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Why Electronic Health Records Aren't More Usable (cio.com)
itwbennett writes: There are plenty of things wrong with Electronic Health Records (EHRs), writes Ken Terry. Among them: 'The records are hard to read because they're full of irrelevant boilerplates..., [a]lerts frequently fire for inconsequential reasons..., and EHRs from different vendors are not interoperable with each other.' But those are all just symptoms of the underlying (and unsurprising) problem: '[T]hey are designed to support billing more than patient care.' A recent study (login required) found that, of 41 EHR vendors that released public reports, fewer than half used an industry-standard user-centered design process. This despite a requirement by The Office of the National Coordinator for Health IT that developers perform usability tests as part of a certification process that makes their EHRs eligible for the government's EHR incentive program.
They aren't more usable because anyone who deals with them wants to use their own proprietary format, which they of course work with absolutely no other companies to share or interoperate with.
Until the government steps in and actually does its job, digital records are worthless to the patient.
This is what happens when companies lobby for stupid laws like we have now ... things like 'requiring X% of your patients use your patient portal ... which means that I don't have a choice any more about my medical records being online ... because now every doctor basically FORCES it ... so they don't get fined for not having X% using their patient portal ...
Instead what happens is I have fucking spammers calling me about my god damn 2 year old son because my pediatricians shitty web portal had less security than swiss cheese and was hacked, of course it also took involving a lawyer to even get them to admit to the fact they had a damn data breech ...
And all of this has nothing to do with you getting your records easier, it has to do with companies like AllScrip and its ilk lobbying and buying off congress to get stupid laws passed that do no good to patients but make a fuckton of money for some shitty industry that shouldn't even exist in the first place.
The reason medical records in digital form are useless is the same reason that Obamacare is a big pile of shit. Its not about the people, its about how entrenched corporations can make more money faster by making you a customer that doesn't have a choice in being a customer, you are required to buy their service no matter how shitty it is.
Its like your ISP except worse. You can choose to simply not have an ISP. You can not choose to not have your medical records online and you can not choose to not pay for bad insurance.
Persistent Volume manager for Kubernetes - https://github.com/dwimsey/openshift-pvmanager
I am my no means an expert on EHR. However I have dated a couple of RN's and have several in the family.
What I can say is that who ever develops this crap does not seem to ask the Doctors or RN's how they do there job.
There was a different 15digit code for every procedure, option, action and the RN had to key each in for every step and often had to click a "yes that is right" box or have a Dr come over and acknowledge that yes that is the correct prescription, etc. Im not talking about new prescriptions, Im talking about standard daily doses given in a care facility.
In every case it took 3x longer for them to do the computer entry than it did for them to do the job and add written notes to the charts. Every RN I know complains that it is cumbersome, time consuming, and takes away from their time caring for the patients.
It really reminded me of some of the time keeping systems I have used. Ones where Accounting laid out the system so you had to enter the time code for each task in no smaller than 15min increments and you had to make sure every min of your day was accounted for.
Seems right - the US cares about everybody getting corporate-provided insurance, not healthcare, so it only makes sense that the systems suport that.
The models where so-called insurance has been abandoned are where the costs are lower and the care level is higher.
My God, it's Full of Source!
OUTSIDE_IP=$(dig +short my.ip @outsideip.net)
Is this just another example of well-intentioned government action backfiring through sheer incompetence? Did the bill's authors just assume that digitizing the records would be it? Did they even consider establishing a standard? Were any requests for proposals even issued?
.
Patient health is merely a conduit to profit for the insurance companies.
Just so you know, no government decision in the last 30 years has been about patient care. I'm no libtard, but I'm here to assure you that every government decision in the last 30 years has been for the specific benefit of insurance and medical providers. They've all been for business interests. Patients are just and annoying and necessary evil in a very lucrative industry.
The entire system is setup to extract every last dollar out of you before you die. The faster you go, the faster they get paid. Although, they do have to work faster to accomplish their goal.
The VA figured out a universal export that others have picked up. But you can not import to most of them.
Fun issues like well you only see lab work done by x y or z even though that doctors office has the results in there electronic system. For those of us that detest quest it's fun.
Some you can export calendar events some even have a calendar you can link to. They still insist on robocalling to remind you till you press a button to let them know you got said robocall.
