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!
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.
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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: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: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.
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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
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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.
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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 insurer
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Moving from an old 'in-use' system..to a better one, with a functional data model, and interface. Having to be backwards compatible and all with old systems, (not only data conversion, but, requirements that you also feed other legacy systems) is what makes much of this so tough.
I dunno. Maybe design new medical centers to use a better designed system. And then, over the years, one institute at a time, start moving over their data into it, so they could eventually ado
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 :)
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stretchability, lol - meant search-ability. Firefox spell check for the win...
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!
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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".
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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.
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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 guess
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.
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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, betwee
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Sorry, didn't mean to imply that the software can't do this - it quite obviously can, and smarter people than me work in the industry...
The problem is that doctors are loathe to accept this kind of stuff, and hospitals tend to be a big monoculture with doctors straight up through the administration. Doctors are great, mind you, but monoculture is bad... take the congress we have which is full of lawyers, for instance. Lawyer jokes aside, it would be nice to have different perspectives.
Ohh, secrete those enzymes! (Score:5, Funny)
Digital Medical Records Are No Panacea... but they are pancreas!
Interesting... (Score:3, Insightful)
But it's anecdotal evidence, as much as it may affect the author, doesn't necessarily prove the point.
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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.
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?
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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.
They're not rich enough to pay for the same Get out of Jail Cards.
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Most of the breaches are not "major credit card companies". They're retailers who didn't take security seriously.
The major credit card companies have, on the other hand, been very serious about card security, and in fact created an industry organization [pcisecuritystandards.org] specifically to create security standards that are required for doing business with them. Failure to meet those standards opens retailers up to getting sued into the ground.
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.
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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.
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With digital records anyone with an internet connections can concieveable gain access to the files from anywhere o
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Electronic need not mean remotely-accessible.
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Sure, of course that's the situation, and that's probably unlikely to change.
But, which is more secure? Physical patient files on desks, at the foot of beds, hanging on doors, rooms full of them...or electronic files that have at least the potential to require appropriate credentials to be accessed? Yes, both can be broken or abused, but one has the potential to be more secure.
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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 insta
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Oh, my god! You are right, medical records should be carved in slate stones and carried by mules. That's the only way to be secure.
Isn't all this FUD just an organised campaign from the ones who have something to lose if the USA institute universal socialised health care? Because having a normalised electronic health record format may just be the first step...
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I've been in the field for many years in various areas (health care, clinical drug trials, pharmaceuticals, etc) and have done several research studies on it for one of my graduate degrees.
In theory it is great access to your medical records, better patient/doctor conversations, abilit
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There was a recent article about medical records being available on torrents from people installing P2P software on computers in doctor offices, not realizing that they were sharing documents on said computers.
I absolutely agree with your point that if credit card companies can't keep your data private, how do they expect medical records will stay private.
HIPAA (Score:3, Informative)
How it breaks down is this:
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.
US? (Score:2)
Or is it also true for other developing nations?
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"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.
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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
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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.
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Wouldn't it be better... (Score:4, Insightful)
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Not necessarily. Some patients die for lack of diagnostic equipment. Others die due to lack of historical information.
I don't have the figures, but it's possible that spending x dollars on always accessible medical records will save more lives than saving the same amount on diagnostic equipment.
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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 w
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On the other hand, Pieces of paper would be destroyed in the destruction of a hospital building. Electronic records could allow for decentralized backups. Also, if a patient is not in his hometown for a disaster, electronic record transfer would allow for doctors to get important information about an incapacitated patient. Ther
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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
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.
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!
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.
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Having worked with neuroimaging software before, very few of them offer to save to a "normal" graphics format (doing so is not generally useful because there's a lot of information loss and no valid purpose for medicine or research).
On the research side of things, we're generally cautioned by lawyers not to give people these files because we may have some liability if people look at their brain, freak out about something, and do something stupid. Many researchers will anyhow because that's ridiculous.
