency room and they must at least stabilize you, or so I've heard). Government then regulates the tracking of information (privacy regulations - no such privacy regulations apply to FedEx package locations). If something goes wrong, government is involved in deciding malpractice verdicts and awards. From start to finish, government has its hands in the mix.
I remember reading about the difficulties the IRS had with automation due to the complexity of the tax code. Is it any wonder the medical profession would have trouble automating given the complexity of the rules associated with health care in this country?
A couple other key differences between FedEx and Health Care. First, most people feel no moral obligation to provide package shipping to everyone in the country.
Second, it is far easier for consumers to evaluate the effectiveness of FedEx than it is for them to evaluate the effectiveness of their medical care. With FedEx, you can verify that the contents weren't broken, and you can compare the speed similar shipments sent by other companies. That's easy. With doctors, well, recently someone I care about had an abscess in his neck. The doctor was thinking the pain was just lingering effects of a sore throat. But when it didn't clear up. he theorized an abscess and sent the person to the emergency room for an MRI. The abscess was found and removed by surgery that night. Did the doctor nearly cost this person his life by not recognizing the abscess until it was close to breaking through a vein causing blood poisoning? Or did the doctor save this person's life by recognizing the abscess in time? It's not so easy for someone like me to know.
I often don't like the choices people make, but I like the fact that people make choices. That's why I'm a conservative.
"4. They don't inter-operate. (When I request old records from other physicians with electronic charts, I enter the pertinent data into my electronic chart by typing it in.)
If any skilled group of software engineers were to write a decent, usable EMR that was extensible, and didn't cost an arm and a leg, with an eye to being excellent first and profitable as a consequence, they could be up for a Nobel prize. "
Whenever this topic comes up, the same answer always eventually comes out to address "4", which is of course VA's VISTA/CPRS. Not only is it customizable and extensible, but the program and code are free to anyone who wants it. And I don't see the programmers from the VA winning any Nobels any time soon ;-). Read "The Best Care Anywhere." Even if you disagree with the premise, Longman presents an interesting section on how VISTA, and later CPRS came into being. It's his position that an important (if not primary) reason there is not adoption of electronic medical records in the private sector is because it can actually create a competitive disadvantage.
Massing huge amounts of electronic, easily accessibly medical information on an individual is really only advantageous to the patient, provider and system if the patient remains with the same providers and same health care system, which of course is true for the Veterans treated by VA. Long term, detailed information on a patient is advantageous on the patient level because you can monitor more easily preventive health measures and track health status over time; for the provider it means decision making can be more informed which should improve outcomes; for the system it means better outcomes and presumably more competitive advantage. But here's the rub: patients don't stay with the same providers or same systems. Health care has become so complicated that person's change their care plan, and hence their providers and health care system often. If I'm Blue Cross, I can guarantee you I know exactly what the rollover of the person's in my panel are from year to year. If I'm a hospital administrator, I know exactly how many person's come and go through the plans I have contracts with and how many are seeking care at my facility. As you point out, unless a facility takes a stab at VISTA/CPRS, EMR's can be insanely expensive to develop. And deployment, penetration and compliance within a facility/system is a herculean task requiring a major change in culture to ensure adoption. So, as some sort of health care system administrator, for every patient that moves to another plan and hence gets care from other providers in other hospitals, I have just given my competitors an enormous advantage in their care of this patient. The patient is able to bring them their complete, beautifully printed out and organized medical record to aid their providers in the care of this person.
Now, of course, it also says I would have the same benefit when patients come to my system. The problem is who is going to budge first? And if someone else budges, and I can attract those patients to my system, then maybe I don't have a good incentive to develop an EMR for my facility in the first place. Maybe I should spend more money on a finely landscaped, aesthetically beautiful, modern bed tower? Because, really, the patient is going to leave and go elsewhere eventually. When they change jobs, their health care plans change. When life circumstances change (e.g. they now need a family plan), their health care plan changes. There's a ton reasons person's change health care plans, and very few of them have to do with actually wanting to see a certain person or get care at a specific facility. Without these lifelong relationships between patient, provider and system, it's hard to convince a facility of any size, be it a small practice of primary care providers to large health care systems buying up hospitals, to invest the time and energy in an EMR. And it will remain this way until there are clear financial incentives to do so; or the health care system is totally revamped such that lifelong relationships between patients and providers is again feasible.
later,
jeff
Go to any doctors office and ask how much they like their software. There is so much crap out there it isn't even funny. I know for a fact, one software company that services more than 20 hospitals and 200 doctors office recently discovered that they had a rounding error in displaying pharmaceuticals. Obviously nothing extremely dangerous... but the fact is there just isn't that many affordable quality software companies out there.
Hell, http://www.physiciansehr.org/index.asp and companies like it make it their sole business to find software suitable for your office, and help in the transition. It's huge business.
I don't honestly believe most medical practitioners are worried about that being used as medical malpractice fodder when weighed against the benefits. The problem comes with the cost and quality. Most doctors don't understand nor care since they have little interaction with it.
I've evaluated over 20 small doctors office software apps that are rated high and let me tell you... 99% of them suck ass. I officially dub "suck ass" a technical term meaning, someone was smoking crack when designing the user interface and knew more about making an annoying, non-user friendly piece of trash than making ANYTHING remotely useable by the medical field.
The transition will happen eventually but some standards need to be in place and universally accepted accreditation certificates need to be available to say "Yes... this software meets these standards". We all know that this will be abused and the bare minimum met... but you have to understand... the standards are SO low... that companies release bugged software knowingly...
Just ask E-Cast. I can't wait for a federal investigation to happen to those guys.
Disclaimer: I do not work for E-Cast, nor have I ever worked, contracted for or through any group associated with E-Cast.
In countries with sane health care systems, the government forces the hospitals and practitioners to do exactly what you say: "making medical records available for data analysis might expose redundancy, over-testing, and other methods of extracting profits from the fee-for-service model".
They can do this, because the government is the one paying the bill. Optimizing the quality/cost ratio is an important part of keeping health care payable.
I guess the US has some catching up to do to stop all the abuses of private health care.
The reason the NHS system is such a debacle is the culture of absolute gold plating everything so that the blame can never be laid at your door. This leads to people taking on consultants who themselves can justify taking the project to the nth degree of abstraction and documentation. I work on agile projects - they expect production ready code for a tiny vertical slice of the system in 2 weeks from the project start. We have delivered enormous (globally renowned .coms, oil pipeline systems, you name it) by this method. This is how public sector software should be delivered - demonstrate your progress with a working system, not with documentation.
Sometimes paper is better than anything else. Certainly with paper, data security comes down to physical security, whereas with digital, security is a mix of physical and electronic security. Paper doesn't crash, paper doesn't need electricity.
i work as a systems engineer for a healthcare company. on a daily basis, i have to deal with nurses that use our systems. what it comes down to is nurses might be good at what they do, but they otherwise lack the skills to do anything else. most of them, even the ones in their twenties, barely know how to use a mouse. putting everything on the computer adds a step of complexity to what they do. management at our facilities loves what we do because it makes reporting and accountability easier. nurses hate what we do because regardless of how easy we make it on a computer, it will always be easier to write it down on a form. they also hate it because it makes it easier for anyone to expose mistakes that they make.
if someone keys in Joe Bob's diagnosis and medications wrong, we know exactly who did it. if someone steals meds while they are stocking our machine, we know exactly who did it. that is a threat to a lot of people and really puts the management of a lot of places in a bind. on the one hand, it's hard to get good people; a nurse could be an excellent nurse and be completely computer illiterate. on the other hand, it's easier to run reports based on stuff in a database as opposed to stuff written on forms.
what we've found is that if we make it "idiot proof", they will find a way to be a bigger idiot. 8)
stephen
I've been working with the ICS project (similar kind of mandate, but for children's social services - in the UK again) and we're seeing exactly the problems you've described. It's got nothing to do with the system being conceptually difficult, and everything to do with massive, chronic project mismanagement by central government from the very start.
