Slashdot Mirror
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."
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...
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.
...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
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 don't have a theory I have experience.
I work for hospital that went digital (for patient recodrs) in 2006. All (billing) administration was internally digital (using different, obsolete system working on DOS and floppy disks) from 1997 and to outside world also, depending to health insurance company involved.
After 6 months of education, switch was made in one day. It was horrible, but after two weeks things were looking just as before. After several months, 75% of administration was more efficient than before, and now, 3 years later, we still print outgoing documentation, but doctors rarely look at papers. Nevertheless, printing expenses went 30% down this year.
Last year all waiting lists were computerized, and made available (with no patient data) at the web pages. That saved us so many work hours at all departments, but two people switched to that department. This year we are looking into making all internal administrative procedures digital. Hospital restaurant was really happy after we made their menu available online at intranet.
Several months before introducing the system, all work places received computers with unified user interface, and demo program installed. It was made really clear that someone should consider finding another job if they refused to work with system. People near the retirement (2-3 years) were exempt from this rule.
The problem very often lies in wanting too much (all). Process should be step-by-step. Billing first, patient records second, intra-hospital administration third or any other way. Every step should be planned, because people will suffer at it, and don't rush it. It takes months, sometimes years for one (new) work flow to settle in.
Radiology department is still not filmless, probably because it costs as much as putting all patient records in computer. Volume of data that our radiology department produces in one day is equal to 1-2 years of data from whole hospital. On the other hand, introducing PACS and RIS is so much more widespread, but the volume of data makes project harder in the long run. After testing almost a dozen of PACS/RIS demonstrations, one free PACS amazed us with results, holding test data (0.5T of images) and working better than some very expensive solutions.
Doing a good job is like spilling coffee on a dark suit, you feel warm all over, but nobody notices.
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.