Why Digital Medical Records Are No Panacea 367
theodp writes "As GE, Google, Intel, IBM, Microsoft and others pile into the business of computerized medical files in a stimulus-fueled frenzy, BusinessWeek reminds us that electronic health records have a dubious history. Under the federal stimulus program, hospitals can get several million dollars apiece for tech purchases over the next five years, and individual doctors can receive up to $44,000. There's also a stick: The feds will cut Medicare reimbursement for hospitals and practices that don't go electronic by 2015. But does the high cost and questionable quality of products currently on the market explain why barely 1 in 50 hospitals have a comprehensive electronic records system, and why only 17% of physicians use any type of electronic records? Joe Bugajski's chilling The Data Model That Nearly Killed Me suggests that may be the case."
Re:Wouldn't it be better... (Score:1, Informative)
The idea is to cut down the wait time for MRI's by getting rid of redundant and unnecessary tests by having complete and easily accessible records.
Healthcare IT is horrible. (Score:2, Informative)
Re:Can't get a copy of X-Rays? (Score:1, Informative)
IAABE I am a Biomedical Engineer.
At the clinic I work at, the scanning station is mostly just a dumb terminal: enough memory to hold the images while they are uploaded to a local server. Only the crudest processing can be performed on that terminal, its mostly just there so the technician can see if a shot was dreadful, or potentially salvageable.
In another room there's a beefier computer with a connection to the server and considerable editing and processing options. Not to mention highly accurate grayscale monitors. This is the station from which the technician makes any notes or corrections before sending the images downtown, or prints or saves a copy for patient release.
Having seperate components like this (scanner, server, viewer) introduces more points of failure, yes, but it also reduces the severity of any failure. It's a lot cheaper to replace a single, specialized component than to replace an all-in-one unit.
TL;DR: I wouldn't be surprised if the "big monitor" you tried to download films from has no capability to do so. You probably shouldn't be playing around with that equipment either.
Re:Are you kidding? (Score:3, Informative)
ncoherent database design isolates patient information from one department to the next and from one organization to the next. This wastes time and increases errors because medical personnel must enter patient information into a unique view of the system that corresponded to user identity and department - this prevents one medical professional from seeing patient information input by another medical professional.
There's not much point in a computerized records system if the information can't be shared, it might as well be on paper, locked in a filing cabinet.
Re:Security? (Score:5, Informative)
Major credit card companies depend on thousands of small merchants who use swipe machines. To improve security, these would have to be replaced. It'd be a big headache. Besides, the credit card companies have been quite successful at pushing fraud and "identity theft" onto the victims (merchants and purchasers). They are fairly protected against data breach, in a sick kind of way. Their problem has become your problem.
But medical offices aren't like that. They have computers (that are re-programmable). There are fewer doctors than general merchants who take credit cards. And medical data is more difficult to turn into revenue than credit card numbers.
I don't think that the money is the dominant part of what makes a good system. Very capable, secure systems can be built on the cheap. The basic things that need to be used are available in open source software (image manipulation, cryptography, databases).
"Can you imagine a million patient digital medical record breach? The black mail or power that could be leveraged over people?"
Yes, I can imagine such a breach. It'll probably happen eventually. Good use of cryptography can mitigate the damage. But the idea of filtering through a million records looking for good blackmail candidates, then conducting said blackmail ... for that effort, you could start a legal business.
Digital records make sense: they should be more secure and easier to transfer. There will be pain switching, but the new system will be more efficient in the long run. There were pains moving from horses to cars, from gas to electricity, from wood to coal. But they all got ironed out.
Nebraska and EHR's (Score:4, Informative)
I saw my doctor last week and was presented with a new form to sign to opt-in or opt-out of putting my records into an electronic format. Being a paranoid, tinfoil-hat wearing, "I remember Diebold voting machines" kind of nerd, I opted out. The form explained what EHR's are and espoused the benefits of them. I'll continue to rely on good old fashioned paper records for now, thank you. This is very new because I lost saw this doctor four weeks before then. They also mentioned that psychiatric information will not be stored in the EHR.
