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Health Care Providers Failing To Adopt e-Records, Says RAND
Nerval's Lobster writes "Back in 2005, RAND Corporation published an analysis suggesting that hospitals and other health-care facilities could save more than $81 billion a year by adopting electronic health records. While e-records have earned a ton of buzz, the reality hasn't quite worked out: seven years later, RAND's new study suggests that health care providers have largely failed to upgrade their respective IT systems in a way that allows them to take full advantage of e-records. Meanwhile, the health care system in the United States continues to waste hundreds of billions of dollars a year, by some estimates. 'The failure of health information technology to quickly deliver on its promise is not caused by its lack of potential, but rather because of the shortcomings in the design of the IT systems that are currently in place,' Dr. Art Kellerman, senior author of the RAND study, wrote in a Jan. 7 statement. Slow pace of adoption, he added, has further delayed the productivity gains from e-records."
It has been my experience that every health care provider that I have dealt with that offers electronic records, also charges you an "administrative fee" to get a copy of said records at over $1 per page (regardless if it is an electronic document emailed to you).
Need an example? Altoona Regional Health System
"When life gives you lemons, don't make lemonade. Make life take the lemons back!" -- Cave Johnson
Because the credit card companies have done such a good job with information protection...
"I say we take off, nuke the site from orbit. It's the only way to be sure."
I support several small medical practices. They don't (or say they don't) have enough money to upgrade their systems. Like any small business, potential savings in the future don't always translate to extra income now. New systems are expensive and often included monthly fees from the software providers. In addition, if their analog, handwritten system has been working for decades, there's not a lot of incentive to switch.
... help them actually code procedures correctly for insurance, and maybe assemble one whole entire bill without committing at least one major error, and to stop sending me bills that I shouldn't have gotten at all then telling me to just ignore it when I call?
Because not having to call someone—usually more than once—to get the hospital's billing fuckups fixed after a majority of visits would be awesome.
I'm contracting in the industry right now, and... The problem with e-records is draconian HIPAA requirements. Also all our systems have to be able to pass an audit by the FDA, meaning if I add a piece of javascript to check for numerics... re-validation! I'm not saying the government should back down, medical records need to be private, but they've got IT management and senior staff here trembling at the mention of their existence. Supposedly, it's kept the main production system from being update for the last couple of decades or so simply because nobody wants to take on the responsibility of potentially getting the business shut down... then again that's operations, and they can be a bit dirka dir, but it's definitely a problem from both sides of the fence.
And as soon as a provider gets their system updated it will be out of date. Think this is another 'follow the money' idea?
Working for a health care company that has had an EMR since 2004, it's not a matter of just upgrading their systems. Yes, many smaller health care IT shops didn't plan or have the talent to build accordingly but that's not the only reason they have not moved to EMR.
State, county and yes even Federal regulations have a lot to say for what you can and cannot do. There's this little thing called HIPAA which highly regulates what can and can't be done in regards to access to records. Medicare/Medicaid reimbursals still require us to use a DOS/Windows NT system to submit for reimbursement, because the system at the state's end has not been upgrade. That's not something we can just arbitrarily upgrade/replace.
New provider applicaton/submission? Fax the form over. Why? State regulations specifically list email as unacceptable, it's not "secure", but a phone number on an analog line is. All this article says to me is "flame bate"
My physician's office explicitly tells me why they stick with paper-only records: They don't want to deal with the data security mess. They are a medical office, not an IT shop.
Amazingly after all these years on paper records, I don't get double-billed, I've never had a problem between them and the insurance company, and they manage to handle my billing in a timely manner.
Go figure.
//TODO: Think of witty sig statement
I am involved as a consultant to several practices and frankly the software stinks.
Buggy, incomplete, error prone, and over priced.
If I had a nickel for every time I have been told it will be fixed in the next release I would be a millionaire.
I feel sorry for the medical professionals who have to deal with the garbage software on a day to day basis and the consumers who get sub-par service both medical and billing because of it.
One example is:
If one thing is billed another is automatically added to the bill because they were often used together.
The problem: They are no longer recommended to be used together as a better and cheaper test has replaced one of them.
A year and a half later the problem is still in the software and if someone forgets to manually remove it the insurance rejects payment and the patient gets a bogus bill for several hundred dollars.
"RAND’s 2005 report was paid for by a group of companies, including General Electric and Cerner Corporation, that have profited by developing and selling electronic records systems to hospitals and physician practices. Cerner’s revenue has nearly tripled since the report was released, to a projected $3 billion in 2013, from $1 billion in 2005."
Is due to the fact there's no standardization for medical records from hospital to hospital. To accomplish it we first need to nationalize and unify every hospital in the United States. I use the VA Hospitals as my model. They have electronic record interchange already.
