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."
Impossible!!! (Score:4, Insightful)
Everyone knows that everything should be computerized, since everyone knows that big, REALLY COMPLICATED data systems always work and always come in under budget.
Like the redesigned FBI data system that works so perfectly!
Interesting... (Score:3, Insightful)
But it's anecdotal evidence, as much as it may affect the author, doesn't necessarily prove the point.
Re:Impossible!!! (Score:4, Insightful)
I'd say that if you want an electronic records infrastructure that works well, check out what the Dept of Veterans Affairs has been doing. Most of their records have been 'online' (at least in a computer) for well over 20 years.
And in case you're worried about the security of the code, almost all of it is available via FOIA and is available online.
ObDisc: I used to work for the VA in the early '90s and worked on their FOIA code release.
"The Stick" is typical in business (Score:3, Insightful)
There's also a stick: The feds will cut Medicare reimbursement for hospitals and practices that don't go electronic by 2015.
I know that might seem like a really bad thing at first, but consider this. Wal-Mart, Supermarkets, and any retailer with shelf space to "sell" to companies trying to get their product sold to the end user have major pull. Most all of these stores require some form of electronic invoicing. Many will require you to pay fees if you do not, and some will simply not carry your product.
That isn't much different from Medicare. If you want to accept patients with medicare, and get paid for the service you provide, you need to use *insert desired service here*. The government is the one with the pull (they have the cash), and so they can require you to do this. All I am saying is this might not be a case of the Big Brother, but just simple market forces.
Wouldn't it be better... (Score:4, Insightful)
Re:Can't get a copy of X-Rays? (Score:4, Insightful)
I'm failing to see the problem here. This sounds no different than photocopying a set of printouts. The HIPPA laws only cover leaking records to people who aren't authorized to see them. Since it's your wife's records, you don't fall in that category and should be allowed to see them.
Are you kidding? (Score:5, Insightful)
The author was repeated asked for his medical information, his doctor's written instructions were ignored and different departments within the hospital did not communicate. Therefore the problem is Obama's computerized data record system that doesn't exist yet.
The whole time I was reading it I was waiting for the author to tie his experience to how computerized medical records are bad. He never did, his experiences were caused by humans that did not care enough about patients to read computerized records OR paper records.
The author fails to explain how his experience proves anything other than that particular hospital is terrible and that the health professionals employed there are less than friendly.
Comment removed (Score:4, Insightful)
The plural of anecdote is not data ... (Score:5, Insightful)
... and here we have just a single anecdote about how the system did not work in one instance. If we are playing the anecdote game, I'm sure I can find a similar example where non-computerized health records lead to bad care. Of course, while the anecdote game is very effective at playing at human emotional response (we tend to assign more weight to a story that we can associate with a single person versus aggregate statistics), it's useless as an actual policy question.
Since every complicated system has failures, even the critical ones like hospitals and air traffic control, the important policy question is not whether it works in all instances, it's whether it produces overall better care than the system it's replacing and whether that improvement is worth the difference in price. If the new system actually reduces costs, then it's a good idea so long as it doesn't degrade care (since, ultimately, reduced cost means either more health care or more dollars to satisfy other wants).
I'm not going to comment on the data myself, since you should read the studies for yourself and draw your own conclusions.
http://journals.cambridge.org/action/displayAbstract;jsessionid=7C274D08947B0625B3B540BEF2E70367.tomcat1?fromPage=online&aid=416400 [cambridge.org]
http://content.nejm.org/cgi/content/abstract/348/22/2218 [nejm.org]
(PDF)
http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1421388 [nih.gov]
PS. Of course there's no panacea for our medical problem. The question is whether EHR are better than the system we've got, not whether they represent the best possible system. The perfect is not the enemy of the good.
PPS. I have a sneaking suspicion, reading my post (yeah, some /.ers actually read their own posts before hitting submit :-P) that I will be accused of not having the proper sympathy for the guy in TFA. That's not true. I have sympathy for him as an individual, but I'm not going to let that sympathy for him cloud my judgment on the merits of a system.
For example, suppose there was a highway by you that had no center divider, just a grassy median. Suppose also, for the sake of argument, that installing a jersey barrier (http://en.wikipedia.org/wiki/Jersey_barrier [wikipedia.org] will lower the injury/fatality rate in accidents by a statistically significant amount by preventing out-of-control cars from going into oncoming traffic. Now, hypothetically, someone could be in an accident where the jersey barrier caused him serious injury or death (say, by flipping his car even though they are designed to minimize that chance) where the old system would have been just fine (say, because there was no oncoming traffic at the time of the accident). Does someone that still says we have jersey barriers not have sympathy for that guy? No. His death is regrettable but because we can't make a perfect road, we have to settle for the best road we can make.
