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."
Security? (Score:5, Interesting)
Now what makes you think hospitals, private doctors, etc. are going to be able to protect their data any better? They have less money then the credit card companies.
Can you imagine a million patient digital medical record breach? The black mail or power that could be leveraged over people?
Can't get a copy of X-Rays? (Score:5, Interesting)
When my wife was in the hospital with a broken ankle I tried to get a copy of the X-ray, because it was on a big monitor out of view of the patient. The user interface of the DICOM viewer did not provide a way to print or save the image... presumably to protect patient confidentiality.
The next day I went in to the hospital to pick up the "films" for her doctor, and they gave me a copy of the same files on a CD, completely uncontrolled, and I used OsiriX to convert them from DICOM to JPEG so my wife could see them.
Having the files in digital format is great, but let's have some appropriate level of controls. If the patient wants the images on a flash stick, it's THEIR records, let them have it!
HIPAA (Score:4, Interesting)
the article did point out a lot of problems, but HIPAA is the culprit. It was passed in 1996 and took effect a few years ago. it says medical info has to be controlled so that only the people who need to know, get to know about your condition.
Any electronic data model has to be built around this. and medial people are as scared of HIPAA as other people are scared of SOX and everyone goes overboard
Re:"The Stick" is typical in business (Score:3, Interesting)
Yes but, remember when you have a payor like the omnipresent federal government, they already use that 'stick' almost daily. Case in point, Medicare just waved a magic wand again with a doctor-friend of ours and instead being reimbursed 80% of the Medicare allowable and they lowered it to 62.5% with no explanation.
So, he gets to treat his patients but get less money for the same labor. I do know this: A lot of doctors will opt-out of Medicare/Medicaid patients altogether very soon. They know there will be a market for CASH patients who neither want their demographics or medical records stored remotely.
They seem to like to penalize doctors under the current system, it'll only get worse.
Re:Security? (Score:3, Interesting)
Put on some scrubs, don a white lab coat, and walk around with a clip board and see how long it takes for someone to notice you at a big hospital. Answer: they won't. In this instance you have physical access to both the hard and soft copies. No, the threat here isn't haxors when the physical security is not up to snuff.
HIPAA Request (Score:3, Interesting)
To prevent this problem, you might try contacting your regular health-care provider right away. Assuming they fall under HIPAA, you usually have the right to make requests to the provider regarding how they will handle your medical records, and who can access them. Make a request that your records not be stored in a shared electronic database.
The provider can refuse the request, but few do.
(Of course, 15 years from now, when your new doctor at General Hospital does not realize that you're the ONLY patient who still has paper records in that filing cabinet at the back of the server room, there could be a problem...)
Re:Are you kidding? (Score:3, Interesting)
Doctors who wont use Electronic records (Score:3, Interesting)
This guys rant about the medical system is more just a problem with over-worked health care professionals, and physicians who are used to doing it their own way, and has very little to do with the electronic records system in use.
One we have physicians in place that have used computers their entire lives, and are comfortable with their electronic systems then we will start to see the benefits provided by automation.
There are already organizations that are planning complete open-spec systems, it's just a matter of ensuring that the proprietary systems comply with the specifications (hl7.org)
It can be done wrong, it can also be done right. (Score:5, Interesting)
Like all software, digital medical records can be done badly. But they can also be done right. Joe Bugajski's story is gripping, but I want to compare it with the story of my mother.
My mom was in her mid-50s when she became ill, apparently healthy but in fact hiding a serious alcoholism problem. I'll skip the details, but suffice to say that a lifetime of drinking can destroy your body's natural blood-clotting system, leading to internal bleeding. So don't drink, kiddies.
Anyway, once she was medevaced to Queen's Hospital in Honolulu, we never saw a single obvious piece of paper. Everything was recorded digitally. But the key difference between my Mom's story and Joe Bugajski's is that the data was *available* once entered. I got a chance to look over the doctor's shoulder as he reviewed her chart. He was able to look at blood tests, x-rays, up-to-the-minute vitals, every piece of data the hospital recorded, at his fingertips in seconds. And he drove the software like a pro.