Then you can use best practice to standardize all procedures from actual medical procedure to operational procedure and everything in between. Then once you've nationalized the hospitals, setup several NATIONAL universities that grant M.D.'s and integrate the training.
Quality of care is also important. I have a relative with a mental illness. Occassionally they need to be confined to a hospital. Everytime they go in, the hospital doesn't have their records. This means the doctors start from scratch each time. They start off with the same treatment that doesn't work. They then rerun the same tests and experiment to find a treatement that works. 3 or 4 days to get records is a long time.
If I call the hospital to speak to my relative my call is forwarded to a nurses station. That station then looks up the patient list on paper and if my relative is not found they forward my call to a different station. After 3 or 4 forwards I get my relative. Some hospitals in the USA are still in the 1980s.
"RAND’s 2005 report was paid for by a group of companies, including General Electric and Cerner Corporation, that have profited by developing and selling electronic records systems to hospitals and physician practices. Cerner’s revenue has nearly tripled since the report was released, to a projected $3 billion in 2013, from $1 billion in 2005."
If want to see a terrible example of electronic document conversion, google e-health ontario. Between government incompetence and contractor dishonesty, we ended up (as a province) spending millions in order to get ... nothing.
And that's with ONLY 13 million people.
- Nec Impar Pluribus, or so I'm told.
could save more than $81 billion a year by adopting electronic health records
Needs a better reason. You'd pay anything for your health, right? And with the miracle of insurance you don't have to pay anything at all...
So why would patients or hospitals be even remotely interested in this?
"Science flies us to the moon. Religion flies us into buildings." - Victor Stenger
Can [VistA] calculate the correct amount of a drug to give an infant vs. an overweight man?
I don't know much about the pediatric capability (or lack thereof) in VistA. But I imagine that there are plenty of fat veterans, especially given the "diabesity" epidemic that's comorbid with "affluenza".
I am a physician and operate a small practice. The issue for my practice is simply the cost. To make the switch I will have to invest thousands in IT upgrades, and pay thousands of dollars every year for the privilege of continuing to use the software. Further, if this slows me down to the point that I see one fewer patient per day, it will cost me an additional $10,000+ per year in lost revenue. I'm sure an EMR would streamline things for insurance companies, but my practice will see none of the benefits. I feel I provide high quality care with my current system and I don't believe a different record system will improve that. At the end of the day, switching to an EMR means a huge paycut with no improvement in patient care. I just don't see how that makes sense.
I work in supply chain management, and one thing that is a very recent development is an increase in the awareness in hospitals that they do not run the business end of their facilities very well. The reason is quite simple: the board of directors that runs a hospital is mostly staffed by doctors, therefore the focus of the management of the hospital is always on providing patient care and having good procedures. Anything "business" related was typically a process improvement done mostly to reduce the time constraints of doctors and nurses, but very little if any attention was paid to issues such as quantity buys to obtain discounts on supplies, such as needles, bandages, gauze, etc, managing inventory and how much money should be tied up in supplies at any given time, or even the shipping methodology of those supplies. A friend of mine became a supply chain guy after originally going to school as an RN because the hospital needed someone to handle those issues, so he got stuck with the work. He found his hospital would not order new materials until they ran out, and then since they were out it was always a rush to get it so they were always shipping new materials by air. He implemented some basic forecasting and planning methodology so they could ship by truck, now they never run out and he reduced their freight bill by 90%. But unfortunately these concepts are relatively new to the healthcare world.
Second, I'd just like to point out that insurance carriers are part of the problem in rising healthcare costs when it comes to "wasting money". I recently switched to a high deductible plan ($3,000 annual deductible) and an HSA; with my deductible I'm basically paying for my own medical expenses wherever I go. My chiropractor basically charged me his "uninsured rate" whcih was a 40% discount. A therapist I am seeing for some issues is giving me a 40% discount for not having to go through my insurance. And my prevantitve stuff is all free. My high deductible costs less than 10% of my old insurance, and the remainder of what I used to spend is mine in my HSA, not my insurance company's. The total cost to me is acutally cheaper than my old insurance (an HMO) with it's co-pays.
I used to regularly visit an ophthamologist for a chronic eye condition. Every visit the doctor would sketch by hand an image of the irregularities on my retina. Imagine the licensing costs of software and hardware required to do this, vs a plain paper template. Not everyone at RAND is a genius...
I have a better title, "Utter Crap Software Failing To Live Up To Provider Expectations".