Specifications were set out without any significant consultation from users, practitioners or even IT project management specialists (a field full of charlatans, but some experienced input at the initial phase would have been helpful). The specs were then handed - untested, mind you - to software suppliers, most of whom have been in the business of supplying under-performing systems to the public sector for decades, and who therefore know exactly what they have to say in order to win contracts, and what they can get away with while still turning a profit.
I'll lay out the process:
The whole merry-go-round keeps turning, and there's no way off it because it's an inevitable product of a system of government that lends itself to knee-jerk policy- and decision-making according to the whims of the press and public rather than the mandate of their manifesto.
Reactionary "solutions" to systemic problems invite crooked opportunists when the money starts flying, and I don't see this changing, ever.
Meta will eat itself
isn't HL7 [wikipedia.org] precisely what solves that?
I wish. The problem at this point isn't one of structure, it's of coding. Within that HL7 message you have to express the patient's information in a format that something else can read. LOINC is a common codeset for measurements, originally created to uniquely identify every possible laboratory observation, but since expanded to cover just about any observation anyone can think of, including physical examinations and such. The problem is that unlike ICD9, there's no notion of specificity (not that ICD9 is a great example of it, but it's almost arranged in such a way that say (fake code) 123.1 is a fever, then 123.1x are different kinds of fevers). There are 20+ different ways of collecting a blood pressure, software X (or its user) has to pick one code and hope that software Y (or its user, fortunately HL7 provides for human-readable descriptors) recognizes it as a blood pressure. Sure, maybe a specialist cares exactly which device, location on the body, and whether the patient was sitting, standing or laying down when the bloodpressure was taken, but I guarantee that the other 95% of the doctors your medical information may encounter just wants to (have the nurse) type the numbers or just wants to read the numbers. SNOMED (medical "concept" list designed to codify the results of a physical exam or review of systems as well as other medical information), NDC (FDA-assigned drug "packaging" code, nobody cares whether your viagra was sent to the pharmacy in a bottle of 100 pills or a box of 20 50 pill bottles or whatever, yet each of these possible packages has a unique code), and so on all suffer from the same problem in various flavors.
I worked in a hospital in college and for insurance companies after and I can confirm this. Doctors, for example, are only in it for the money. While some of you may be able to cite examples of good doctors, they are rare. Most are in it to get rich and so it follows obviously that they are going to do as many tests as possible--cost be damned--and if called on it they can claim they're protecting themselves from malpractice suits. In fact, it's just wallet padding. Insurance companies have their own version of this. They are trying to find any excuse not to pay for stuff while they are collecting their ever-rising premiums. The only solution to this problem that I can see is the Public Option. Hence, all the entities who have gotten fabulously wealthy on the current Fee-for-Service model, are against it. That includes physicians, Big Pharma, medical product vendors such as Baxter and of course hospitals and the insurance industry. The public option is the only way to go my friends, unless you or your immediate family are one of the few getting rich off of the status quo.
It's not protectionism or any of that other trite conspiratorial nonsense that keeps physicians from using EMR (you can't get ten physicians to agree on damned-near ANYTHING, from what PACS software to use, to what size coffee cups to keep in the surgery waiting area... how do you expect them to engage in any kind of organized conspiracy to keep using paper?) You want to know why physicians dread EMRs?
Well... being one (and a tech geek to boot), I'll tell you:
It's the UI.... that and the cost. If you can make it fast, user-friendly, intuitive, lightweight, and inexpensive, the world will beat a path to your door.
For example, when I was an intern, we were evaulating a hospital-based order-entry system from TDS. It was the old light-pen system, and the damned thing took 14 screens to order an Xray.
I'm now a practicing ER physician... nobody is under greater time pressure than I am, and the EMRs that I've seen so far will slow me down. My colleagues at a nearby hospital who use one of the tablet-based systems complain bitterly about how slow it is.
Make it faster and easier to use than paper. Make it... you know... an actual upgrade? Not some ugly, unwieldy kludge forced by some data-mining, numbers-obsessed bureaucrat. Doctors generally aren't geeks... they care about ease of use. A system that doesn't make it easier to take care of patients will be universally despised, and resisted by everyone on the medical staff.
Physicians have enough to do, and enough to worry about. Want to have medical staff buy-in? Make the EMR an asset instead of a liability.
Even if a man chops off your hand with a sword, you still have two nice, sharp bones to stick in his eyes.
This the kind of paranoid, conspiracy theory BS put out by chiropractors and other 'alternative medicine' quacks.
Rather than argue science they make these kind of accusations to redirect attention away from the fact that they have nothing valuable to offer and no credibility. Here we have a the 'the cabal is keeping us out' in the costume of IT as the enemy of MD uber-control.
If this were a story about a successful IT deployment at a hospital, you'd see these comments saying the IT infrastructure supports the MD dictators.
Our hospital is looking at the cost issue closely. I think we are close to deciding to allow our partnering physicians to pay a huge discount for an EMR system that we are developing and can be used for all their patients. I think that a relationship like this is where the industry will go because hospitals have the volume to justify the costs of setting up the system, and offering a low buying to the system and free setup will engender loyalty from the doctors.
Yes, HL7 is exactly what solves this. Most people in health care aren't even aware of HL7 (as seen in the comments further up the page)
The DICOM standard was developed for interoperability, for this reason.
The problem is is that Equipment Manufacturers (I am looking at you, Seimens) interpret the DICOM standard differently.
When a Hospital system purchases their PACS systems, they usually purchase froma manufacturer that that supplied their other radiology devices (C-Scans, etc). There are exceptions to this rule, but that is usually how it is done.
I have worked with PACS admins that have pulled their hair out trying to get a Fuji C-scanner to communicate with a Siemens PACS, and Fuji is one of the ones that follow the standard closer than most, and is really great with DICOM communication.
IT can have a terrible effect on Dr's office patient visits (especially primary care).
Reason is that Dr's time is generally very limited, especially since most primary care docs now have to be employees and generally operate under some kind of quota system.
Paper records do have the advantage of being able to be reviewed very quickly - a great deal of info can be scanned for the relevant data, and notes may be present within the records exactly at the appropriate places.
Reviewing electronic records can be much slower (click click page scroll click page scroll mouse around some more wait for next page click wait for next page etc etc etc etc). (Paper can also be used much less intrusively while interacting with a patient.)
As an IT guy, I see the advantages of electronic records (access from different points, patient reminders, interdepartmental / interorganization coordination, outcomes analysis, etc etc) are overwhelming.
But for my wife the primary care doc, the time lost to her may have to be time taken from each patient encounter, and also be a threat to seeing enough patients in a day to pay the bills.
