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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!!!
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.
Government hospitals (like VA hospitals) have NO money to even fix aging equipment, let alone buy new or have fancy things like IT.
HUH ????
The VAs electronic health system is called VistA, and it is the EMR in the largest health system in the US. It covers all veterans, it is used nationwide, and it is so prevalent that most everyone who talks about standardizing medical records and medical data all talk about matching the VistA system in doing so.
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
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
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.
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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.
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?
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?
"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.
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.
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.
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...