When my data is on paper in a doctor's office, I know who can see it... the doctor and anyone I ask him to send to. Why do you think there is such a manic PUSH for all the digitized records? The cynic in me says it's a Data Mining Goldmine for insurers, advertisers, those stupid background checkers, anything at all.... There is so much money to be made from 3rd party access to our records, it's just disgusting. It's like jackals circling in for a piece of the carcass. And don't tell me any BS about "congress ensures only people who need to see the info will see it". Not only is all computer security laughable, just wait. Maybe not this congress or the next, or the next, but eventually, some congress will say "we are now allowing access to this information for the good of the children". Then collect all the fees for the use of our private info. Just wait.
right now there is a huge rush to get EHRs up and running to meet meaningful use. Epic has one of the better EHRs. One of the best features in the patient portal. Super easy to setup and super easy for your patients to grab their data and monitor their test results.
The evidence is very mixed on this topic. RAND's isn't the only study out there. The overall concensus is that such systems don't necessarily save money but certainly do improve the quality of care. The VA, for example, has used a system for years, and the error rate on prescription fills, for example, is on the order of a fraction of a percent, wheras out in the "wild" it is closer to 7%. Also, their records were the only ones to survive Katrina. The real solution to financial sustainability is a single-payer system, where the single poayer handles all billing. Again, the VA, a single payer, pays about half of what Medicare pays for drugs (even though Medicare is a single payer it is prohibited from negotiating for drug prices for unexplained and certainly unsupportable reasons).
Could it be that RAND has it wrong? My wife just finished residency, and I don't think they are including the cost of "upgrading" the physicians. To make it more clear, many older doctors are fairly rigid and set in their ways. It will NOT be easy to get 60+ year old doctors to simply move to a system they aren't comfortable with. They have options and will move on. Add in the costs of HIPAA compliance and they could be grossly underestimating the real costs of an upgrade.
At the hospital I use (fairly large regional hospital), they don't even have electronic standardization between different departments. They keep asking the same questions over, and over, and over... and often I'm not in the system when they send me to another department so I have to fill out another personal health history. I don't believe there is ANY incentive to get this properly implemented between practices (General Practitioner -> Specialist, etc.) because there are too many proprietary systems out there that don't share data.
Slow pace of adoption, he added, has further delayed the productivity gains from e-records
Perhaps it should read:
Slow pace of adoption ... has further delayed the massive lawsuits that fly when things go bad and patient date leaks on a massive scale.
Knowledge is how to play a game, intelligence is how to win, wisdom is knowing what game to play.
Healthcare providers are averse to taking risks when their patients' well-being could be affected. For better or for worse that's part of their professional ethics. Add to this draconian and indiscriminate regulatory environment, including HIPAA, MU and FDA, and you've got a prescription for killing innovation industry-wide. To navigate this mess you need to be an insider with deep insight and connections, which come from years of industry experience. If you are just an entrepreneur with fresh ideas -- forget it.
Imagine the possible chaos if I'd made that typo entering patient data in an electronic health record.....
Knowledge is how to play a game, intelligence is how to win, wisdom is knowing what game to play.
My wife is an MD and (relatively speaking) is computer literate. She can touch type and navigate typical desktop machines.
Her clinic converted to EHRs several years ago and she still hasn't reached the level of efficiency she had with paper charts. At this point she's gone back to dictating parts of her chart (via speech recognition) to try to regain some of her lost productivity.
A lot of the problem is that the data is VERY free form. The mundane measurements (height, weight, temp, BP, etc) are easy to insert and digitize, and you can pass it off to another health worker to enter it. The really important information, however, doesn't fit into an established structure.
MDs learn how to collect and document patient status during med school and residency. The details vary from one program to the next. The efficiency of an office visit and its subsequent documentation all depend on how well the EMR flow (and even the number of clicks) fits how the MD does an office visit and/or documents a medical procedure.
The disconnect between habits and automation will continue to affect MDs until we have a generation of experience.
And it isn't just hospitals. Even school system record keeping is all over the place. A friend of mine is head shrink at a school. He laments the database conversion done where they assured him everything would be fine only to find a lot of data just missing.
To the point where they want me to re-engineer their old app and add some functionality to it.
While we are finding that medications, drugs, and various substances in fact are reduced in error rates due to adoption of electronic forms, due to table lookups and the lack of data corruption on transcription, it is not always a panacea.
For data capture of patient histories, especially in medical research, due to the complexity and fallibility of the humans involved - our source data, if you will - we find that paper records sometimes are better at allowing us to capture a more correct record of what is happening.
Hence some of the resistance.
Some of the electronic forms take longer to record data with, and slow down patient/doctor communication and observation. Some of the electronic forms incorrectly presume that the patient has all their limbs, or that data is correct as first given. We have a lot of problems with veterans in terms of such data.
But that's my personal observation.
Just because you can capture things electronically, doesn't mean it's always the best method.
-- Tigger warning: This post may contain tiggers! --
It might be cheaper to the nation but in each individual medical stand up it's an enormous investment.