The problem is that you can point to someone that's injured (and provoke an emotional response related to his regrettable accident) but the only thing the jersey barrier proponent can do is point to the statistics that say there are fewer serious injuries since they've been installed. There's no emotional resonance to the thousands of people that travel without incident each day because they don't make a good story. "Man drives to work safely" isn't news, but because it happens much more often that "Man killed in car wreck", it's actually much more important in the grand scheme of things.
We aren't privy to all the stories where EHR made things smoother, cheaper or helped prevent calamity. Largely, these will be small victories, unsung
Re:HIPAA (Score:4, Insightful)
Re:Impossible!!! (Score:3, Insightful)
Re:HIPAA (Score:5, Insightful)
I RTFA, and there is a very telling reader comment at the end...
The moral of the story, then, is that no amount of even well-organized information can compensate for a break in the continuity of care. The allergist tossed this guy to the wolves with a post-it note stuck to his forehead. The current system couldn't cope with that, and it's hard to imagine any system that could, because the hospital et. al. can't morally or legally just follow the instructions on the post-it note; they have to start from scratch.
The allergist had to know this, but dropped the ball anyway. Find a new allergist.
Re:Impossible!!! (Score:5, Insightful)
My wife works at a hospital with digital records, and it seems to work fairly well - no worse than paper charts anyway.
The major issue that I have is that they use it only to a fraction of its potential. They use it just like they did charts, with no real capability increase other than stretchability and speed.
For instance, they could use it to prevent some medical mistakes by requiring an override if a physician changes an order. Right now one doctor (or even a nurse) can simply walk over and change the order given by another doctor. At the very least, another doctor who is on call should okay the change so there are at least two eyes on it.
Another example is medications. A groggy doctor woken up at 4AM can and will make mistakes, sometimes as severe as mixing mg and micrograms. You can bet that a dosage 1000 times higher than indicated will not be good for a patient, and currently they rely on the pharmacist to catch these errors. The computer could be programmed to require an override by a second doctor before allowing such orders.
Also, due to lawsuits, everything at the hospital is a CYA system, and patient care suffers. Computers could be used to help this situation, too - but I'm getting carried away now :)
Re:Real Need (Score:3, Insightful)
Just from the number of organizations involved, it reads like "We like standards so much we're collecting all of them!".
A single standard would permit patients to move from hospital to hospital easier than it is currently. Multiple tests for the same condition wouldn't be required.
Which is why it seems the health care industry is against it.
Patients which leave don't provide more funding. Redundant tests can be a way to increase billing as well, so eliminating those cuts down on hospital income.
Re:Are you kidding? (Score:4, Insightful)
Don't blame the computer for human incompetence. The computer system is symptomatic of a broken communication system in the hospital, not causal.
People have the ability to speak and think, none of the health professionals in the article did that. Blaming the computer is not acceptable for their failure as professionals.
Re:Security? (Score:3, Insightful)
Or once we go digital the odds are all your medical records will be in one stored spot. Get that I have all your info. Right now if you want all my medical info you would have to go to various hospitals/providers/etc. Not as easy and a lot more riskier (i.e. having to break into physical buildings).
Digital records will do a lot good however in this case security (from systems to users not installing crap, etc) have to REALLY be addressed this time around.
And like all things I believe it won;t and simply be dismissed as paranoia
Market forces (Score:2, Insightful)
Although having more doctors would help, the problem is insurance. Because it's a tax-free benefit, we press our employers to provide the best possible health insurance. When we need health care, we have no incentive whatsoever to shop for price. It's an all-you-can-eat buffet and we have season tickets.
The insurers have the system rigged so that uninsured people get screwed. They negotiate price very effectively, to the extent that non-insured people are expected to subsidize the discounts that the insurers demand in exchange for a steady flow of patients that keep utilization rates high. The government plays the same game with Medicare and Medicaid.
Example: 10 years ago, I had inpatient surgery that resulted in an overnight stay in the hospital. The bill was $5800, of which insurance covered all except the initial doctor's visit co-pay of $10. But the hospital accepted $1500 from the insurance company as payment in full. If I could get the same type of pricing, I would be thoroughly tempted to go self-insured.
Market forces are the ONLY way to reduce cost. But we have to be careful to avoid a system as dysfunctional as the airlines.