"Ease of use" is more than just "nice to have" in this case. Seems to me that IT is just barely becoming adequate for this task, and that IT types who automatically condemn docs for their resistance may be guilty of that arrogance and ignorance that IT is occasionally famous for.
Seen both sides -
Having worked for a major hosptial here in Cleveland I have to say that this story is just wrong. You must be signling out one aspect that you don't have a grasp on and claiming to know something.
If you want to complain about something complain about the two faced government who through Medicare and Medicaid agree to pay an amount for procedures, but can and do decide to pay less. They will retro-adjust the lower reimbursements for several years!! You should try to run your business when Uncle Scam has his fist where their heads up your arse.
Doctor Dugan, is it? I have to ask what specialty you practice, and what sort of practice environment you inhabit.
You sound like you're one of those who wants to throw open the health care licensing gates to anybody who wants to take care of a patient. Having seen some of the stunts pulled by my fully-educated colleagues over the years, I'm a bit leery of turning over those keys to just anybody, particularly those with even LESS training and knowledge.
What, exactly, are you proposing as an alternative to the current system?
And spare me the thinly-veiled "profit-driven whores" implication in why physicians didn't adopt EMRs 30 years ago. That isn't why, and you know it. The truth is that the technology sucked even more then than it does now.
Even if a man chops off your hand with a sword, you still have two nice, sharp bones to stick in his eyes.
Hospitals/Clinics are one thing but there is a movement to capture some even more valuable date - ambulance / emergency response calls. http://www.nemsis.org/
Ok, I am in the heath care industry and am in I.T.
My first thought was that this is yet another attempt by an Obama supporter to help try and gain support for his socialist program. I think I still may be right on that one.
However, the core reason is that the health care industry is slow to move is that the cost of validating systems is huge. If a mistake is made it can put a company out of business. I am not saying this is a bad thing but a lot of businesses do the math and say it is cheaper to do it in a manual way. Now it looks like we want to force these companies to spend the money weather they like it or not. This is good for me, but I realize a lot of companies will be going out of business because of the cost. Sometimes a Rolodex works better than spending 5 million on an Oracle solution.
The more I learn about science, the more my faith in God increases.
... if they would just come up with a standardized paper form for health history. It could be a word, ooxml, pdf, whatever. I walk into the specialist du-jour, and just hand them the #!@#$@!$ piece of paper.
The initial article's analysis of these complex issues is infantile and myopic. Referring to conspiracy theories to explain why everyone doesn't jump to the commands of those who push EMR is just paranoid, and gets about as much respect from me as the schizophrenic ED patient's reports of what the voices in his head are saying.
Disclosure:
I am an MD. After 4 years of college (undergrad degrees in math & chemistry), 4 years of med school, 5 years of general surgery residency, 2 years of fellowship training, and 3 years of bench research, I now have been an attending surgeon for over 10 years. Despite the below experiences, I was and am still an advocate for mature, reasonable, responsible, and efficient EMR and POE.
As an intern, I and my peers were subjected to the introduction of the first-ever system-wide "physician order entry" system. The best comparison might be the African-American patients "enrolled" in the Tuskegee syphilis studies.
The experience has been reported by Dr. Massaro, although a number of points are missing:
Massaro TA. Introducing physician order entry at a major academic medical center: II. Impact on medical education. Acad Med. 1993 Jan;68(1):25-30.
Massaro TA. Introducing physician order entry at a major academic medical center: I. Impact on organizational culture and behavior. Acad Med. 1993 Jan;68(1):20-5.
The so-called "pilot" project took all of the feedback from the resident physicians, which was 98% negative, and cherry-picked out the 2% positive responses to justify a full roll-out of the system.
To state that there were confrontations with the housestaff is putting it mildly. Many of us were computer-literate. The obvious inadequacies of the system and inefficiencies which dramatically took us away from patient care were persistenly NOT addressed for YEARS. Documentation of adverse patient outcomes and events rooted in the inadequacies and check failures of the system was universally spun around and regurgitated as a failure of the end-users to "understand" the system. The only way the end-users (residents, NOT attendings or administrators or nurses) were finally able to get any audience with the company representatives and the hospital administration was through confrontation.
The inefficiencies of the initial system were disastrous. As an intern on a busy surgical service, a typical day consisted of over 8 hours inputting orders at light-pen-enabled computer terminals located at central nursing stations and visible to the patients, who often remarked how their doctors did not have time for them but instead were "playing computer games". Shifting a SINGLE intern from putting in orders from the preconceived structured pathways (e.g. IV fluids -> D5NS, 1000 mL -> rate: 100 mL/hour -> start: now) to instead a simple free-form type-in (e.g. please start IV fluids: D5NS @ 100 mL/hour) shut the in-patient pharmacy down in a single day, as they had eliminated the capacities to handle any exceptions.
The housestaff voted to go on strike when we reached the point where we felt that continuing with the system was causing more harm than just shutting everything down; in the state of Virginia, we were classified as state employees and did not have the legal right to strike. Our initial access to free legal counsel options from the University's Law School students (imagine a free legal clinic run by the students) was terminated by the administration, so we assessed dues from all housestaff and created our own independent legal fund.
Ultimately, the only things that seemed to work to finally get our grievances with the system heard were:
1. the adverse patient outcomes attributable to the system being leaked to reporters for both local and national newschains
2. resident complaints to the ACGME and RRCs resulting in site reviews of all the residency programs
The system was revised, and by the end of my residency, was efficient and flexible to the point that it was
The article seems to define health care as what some of us would call 'direct patient care'... but doctors and hospitals are only part of the big health-care money pie. There are the companies that manufacture the drugs and medical products, and those (like the one I work for) which distribute them. Getting everything from stents to splints distributed to your local doctor, hospital and pharmacy (much of which is ordered electronically) takes a huge amount of IT capacity. Patient records will catch up eventually, but anybody who has worked in an office over the last 20 years and heard "next year, we're going to buy document imaging and scan it all into the system", knows to take that with a big grain of salt... believe it when, and not before, you see it.
I'd have a personalized plate on my car, but "toxic bachelor" won't fit into 7 letters.
One thing everyone seems to be missing here (including the author of the article) is that medical data is an odd duck that just doesn't fit easily into a digital record. (I'm an MD, a medical informatics guy and CTO at a medical software company)
If you're running a McDonalds you can easily computerize everything: You have a fixed menu your customers can choose from, and every purchase can easily be stuffed into a relational table. Medicine isn't like that.
Trying to enter a patient encounter into a contemporary medical record system is an extremely unsatisfying experience: Humans are just weird and idiosyncratic and every time you treat someone there will be parts of the patient visit you can't represent symbolically in a piece of software. This is still largely an unsolved problem- If you read the literature on Description Logics you'll see that even PhD logicians have a hard time symbolically storing this kind of abstract data into a piece of software, let alone a doc with little computer training.
Because of this, most current record systems use a lot of "free text" for storing medical info, which is a pretty ugly hack and everyone realizes this.
I think this is a major reason for the problems people have with digital records: They don't work very well right now for fully capturing a patient encounter in a rigorous, symbolic fashion.
I'm currently working in an office that primarily serves elderly Hispanic patients. There's one doctor and the support staff. The doctor happens to be a technophile and converted the office to an EMR back in Nov. of 2007. There were a LOT of bumps along the way, but 18 months later, we have other doctors tour our office to see the way we've successfully integrated the EMR into the office workflow.