Epic is a useless sack of crap, it is clearly designed to make practicing medicine an unlivable hell, it is also clearly set up to make communication with other Physicians miserable. Epic is designed for managers to get incentives and for billers to optimize billing. It is also designed to punish Physicians.
Physicians are leaving large organizations who implement it.
Physicians are always leaving organizations....most hospitals will be on Cerner or Epic in 10 years. Both systems are only as good as the people who implement them.
Any savings would be kept by them. Patients would never see it.
That took out some of the luster in having a nice E backlist system.
A lot of people are leaving our organization
large organizations force their physicians to lie to meet meaningful use criteria (such as after visit summaries). (small organizations will also arrange data to meet these criteria.)
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html
I was forced to sign my right for my organization to obtain the meaningful money, I am still liable at the end of the day.
There are a ridiculous number of emr systems out there, several with available 3rd party support to manage your IT setup, and some that will offer a VPN or secure citrix environment to work in.
I worked as an intern in IT for a large medical group a couple of years ago, and the consulting firm i work with now does a lot of support for just clinics/doctor offices and the IT aspect alone is expensive. In particular we help them upgrade IT infrastructure in a clinic so they can go live with their central EMR system.
there are workflow assessments to be done, and IT assessments to be done. We charge $95/hour per person, i can spend 3 - 8 hours doing an assessment and documentation for an office. They have staff to do the workflow assessments. We have assessed and rolled out 40+ offices in the last 12 months.
There are PCs to buy (Figure ~1 grand each, though they use thin clients now and again....just not often) and even a small clinic may need 6, a large one may need 30 or even more. Dont forget printers, patients are required to receive after visit summaries from their providers. and a couple of scanners for each clinic.
There is cabling to run...a lot of older buildings have zero cat5/6 wiring so that can be expensive.
there is networking equipment to buy (switches and wireless APs)
there is bandwidth to pay for (most clinics for this group have metro to get them to the main IT office)
there are laptops to buy (often with rolling carts for mobility/convenience)
sometimes we install mounts for the desktops in patient rooms.
there is labor required to image and prep the PCs and laptops, and labor required to roll them out and train the users on the very basic IT concepts they need.
There is training needed to prep users for the EMR system and massive training to get into details and customize the EMR system for a practice or provider.
I don't want to know what the average cost is to take a clinic live with EMR for this group. I know we billed out $300k in IT and cabling services last year, so thats several grand per clinic, minimum, in IT support. nevermind the emr staff and all of the equipment needed. Then the follow up IT support for misc PC issues, misc EMR issues, misc printing issues.
Some clinics already had a 3rd party supported EMR system that got replaced, but they have to keep it available for years. some of them were on their second system before we took them live on the new one...i have no idea how the very first one is supposed to get supported as legally required, but they were told to keep vendor support for anything they can as long as legally required because the medical group cant support anything but their own system.
for some clinics its a nice, welcome change. for some they equate to some level of hell. for everyone clinic there is a pretty serious cost to consider, and a lot of clinics had a very old or limited IT infrastructure to support what they already had.
By and large, language is a tool for concealing the truth. -- George Carlin
It's a different set of risks. They still need to have backups of all those physical records in case the place their keeping them burns down. Burglary isn't a likely risk as somebody would have to know what they want and where to find it, however, it makes knowing who is accessing the records impossible. Plus, when I went to the ICU a couple years back, they had access to all my records damn near immediately as the doctor already had an agreement with that hospital to share my records. So, rather than having to drive over there with records, the records were there within moments of being approved.
And places like Group Health have been using electronic systems for many, many years as a way of better tracking down what's actually being done. The only time I ever see them writing something out is when they write a prescription for something like Ritalin or Adderall, and even then they fill out the form on the computer and print a copy to sign. It greatly reduces the possibility that I'll be given the wrong medication because of poor penmanship.
And yes, of course, you've never had a problem, a competently run office should have problems, but if they have one problem in 30 years it could potentially be lethal.
Greed. Pure and simple. That is what has killed electronic medical records.
It's anywhere from $60,000 - $100,000 for an EMR system. And if your EMR of choice doesn't do practice management, you have to spend another $10,000 - $20,000 for that.
The big promise of EMR is data portability. And here's the big secret that no one seems to be talking about: the data *is not portable*.
If I have ABC Company's EMR and you have DEF Company's EMR, I cannot export a patient chart, send it to you and then you import it. You cannot connect to my EMR and get charts for patients I refer to your clinic. So there is no universal patient chart that follows you where ever you go.
Plus, if you *do* have some other electronic system that has to interact with your EMR (say a pathology system or a perscriptions system) you have to pay *both* companies typically $10,000 *each* to do an HL7 link between to two systems. And even then, the link between the systems is spotty at best and half the time doesn't work.