In the end, my mother died, but it definitely wasn't because of bad recordkeeping software.
The current paper-based system is an outrage (Score:2, Interesting)
Here's how an admission would go in the middle of a typical call night: I'd get called at, say, midnight to admit a patient from the ER. I'd go down there to examine the patient and admit them, which means find out what's wrong, formulate a plan of action, and stabilize them for the night.
We actually did have a primitive EMR, which held any recently (within a year or so) dictated discharge summaries -- those are a lengthy summary of what brought the patient in last time, how it was handled, what meds the patient was sent home with. Those were available to us about 1/4 of the time, and were a goldmine of information.
The remaining 3/4 of the time, we had nothing except the patient's memory (they're ill, it's the middle of the night, majority of patients don't keep track of their long lists of meds and dosages). So I'd request the patient's chart to be found. Usually, I'd hear the following from medical records:
A) The chart will be here in the morning: they're understaffed right now (they'd have 1 clerk in there at night)
B) The chart is off to some doctor's clinic from a recent visit, and hasn't come back yet. It'll be a couple of days
C) We have no idea where the chart is.
So I'd have to rely on the patient's recollection of what meds they are taking, what their medical history is, what their allergies are, etc, etc. If you've ever had to go to the ER in the middle of the night, you know how hard it is to remember that stuff about yourself, and how annoying it is to be asked the same questions by the clueless medical staff over and over again.
When I saw patients in my own clinic, it was just as bad. The records were often gone -- to the hospital for a recent admission and still being processed, to another doc or clinic, etc.
I bought a Vaio subnotebook and as an intern kept my own notes on my patients, and carried the notebook with me everywhere. I was ridiculed a lot, but I always had critical info about my patients at my fingertips.
Then I went to another hospital system for residency, and spent some time at the VA, which had an early EMR called VISTA. It was just fantastic! It had usability problems, and required a lot of typing, but it was amazing to see a patient's current medications, list of major problems, past history, etc, all instantly, integrated over hospital and clinic visits, and even across different VA systems across the country if the patient recently moved. It revolutionized care, in my opinion.
So no, it's not a panacea, but a damn sight better than what we have now in many instances!
Re:Impossible!!! (Score:3, Interesting)
Re:Impossible!!! (Score:3, Interesting)
I agree, the VA's system works very well. You can get lab work done in one clinic and every doctor you'll meet from that day forward (no matter where they are) will have access to it. Including X-Rays and all the fun stuff.
OT: I had to get shots in a clinic that still used paper records once... i left that place poked full of holes : / Tetanus booster, HIV, and god knows what else
The only shots i've ever escaped is flu (dodge it everytime!) and the dreaded Anthrax. Worst shot ever is smallpox though, it's like babysitting an open sore : /
Some big issues with EMR... (Score:4, Interesting)
I agree that medical records should be electronic for the most part. However, there are some big challenges that our current IT business model can't solve:
1. How do you prevent Oracle, IBM, SAP or some other large vendor from getting a permanent lock on the market for EMRs? If this happens, a closed standard will develop and mo one will ever be able to make changes without paying mullions of dollars.
2. Opposite problem -- if there is no standard, or it's so loose that it might as well not exist, what's to prevent a million small companies from developing EMR, EMR 2.0, OpenEMR, StarEMR, YetAnotherCoolEMR 3.2.10.23alpha8, and so on? How do you get providers using different standards to share? (The answer, I think, is open protocols, but that way lies 800 MB XML files and crappy J2EE applications written by developers who don't understand optimization.)
3. Privacy. In the US, healthcare and insurance are for-profit businesses. How much do you think a life insurance company would love it if they were able to see your entire birth-to-present health history? Insurance would be even less affordable than it is now. In countries where everyone's on the hook for medical costs, privacy is much less of an issue. But when it can cost you the ability to get treatment that doesn't bankrupt you, it's a big problem!