In other related news:
This 2-page PDF [creighton.edu] from the Nebraska Medical Association and Creighton University Medical Center dated June 27th, 2007 gives some numbers on offices that have adopted or thinking about adopting an EHRs.
If you are a Nebraska health professional or just have too much time on your hands from hiding from the pending Swine flu pandemic, you can go to this website [ehrnebraska.org] whose tag-line is, "Enhancing clinical practices through the adoption of health information technology in Nebraska".
Here is a letter [nebraska.gov] (blog entry?) from the office of the Governor of Nebraska posted on April 10, 2009 talking about the pilot EHR project in Nebraska.
Enjoy!
I've used them both in the US & UK (Score:3, Informative)
I've used electronic medical records in both the NHS (UK) and the United States. Cerner is the big player here and it is one of the most ugly, inefficient, and convoluted interfaces I've ever used. It makes some more famous UI messes discussed on Slashdot look line the Mona Lisa. For those of you who don't understand how electronic systems work and why there is so much resistance let me explain how a basic patient encounter works for me:
1. Do a history and physical (H&P) on the patient and record the results on paper.
2. Enter in pertinent information into the computer system about the type of management I want started.
3. Dictate my history and physical for transcription.
4. Wait several hours for the dictation to show up in the EMR. Until which time all other doctors and nurses must refer to my hand written notes.
5. Heaven forbid I have to call in a consultation from cardiology, GI, or some other specialty in the hospital. If I do, then we use our text-based pagers to figure out when the hand-written note has been dropped off because every specialty has to go through steps 1-4. As they follow these patients, they too have to physically recheck the chart since dictated H&Ps and progress notes take time to show up.
6. I can very easily see how a mistake could be made in drug dosing because computers are another step in the way. Plus dosages are selected via a regular dropdown box. All dosages of compounds are rechecked by pharmacy anyway. We can get quite a few calls from pharmacy if something is non-standard or rare.
The EMR is a few extra steps in the management of a patient and does not guarantee that mistakes won't be made. Management plans are checked and rechecked as are drug dosages.
The places where EMR is helpful is getting lab results, radiology results, and study-based information on a computer. However, we have several different systems for viewing different sorts of radiology films that can't be viewed in some types of EMR. Then there is the problem of making sure the COW (computer-on-wheels) we take on rounds has a working battery back and the Cerner database hasn't taken a dive into the deep end. If its all working then it's very helpful that old notes can be looked up without giving medical records a call to haul up a 10 volume chart on a chronic COPD patient we see every other week. Unfortunately, coding for billing is still a pain. The system is so complicated that professional medical coders are needed to maximize profits through proper billing to insurance companies and government agencies.
Another problem not addressed by EMR is the fact that every hospital and practice uses a different system. If I need records from an admission at another hospital then I still have to get a Release of Information form filled out and then hope to god the other hospital can fax over copies of the chart to me. These faxes are huge sometimes, completely disorganized, and at times illegible because notes are hand written. There is no electronic transmission. If I need radiological studies then I better pray the patient or ambulance brought copies on a DVD for us to view. Then we better hope a computer system with sufficient privileges and the right Microsoft Service Pack can run the disk. The NHS system tries to address this but I left long before the system was full operational.
The current crop of EMR systems aren't fitting in with our workflow and our IT teams aren't drawing up a way for us to deal with all the variety of systems we may need to deal with in a streamlined fashion. If a consulting company could come up with a system that worked from point of admission through discharge and follow-up (and billing) of a patient with "it just works" simplicity without forcing me to add tons of different steps then we'd have a reason for EMR. Until then, its just a disaster.
This is one place where a computer alone isn't a solution. We need a solution from start to finish that works with us. A government deadline won't solve this problem. However, if a consulting team made up of a group of doctors, programmers, UI designers, and device integrators/manufacturers got together to attack this problem in an Apple-esque way they'd be billionaires.
Re:Not Microsoft (Score:2, Informative)
I think all Slashdot users can agree it would be terrible if Microsoft got in this game. If this might happen, show me where to protest!