I started working here a year after the conversion, but I was the first IT-competent person hired since then (I wasn't even hired for IT purposes). As such, I've been able to significantly streamline office practices to the point where lab results are directly inserted into progress notes from Quest, the doctor gets real-time indications of patient insurance drug coverage while prescribing, ePrescribe capabilities which allow the doctor to send the Rx to the pharmacy while noting the medication in the progress note, fax records and progress notes directly from patient charts, etc. Pretty much any piece of paper that passes through the office (billing aside) gets scanned into the patient's chart. We do this both for ease of reference (easier to just pull up the high-quality TIFF than typing in a summary of a consult or diagnostic image) and for legal purposes. The doctor, contrary to some of the other comments, feels much safer legally having everything scanned, titled, timestamped and easily accessible. Oh, not to mention how much time is saved when we're subpoenaed for records and it takes the better part of 30 seconds to do a multi-doc fax.
The only real complaint I have with our EMR is its lack of ability to share records. We still have to fax records (certainly not snailmail!) and burn through reams of paper receiving records from other offices. I would love to see a connectivity standard between EMRs. That may be putting the buggy before the horse, though, with the lack of adoption we've been seeing in our area. Medicare's office a lot of incentive bonuses for using the EMR and ePrescribe, which are a lot more beneficial for early adopters, but still doctors seem to be dragging their feet. Maybe that'll change when they start seeing a 2% penalty tacked onto their Medicare payments in 2014?
A medical database that crosses the boundaries of multiple hospitals and multiple insurance carriers exists today. Take a look at the work being done by the Regenstrief Institute (regenstrief.org), a pioneer in medical databases since the early *70s*. Regenstrief has a functioning medical database in use in Indianapolis, IN that aggregates patient data from all the area hospitals. Regenstrief is not affiliated with any insurance company nor the government (well, they do receive NIH research grants..).
This can be done...
A lot of problems in driving the industry towards higher rates of adoption of modern technology are the arcane and sacrosant practices of doctors.
In my experience, in most situations, a simple algorithmic deterministic decision tree (with the right medical tests at the nodes) is sufficient to correctly diagnose and treat most diseases. I've seen my highly paid doctors I've been to under my snazzy uber-exclusive insurance plan repeatedly go to a *.nih (I think) page and reading about the various possible conditions. The human doctor is only important when dealing with the exceptions and the hard / rare cases, not with the bulk of minor, commoditized afflictions that affect mankind.
It is purely a matter of personal preference that the current generation of middle aged baby boomers are so attached to the personal touch of another human reading them a website. However your kids, raised in a webcentric era, might feel differently when asked to choose between paying $1,200 for 60 minutes with a reputable doctor (most of which spent filling paperwork and waiting) and $89 for going to a modern clinic where they follow an automated set of tests administered by a nurse, with results feeding into a computer (a doctor is called only if an exception is triggered).
And yes, don't give me the sob story of that one time where sheer human genius saved someone's life. First, there will always be a doctor on standby to deal with exceptions, and complications. Second, you cannot drive policy off exceptions like this. Third, the high price of current practices drive many people away from medical care early in their afflictions, possibly outweighing the benefit of customized care.
Also, customized care means you are relying on your knucklehead doctor to be up to date with all the medical research not only in his field, but in all related fields. Put it this way - who would you rather ask your random general knowledge questions: wikipedia, or a single smart educated professor?
In conclusion, the best thing to do might be to offer people both alternatives (at appropriate price points) and let them choose.
In January of this year, I went in to an outpatient surgery center for a procedure. My operation was scheduled for 10 AM, so I was on-site just before 8 AM. When I arrived and was ushered back into the staging area, I was next to a septuagenarian who, it turns out, had been at the center since 6 AM. He had been driven there by one of his adult children, and he hailed from a small town three hours away. He left home before 3 AM to make sure he arrived on time--his was to be the first procedure of the day for a particular surgeon. [I picked all this up from hearing him interact with his daughter and other family members who were also present.]
My surgeon was running late due to complications in an earlier procedure, so when 10 AM rolled around, both the septuagenarian and I were still waiting for our procedures. For me, it would clearly be a matter of time. From overhearing the family, the doctors, and the nurses, however, it was fairly clear that the old man would not have his surgery that day, because he was presenting symptoms that suggested he may have bronchitis or pneumonia.
As is standard procedure, each surgical patient has a pre-operative screening with his or her regular physician, to ensure that the patient is well before the operation. This man had his visit, including a chest x-ray, but those records never made it to the surgery center. The man's clinic had EMR technology, so one doctor suggested that they just pull up the records. That's where they ran into some problems. The only terminal with EMR access at the nurses' station in the surgery center could not access the records for that patient. Multiple people tried their logons on that terminal, but none of them could pull up the records. There were discussions as to whether or not the clinic was on the same EMR network as was the hospital. One nurse commented that she had cared for a patient in the main building and accessed records from the same clinic system. Finally, another nurse mentioned that there was another terminal in a records room in the surgery center, so she and a doctor headed off to try to access the EMR from there.
In the mean time, this poor old gent is starting to cough a lot, and appears to be in much pain. No one was able to reach his primary physician by phone, and the patient's home-town clinic was not open that day. The doctor and nurse returned from the records room, and indicated that they had no better luck. An older nurse then mentioned that she thought the main hospital had access to more healt-care networks than did the surgery center. Someone was dispatched to the hospital to try and pull up the records.
It turns out that my physician was havin a really rough time. His first patient, who was in for what was thought to be a minor rotator cuff repair, apparantly had old baseball injuries about which the physician was unaware. In the end, the doctor was able to patch him up, but three out of four of the primary ligaments or tendons were beyond repair. [That bit of information was picked up by my wife in the waiting room, when the surgeon came out to tell the other man's wife how things went and why they went long, and to tell my wife why I was not yet in surgery.] I'm just noting that so you'll understand why I was still waiting for surgery as the hour neared 1 PM.
The surgery center called over one of the on-call physicians from the hospital, who checked in on the man numerous times during the morning. He was convinced that the man was too ill for surgery, but the man insisted that his own physician had told him to go ahead. The family members were upset, because travel took a lot out of their father, and he made the three hour trip specifically for the surgery (a hip replacement). The on-call doctor made it clear that there would be no surgery that day. Why were they keeping him waiting is what the family wanted to know. The on-call doctor wanted to consult with the man's physician, because he felt the man should be admitted to the hospital. He was trying t
I use irony whenever I can, but my shirts are still wrinkled...
T in health care has been growing since the 70s. Companies have continually been developing auditing, quality assurance, and regulation software for years. Just because this isn't widely known doesn't mean it doesn't exist. ...and yes, I'm sure plenty of health care facilities out there don't implement as much technology as they should, but many do. Data Oriented Systems is one of the oldest health care software providers I could find. They have been in operation since the 80s. http://www.dataoriented.com
I spent a few years writing commercial healthcare software, and here are a few quick thoughts:
1. HIPAA is a problem. everything you do, EVERYTHING, has to be HIPAA compliant. this means checking, rechecking, checking a 3rd time and then hiring an outside party to check your checking. if you screw up in any way, it's possible to be held criminally liable, personally. the HIPAA rule book was around 1200 pages long the last time I had to use it. My small company (150 employees) had a full time staff of FIVE that did nothing but interpret HIPAA and document changes everytime some politician lobbied some bullshit minor rule change thru the system. Each time this happened, we had a mere 90 days to version our software to match. This is a big deal when you have 3 developers working on 4-5 million lines of code. Summary: any screwups can land you in jail, so review and testing is off the scale thorough.
