IT and Health Care 294
Punk CPA writes "Technology Review has some thoughts about why the health care industry has been so slow to adopt IT, while quick to embrace high technology in care and diagnosis. Hypothesis: making medical records available for data analysis might expose redundancy, over-testing, and other methods of extracting profits from the fee-for-service model. My take is that it might also make it much easier to gather and evaluate quality of care information. That would be chum in the water for malpractice suits."
Electronic Health Records is very hard (Score:5, Informative)
A very large HMO has spent Billions on an EMR, with major IT consulting involved, and little to show for it. The benefits were very clear over 15 years ago. The medical community wants it to save money, and also to document against malpractice suits. The OP's take on why it has not been adopted was definitely not the view at the VP levels of the HMOs...
I have a different theory (Score:4, Informative)
Easy to test (Score:5, Informative)
Were your hypothesis correct then there should be a visibly greater level of non-clinical IT adoption in tolerably resourced, state-funded healthcare schemes - eg the UK.
lots of work for very little gain (Score:5, Informative)
However, the biggest stop to systems like this is the medical staff. Doctors seem to think they're above having to enter medical details - as it's mere clerical work (I've heard: "I didn't spend years at med. school, just to be a secretary") and they, personally, don't gain anything from a system such as this. Until somoeone gieves the profession as a whole a kick up the rear, this kind of prima-donna attitude will prevail.
In the end, it's a people problem - not a tech. problem.
Re:one word: protectionism (Score:5, Informative)
1. Cost is not a barrier? Our EMR costs each physician many tens of thousands a dollar a year in application support, licensing, databases, and for a phalanx of IS personnel in various departments (local, regional, EMR, hospital IS).
2. MD's have a monopoly? What planet are you on? DO's have had precisely equivalent standing for decades in medical practice in the United States, and NP's are far from being "wiggled in." As a primary care physician, when I send a patient to the cardiologist or pulmonologist, half the time the entire consult is done by a PA or NP.
3. Please direct me to the land you describe where I can have control over my care environment and take home most of the money. I can't get a contracting pregnant lady into labor and delivery without asking for permission from two nurses, and I'm not aware that the balance of power in any health system I've worked in has been any different before and after transition from paper records. Medical care in most locales in the US has long been collaborative, team-based system, even if you've met a few physicians who are jerks or drive nice cars. (I am looking forward to upgrading my '94 Corolla by 2014.)
EMR systems have poor market penetration, in my direct experience over the last 9 years, because:
1. Many, if not most, suck in a medium to large way;
2. They are incredibly expensive;
3. They can often be hard to use, and are typically more labor-intensive than paper charts for most physicians in the US;
4. They don't inter-operate. (When I request old records from other physicians with electronic charts, I enter the pertinent data into my electronic chart by typing it in.)
If any skilled group of software engineers were to write a decent, usable EMR that was extensible, and didn't cost an arm and a leg, with an eye to being excellent first and profitable as a consequence, they could be up for a Nobel prize.
TFA refers to cardiac CT to prevent heart attacks. The author, too, lives in a dream world - contrary to her thesis, this test has been shown to help with the boat payments of radiologists and equipment manufacturers, but there is no evidence it helps prevent heart attacks.
Re:Electronic Health Records is very hard (Score:5, Informative)
Not all medical systems are equally sensitive, and if there is a one in ten million risk of a technical error causing incorrect data for a patient the risk of prescribing the wrong medication is a lot higher if the doctor can't get the whole picture because information is locked away in an inaccessible system or only exists on paper.
There is the Unified Medical Language System [nih.gov] that is supposed to address some of the issues regarding interoperability, but I'm sure that there are a lot of problems left to take care of.
Another problem with medical records is the privacy issue. Some data may be embarrassing like sexually transferable diseases. Others like broken bones are rather harmless for the privacy.
And the issue of keeping medical records accessible is an international problem.
As someone who has worked on it... (Score:5, Informative)
...there are multiple reasons and road blocks (natural and artificial):
1) Healthcare is about making profit. It is not about caring for health. I have seen many IT companies bite the dust during proposals by stating their systems could help caring for health quicker and much better. That's the last thing Blue Cross or anyone else wants.
The idea for IT companies is to open a presentation with how to increase profits. That, as far as i know, is the only presentation which interests the healthcare company.
2) There are combinational factors; for instance doctors and software don't go well together psychologically except in times of peace, which is rare. Instead of adopting touch screen systems and throw-away laptops small enough and tough enough, most companies insist on producing massive software run in PCs and Servers in a serene a/c room. Excuse me, which doctor has sanguinely traversed through a maze of Visual Basic or PowerBuilder application menus?
3) IT companies should seriously stop considering "integrated" systems which connect doctors with nurses with patients with pharmacies. No, for the last fcuking time, no we don't need integrated crap. All we need is a simple system that can be accessed with a max of three clicks and accepts voice input.
4) Record management: HIPAA is not exactly an easy job. Any standard created by a committee is, by definition, an as$ to work with.
5) Changes in systems result in changes in behavior and processes: something hated by surgeons, doctors and hospitals.
Don't attribute to malice what can be explained by stupidity.