You can send emails etc, one took more than 30 days to notice the message and get back.
Healthcare in this country is still working on voicemail and faxes. If the government wants to provide incentives it should be to connect to the provider of the patient's choice for all medical and related scheduling information the existing va blue button XML format is a good basis to start with. Make it clear under the law that all patient records data etc are the patients property and make not be resold etc without explicit consent every time.
No sir I dont like it.
at least with time keeping system when you put down like 30 min a day just for time keeping then the PHB's get a clue.
The study described in the web page accessible from the login-protected link (which is not the primary source) has been published on the Journal of the American Medical Association: http://jama.jamanetwork.com/ar... (protected too, but at least is the real thing).
Here the AMA news release about the results, sufficiently informative: http://media.jamanetwork.com/n...
This despite a requirement by The Office of the National Coordinator for Health IT that developers perform usability tests as part of a certification process that makes their EHRs eligible for the government's EHR incentive program.
"We did perform usability tests. We found it unusable."
(-1: Post disagrees with my already-settled worldview) is not a valid mod option.
The S/W folks are accused of not following UBD.
They say they spend all their time making the s/w fit the DHS regs.
The result is more about doctors providing info to get paid than for keeping folks healthy.
Also there is more than one s/w company, each with incompatible info formats.
So much for automagically transferring patient records to where they are needed now.
Vendors like this because it permits customer lock-in.
Sounds like DHS got what they asked for in the regs.
Perhaps DHS should follow UBD when they made and used the regs.
Resident MD here and use EHR extensively. They are a royal pain in the ass for even daily users like me to read, due to things like:
1) Lack of standardized reporting format. There is extensive variability between records from not only different hospitals, but different departments within the hospital. Different companies uses different formats, which of course aren't interoperable (probably by design).
2) Lack of streamlining for user experience. There is a lot of "unnecessary data" that a user sees, whether you're a physician, nurse, patient, lab, lawyer, etc. Imagine your car's dashboard spewing every OBD sensor data on the dashboard. Is it important? sure or maybe. Does every one need to see every bit of generated data? certainly not.
3) Lack of instantaneous access. Patients have the right to see their data more easier than: figure out the process for records at each provider > submit a records request at each provider > receive 10-1000 papers > sort through #2). Physicians deserve be able to access their patient's data relatively fast even if the patient went to a different hospital system (say traveled to a different state for thanksgiving), without having to call the office > find out the fax number > fax a request (find the patient to sign the request) > wait for 6 hours to several days while the recipient processes the request. What do you tell the patient while they are waiting in your office? Banks manage to do both #1 secure financial data and #2 make instantaneous transactions, but healthcare IT is lagging.
The way it currently stands, EHR system is a net negative experience practices, and in some cases outright dangerous (think of missing important information with data overload). The hope among physicians is that as the technology matures, the problems will get worked on and turn EHR into a net positive.
There is a standard for transferring medical information between and within medical facilities called HL7, or Health Level 7. It's a fairly simple text protocol with fields designated for particular types of data separated by pipes ( | ). Those fields are sometimes then further divided. This standard is meant to ease the flow of data between disparate systems. Within a hospital you may have a radiology information system (RIS), an EHR or EMR, practice management software, scheduling software, PACS archive, lab software, interface engines, emergency department systems, and a whole host more. These are systems are made by niche companies you've never heard of, and large corporations that everyone's heard of. All of these systems need to talk to each other to some degree.
Here's the dirty little secret that makes my job more difficult...
NO ONE FOLLOWS THE STANDARD!
Seriously. Here's how a call between me and a vendor might go (simplified):
Me: Where is the scheduled datetime?
Vendor: It's in field C.
Me: But that's where the observation datetime should be. So where's the obs time?
Vendor: Oh that's in field A.
Me: Field A is for completed datetime. So where that then?
Vendor: We put that in field B.
M: Are you messing with me?
Vendor: Uhhh...no?
Me: Grrr. Field B is where the scheduled datetime should be!!! Why is it built like this?
Vendor: Mmmm...not sure. I'll have to check with one of the engineers and get back to you.
Me: You may want to give them the HL7 specification while you're at it. It's published. Online. Freely accessible. You want the link?