A company that has very little in the way of technology wants to transition to EMR. So they have to spend $30,000 - $40,000 just for the computer hardware (workstations, servers, printers, scanners, routers, switches, etc.) and then another $60,000 - $100,000 for their EMR and practice management needs. THEN, the users have to be trained. I do IT and primarily work with medical offices and sugrical centers. I can tell you that doctors *do not want* to learn how to use computers and software. The office employees fight it, everyone fights it. Eventually they give up and don't use it and let $100,000 worth of hardware and software go to waste because they become too frustrated to use it, it slows them down exponentially and it hasn't made anything easier or more portable. I have seen so many offices basically throw money down the toilet on these EMRs. They get them, and within a month they can't stand them and just go back to paper charts. Not to mention how much they get in the way of patient care. My wife recently went to see the doctor. The doctor was hunched over her computer the whole time and seemed more concerned with making a typo than with paying attention to my wife. Paitent care is suffering greatly.
THEN, the EMR companies want to hold back common sense features and charge you tens of thousands of dollars to implement them. One office I worked with had a web-based EMR and the doctor wanted to be able to recieve faxes right into the EMR. They said sure, you can do that. She asked if they could download and print out the faxes if they needed to. The company told them that yes, they could, but that was an extra feature that would cost $10,000.
Vendor Lock-in is not just something that they strive for, it is the very *core* of the EMR landscape right now.
EMR is a complete and total failure and you can lay that failure squarely at the feet of the greedy bastards who sell it.
face it the software is far from optimal (I have used cerner too and it is better in my opinion (at least to find info). )
Epic leaves a lot to be desired, it is bloated crap, if you work anywhere which doesn't have a very fast pipe it is slow as hell. What it spits out as physican notes is inadequate (10 + pages of crap to hunt through to find out what happened during an E.D. visit). It impedes communication between physicians at different organizations.
don't get me started on "media manager" for newborn screens!
If you work in more than one health care system which uses Epic, who the hell knows which one your refills will go to.
Portal, ha, hahaha.
God help your nursing home patients when they go to the emergency department and their meds from the previous hospitalization get pulled forward (too bad numerous changes have been made since then).
Snowbirds (half their time spent in another health care system), oh how much data entry there is to be done when they come back for a summer.
The layout is crap, stuff is very difficult to find in a timely manner.
The rounding tab is ok (but pended orders suck, verbal orders suck).
Sending someone over to the hospital in town for any sort of test (their epic is different than ours), creates a mess (orders get locked in some funny way and create a deficiency).
did I say pended orders suck, along with chaining orders (very frustrating).
The nurses see different things than we do, this creates chaos.
Delivery of twins, I hope I never have to deal with that again.
This software is not ready, I stand by my point that it is a steaming pile of crap.
most hospitals will be on Cerner or Epic in 10 years.
And hospitals own what, 20-30% of practicing doctors? Your pediatrician will probably never use EPIC or Cerner.
I own a software house that makes EMR software.
We distribute to 18 countries, but our primary business is in Australia. We do not sell into the US (and don't want to).
In Australia, the government standard for cloud based EMR is 'Patient Controlled'. They call it PCEHR (Patient Controlled Electronic Health Record). We've nicknamed it 'pecker'. In one sense, it is a good idea, as the patient owns their own data and cannot be held to ransom by their health care provider. Arguably, the authorities could never have made the decision for the data to be owned in any other way.
However, it also means that the electronic patient record contains only the data that the patient wishes to include. Any practitioner would be crazy to accept that record as 'complete' - and for the sake of their PI insurance (and the patient's wellbeing), they basically have to disregard the online electronic record and start from scratch every time.
Furthermore, most health care providers value their business based on the IP in their electronic records (more traditionally known as 'Good Will'). They will not willingly give up that information - at least, not quickly.
Sadly, I can't see an easy solution. It will take time and a bucketload of stakeholder engagement by the government - something that most governments are not very good at.
Come back in 10 years.
http://www.ama-assn.org/amednews/2012/11/19/bil21119.htm
64% of physicians hold no ownership stake in their practice. Which means they either work for a large physician group owned by a corporation or a hospital, or they work in a hospital. The reasons sited in that article are exactly the concerns mentioned in the comments here. Regulations and overhead are too much for the independent physician.
I recall reading, sometime in the last 2-3 years, and my wife's often told me, that the solo practitioner has to see a minimum of 48 patients per day in clinic to pay the bills. A few years ago, I suspect this included some salary for the practitioner. Today I bet the number of patients is higher, and the practitioner's take is smaller. My friends are leaving private practice in droves. They're going to hospital or (large) clinic practices. It's how they can earn a living.