2. Mistakes can be fatal. During my time writing healthcare software, I had to opportunity to work on a system I'll call the Pill-Counting-Robot. It did exactly what you'd think it would do: scripts would come down the wire, the robot would count pills into a bottle and label it. Counting the wrong kind of pill can mean instant death for a patient. Counting the wrong number of pills can make a patient very sick or dead. Printing the wrong instructions on the label can also kill them. ZERO SCREWUPS CAN HAPPEN! None. Not one. We debugged that thing for months on end, trying as hard as we could to break it... we did testing with red and green M&Ms to make sure it never mixed medicine. You really don't even want to hear what kinds of scary mistakes that thing can make when it jams or crushes a pill or breaks a pill in half, etc, etc. Summary: a tiny glitch can kill people.
3. The final roadblock to quick progress is ancient standards. When scripts go over the wire, they use a format called NCPDP. This was made in the 70's for use over non-duplex modems. It is slow as snot. It cannot handle whitespaces in the wrong place, it can't handle variable length text, and it can't handle certain kinds of punctuation. It definitely can't handle long names or hypenated names (e.g. married folks who share names with eachother). And yet, as bad and old and broken as the standard was, we were required to use it because of a federal mandate. See Item 1. Summary: laws make the field obsolete and obtuse.
In Soviet Russia jokes are formulaic and decidedly non-humorous.
The subject says it all
This guy has no clue what he's talking about - it's completely hearsay and conjecture
The man exhibits absolutely no experience or insight in to the health care industry as it relates to IT.
It'd be like me writing an article about art.
Just looking on the billing side alone, the two-volume set of hardback books describing just the 837 EDI transaction (payor's outbound patient claim) is 2000+ pages of text. There are many, many different transactions, making tens of thousands of pages of documentation just on file formats. Save a very, very few projects ever successfully built, it's hard to find a business with more required process. The human body is complex, and I think we often underestimate the scope of the healthcare system; it's much more than just getting a yearly flu shot at the family practice doc's. Someone spoke about Obama saying that FedEx can track a box anywhere; why can't we track medical records? Well, we *can* track medical records anywhere; we just can't always read them. Can FedEx track UPS packages? USPS? UK Postal Mail? It's a bunch of different systems, and the analogy was so broken, it kind of illustrates he doesn't yet understand the types of problems the industry has to overcome. Much like the ongoing disaster of rebuilding the air traffic control system, peoples lives depend on these systems for proper care and treatment. Give us awhile. We'll get there, but we write code, not magic; it's going to take awhile.
neutrino? i think the odds of a neutrino hitting a transistor are about the same as the odds of a 1000-bed hospital's patients all going into spontaneous remission from everything simultaneously, then living to 120. photons or cosmic rays or something maybe, but neutrinos have a 50-50 chance of getting from here to alpha centauri through solid lead.
People say "neutrino" just to put a label on the phenomenon. Random bit flipping is present and is usually not caught unless you're anal about data integrity:
CERN found an overall byte error rate of 3 * 10^7, a rate considerably higher than numbers like 10^14 or 10^12 specâ(TM)d for components would suggest. This isnâ(TM)t sinister.
http://storagemojo.com/2007/09/19/cerns-data-corruption-research/
CERN's paper (PDF form) is available at:
http://indico.cern.ch/getFile.py/access?contribId=3&sessionId=0&resId=1&materialId=paper&confId=13797
Why would they want a nobel prize when they could make 100x that by making profit their priority? It's like asking why don't more doctors donate their time to third world nations, or even the working poor in the states, because it would be a good cause. There's a lot of greedy people pervasively through out the system. I do work in IT for a Hospital and clinical entity, and I've seen it from the vendors, I've and i see it from the physicians, and you also see it in the administrative staff.
My personal observation is that it's hard to compare most hospitals/clinics/whatnot with wall street/airlines. The reason is that it's like comparing a 5,000 LB gorilla's buying power with that of a mosquito. I don't know these industries, but I'd wager they are large enough they rolled their own systems, or contracted a system out for specifically their needs. One would think a hospital's needs would be largely identical from place to place, but from everything I've seen, that is not the case.
I agree with you, cost is a huge barrier. After paying for the product---and let me say you never buy one thing.... it's many modules of one company for each hospital niche, or different products for different niches. Modules are just as expensive as full systems from other companies... The pricing is disgusting, then tack on 20-30% yearly maintenance, for every module or system you purchase, then the the various 'time' you buy from them for odds and ends, the IT staff, the servers, the power, the cooling. It all adds up, but my observations is that the vendors systems and modules take up an absolutely incredible amount of the cost, and their often priced on a 'bed size' 'physician size', etc metric.
So, by saying cost needs to come down, i agree, but take a look at not just the hospitals, take a look at the sick profits of these hospital vendors take in: GE, Siemens, Phizer, Mckesson, Cardinal, etc. You want to see where money goes. That is where a whole giant chunk goes.
I prey upon your morbid fears of terminal disease
You won't know the difference, now it's time for surgery
Another shot, another pill, two weeks therapy
I take all major credit cards, it's your money that I need
I'm a healer!
I will keep you all alive.
I'm a healer!
Fake healer.
(and more, but you really got rock the fuck out to these words instead of just reading them, so get the CD because it's ALL good)
You have the following requirements:
1) Data integrity. This is very hard. Your typical programmer doesn't understand it. This is a disaster waiting to happen. I personally do not want my records in electronic format. See the disaster called electronic voting as an example now increase the complexity.
2) You need tight security of records. Electronic security is a joke. And who is liable? How many breaches have there been in the private and government sector in the past few years see this article: http://hardware.slashdot.org/story/09/06/25/0243221/Reporters-Find-US-Govt-Data-In-Ghana-Market?art_pos=5
And security is orthogonal to ease of information sharing.
3) Ease of data sharing. A major selling point of electronic data is the ease in which data can be shared. But this is orthogonal to point #2. Also if data integrity is violated and the data stream becomes polluted, as in point #1, this is a major liability.
Getting all three of these major requirements is hard. Very hard. Probably harder than running tests or doing many surgeries. A simple screw up here can have ramification not just for one patient but for millions. See the nightmare called electronic voting to see what will happen.
AFAIAC, electronic medical records will cost more in lives and money than they will save.
putting the 'B' in LGBTQ+
Expressing annoyance at a recent change that eliminates the space between "Coward" and "on" is Flamebait?