It'd be like every web browser and web server all agreeing upon a standard markup language, HTML for instance; then each rolling their own version anyway. So Chrome looks for a HEAD tag, but IE calls it the TOP tag, Apache calls it the BEGIN tag, and IIS uses a FRONT tag. You may be thinking, well since IE and IIS are both from Microsoft they wouldn't do that. And my answer would be, you obviously haven't delved into the world of SharePoint.
I'm sorry, but your opinion seems to be wrong.
I had orthopedic surgery a few years ago and at followup office visits, my surgeon had a dedicated data entry person with a laptop who followed her around and did record keeping for her.
At the time, I wasn't sure if this was a statement on willful ignorance, her elevated partner status or the sheer lack of usability of the record keeping system.
"bbbbut it would be so much easier if we all just had free everything"
Wait, was that a micro-aggression against those who are health-challenged?
Finally lets remember what Obamacare really did. It did not expand access to insurance.
That is 100% incorrect. It absolutely did expand access to health insurance to millions of people. Prior to the Affordable Care Act millions of people literally could not buy reasonably quality health insurance outside of their employer. Losing your job generally meant losing your health insurance as well. More people have health insurance not than before the Act. QED it expanded access to health insurance.
It expanded/required access to health management. If anything Obamacare made actual insurance in the traditional sense of what insurance used to mean illegal for all practical intents.
Complete nonsense. It imposed penalties for not having health insurance but in no way shape or form did it change "what insurance used to mean" or make it illegal. Everybody has to use health care so having a system where some people don't or can't participate is a broken system. While the Affordable Care Act by no means fixed all the problems in our health care system (not even close), it did provide a way for almost all Americans to obtain health insurance for reasonable amounts of money. It's not even close to a perfect system but it was a system that was politically achievable and better than the one before. You know, the one where if you had a pre-existing condition you might as well declare bankruptcy because you couldn't get insurance at all.
I work for a private non-profit mental health provider and we use an EHR that is supposed to be an "industry standard". However, in order to share records with another agency we have to print the records and fax or mail them. I use a fax machine every day. Even when I'm sharing records with a facility that uses the same system, I'm unable to send them electronically. We can't even email records because there doesn't seem to be an industry standard for "secure" email. The secure email system we have basically uploads the message and associated document to a server and sends the recipient a link. They then have to register a user name and password. In the end it's just easier to fax them the records. I'm told by people in our medical records department that when they get records on a disk, they have to print the records and then scan them into our system because the files aren't compatible with our system.
A recent study (login required) found that, of 41 EHR vendors that released public reports, fewer than half used an industry-standard user-centered design process. This despite a requirement by The Office of the National Coordinator for Health IT that developers perform usability tests as part of a certification process that makes their EHRs eligible for the government's EHR incentive program.
So, the obvious flaw in the logic is: If less than half of EHR's follow it how can it be an "Industry Standard?"
The REAL problem here is the Fed, looking for short term boosts in the IT sector to distract from the imploded housing and derivative bubbles, announced a big dollars giveaway to the healthcare IT sector WITHOUT there having been standards in place before doing so. (And Doctors thinking they'd get meaningful cash bonuses for participation, only to see those bonuses go right into the nickel-and-diming EHR suppliers' pcokets.)
Which leads to colossal fuck-ups like the Federal Government changing the rules in October of this year for the participation standards for this year's incentives. (When it was supposed to be measures applying the whole year long.) And I attribute that to having bureaucrats deciding how the healthcare sector shall employ electronic records, instead of allowing the healthcare sector to grow such standards organically. (As well as doing dumb-assed things like setting standards that absolutely require patient active participation and cooperation, like signing up for portal usage. Then having to relax that standard once the actual providers pointed out how little participation some providers can actually have occur. Hell, you can't even get a patient to take medications as directed in many cases.)
And yes, Virginia, any IT system for healthcare has to be built around billing in addition to medical records. Your physician does deserve to get paid, and the Iron Law of Bureaucracy infected healthcare billing IT long before anyone thought digitizing the medical record was a good idea.