Never ascribe to malice that which can adequately be explained by tenure.
don't forget that there is no consistency with regards to what nurses and doctors see, this creates some problems. Also there are a lot of little things which are not accounted for (which happen on a not to infrequent basis). (twin birth being one particular waste of 4 hours of my time in the middle of the night.) (also if one of your practice locations uses epic then your refills from large organizations tend to go to that organization (frustrating if you only cover call there a few times a month)), along with many other problems. (try and discharge someone on iv antibiotics given by a visiting nurse). I could go on and on with epics shortcomings, it is not fit for purpose.
To all physicians out there, avoid epic if you can!
(also the people sent to train you have no clue about medical practice and the things you may encounter).
In other news today, the medical providers have yet to spend the 100s of billions of dollars to fully upgrade computer systems to save 81 billion dollars.
And when you are talking about a small doctor's office, I can see why they are in no hurry to migrate from paper to electronic. They have just added a layer of complexity that they don't already have, and don't have to incur additional costs.
Throw in people's personal experience with their own computer system, and one can see reluctance in changing to a computer system
My wife recently went to see the doctor. The doctor was hunched over her computer the whole time and seemed more concerned with making a typo than with paying attention to my wife. Paitent care is suffering greatly.
I have to agree, as a medical student I've been rotating through various practices, and EMR systems are causing serious problems with this. Some physicians adapt and find ways to manage both the demands of the EMR system and patient social/psychological interaction, but they only succeed by constantly rebelling against the way that the system is pushing you to work.
From this perspective, the best EMR systems I've seen are the limited ones that don't try to do too much, and allow you to do more talking and less typing. The worst are "manage everything" systems that handle all your scheduling, e-mail, and inter-departmental interaction, all the while requiring constant clicking and typing interactions with the system during the patient encounter itself.
Re: Are you kidding me? The difficulty with HL7...
.
Problems with HL7? Just wait for the third iteration after HL7 to see it crash and burn... Remember what happened with the last HL10? http://en.wikipedia.org/wiki/HL-10#Fictional_references
We ended up with the Bionic Man. Hell, if we could do something like that for $6M-USA these days, wouldn't that be amazing?
Being unwilling to cough up the cost of the paywall, I haven't read the Rand report, but the second hand descriptions of it, as well as many of the comments, seem overly focused on the big names (Microsoft, Google) or reflections of the author's preconceptions.
I have worked in the medical interoperability industry for 15 years; here is my perspective: The medical industry has been working towards patient record interoperability for well over two decades. The first major accomplishment is there is now a firmly entrenched, ubiquitous standard for medical images. That format, DICOM, allows medical transfer between medical scanners, display, and long term storage systems. It is a complicated standard, and has evolved as medical imaging devices have become more sophisticated, so transferring images between systems is not always painless, but if you can transport DICOM images from one system to another, the receiving system can nearly always use them.
The bigger hurdle is to transfer a patient's diagnostic reports and medical history between medical providers, for example, two different doctor's offices. That's a difficult problem for numerous reasons, and for nearly a decade, the medical industry has been working of approaches to make that happen. An international cooperative effort, called Integrating the Healthcare Enterprise (IHE), has been working on standards and approaches, the flagship of which is Cross-Enterprise Document Sharing (XDS), although technically that is just one of a number of related sets of standards.
It's taken time to define the pieces of this, and has changed over this time thanks to trial and experience. Product vendors meet for multi-day cooperative testing and evaluation held once a year in the United States (near Chicago in the dead of winter – now that's dedication) and once a year elsewhere in the world at varying locations.
Either XDS (and its related "profiles") or some local variation has gained acceptance in many parts of the world; the United States is a trailing adopter. That's largely because the USA was a leader in establishing medical systems, so there is now a large, established infrastructure that predates these efforts; countries that modernized their healthcare more recently have been able to just adopt the new standards.
The key piece of this, as RAND correctly points out, is having a format for patient history that all systems can understand. But, rather than being a missing piece, this is a success in the making. Different organizations have tried to define a common format; in 2007 HL7 and ASTM, the organizations between the two major contenders, joined forces to define a harmonized Continuity of Care Document (CCD), which is based on HL7's Clinical Document Architecture (CDA). It is used in numerous countries, and is part of the US effort for "Meaningful Use".
Recognizing the costs of replacing systems, the government has a program providing financial assistance and incentives for medical organizations to adopt interoperability standards. The money comes with strings: they have to use systems that have been certified to support these standards, and they have to show that they are actually using these systems in ways that promote interoperability, hence the common term "Meaningful Use" for this program. Recognizing the difficulty of replacing systems, this is a multi-year effort that we are still in the middle of.
In addition, many states and regions are experimenting with regional health information exchanges, and the Federal government has a national health information network backbone. These may grow into the systems that will provide better medical information exchange, or they may help provide experience and information for whatever will come to replace them.
It's slow. For a very long time, medical reports came by mail, by FAX, or by other physical delivery. Electronic reports today tend to be either PDF or a barely formatted text approach (HL7 ORU). Not great, but good enough to slo
Because the credit card companies have done such a good job with information protection...
