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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."
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.
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.
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.
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Your reasons 3 and 4 contradict each other.
It means you don't get to see the physician twice, and learn about each other so they can tell when you're lying and you can tell when they're full of horse pucks. And it means that you can't organize your visits to arrange for expensive, long-term treatments for those chronic conditions like sleeplessness, work-related stress and RSI, diet and lifestyle changes. It's also a way to avoid providing mental care, which is very dependent on generating trust and non-verbal communication between a therapist and a patient.
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
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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.
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.
The cost of having someone re purpose a computer is actually really high. Considers the following:
1) It is the software licence that make up most of the cost, not the hardware.
2) The second highest cost following the software is not hardware, it is the trainning
3) The third highest cost would be.... still not hardware! It is support
4) Ok, what about the fourth highest? Depends on department (Radiology have really fancy monitors, those don't count) it is usually networking and management
5) Finally we got to hardware, but vendors tend to have big issue with their software running on unqualified or untested hardware. You risk voiding your support or paying a premium for reusing old computers.
When he said "Computer", he really means "Computer, the software, the training to use those software, connection, and support when shit hit the fan". Not just computer.
I would imagine the article submitter doesn't understand the concept of "other countries".
I could imagine providers overtesting in a US style pay-as-you-go system - the incentive is clear. But why would the NHS in the UK (OMG!!! teh sosherlizzum!!!!) do such a thing? And as you hint at, the NHS has a long record of failed IT implementations too.
I suspect the problem is to do with medicine itself - every case is different and partly the attitude of its practitioners - doctors are set in their ways and often arrogant.
Confucius say, "Find worm in apple - bad. Find half a worm - worse."
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.
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