4. The huge "obfuscated mess" problem -- Go look at the system the Veterans' Administration uses for EMRs. It was written years and years ago in a language called M, and the source code (publically available) looks like line noise. It works fine from the front-end, but I can imagine it's a disaster to administer, make improvements, etc. How do you prevent a system from getting so stale that no one knows how to modify it anymore?
From what I've read, EMRs work well for the VA, precisely because they have to keep costs lower than for-profit hospital systems. Their patients are also ex-military. When you join the military, you give up the right to privacy.
Re:Impossible!!! (Score:5, Interesting)
Good points.
Any system can only be as good as the people that use it. 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. Not saying whether it is actually a good electronic system or not, impossible to tell...but enough people had enough direct access to critical information, without even thinking about the electronic system, that this guy should not have had the problems he had.
Is it really the data model's fault that not only did no one use information provided on entry to the er, they didn't even READ it? Sounds to me like the real problem is that new systems were put in place without new processes or training being put in place...and then on top of that the users of the system failed to even fall back on the logical concept of direct communication!
I do not for one second believe that this situation wouldn't (Or for that matter hasn't) have happened even with the use of standard physical medical charts instead of the electronic record system in place. There is really nothing at all in the story that makes the problem specific to the system or the model being used in that system. Can't believe that had a physical medical chart been used that the same mistakes the medical staff made in this case would have somehow miraculously NOT been made on paper as well.
Basically, what I take as most important from this guy's story, is that that is NOT a medical facility I ever want to step foot into under any circumstances, electronic records or not!
Re:Interesting... (Score:5, Interesting)
I would go even a step further than that and posit that a good portion of his problem was stemming not from the system as much it came from the active resistance of the people attending him in using the system.
I don't directly work in healthcare, but I do work in a corporate environment for a large healthcare company that recently (in the past decade) made the switch from paper to a 'global' electronic system. At the start, stories like this were common, as people fought the system rather than use it.
Yes, not all systems are equal and it's entirely possible to design and implement an completely unusable one. But there is no avenue for improvement when the default behavior to burrs in the system is to revert to a far more inefficient (and porous) paper method, which, due to the introduction of the electronic system, is not even being monitored as well as it was when it was the only method.
In the end, the improvements that were introduced and enabled by converting to an electronic system far out weighed any of the temporary and transient issues such as this.
Re:Unfortunately for us... (Score:3, Interesting)
I've looked through the VA's code for VISTA. What unreadable garbage. MUMPS has supported functions and variables with names longer than a few characters for years now. The spaghetti-code logic is terrible. It's pretty apparent that the software was developed by multiple contract agencies over several decades when, quite literally, the left hand didn't know what the right was doing.
Some of that I won't dispute (the spaghetti code - I still have dreams^Wnightmares about a 'three slash stuff'). At the time, the issue was there were still VMS systems from the '70s that were still in use and had limited features.
That being said, the coding standards that were used were first-rate. I learned a lot about proper coding and code review at the time. I'm not a coder by trade anymore, but I almost never see code to those standards anymore.
There was a facility for getting payments from insurers (it was a revenue source for them at one time). It's been 15 years since I did any work on it, so a lot of my memory on it is a bit fuzzy now. Then again, perhaps some of my code still lives on.
Re:Impossible!!! (Score:3, Interesting)
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.
Companies can interoperate when they have to.
Take (just by pure example) computer networking.
Re:Are you kidding? (Score:3, Interesting)
Words, words, words. Did you know that civil war-era bureaucrats argued vehemently against the introduction of repeating rifles? I bet they used language just as histrionic as the article. "If we start using repeating rifles, Johnny could be so busy shooting Billy, he doesn't hear a critical order, and is killed! Do you want to be the one explaining that to his family?" "The armories will be in a panic, and critical supplies will not be delivered! Is that worth the lives of those boys?" etc.
People always resist change when they can't imagine or understand anything better. Their imaginations are too limited to see how things would be better, and they wail and sob over every potential or realized fault. Therefore, these narrow people lack a big-picture view of the situation.