For starters, health care expenses (except insurance premiums) should be 100% tax-deductible. There are some tax breaks available, but the government tries really hard to make this more difficult than it needs to be. It should be as simple as the mortgage interest deduction. Every dollar that is spent outside the insurance industry is helpful to the system and should be encouraged. Current policy does the opposite.
Next, there should be a universal price policy for health care providers. Let them charge whatever they want, but they should offer the same price to all. Individuals should be able to pay the same price as the insurance company. They might have to require payment upfront to avoid collection hassles, but it would be cheaper than playing the reimbursement game with "managed" care providers.
Insurance should be mandatory, but limited to big-ticket expenses with high deductibles.
Getting prescription prices under control is as easy as opening the door to Canada, India, or wherever. God knows, the pharmaceutical companies are quick to go with offshore outsourcing when it serves THEM. Why should the customers think differently?
Any solution that leaves the insurance and pharmaceutical industries unscathed is not a solution at all.
Digital Med Recs vs. A Real Solution (Score:5, Insightful)
The administration either has an undisclosed agenda or no idea what is really wrong with the health care industry. I work for a large medical institution in their IS department and I spend most of my time moving medical data around. In the short time I've been here, I have run across several roadblocks to providing efficient, safe and effective medical treatment.
The most detrimental entity in all of health care has to be the private health insurance industry. Insurance companies have spent a great deal of time and money developing strategies to MAKE MONEY. They are not in the business of making people well, they are constructed to make profits and protect those profits at all costs. They have nearly perfected the art of delaying or denying treatment for sick people all in the name of the almighty dollar.
The lack of standards is truly astonishing as well. There are dozens of large companies vying for stimulus money to develop electronic medical records. Do you really think they'll be working together to provide a single solution that can be transported all over the country? These companies are also out to make a buck and it better serves their interests to develop the one standard format and be the holders of the golden goose than to work collaboratively on a solution that fits all (or most) needs. See: Blue Ray vs. HD-DVD or VHS vs. Beta-max. I would estimate that 9/10s of the stimulus money directed to these companies will be an utter waste, and the remaining 10th will got to produce fortune for a single organization.
Whenever a format *is* declared the winner, it will likely be so inadequate that it will be routinely altered and hacked to fit the specific needs of each institution. It will be rendered nearly useless. HL7 is great example of this. It's designed as the de facto format for transmitting health care information from one site to another, however, I have yet to see two institutions or vendors do it alike.
Pricing and billing are two other concerns. Both are seemingly completely arbitrary and vary widely from one facility and/or patient to the next. A simple lab procedure, let's say a white blood cell count (literally counting white blood cells), could be done in one location for X while in another location for 6X. The worst part, you have no way of knowing what that charge will be until you are billed. Then, if you have insurance, they get to choose whether to pay all, part or none of the bill based on what loopholes are available to them.
My personal opinion, I represent no one other than myself, is that the single most effective action that any government can do to help solve the health care problems is to do away with privatized health insurance as we Americans know it today and replace it with a system that is much more socially responsible. A standardized digital medical record will be a good thing, but it will likely show very little impact on patient care.
A good EMR is more than medical records (Score:4, Insightful)
Auditing. I help an audit team look at who's pulling up whose records. With paper, this would be nearly impossible, but with electronic records it's quite easy to see that user X is pulling up the medical records of their ex-wife or the visiting famous person. Though this has been hard for some, I think it's made our organization much more respectful of a patient's privacy.
Moves. We moved our hospital recently and I got to write the system that tracked each patient as they went through the various staging areas to their new bed across town. Our EMR made this like tracking packages in FedEx and it worked great.
Widespread Communication. On a more practical note, this is the big one. It used to be very difficult to move charts and images around town or even to other cities. Now people anywhere in the sprawling healthcare system can see the latest on your medical condition.
Reporting. We have a massive data warehouse that lets us see the effect of our various health improvement efforts and gives us the ability to more accurately report quality data (e.g. are we giving asprin to everyone who comes in with chest pain?). Evidence based medicine is big in our organization, and it requires good data to support it.
Fixing Errors Before They Happen. This is the most challenging one, and I think we're still in our infancy. I helped make a lab cross-reference system whose purpose is to make sure nurses know what lab a doctor really ordered. If they ordered something vaguely cryptic, they can key in the lab name and it will give them the different names in different electronic systems, in addition to hand-entered names that some doctors use.
EMRs alone aren't going to improve healthcare greatly, but they open up a lot of other options that most certainly will.