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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
Real Need (Score:2)
The real need is not multiple, most likely incompatible, electronics records systems. What is needed is a standard for securely storing medical records while allowing for transfer of this information to authorized parties who need it for medical purposes.
With the money, $$$, being thrown around, you know several big companies are already working on making these systems. And I am sure their accountants are already counting the monthly support contracts and other associated profits from these mega systems.
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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.
Healthcare IT is horrible. (Score:2, Informative)
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.
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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.
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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.
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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 re
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: (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.
Re: (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
Very good article (Score:2)
Comment removed (Score:4, Insightful)
Re: (Score:2)
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)
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 ins
Re: (Score:2)
There are not enough doctors, not enough competition.
So, what exactly are they to compete on? My wife's a doctor, and she can't fit any more patients into a day without sacrificing quality of care. She can't compete on price because Medica{re,id} and insurance companies effectively set her prices. All she can do is try to keep her patients happy so that they come back when they need to see someone, and she's apparently doing that pretty well (judging by her appointment schedule). If you doubled the number of practitioners in her specialty in our city, the
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:HIPAA (Score:4, Insightful)
Re: (Score:2)
Mod the parent's parent up. HIPAA goes way over the top, or rather HIPAA implimentations are over the top as this law has health care people scared shitless.
It's not about trusted systems, it's that everyone is scared to share information when what needs to happen is more sharing. It's that the data get's compartmentalized when the physicians need as much information as they can get. Even with the records being electronic the left hand doesn't know what the right hand is doing.
Currently there are secure sys
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.
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: (Score:2)
I'm sure I can find a similar example where non-computerized health records lead to bad care
I've seen reports that tens of thousands of people are seriously injured or die because the pharmacist can't read the physician's hand written prescription.
I recently took my daughter to the doctor for pink eye. After he had diagnosed it, he used his laptop to send the script to the Target pharmacy without any paper in between. At Target, they know how old my daughter is, and the computer can double check that the dosage is appropriate.
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...)
Probes limit of representational technology (Score:2)
The problem with medical records is, essentially, that our present ways of representing data lack sufficient abstraction to let us manage all of the complexity.
I've worked on systems that track what goes into just -buildings- for insurance and those have enormous interoperability problems compounded by terrible standards. Just imagine what a field like "building type" could mean across vendors. I can't even imagine what a medical records system might look like, and, it probably doesn't help that the taxon
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: (Score:2)
How (Score:2)
I suppose electronic records are inevitable.
I wonder how it will be done do capture useful info. ... its not very useful. But a list of every drug you have ever taken with dates and times could be useful. For detecting side effects.
If its just a PDF of a doctor's hardcopy scribbling
Re: (Score:2)
Every time I have a prescription filled that I have never had before, I always ask for a consultation with the pharmacist to go over possible side-effects, warnings and possible negative reactions with other meds I am currently taking (trust but verify). The pharmacist eventually explains that they go over that information in the computer when they are filling the prescription. So as long as I stay with the same pharmacy in the same retail chain (like Wal-Mart pharmacies) my drug history records should be
Not Microsoft (Score:2)
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!
Re: (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]
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.
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.
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 the
VistA (Score:2)
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?
Yea, right. The Veterans Health Administration has a computerized record system called VistA [wikipedia.org] that is quite successful. The U.S. Department of Veterans Affairs (VA), the largest integrated health care network in the country and has been using VistA successfully for at least 10 years.
The software, being developed by the United States Government, is in both the public domain and open source versions.
I read part of the Newsweek article I and I don't have a clue what they where talking about, except wast
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.
JAVA Improving Healthcare in Brazil (Score:2, Informative)
The Author Sounds Like A Partisan Hack (Score:2)
The author loses a lot of credibility by starting off the article with snarky remarks about President Obama. ("The law makes a job for yet another bureaucrat to oversee the vast program - is this change we can believe in?") He initially attacks the creation of a standards-creating body for electronic health records ("It defines rules for health information standards by designating a new standards board - everyone desires more data standards and standards groups"), but concludes that we need to create a unif
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.
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.
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".