I have bad news for you...they already are http://msdn.microsoft.com/en-us/healthvault/default.aspx [microsoft.com]
Billing drives EMRs, not medicine (Score:5, Informative)
I'm a resident physician, and so I've used various EMRs in different hospital and clinic settings, and they pretty much all suck in different ways. EPIC, which is based in Internet Explorer of all things, is the worst, but seems to the the one that's being adopted at the most hospitals.
The UI design is just horrible, but beyond that I had a hard time putting my concerns into words until I read an article somewhere that talked about something called "cognitive support to the physician." That is what most EMRs lack.
As a physician, I want an EMR that lets me rapidly get at important clinical information and give me targeted alerts that I need to make a decision. Instead, the systems are centered around billing and cover-your-ass medicolegal documentation. In the paper chart word, these issues had already diluted the meaningfulness of the chart. (Ever see a hospital chart - maybe 10-20% of it has meaningful clinical data in it, the rest is full of useless legal/billing/redundant crap.) Many EMRs just translate the same troubled paper chart system into electronic format, but then the ease of electronic data entry means that even more useless information is included/required, making it that much harder to find the info you really need to make a clinical decision.
I have to say that the best EMR I have used is still good ol' CRPS at the VA. It's not as slick looking as the newer ones, but the data is easily accessible and I have never had to waste my time looking up a billing code. It's been chugging along for over a decade, sharing data between hundreds of sites across the country. (And the issue in the first article about the EMR causing more deaths because you can't put in orders while the patient is en route - not an issue in CPRS, we do this all the time at our VA.)
My understanding is that the code for CPRS is open and free to anyone who wants it. I would gladly choose CRPS over the ability to type my notes with colored fonts in EPIC. They were considering adapting it for the large county hospital system where I work now, but in the end went with EPIC because... wait for it... it was easier for billing.
JAVA Improving Healthcare in Brazil (Score:2, Informative)
Re:Wouldn't it be better... (Score:3, Informative)
Medical errors are the fifth-leading cause of deaths in the US, with up to 98,000 deaths annually [medicalnewstoday.com]. "Medical errors in the healthcare system arise from miscommunication, physician order transcription errors, adverse drug events, or incomplete patient medical records," says David Plow, Senior Analyst at MRG.
Re:You know what would REALLY help lower the costs (Score:4, Informative)
In Oregon, the number of new nurses accepted every year is severely limited to "ensure only the best candidates" are accepted. This is decided upon by a panel of nurses, who benefit from the shortage driving up wages. I know of people with 3.8GPA's, that were not selected for the nursing program, and told to apply next year, two years in a row. Yet the state screams about how much more it needs to pay nurses, to attract more, while it is turning them away.. Talk about either a scam, or just plain stupidity.. (or both)
HIPAA (Score:3, Informative)
How it breaks down is this:
HIPAA is very specific about how data is to be handled and audited from end-to-end, and includes specifics on how data can be properly de-identified. As a systems and network administrator at a major trauma center, HIPAA has been a nightmare to implement and a security officer's dream come true. That said, the focus on personal accountability and the high level of monitoring and enforcement leads to an environment much different than a credit card processor or company.
Re:Impossible!!! (Score:5, Informative)
[T]he VA is run entirely by the government. What the rest of the US is going to wind up with is a huge train wreck of competing standards and products by proprietary vendors who don't want to interoperate.
Once again it's probably worthwhile to note that this was a major part of the motivation behind the original ARPAnet project which grew into the Internet. The US Dept of Defense was trying to deal with a growing problem. They were collecting all sorts of fancy electronic gadgets that generated and consumed data, but most of them would only talk to other gadgets from the same vendor. It was clear that this wasn't an accident. Every vendor wanted a to be the sole supplier, and one way they all saw to do this was via proprietary data formats.
The ARPA gang's solution was to build what they called Interface Message Processors (IMPs), whose job was to talk to a proprietary gadget in its native language, translate the gadget's messages into a standard format, and transmit that to another IMP, which would translate it into the native language of another recipient gadget. They knew from long experience that their vendors wouldn't cooperate with this, and would do everything in their power to sabotage the ability of other vendors' gadgets with their own. So the ARPA people farmed out the task of building the IMPs to people who had a history of successful communication with their competitors, the people in academia.