That is why I am so appalled that, here in the Netherlands, it is the insurance companies that force these systems onto doctors and hospitals. What could possibly go wrong?
Nae king! Nae laird! Nae yurrupiean pressedent! We willna be fooled again!
Rand: This will be magnificent! So efficient and soooooo many savings! Wow! Whiter-than-white! SRSLY!!! ...7 years later...
users: Err, what's up dude? This whole thing has become totally messy, has cost us a boatload, and is often hampering efficiency.
Rand: U R totally doing it wrong! Do it different! Do it better!!! Y U fail on magnificent promise? U no worthy!!
Well, only hospitals or huge groups (sometimes huge groups belonging to hospitals) could afford all the IT investment that is going to be required. Not only that, I think everyone sees how the ACO model is going to reward those who have good relationships with hospitals, and the hospital and the major groups that practice there are all pulling tighter together. Of course, in the end the hospital will swallow the practice as they both fight to stay alive. Solo practitioners or two-man partnerships just become outright employees.
The current status of our free market economy and the healthcare industry is a cross between âoeFlip This Houseâ and X to the Z's âoePimp My Rideâ. The government insists (with sticks, ie penalties) that all physicians and hospitals start using IT for health records, but sets extremely minimal standards for its IT infrastructure roll out. With carrots (short term incentives) any startup can literally throw crap products together that barely meet the minimal requirements of the government requirements for that given year and contra-spray-gun sell them across the country with a 1-800 number to a clueless India call bank for any sort of support or training or installation. This has resulted in a cacophony of Pimp-My-Ride EHR (Electronic Health Records) brands lipsticked up by the VC sector with the only intention to lock clients into a known garbage product they are going to flip anyways. For the low low price of $100,000 (they never tell you that up front) and $500/month maintenance contract, you literally get a CD or download, license key and phone number to India. The code, keys and clients are usually sold or merged with another organization within 2 years. Once flipped, clients (physician offices) are at the mercy of the new owner who just bought the code to the old, now sunset and unsupported product. Clients are now forced into buying the next product because it is the only way to preserve/extract their patient data, which physician offices have a legal obligation to maintain for 10 years. The new owners / mergers will never support a sunset product and always force a conversion that takes no less than two years for full roll out and the worthless support they all offer. Then that product gets bought, flipped and sunset... and clients are at the mercy of a new buyer and yet another costly conversion again. They do this every two years. None of these products are ever compatible or have any consistency to easily crosswalk data from one to the other; itâ(TM)s a custom migration solution for each client based on what they were package they were sold by the last owner of their EHR product. Itâ(TM)s a tough pill to swallow for any small business eating hand to mouth on dwindling Medicaid / Medicare reimbursements (another lecture all together). Each migration/ conversion is a fresh start, with usually a 20%-50% decrease in income for at least one year during the training / learning phase for each conversion and implementation of a new product they have just been forced into. Clients have long spent the government carrots that forced them into this mess, two conversions ago. If you don't continue to ride the conversion wave and continue to go further into debt, government gets out the sticks slowly reduces your income or essentially closes your facility all together with poor quality measures and sanctions for non-compliance. Even if someone threw their hands in the air and said fuck it and closed up shop to become a Wal-Mart greeter, as stated above, physician offices have a legal obligation to maintain medical records for 10 years in an extractable, usable format or migrate to a new âoesupportedâ EHR. The new proud owner of that code and keys are the only people who can extract your data, and there is a fee for that. Itâ(TM)s yet another form legal extortion, or creating indentured servants out of independent physician offices across the country. Many people have tried to sue their EHR vendor, but when a small physicianâ(TM)s office is already in debt $250,000 to the banks for various EHR licensing scams and failed installations that India canâ(TM)t figure out, who could possibly afford years of attorneys fees and litigation? Healthcare systems need to be able to talk to each other and report/extract meaningful data. There are no two ways about that, and I don't think anyone can argue any legitimate point as to why this isnâ(TM)t mission critical. Government had a great idea and stepped in, but not all the way in like it should have... and left it up to the
for some clinics its a nice, welcome change. for some they equate to some level of hell.
Just to be blunt - if the average age of office staff is closer to 60-ish, then it's hell. If its closer to 30-ish - they love it. Just sayin'.
(Been doing the same medical IT for 15yrs.)
--shame IT doesnt test out a couple of other models, or support ANY tablet PCs
--- one manager has started to support iPad access to the system on a limited, request only basis. he wants to expand this.
How much of this is due to Apple's review process? To test the software for use with the App Store, an Apple employee needs to be given a functioning user account. Otherwise, the developer is allowed to use only those functions that can be implemented in the subset of HTML5 that Safari implements. Perhaps the "limited, request only basis" means they only have a few provisioning points left on their developer license.
we cannot get Vista to meet federal meaningful use requirements.