EHR has been a problem for decades. Don't blame this on Obamacare, blame it on the asshole corporations that are more interested in money than patient care. If anything, the problem is that Obamacare lost its public option because Republicans are stupid. The government runs healthcare in most countries, and it can be competently done if people don't fight it based on the fact that their rich CEO buddies wouldn't be able to buy their third summer home should profits go down because they're forced to spend more money on care instead of funnelling it to numbered Cayman Island bank accounts.
Without those mandates, the insurers would be able to continue to abuse their customers freely. Imagine getting cancer, after paying exorbitant premiums for years, only to find your insurer has cancelled your coverage for no other reason than paying for your treatment would eat into the profits. Imagine getting denied health insurance because you used to have asthma.
Companies don't do the right thing unless they're forced to - and it's the government's (read: the people's) job to force them to do it. Health insurance is largely insulated from market pressures, so "free market" principles do not apply. I certainly wouldn't pay $850 out of my pay each month (with my employer picking up the other half of my premium) for coverage that didn't pay out a dime until I've spent $5000 out-of-pocket if I had a choice. Yes, I could go to the exchanges, but I'd lose the money that my employer pays towards what I do have - and I make too much money to qualify for subsidies, but not enough where I can pay $1700 a month for health coverage. Without a public option to drive costs down (or force better behavior), this is what we have. Conservatives tore all the value out of the bill and now they're pointing out all the problems that are caused as a result (which were their own doing.) It's like slashing the tires on a car and then complaining that the ride is bad.
Never underestimate the power of stupid people in large groups.
US Healthcare is here in part, because the American people were mad about Iraq, and the sudden crash in the economy. The democrats got control of the Presidency, House, and Senate. With their power, they rammed through Obamacare, which includes mandates for electronic medical records, and all sorts of other stuff.
The first part is true. The second part, not quite. It wasn't rammed through, no matter how much spin is spun to portray it that way, the fact is, it was highly debated and discussed over decades. And it was full of compromises and such, and didn't differ greatly from the plans proposed by numerous others.
The Republicans just took political cover and refused to stand up and vote for it, so almost all the Democrats did instead.
The Republicans don't want the government running health care. They are hessitant about the VA.
The Republicans are hesitant about the VA being given the tools they need to take care of our veterans. That's not profitable enough for the "health-care" industry.
Especially if a government program is successful, then it would make the private entities look bad. So they don't let it happen. And they try to convince us that the rest of the world is suffering in some state of poor medical care and make us fear death panels and that the VA is failing at a much greater rate than anybody else.
Meanwhile the governor of Florida was CEO of a company that stole billions from the government for work they didn't do. Yay?
There was even a shutdown over this.
Yes, that was the toddlers having a temper tantrum. Even though the ACA they did get was straight out of their Presidential nominees playbook to a high degree of correlation. But no, no, they must have us believe it was different, somehow, someway.
And they will replace it. Right? Where's the replacement first?
Now, health care was very expensive under the Republicans, but doctors didn't go around doing stuff they thought was stupid.
The hell they didn't. Doctors are always complaining about doing stupid things to comply with the government. Sometimes legit, sometimes not. Really, before Roe v. Wade, doctors were obfuscating the abortions they did perform under various terms, and some probably still are, and even before that, doctors were indignant about washing their hands because they couldn't carry disease.
Doctors, like everybody else, can be right. Or they can be wrong. And it can be the same person.
Go figure.
It wasn't rammed through, no matter how much spin is spun to portray it that way, the fact is, it was highly debated and discussed over decades. And it was full of compromises and such, and didn't differ greatly from the plans proposed by numerous others. The Republicans just took political cover and refused to stand up and vote for it, so almost all the Democrats did instead.
Except that, at the last minute, they passed it under reconciliation because Massachusetts elected Scott Brown to the seat that had been held by Ted Kennedy on the platform of being the vote that would block it being passed. The Senate bill did not exactly match the House bill, so the House had to go back and pass it again. I forget the exact shenanigans, but in order to get it passed the House inserted a rider into the bill they voted on that "deemed" part of it as passed without ever voting on that part.
If that is not ramming the bill through, I am not sure what they would have to do for you to consider a bill rammed through (I am guessing that you would only consider a bill rammed through if the Republicans were putting it through).
The truth is that all men having power ought to be mistrusted. James Madison
It's much worse:
Garbage In, Garbage Out.