Parent either is full of it or lives in a parallel universe. 1. Cost is not a barrier? Our EMR costs each physician many tens of thousands a dollar a year in application support, licensing, databases, and for a phalanx of IS personnel in various departments (local, regional, EMR, hospital IS). 2. MD's have a monopoly? What planet are you on? DO's have had precisely equivalent standing for decades in medical practice in the United States, and NP's are far from being "wiggled in." As a primary care physician, when I send a patient to the cardiologist or pulmonologist, half the time the entire consult is done by a PA or NP. 3. Please direct me to the land you describe where I can have control over my care environment and take home most of the money. I can't get a contracting pregnant lady into labor and delivery without asking for permission from two nurses, and I'm not aware that the balance of power in any health system I've worked in has been any different before and after transition from paper records. Medical care in most locales in the US has long been collaborative, team-based system, even if you've met a few physicians who are jerks or drive nice cars. (I am looking forward to upgrading my '94 Corolla by 2014.) EMR systems have poor market penetration, in my direct experience over the last 9 years, because: 1. Many, if not most, suck in a medium to large way; 2. They are incredibly expensive; 3. They can often be hard to use, and are typically more labor-intensive than paper charts for most physicians in the US; 4. They don't inter-operate. (When I request old records from other physicians with electronic charts, I enter the pertinent data into my electronic chart by typing it in.) If any skilled group of software engineers were to write a decent, usable EMR that was extensible, and didn't cost an arm and a leg, with an eye to being excellent first and profitable as a consequence, they could be up for a Nobel prize. TFA refers to cardiac CT to prevent heart attacks. The author, too, lives in a dream world - contrary to her thesis, this test has been shown to help with the boat payments of radiologists and equipment manufacturers, but there is no evidence it helps prevent heart attacks.
Ok, You wrote my comment for me. But I'll add my bit. My background is Chemical Engineer, Internal Medicine (because they were easy and fun to study), then Emergency Medicine (because it was fun to do) for the past 30 years. During that time I was mostly in direct patient care but did have various administrative duties. Naturally, as a Slashdotter I had a continual involvement with computers. After evaluating numerous awful EMR systems for our hospital I checked to see why. Generally there was little clinical input at the levels that mattered, but I agree it is harder than it looks to do it right. Getting long in the tooth for the ER, I thought to apply to some of the software companies for employment. The response was, "We only have openings in marketing." I second all the comments here regarding lack of any conspiracy. None of us are that good.
The lawsuit nonsense is just media hype. Texas has capped damages on medial lawsuits, and guess what? My health insurance didn't go down one bit. In fact it keeps going up. Time to retire that stupid meme.
Healthcare Information and Management Systems Society. That's the professional organization and journal dedicated to the subject. The picture they paint is very different from that of a Wall Street analyst writing for TR, apparently in a backhanded attempt at promoting his book on the subject. From TFA: "Using electronic health records, in combination with data mining and search technology, would make this kind of analysis much easier." Would? Try has, and incorporates distributed archiving with fast retrieval, administrative and management analysis functions, billing, interfacing with all sort of outside agencies using their own formats, all conforming to stringent security requirements but capable of being examined by governmental oversight agencies.
For my MHA, I specialized in medical informatics. It was a huge field 20 years ago, and has grown more since then. The main hurdle for the industry as a whole is the fact that it's so diverse that there's no standardization and so enormous that none is likely to happen. And like any collection of commercial enterprises, the various entities are continually coming up with improvements, "improvements", lateral changes, and repairs to the FUBARs created by those.
While the industry as a whole is somewhat hobbled, the individual entities where records, treatment, billing and admin/management are required to perform with high proficiency (due in large part to liability) have adopted IT extensively and make good use of it. At my local clinic here in Appalachia there are as many support and admin people as there are doctors and nurses just to keep the IT based ball rolling, and virtually nothing happens that's not pushed through their in house net to at least 3 people. My main provider is the Veterans Administration, with an abysmal record of institutionalized foot dragging and bureaucratic quagmires. But they're heavily wired inside and connected to all other VA facilities outside by a network so extensive, complete and blazingly fast that it'd make any provider network proud and makes a mockery of the VA's constant insistence in almost every other area that it can't do this, can't afford that, and sorry that's not might job and I wouldn't do it if it was unless three people agreed to make me and figure the odds on three people agreeing on something in this place.
The delivery end of the industry is 18% of the US economy. That's a lot of industry to supply and support. At its present growth rate it'll double in 30 years. That means they'll need to be supplied in that time with as much as exists already, all the while continuing to support and upgrade all that presently exists. One skewed statistic that makes health care IT appear to lag is the fact that they spend 2% of their revenues on IT where banks spend 8%. Fine, but consider the fact that health care handles far more customers with the same infrastructure, and the supplies and equipment cost much more than in other industries, plus the fact that it has far more higher paid workers.
And the US$19Bn infusion from the Obama administration? That'd cover 14 months of IT spending in US hospitals. Entities smaller than hospitals, support agencies, suppliers, and the associated juggernauts of insurance and health related government agencies aren't included in that figure. Figure those in and the 19 billion will add about 30% to the amount expected to be spent in the next year on IT industry wide.
Health care is not slow to adopt IT. They love it and adopt all they can. IT can't keep up with health care. Not their fault, they do a great job trying, but it's like trying to keep track of all the pieces from an explosion in progress. How tough is it to keep up? Consider:
The gross national product of the US rose from $2Bn to $4Bn from 1951 to 1971. The US health care industry including all associated support, supply and financial control (ie. insurance) will grow from $2Bn to $4Bn from 2008 to 2015. Not the same "dollars", but it's still a doubling rate almost 3 times the US "golden era".
"I may be synthetic, but I'm not stupid." -- Bishop 341-B
HL7 is an expensive pile of shit.
The Kruger Dunning explains most post on
I have been developing EMR software for 3 years now. The company is small, but our software is an industry standard and is deployed in thousands of facilities across the world.
The main problem I see is one of trust. Our software runs entirely as a black box, without the client having knowledge how the software works or even how the database is structured (mostly because we don't know either *sigh*). Clients have to call our tech support to even add a new user to the system. The proprietary nature of our software ensures a) low quality, and b) 100% dependence on us for routine maintenance. New facilities, especially smaller ones, will not be willing to give up such control.
Then there's the problem of interfaces. All these proprietary systems must talk to each other in a flawless, seamless manner. HL7 goes some way to fix that, but in my experience HL7 is simply a business TLA-buzzword that really means nothing. Each interface is coded specifically for the system its talking to, because they all have their different quirks.
I believe the first EMR that is truly transparent and open source will be the turning point in Health Care IT. This industry is basically made for the software-as-service model. However, that requires a fundamental shift in our business model, and we all know how easily that happens.
6th Street Radio @ddombrowsky
I can tell you what the problem is. It's a problem of process.
Any half decent programmer can implement the framework for an EMR, it's not really all that technically difficult. Providing access to a database isn't hard, putting security descriptors on a database isn't hard, converting physical records to electronic ones isn't all that hard either.
What's hard is getting the data from all the doctors and hospitals into one place, positively identifying the people involved(doctor, patient, etc), working out who ought to be able to see the record and under what circumstances.
Every one of these projects treats the problem as a purely technical problem. It's not, from a purely technical perspective it's not even particularly challenging, a 1st year Uni student could probably implement most of it.
The fundamental problem is that in order to be able to generate a centralized Electronic Medical Record you have to be capable of generating a centralized physical medical record, at least in theory even if it wouldn't be practical. At present, no country has the capability of doing this and so each and every one of these projects fails.
Lawyers are not more keen to see clear medical records. They benefit from misinformation about medicine & science in general. Lawsuits just have to show that maybe, just maybe, the doctor is a at fault.
Consider Cerebral Palsy lawsuits. The lawyer doesn't have to show that the doctor's actions caused the condition. There just has to be "something more the the doctor could do" to prevent it. Of course, medical records might eventually prove that no obstetrician can prevent Cerebral Palsy, and take away the lawsuit avenue all together.