Is the Veterans Health Administration exempt from these "federal meaningful use requirements" or something?
Part of the problem here is equipment, but part is also definitely laziness and/or stubbornness. At the hospital where I work, most of our radiology equipment (for instance) evidently only interfaces with a single proprietary EMR, so while the the hospital is officially on Cerner, we have to have two EMRs in radiology or replace the machines. Since replacement would carry a cost in the millions, we just have to deal with it. Similarly, in one clinic that is part of the hospital, the physicians have insisted on using their own practice's EMR for scheduling appointments, while Cerner is used for the final record of the visit. The result, of course, is chaos.
Plus you switch to one of these systems, too many try to move the paper workflow straight into the PC and force it to work...
People work differently on paper than on a PC, so it should be a different flow, hopefully a better flow.
There are a ton of benefits, but yea, it's pricey. And when you have the internal staff, the person paying the doctor is paying for a large amount of things... you have to pay the office workers, the cleaning people, the building costs, the administrative offices, data center, all the engineers, HR, the office supplies... there are a TON that you never see that is absolutely required to run things decently, and they have to get paid from somewhere...
I strongly suspect (having worked in IT but not in a health care setting) that part of the problem with getting EMR systems implemented is that most doctor's offices/hospitals would sooner rip their own arms off than adequately fund IT for their organization. If these IT departments were 1) staffed sufficiently to sanely handle the workload (they never are) and 2) trusted to know what they're doing, things would improve. Doctors and nurses push back a lot on new systems, and I think part of the problem there is that IT has to do what they say, no matter how stupid/inefficient/illegal it might be. If the medical staff were told that they could either follow the decisions that are made within IT (since presumably they know what they're talking about, otherwise they need to be fired and replaced) or they can find new places to work, I bet you'd find adoption much easier. Give IT some teeth and I think you'll find that acceptance of a new system goes a lot more smoothly. If an IT staffer can be fired because some bigshot MD won't follow IT policies, then what's the point? The answer to that situation should be "Doctor, you will change your password every 90 days (or pick another IT policy) or you will find yourself without privileges here.", not "Fix it so I don't have to change my password or I'll have you fired."
That doesn't fix the problem of most EMR software being complete and utter shit, but in theory more people being forced to use a new system provides for more feedback about where the system can get improved.
Also, part of the problem is that medical offices or other health care providers already have to spend a freaking fortune on administrative staff for a number of reasons, not the least of which is that we have private insurers in this country, who will take each and every opportunity to deny claims (legally or not, they don't care). If you're not 100% on top of that, and make an unholy stink whenever Blue Cross decides it's not making enough money off of your patients, you will find yourself out of business quickly.
Never underestimate the power of stupid people in large groups.
The doctors I've met and worked for felt that they were getting jacked around by EMR vendors. One of the biggest promised features for 2012 that won't be added until the 2013 version, requiring double the cost that was originally quoted. And since the feds have kept pushing back the dates for some EMR requirements, many practices are taking a wait-and-see approach. Also, billing is often done through aggregators who will accept older versions of billing software submissions; this means practices don't have to implement the latest and greatest, sometimes saving tens of thousands of dollars and all the hassle that comes from having a workforce who doesn't know how to operate the new version of the EMR.
Remember kids, if you're not paying for the service, YOU ARE THE PRODUCT THAT IS BEING SOLD.
vendor lock-in is certainly prevalent with EMR systems. In most cases, they refuse to provide a schema or export features so once you get your data in the EMR, you're stuck with that system.
Remember kids, if you're not paying for the service, YOU ARE THE PRODUCT THAT IS BEING SOLD.
in fact after your first visit to anybody part of the Wake Network your discharge papers has a page with an access code to get into myWakeHealth.org where you can see just about everything (down to all your test results no pix but...).
After you have your login you can use MWH to access the entire WakeMed "stack". (from Docs to Drugz)
Any person using FTFY or editing my postings agrees to a US$50.00 charge
Hes doing fine the way it is now & couldn't be fucked buggerising arround for no net gain to his patients.
Exactly. I've seen in a number of offices where they have an older practice management/scheduling system or one particular EMR and want to either implement an EMR or move to another one. I have so far see only one EMR company that can properly (well, most of the time) import patient info from one system to the new one. Most of them don't do this at all (either import or export). I've been told in several demo meetings "There's no way to import, you just simply have to run your old EMR concurrently with the new one until your data retention laws say you can do away with it."
Every errant e-mail and embarrassing photo is preserved for eternity on a server somewhere. If people weren't so concerned about who knows their the status of their colonoscopy we could just put our records in an e-mail. Google will compile, sort, and preserve our medical history for free.