Here's an anecdote for you: I would've rather swiped a card that had my info on it and been admitted to the hospital rather than have to explain to an incompetent nurse that I couldn't fill out her forms because I had second degree burns on my right arm from the knuckles to the elbow.
EHR (Score:0, Interesting)
I work at a large clinic in Illinois. We use Allscripts for our EHR management, which includes everything from prescriptions, med history, dictation of doctor's notes, every single scanned sheet of medical information that exists about the patient (including from outside sources), task list for nurses and receptionists, you name it. It doesn't always work exactly like you want it to (that's what our systems analyst are for), but it works pretty damn well, and I for one would prefer a doctor or nurse to look me up this way, rather than wait for my doctor from ten years ago to fax or snail over my history. That scares me a lot more.
Re:Impossible!!! (Score:3, Interesting)
Having worked on a project where we considered using VISTA...the interface is truly god awful and coding MUMPS over CACHE doesn't offer a terribly attractive platform over which to attempt writing a user interface any actual practitioner is going to want to touch.
It's a thorough system, but it's just horribly unmanageable by anyone who isn't already deeply entrenched -- and getting end users to buy into an interface that barely passes as 1980's technology just isn't going to happen.
Re:Wouldn't it be better... (Score:3, Interesting)
I'd worry more about a doctor 5 years ago noting in the file "Hypochondriac. Prescribe placebo to make him happy."
In my case, I wouldn't be terribly surprised if a doctor noted "Complains about pain, probably just wants drugs. Prescribed to keep him happy." I can give them my full history verbally, because I lived it.
I was in a car accident several years ago. I had to be convinced by friends to go to the hospital. I had a concussion and was delirious, so I was refusing to go. If I had been all together, I would have known I needed to go. The hospital didn't see an immediate need for treatment, other than pain killers, muscle relaxers, and bed rest. They also told me what doctor specialist to go to first thing in the morning. As I recall (which was fuzzy because of the concussion), they were very stern about needing to go FIRST thing in the morning. The had arranged a 9am appointment for me.
6 months of therapy 3 times a week later, my insurance wouldn't cover it any more. During that period, I had X-rays, an MRI, more test and treatments than I can count. I was advised that I had muscles that were badly torn, and two bulging disks that may need surgery in the near future. I was doing ok after the therapy. Not great, but I was walking and talking, and showing up to work. After hard physical work, I was usually in pain. Years later, after moving several times, I found it necessary to go to a doctor about it. They asked for the old doctor's info. I didn't remember his phone number, nor street address. Most of my files had been trimmed down over various moves, and I couldn't find any paperwork about the doctor. I did remember his name, the main street he was on, and approximate cross street. They couldn't find anything about him. They treated me anyways, based on my complaint, and verbal account of my related history. After a while, things were good again, and I went about my business.
A few years (and a couple moves) later, I was in a lot of pain again. I woke up one morning, and couldn't roll over. I couldn't lift my head. Any movements caused tremendous pain. My wife had already gotten up, and there was no one to find me stuck in bed. Over the course of the next hour, I managed to move enough to get to my cell phone on the bedside table. I called my wife. I called into work 1/2 hour late. We took a drive to the new doctor in this town. I rode in the passenger seat, literally holding my head up in my hands, trying not to move anything from my mid back up, because it all hurt badly. All I could give the doctor was my verbal account. he asked for the doctor history, so I told him about the 1st doctor after the accident. I was back in the same area, but this doctor had never heard of him. I told him about the second doctor, who did share my patient record.
My new doctor (still my current doctor) is a really nice guy. He did warn me that because of how long it had been, my X-rays and MRI were probably already destroyed due to document retention policies. There may be paper files, but for a doctor who's not practicing any more, it could be virtually impossible to get those records, assuming I could find him. What if he retired, and moved out of the country? So until I can get more testing done (which my insurance minimally covers), there's no real documentation out there other than "the patient complains of.... and has specifically requested ...."