That was about 40 years ago. Now, with four more decades of experience, we can clearly see that the problem hasn't gone away. There is no prospect that gadgets or data systems built by different corporations will ever interoperate sanely. Private companies have a strong motive to sabotage such communication whenever they can get away with it. So, as in the past, the only way we can get useful medical data systems is the same was we've done it with the Internet. We need government-run projects to develop and enforce the standards. Building the low-level gadgets can be a job for the corporate world. But if we ever want to be able to use the data for any meaningful purpose, we must make sure that the corporate world can't control it.
Actually, of course, we have no guarantee that government agencies will do the job right, either. There's no shortage of incompatible data formats in government databases. Unless the job is handled by people as competent as ARPA was back in the 1960s and 70s, it'll still be a huge, expensive failure. Sorta like the medical data systems we have now, which were mostly developed in-house at hospitals, and even the nonprofit hospitals have a poor record of interoperability. (Yes, I've worked on some of their systems, and it's not a pretty sight.) So we should be watching how the governments deal with the problem, and be quick to criticise the crappy standards that we know they'll design.
Otherwise we'll end up with medical records based on a standard similar to the Avian Carrier Protocol [faqs.org], but it won't have been published on April 1. You should also read the wikipedia article [wikipedia.org] to read of a real implementation. But most managers in both corporate and government circles don't have a sense of humor good enough to prevent such things from becoming actual standards.
Re:Impossible!!! (Score:3, Informative)
From "The Data Model That Nearly Killed Me", I came to one conclusion. He was nearly killed by serial incompetence.
There's no excuse for a doctor ignoring a wheezing patient who says "I have severe asthma", and many of the things he describes about the health record system sound like inexcusable incompetence as well.
Incompetence can ruin anything.
Re:Wouldn't it be better... (Score:3, Informative)
Oh and anecdotal as this may be, not only have I been a patient that has recieved xrays and an MRI by these fancy integrated systems, I also work at a hospital where my job is to make sure all of those things CAN send/recieve data to all the places they need to go.
Now, not that I disagree that the state of medical information technology doesn't have a long way to go, but medical folks actually are trained to repeatedly ask the same questions even if they know the answers. It is very common for patients (especially the elderly) to suddenly remember that medication they have been taking after you asked them the 5th time.
Re:Are you kidding? (Score:4, Informative)
It's pretty well-written. I suspect a professional writer may have had a hand in writing this.
Not to mention the telltale "I'm a $PERSON supporter, but this is why $PERSON sucks" disclaimer, beloved of underhanded $PERSON-bashers all over. This smells so much like propaganda, as is getting the political slant in while the reader is still interested in the story. Just on internal evidence, I'd call it a right-wing hack job.
It also reminds me of some experiences a friend of mine had, back when hospitals were run on paper. The writer could well have had the exact same problems in a hospital without electronic records.
Re:"The Stick" is typical in business (Score:3, Informative)
A lot of doctors ARE opting out of Medicare/Medicaid, and a fair amount are leaving the practice altogether [physicians...ations.org] due to too much overhead and too little doctoring. I've heard plenty of anecdotes here about cash-paying patients being given discounts because the lack of HMO overhead is enough to make them profitable to the practice at a reduced cost.
With all this in mind, the national health care push that's building up looks a lot less attractive.
Re:Digital Med Recs vs. A Real Solution (Score:2, Informative)
It's a shame that a citizen can not disagree with their government's policy without being labeled a racist, a terrorist or "unAmerican".
I pointed out flaws in the U.S. health care system and suggested areas to be focused on that might have a greater impact on patient care than a nice catch phrase like EMR.
My own political views were not expressed in my post for a reason. I actually find it humorous that you would question my affiliations and/or optimism.
Re:Impossible!!! (Score:2, Informative)
"The language is truly unlike anything most modern programmers are accustomed to." So the solution is to throw out 30 years of hard work because nobody cares to learn it? Where is the "modern" replacement? It doesn't exist because of the monumental effort required to create an EMR. I fail to see how getting new programmers accustomed to the technology is a problem when ISC provides Cache Object Script. Write your code with COS and you never have to use dot syntax again. Curly braces all the way.