Re:Security? (Score:3, Insightful)
Those are available at every doctor's office, every hospital, etc. If we're going to computerize all medical records, add in physical therapy offices, psychologists, psychiatrists, dentists, etc. The terminals might as well be just as ubiquitous as credit card terminals. My mom works in an administrative position at a different hospital and they've gone so insane territorially that people can't access the things they need to under their own accounts (like radiology techs not being able to log into the system they use to send the records back to doctors), so they leave terminals logged in with global permissions all the time. It completely destroys auditing and allows people that don't even work in the hospital to access anything they want if they get a couple seconds to themselves (and yes, they most certainly do). There's also a stack of blank DVDs and a burner there so the techs can send the images by carrier or give them to the patient to bring back to their doctors as well. Nothing like them supplying the media for you to copy someone else's records to too.
Digital health records are going to be even more open to abuse than credit records. I've seen the ease of access first hand. And, I know there are people here that will disagree with me, but to me, my health records are my most private records, even moreso than my banking records. I don't want just anyone snooping through them. I sure as hell don't want my government in them (and I love the hypocrisy from some factions that say it's a violation of your rights to listen to your international calls to a terrorists, but it's cool if they want to not just be able to look through your medical history, but control it)
I found this interesting (Score:3, Insightful)
"Clearly, the networked monitors with alarms sounding so frequently no one believed they meant anything is a serious design problem"
This isn't just applicable to this system. I can't tell you how many places I've been were network and system alarms were ignored and the answer was "that's one that we don't worry about". It leads to a really bad place. It always ends up that a real problem got missed because "app02 always has an alarm".
Re:Are you kidding? (Score:3, Insightful)
First of all, the article is not a criticism of Obama, but merely claims that this particular initiative will not be successful. The author of the article even claims in a comment that he is generally an Obama supporter. Disagreeing with the author does not make you an "Obama apologist".
Secondly, the author says digital health records have a bad data model and provides "evidence" of this:
Incoherent 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.
Patient information is easily lost inside the electronic records system
Hard copy patient information becomes dissociated with the electronic record
etc.
This is not evidence, these are simply more claims. This is what he assumed happened based on his particular experience. All the things that happened to him could be just as easily explained by bad training, stubborn doctors who refuse to learn the system, or even a problem not even tangentially caused by IT, like a doctor not wanting to believe what a colleague he does not like decided, and saying, "Oh, I'll take your history again anyways".
The story is certainly tragic and scary, but the author seems to assume it is a systems problem because he comes from a systems background. He may be absolutely right, but he says nothing in the article that convinced me.
Re:Can't get a copy of X-Rays? (Score:3, Insightful)
Frankly, just getting a copy of your records is almost impossible it seems. Doctors treat them like they're confidential materials not to be shared with patients, and only grudgingly with other doctors (that they like).
A law should be passed requiring all patients to be given a full copy of every record that is generated on any visit. If the patient wants to throw it out when they leave that is fine, but they should be issued. Patients should not be required to even request them - otherwise you'll end up with situations where the office worker tells them "sure, just sit here for 2-4 hours and we'll get right on that." It should be illegal to collect payment for services (including copayment) before those files are in the patient's hands.
Half of the problems in medicine stem from the fact that we treat patients like they should have no involvement in their own care. Heck, I'm all for making almost all drugs over-the-counter (perhaps prescriptions should be required for insurance coverage, and where there is a compelling public interest such as with antibiotics there should be restrictions on access). If you want to mess up your body more power to you. That guy wouldn't have ended up having to beg for his life if his wife could have just given him an injection of the needed drug on her own legally.
Re:Wouldn't it be better... (Score:5, Insightful)
Better to get rid of the lawyers first.
If the medical journals say that there is a 0.0001% chance of deadly condition Y being present given the patients symptoms, and a $5k MRI test has a 0.001% chance of detecting Y, then the doctor is going to have to order it. Otherwise when the 1-in-1-million patient dies from undiagnosed Y the jury will be handing money to the plaintiff hand over fist.
The expectation of modern juries is that every patient gets tested with every modern technology available, has access to experimental technologies that are just emerging, and has a board of doctors meeting in a conference room with House to discuss every aspect of the patient's care.
Re:Security? (Score:5, Insightful)
This depends greatly on your threat model.
If the attacker is some guy with some cash and contacts and they want a photocopy of one person's medical record, chances are that paper will be easier to defeat. However, there is a substantial risk of getting caught (if the guy you approach who works in the file room doesn't take your bribe). If you do successfully bribe the clerk, however, nobody else will ever know about it (no access controls, audit trails, etc).