I am a physician. Physicians are not particularly good at data entry. Most notes in the EMR I use (shared by ~80 physicians in a hospital) has a lot of garbage in the individual notes. The notes pick up the mistakes that others entered into the EMR and propogate them into the next note, so long as no one fixes it.
I make it a point to clear up the notes when they get to me, but I could be the only one in my system that does that. Getting rid of redundant diagnoses, updating the active problem list and past medical and surgical history, etc. (The fun thing is reading that the patient stopped smoking a couple months ago, and reading that in 10 notes over the span of a few years.)
Help! I'm a slashdot refugee.
Or when the Dems get hold of them and all your records go into a central medical database in Washington. Oh wait, they did that already!! The only solution is never to visit a doctor.
The only way I can figure you pay $850/month on a high-deductible plan is if you have 3 spouses, 38 kids, smoke 3 packs a day, drink a bottle of whiskey for breakfast, lunch, and dinner, weigh 375 pounds, fly your own personal small aircraft, and have cancer, AIDS, and several heart attacks as pre-existing conditions.
HDHP plans for normally healthy two parents + two children is around $250 - $275/month for employee + $650 - $850/month for employer.
The police subbed a member of the gang that hospitalized you for you in the hospital room; their gang is now multi Millionaires after suing the hospital....
While it is fun to rag on the lousy user interfaces of EHRs, we need to be realistic. In the past few years we have gone from 20% EHR use to 80% EHR use. That amount of tax payer money spent to move this huge industry is less than the Goldman-Sachs bonus pool over the same period. So we have actually done a lot with a little.
We should also realize that in most industries, computerization occurs roughly a decade before the real benefits of computerization, in terms of efficiency, occur. This is because... people. It takes people a long time to develop new work processes that take advantages of the technology. Before that this just do the same old thing with new, shiny tools.
The comment about billing is also right. The current generation EHRs were developed to optimize billing against typical fee-for-service insurance, not to optimize care. Why? Doctors actually lose money being more efficient because, mostly, they are still paid for doing things, not for outcomes. We are slowly shifting to payment for quality. When that really happens, if the republicans don't undo it, you will see huge advances in EHRs. When efficiency is profitable, people get efficient.
Finally, remember that EHR development is extremely risk averse. Software bugs in EHRs are not like software bugs in Angry Birds, bugs in EHRs kill people. Therefore, radical changes are extremely risky. Stable legacy code is the rule. Changes are slow. While we are beating up EHRs, it may be relevant to remember that your banking probably still runs on Cobol. It was reported that there were a billion lines of cobol written last year.
Another fact for the EHR......they're designed for data analytics. Mass culling of information as to diagnosis, morbidities, and treatment. Patient care runs a poor third to data collection and insurance/billing.
I concur with the GP and other posters here that assert the idea that USA EHR is a hot proprietary mess. I thought this link was appropriate. Enjoy.
https://www.youtube.com/watch?v=xB_tSFJsjsw
This is my job. I've built EHR software with exposure to the internals, interfaces, and connectivity with external systems. I'm now a healthcare analytics consultant and considered and expert in my field. I feel the need to point out that patient-centric EHR systems are very good for system usage by the physicians and staff at the hospitals because they are optimized to retrieve and work with an individual patient's records (orders, results, etc). The flip side of this coin is that the system which works well at the patient level is not appropriately indexed for enterprise-wide reporting. For example, the database indexes make it so that querying to see if a patient is a smoker is very fast, but querying to see what percentage of the patients smoke is a much bigger task... not because of the size of the data returned, but because the tables are set up to retrieve the data in this fashion. As such, it makes reporting a much bigger task than predicted by the people requesting the reports. I'll go on to say that the hierarchy of hospitals is more complex than many people imagine. Hospitals are often owned by a parent organization which divides the hospitals into clusters (usually by geographical location) that share a common EHR system. Reporting overall numbers requires manual calculation or the use of an EHR or data mart with ETL jobs running nightly to capture the data which can't be queried real-time. There's a LOT of overhead and we haven't even touched on the fact that hospitals are bought and sold all the time so an organization will own many hospitals using many different EHR systems so normalizing the data is a task in itself. Welcome to my world. :)
The problem is that the insurance companies exist in the first place.