I think the simple solution is that we need more doctors who will work for less money. Heavily investing in one person to be a tiny god in his practice who only sees patients for 4 or 5 minutes makes far less sense than training several more competent people to listen to their patients and develop care that is effective for that person.
I think one of the reasons medicine is so much more effective and cheaper in other western countries is that being a doctor still holds prestige and dignity, and it's not a career path chosen only to make money. I'd much rather have a person happy to be a doctor helping me with my health than a person who can only see the dollar signs when I walk through the door.
Anyone claiming that you won't get the best qualified people unless you pay them obscenely must have very little respect for our military service members.
I'm a statistician working for a health insurance company. If there is redundant testing, we are the first to know about it, and we will not pay for it. The health insurance industry has had no problems implementing IT technology; we have very good databases. Health care providers have traditionally been in charge of treating patients rather than keeping records, so we have served as a default IT infrastructure. One of the main obstacles to implementing IT in health care environments is the lack of computer literacy. A very large number of nurses and physicians still have no idea how to read e-mail or surf the web, even in 2009; until a few months ago, I used to work in a health care environment and witnessed it firsthand. There is also a shortage of expertise in IT professionals who understand the complexities of health care; a typical computer science graduate knows nothing about medicine and is hung up on the "healing power of echinacea" or whatever. Both IT professionals and health care professionals regard themselves as smart people, they do not like to look stupid, so they resist learning skills unfamiliar to them. In many markets, health care providers are given financial incentives to submit their claims electronically. Larger hospitals and their affiliated clinics can afford to implement such measures, but private practices often cannot. In many patients, there are extenuating circumstances that require the patient to receive treatments that deviate from standard procedure, so judgements still need to be made by humans on a case by case basis; it is not as simple as issuing tickets to airline passengers or shuffling boxes around in a warehouse. In summary, there are good structural reasons why the health care industry has been more resistant to implementing IT, not just "greed" or "conspiracies".
Or how about the braindead people at GE who, when designing an EMR, decided that the tab key should NOT skip between fields of entry but should instead skip right down to the commit button at the bottom of the page? Meaning I have to take my hands off the keyboard and put them on the mouse or trackpad for EVERY SINGLE ENTRY.
Physicians come off badly, I know. Many of us seem like arrogant jerks, and some of us really are. Mostly, though, we are people who are paid for piece work - it is generally true that you get $X to see a patient and treat them, whether it takes ten minutes or ten hours. This of course makes us incredibly time-sensitive: one minute per encounter, over the course of a day, means we get to go home a full hour earlier.
A while back I worked on a rinky-dink dental office package, crAApy!! The way it allowed dentists to document a patient's mouth
was... printing out a template for them to color in. Umm, some people have naturally missing teeth and... The dentists had issues with it. -- not a proper representation, i cant use thiS! GET T HIS POC OUT OF MY OFFICE!
People who complain about the state-of-the-art in Medical records are right -- but it sucks. Thank you Gesix for my job with a POC erp!
Oh, so that happens to everyone. I thought it was general fucked up slashcode since it started shoving long posts into a column less than an inch wide a month or two ago. I started changing preferences to fix that but screwed up some other bits.
The pharmaceutical distribution chain has been computerized for quite a while now. They have histories for every person, drug, etc. It's just that the information isn't necessarily shared across the chains like CVS, Walgreens, et al. But the upshot is that the drug companies and the pharmacies know their customer base very well.
It works and docs find it helpful. I'm amazed that it's ignored in TFA.
Docs won't use EMRs until they need to do so to get paid. That's the long and the short of it.
Most physicians ought to try working in any other profession besides the guaranteed-high-salary-MD-world before commenting on who it is that lives in a parallel universe.
Oh, that's cute! Did you catch the part about his '94 Corolla? From personal experience, I see very few rich doctors under the age of 50 or so. Seriously, that myth died when Medicare and HMOs took over. Young doctors are considered successful if they can manage to pay student loans while living in a house that keeps the rainwater out and driving a car that starts most days of the year.
Sure, you can trot out a few cardiologists or plastic surgeons as counterexamples, for but each of those I can present 100 family practitioners.
Dewey, what part of this looks like authorities should be involved?
Dead-on right. It's not the back-end, it's not what brand of software, it's not the brand of tablet... it's the interface.
I'll say it again... most physicians are NOT geeks, with the occasional exception (confession: I actually have a server rack in my house). People may not realize this, but plenty of physicians can't even type, particularly the older ones.
I have a colleague... I'll call him Dr. Smith. He's a GP, and he's literally been practicing for nearly 50 years. That's not a typo... he started in 1960. He's old-school, and anybody (including me) would be happy to have him take care of them... because he takes all his own calls... comes into the ER to see his patients, even in the middle of the night and on weekends. He's also a hell of a nice guy, and a good doc... a real dying breed.
He's computer-illiterate. Completely. You threaten him with "learn this crappy new system or else," and he's going to balk. He'll retire, or drop his privileges and move to the hospital across town like a bunch of his younger colleagues given the same ultimatum.
You think you can force physicians to simply eat sh*t? Who do you think you are... Medicare? You MUST have physician buy-in, and physicians balk at being told "use this crap or else" by some suit who doesn't take care of patients, ESPECIALLY when the UI slows them down, cuts into their productivity, and interferes with their care of patients. I've worked in environments where that was done as a top-down forced implementation (I'm an ex-military doc), and it sucks out loud (it was also reverted to paper in less than 24 hours after the entire facility literally ground to a halt).
How do you like it when some admin weenie comes down to your server room and says "we're implementing this brand-new system. It sucks, it's slow, it crashes, it's full of security holes... but you're going to use it or else." Somehow, I think a similar industry-wide fiat like that directed against IT, posted on Slashdot, would easily generate a 1000-comment thread... in the first 15 mintues.
Even if a man chops off your hand with a sword, you still have two nice, sharp bones to stick in his eyes.
I think it has more to do with the actual staff not wanting to have to learn how to do record keeping and retrieval a new way. Keep in mind these people have packed their brains with medical data and how to apply it to the point of doing much else isn't particularly easy. So they've learned how to track what they're doing one way and learning how to track it another way could be a royal pain in the ass. Not to mention the time it takes to convert old data to a new system.
But I agree that it needs to happen for a multitude of reasons. The people I know in the medical field, my wife included, who started into their practices after "the age of computers" are constantly complaining about all the paper work they have to do when it could all be done on a computer in a tenth the time, more accurate, and information could flow more easily between medical facilities.
Give it another 10 to 20 years and all the paper pushers will have retired. If you are a software engineer I suggest getting lined up for a huge market potential. They're going to have shit loads of cash and motivated decision makers.
No sig for you. YOU GET NO SIG!
I work as an outsourced IT contractor in the Atlanta area, and a large number of my clients are hospitals, clinics, doctors' offices, and so forth. The main reasons I see for them not wanting to adopt increased IT infrastructure to enhance record-keeping abilities are:
1) Budget. Health care has been one of the most resilient industries in the current recession, but no one can afford to not watch their spending these days.
2) Reliability. It doesn't work 100% of the time. It might, if you added enough redundancy, but then you're running into problem 1) again.