On the other hand, electronic records are vulnerable to some hacker in Indonesia who copies the records of 30 million patients from a NYC hospital without anybody even realizing that it had happened. Most likely the attacker didn't target any one patient or hospital in particular - in fact the security at 99% of all the hospitals was probably completely effective at keeping him out. However, since this was a trawl they will extort anybody of interest whose records they do get, and since somebody will mess up electronic security chances are there is someplace they'll manage to break into. A successful theft might even leave a trail - but most likely beyond the jurisdiction of whoever performed the theft. In fact, the theft victims might just get the guys home phone number when he calls to demand money - and they'll be powerless to do anything but pay it.
Paper and electronic both have strengths and weaknesses. The ways they are likely to fail from a security standpoint are very different.
Re:Impossible!!! (Score:3, Insightful)
I can't help but feel while reading 'The Data Model That Nearly Killed Me' that the problems encountered actually had very little to do with the electronic record system at all. It seemed more like an incompetent system was in place as a whole. The data model didn't seem to do anything wrong, it was the people using it, or not using it.
But failure to take into account real-life human behavior is a major design failure all by itself. Yes, people often try to excuse a bad design by invoking "human failure". The response to this should be that if it can't be used correctly by real people, especially those worn out by an 18-hour shift, the failure wasn't in the humans at all. The computer part was very badly designed for the conditions it must operate in.
We have centuries of development in a field called "ergonomics". The computer software field generally isn't aware of this term or the concepts behind it. But there is a lot known about designing systems so that people can use them correctly. Maybe we should require that the designers of medical systems be at least familiar with the concept. Or we could get really radical, and start quietly hinting that medical software designers actually have training in ergonomics.
Yeah, yeah, I know; the big software companies would never go along with it. But it's worth at least considering. We shouldn't excuse the software designers by blaming the medical people for their inability to use the software correctly.
Re:Impossible!!! (Score:5, Insightful)
I was a medic in the USAF during Viet Nam. I had a strong technical background, so I worked on a medical records database project from 1975-77 at the Air Force Rocket Propulsion Lab in the Mojave desert.
We hand coded, on punch cards, for a Control Data host, about 650 records. Took 6 months.
I thought at the time, "there's got to be a better way!"
In the late '80's, I was CEO of a medical software company that created a networked medical transcription application integrated to "ChartChecker", an expert system for ER physicians, that would analyze a patient record and tell the doctor if he had passed or failed the encounter and was therefore at risk of malpractice litigation. We got the chart through the network from the transcriptionist to the analysis engine and had a result in 30-40 SECONDS. With voice-to-text, we actually did near realtime analysis.
Massachusetts approved a statewide 25% malpractice premium reduction for any ER doctor that leased our system. At the time, the minimum annual premium was around $30,000 and our system leased for $5,000. The average ER doctor stood to net $2,500 a year and that doesn't factor in the reduced chance of litigation.
This was 20 years ago. We spent a LOT of time with the VA, BIA, DoD, CHAMPUS, the Navy and Air Force. I saw a WORKING digital dogtag in 1991.
And where have we gone in 2 decades?
Not far. Not far enough by ANY yardstick.
We have sufficient technology; what we need is a national standard medical record that is mandatory for all who deliver medical services in the U.S.
This is a problem that should have been solved 20-30 years ago.
Re:Are you kidding? (Score:3, Insightful)
1. The author identified NO defects with the hospital software. He speculated on defects in the software based on 2nd or 3rd hand information. Speculation in this case is useless. The defects I could clearly see were with the humans in the story.
2. In fact, the computer software could be absolutely perfect and the hospital staff was not trained in how to use it properly. Their ignorance is not the software's fault.
3. If you genuinely think that a hospital is "an environment that doesn't lend itself to patience, thoroughness and careful consideration" you have watched way too much TV and need a reality check. Life is not ER, doctors don't just do stuff without thinking, measure twice cut once is even more applicable to flesh.
You need to wake up and focus on actual problem in this situation. The hospital staff. They have a higher ethical obligation to patients than to blame their failings on an inanimate object.
Re:The Author Sounds Like A Partisan Hack (Score:4, Insightful)
I think what he was snarking at was the fact that HMOs are essentially a privatized form of socialized medicine, and that as the system shifts toward state-run socialized medicine, the problems we already see thanks to HMOs (where billing and CYA and HIPAA rule, while patient care takes a back seat) will magnify. Take my experience and expand it -- that's what Obama's programs will do.
I remember back before HMOs, when it was easy to find a doctor when you needed one, and when one doctor or set of doctors stayed with you for the duration. Now, it's all broken out into billable hours for the insurance companies, and appointments in the distant future even for urgent problems.