So, if this were put into a centralized database now, it's very likely I will look like a drug shopper. Well, not a very determined one. Two doctors in several years, and prescriptions intermittently requested and filled (i.e., on an as-needed basis).. What if one or both of these doctors noted me as a possible drug shopper? A central database will stop me from getting the treatment I need. Then again, if it had existed years ago, all of my records would exist, and there would be no
Re:Impossible!!! (Score:3, Interesting)
Even though his history probably makes asthma much more likely than pneumonia, if they treated him for asthma without ruling out pneumonia, and he ended up dying, they would be liable for his death.
Maybe that hints at a viable approach. What we need is a well-publicized case like this in which the patient dies. The inquest turns up the fact that the correct diagnosis and prescriptions were all in the medical database, but the doctors and nurses ignored that and treated the patient for what they were guessing was the problem. The family sues, gets a multi-million-dollar settlement. The media gets wind of the story and tells everyone about it. The hospitals (and insurance companies) start triple-checking to make sure that every doctor and nurse has read every patient's database info. This probably saves a lot of time that has been wasted in repeated collection of the data from the patient.
Of course, making that info actually accessible and comprehensible to medical people (as opposed to the IT people who did the database and software design) will take a bit longer.
I've worked on a few medical data projects, and one thing that has struck me was the great lengths taken to make sure that I had no contact whatsoever with actual doctors or nurses. Any software developer knows what the results will be if they are denied communication with the users. You get software that makes perfect sense to a software developer, but is incomprehensible to anyone else. It typically takes several rounds of "beta" testing to overcome this problem, and to rebuild the user-interface stuff so that the real users can actually use it.
But so far, medical people's time is too valuable to waste playing with beta software ...
Re:A good EMR is more than medical records (Score:3, Interesting)
What I want is this:
----snip----
Doctor: Hello, I'm Dr. Foo. According to your chart, you are here because of a sore back.
Me: Yup.
Doctor: You already answered the computerized questionnaire that asked a lot about your symptoms. Why don't you tell me in your own words what feels abnormal?
Me: Well, when I bend down like this it hurts real bad right here. It's a shooting kind of pain. It's worse at night and during cold weather. It's only been happening the last couple weeks.
Doctor: Hmm. Well, between that and your other answers, it looks like three different things might be going on. Let's schedule some lab work to find out. Your insurance will cover an MRI, that's good. The clinic has slots available next Tuesday, can you make it then?
Me: Well, actually Wednesday would be better.
Doctor: How about Wednesday 3 pm?
Me: That works.
Doctor: OK, you're set. In the meantime we should probably get you hooked up with a muscle relaxant and some painkillers. Your insurance covers two relaxants and three painkillers. Do you prefer generics or name brands?
Me: Generics are good.
Doctor: Great. Would you like to pick these up at your pharmacy on file, that would be CVS on 123 Mobile Avenue?
Me: That works.
Doctor: OK. They will be ready after 2 pm today. Let's see, your insurance has already responded to my requests, your MRI and medications are already approved. They expect $30 in co-pays, would you like to pay at our front desk or have them bill you at home?
Me: I'd rather they billed me at home.
Doctor: No problem, that's all set. Would you like to meet with me Friday afternoon to discuss the results?
Me: Sure, is 4 pm available?
Doctor: It sure is. You're in. So: pick up your medications this afternoon, have the MRI on Wednesday 3 pm, and we'll meet back here Friday 4 pm to discuss the results. The receptionist already has instructions for the MRI and a map waiting for you at our front desk. Is there anything else I can help you with while you're here?
Me: That's it.
Doctor: Alright, I'll see you on Friday. Have a good day!
----snip----
A good IT system could take the insurance and pharmaceutical companies almost entirely out of the loop. Let the doctors see ahead of time what the insurance company will pay for and decide based on that how to treat.
Re:There is a logical approach (Score:2, Interesting)
"But really with all the crap, legacy systems held together presently by silly string...you really almost need to start OVER."
Many hospitals are starting over. They're scraping their old, cobbled together systems (seperate Lab, Physician Practice, HIS vendors) and going with a single vendor. Epic, Cerner and the like have seen a lot of interest in going with single vendor installs.