3) Politics. I don't know of a single hospital that doesn't have serious political infighting. This bleeds over into the budget issue again...who gets how much of the budget for what projects, who gets what access levels within the system, and so forth. IT tends to be looked on as an unwelcome but necessary expense, kind of like the power bill. If there isn't an obvious fire or immediate pressing need, getting funds for improving performance or reliability is very difficult. And if there *IS* an obvious fire or immediate pressing need, they're upset that you hadn't already prevented the problem with the budget you've had thus far. It's a catch 22.
I see these as being problems with getting all sorts of industries to incorporate better IT... the medical field is just a big obvious one right now with all the efforts to improve compliance with standards, and the efforts to control the rising costs. The answer I wish I could give to ALL of them is simply: "shit breaks. pay the cost of having it break less, or deal with it breaking. but it will always break. having a plan B is always going to be a good idea."
No question,
it can be done. The VA's system is integrated nationwide. So when a Vet moves from one hospital to another, from one state to another, his electronic medical record travels with him. So technically, it's certainly feasible. I was unaware of the Regenstrief insitute. Thx for the link. For me, the operative paragraph is:
"The Institute receives $2.8 million per year in core support from the Regenstrief Foundation and has an annual budget of approximately $19.5 million generated by Institute investigators, largely derived from federal grants and contracts from the National Institutes of Health, the Agency for Healthcare Research and Quality, national philanthropies, Indianapolis healthcare institutions, and other sources."
They have a 20 million dollar operating budget, I suspect largely funded by soft money. Unfortunately, I can't tell what what the "subscription" costs are to the participating hospitals. But i'll bet it's minimal. Now, this is Indianapolis. Imagine the costs/complexities associated with a similar system in Chicago, LA, New York City, etc... The costs and complexities increase geometrically, I can assure you.
I'm not at all disagreeing that it can't be done, because it surely can. But the direct and indirect costs are so high that, until there are financial incentives to do so, you're just not going to see this kind of thing in very many places. Not unless some goverment entity steps in and provides considerable funding to drive an institute like the one you identified.
take care,
jeff
The nugget of this is not explained really in the article:
Cost is *NOT* the barrier, but "lucrative business model hidden" what they mean is the intrinsic structure of how medical care is delivered and who gets to be responsible for care delivery.
In my opinion, refusal to openly adopt electronic medical records is a direct result of overt protectionism by physicians and surgeons. For good reason, society has left medical care in the hands of competent, trained people. However, competency and training has been industrialized to only 1 kind of person, with one kind of standardized training: the MD, and basically no one else, regardless of training or ability is allowed by license to practice medicine, or reap the financial rewards of such extreme responsibility. NPs have wiggled their way in a bit and DOs are close, but basically no one else.
When physicians are required to interact in electronic, shared systems, they can't lord over all the responsibility in care environments, and then they won't be the only ones who run all the medical care and take home most all the money. They will lose their self-created and maintained monopoly on responsibility for care.
Anyone who has worked a hospital environment learns in the first few weeks exactly what the MD care delivery scheme is all about.
You are so off base you have no idea. The cost IS the biggest factor. The ROI on some of these multi million dollar a year EMR systems is negative. A hospital has to foot a huge upfront bill for a multi year implmentation that may never pay off. The doctors don't care one way or another, they just want to see the highest volume of patients possible to get the most reimbursement. If the electronic system slows them down (and many do, due to poor design) they reject the system and forcing a doctor to do anything without them going down the street to another hospital is difficult.
Never ascribe to malice that which is adequately explained by incompetence. - Napoleon
I worked for years in medical diagnostic technology and some of the US's best doctors were our close partners. In other words, the best docs and med staff were eager to use computers for data and record gathering and analysis.
I'll name some names, and there are many more: Mayo Clinic (duh!), Cleveland Clinic (duh!), Seattle Childrens, Children's Hospital of Philadelphia... Awesome awesome awesome!
I think the general problem is that the medical community is not paid to fix you; they are paid for their time. Obama even alluded to that during the ABC special last night.
I'm not blaming anyone for this- it's just how the system has evolved, but one could make the argument that health care providers make more money "treating" you than curing you. Again, in no way do I think anyone would consciously do that; it's just how the whole system has evolved.
Indeed. I work for the NHS IT programme, and in a meeting yesterday I remarked that system designers want to make trains, when what users want is helicopters.
Trains must follow a particular route and pass through a particular set of stations for that route.
Helicopters can fly where they need to and land wherever they want to.
One of the major problems is that government is stuck in the dark ages of software process, where the requirements have to be carved in stone by as many meetings as possible before implementation begins in earnest. The only successful projects I've worked on are the ones that followed a more agile pattern and delivered software early and often to clients for feedback loops to occur.
Hell, the UK government invented the abomination that is PRINCE2
My wife just gave birth to a beautiful daughter. This is child process #4 for us, and all 4 were delivered at this same hospital. Because of the eHealthcare record keeping, I've noticed different procedures to the health care as directed by the computer system. When baby was born, they held off on doing any of the 'normal routine' of weighing the baby, measuring, giving shots, putting the ointment in their eyes, etc. until the child was admitted into the record keeping system, otherwise it would have meant time spent reentering data.
In speaking with the doctors, specifically the OBGYN, he stated unequivocally that what is driving costs of health insurance up is the costs of malpractice insurance. People are looking for any mistake or error that they can turn around and sue the doctor or hospital for. It is insane.
Good security is based upon reality and common sense. Common sense is a function of having common knowledge.
I worked in this field for a leading UK-based EHR IT vendor.
There's a lot of EHR initiatives going on in North America. There's significant government spending to accelerate the adoption of these systems. It is inevitable that EHRs will replace paper charts and prescriptions, for a number of reasons that I will not go into here.
That being said, if I walked into a physician and saw that they were using my former employer's EHR solution, I would mandate that a paper chart be kept as my primary medical record. Having personally seen what lies behind the curtain, I can honestly say that it is not a pretty sight to see.
Their grandiose statements about the security and privacy of confidential records? Don't believe a word of it. What the marketing team says is orthogonal to what the developers, IT or security employees know. The assurances given to respective government agencies? Lies built on top of other lies. It is a miracle that there has never follow-up audit.
Have your primary healthcare provider keep a paper chart. It could very well save your life. Really.
oh, cry me a fucking river
doctors made the healthcare shitstorm with their own policies and actions.
you clearly have never worked in healthcare - doctors *ALL* earn several time the media salary in the USA, many much, much more. Yes, many bitch and whine about how little they make, but only because they live in the alternate "doctor world", they are the most important living thing in the universe. I'm sure the GP can cough up 200 a month and lease a nice new car if she choose to.
wants to throw open the health care licensing gates to anybody who wants to take care of a patient.
No.
What, exactly, are you proposing as an alternative to the current system?
What the US has now is not a "system" - it is non functional. Much could be done to improve the health of the population, but it reaches far outside what people typically call "healthcare".
implication in why physicians didn't adopt EMRs 30 years ago
Adopt??? Read my post again. Physicians could have built it, but didn't want it then or now, for obvious reasons. The mess physicians are in now is of their own creation.
Frankly, I do know the technology very well, and the issue is *not* technology (order entry, data storage, SOAS, vocabularies, data security... all work pretty well), rather, it is our imprecise understanding of medicine and the habits, training and practice of medicine by physicians that now prevent electronic health data storage and exchange.
Well, you got the point.
Unfortunately, humans do come with no service manual or test points or other service/manual documentation.
Doing a good job is like spilling coffee on a dark suit, you feel warm all over, but nobody notices.