Re:Electronic Health Records is very hard (Score:5, Informative)
As for hardware reliablity: I had 5 servers, 60 workstations, a CT, and 5 radiation therapy machines (which themselves have 3 computers running in a voting redundant system), in the two years I was there we had 1 day that we were down because our database came back with an inconsistancy after its backup. Patients were then treated with the paper method and it was much much slower, treatments easily took twice as long because of waiting for charts etc. It actually turned out not to be bad, it probably was your stray neutrino scenario, anyways we left it in the state we found it in so that the vendor and database supplier could find the problem so it wouldn't happen again. We could of been back up in an hour because we had tape backups of the system. What happens if someone spills their lunch on a paper chart? Also, for another 50k or so you can get a hot standby server to failover to.
Also reporting is much easier from electronic systems. I got questions all the time like "what percentile of breast cancer patients getting 20 or more sessions waited for more than one week to start treatment?", I was able to have the answer over a 5 year period in less than an hour. It was much harder for a physician to bullshit his way into justifying his performance when any claim he made could be verified that quickly. In a paper system it would take days of someone's time to verify that stuff and so it probably wouldn't happen until someone had a bad outcome or a malpractice suit was filed.
Re:Electronic Health Records is very hard (Score:5, Informative)
Strange things can really happen with computers, as stray neutrino can strike a transistor and change it's state and either cause a system to crash or the wrong prescription to be issued.
It's idiotic statements like that which make the non-experts in the technology field shy away from technology. The odds of a human error is many orders of magnitude greater than the odds of a stray neutrino causing a wrong Rx.
IT is only one facet of healthcare (Score:5, Informative)
I think there has always been a serious barrier to the uptake of new information technologies among the medical profession. Most HATE taking notes which is why note taking is left to the junior medical staff on ward rounds. Most clinicians take very brief notes, especially surgeons and only verbose when practicing defensive medicine. Most have a personal way to annotate their notes which cannot fit into any template (eg. unconventitional acronyms, stylized diagrams etc) and are loath to learn new ways of doing things. Sometimes surgical notes only make sense to that particular surgeon or surgeons of that sub-specialty (eg. ophthalmic vitreal surgery... very difficult to decipher...pain in the arse reading their notes.. ) Why? I think some of you guys need to see the amount of stuff medical specialists have to learn and the years of training (at least five here in Australia for specialty training, ( that is after 5-6 years medical school and another 1-3 years as general intern and resident) and then another 2-3 years for sub-specialty training which can involve 2-5 exams and possibly a PHD during the training). There is an incredible amount of stress on the person and their families. (Yes, I think the high standard of medical training IS necessary and not just economic gate-keeping by the medical colleges). During all that training before you are a qualified specialist, your hourly rate can be lower than the hospital cleaners or even not allowed to claim paid overtime at all, as the public hospitals here in Australia frequently runs out of money.
At the end of all that, I don't think many like to be told how to take their notes.
I don't think you need conspiracy theories to explain poor uptake of EMRs. In NZ where basically doctors can't get sued (generally speaking), doctors STILL hate EMRs and do poor job of entering data into systems. I once worked for an older surgeon and we got called for an emergency laparotomy on a drunk 19 yo male who lacerated his spleen in a car accident. The surgeon hated taking notes and hated talking to patients but was one hell of a surgeon. All his patient notes consisted of scribbles on flashcards. The young guy's abdomen was full of blood. We had no idea at the time where the bleeding was coming from. The surgeon was clamping major arteries by feel blindly as the suckers couldn't keep up. After five hours the surgery was over and the young guy lived. I tell ya, I had a new found respect for the "old school" surgeon. There are times when you REALLY don't care whether a surgeon is good at filling out forms or has polished bed-side manners.
Re:I have a different theory (Score:5, Informative)
I don't have a theory I have experience.
I work for hospital that went digital (for patient recodrs) in 2006. All (billing) administration was internally digital (using different, obsolete system working on DOS and floppy disks) from 1997 and to outside world also, depending to health insurance company involved.
After 6 months of education, switch was made in one day. It was horrible, but after two weeks things were looking just as before. After several months, 75% of administration was more efficient than before, and now, 3 years later, we still print outgoing documentation, but doctors rarely look at papers. Nevertheless, printing expenses went 30% down this year.
Last year all waiting lists were computerized, and made available (with no patient data) at the web pages. That saved us so many work hours at all departments, but two people switched to that department. This year we are looking into making all internal administrative procedures digital. Hospital restaurant was really happy after we made their menu available online at intranet.
Several months before introducing the system, all work places received computers with unified user interface, and demo program installed. It was made really clear that someone should consider finding another job if they refused to work with system. People near the retirement (2-3 years) were exempt from this rule.
The problem very often lies in wanting too much (all). Process should be step-by-step. Billing first, patient records second, intra-hospital administration third or any other way. Every step should be planned, because people will suffer at it, and don't rush it. It takes months, sometimes years for one (new) work flow to settle in.
Radiology department is still not filmless, probably because it costs as much as putting all patient records in computer. Volume of data that our radiology department produces in one day is equal to 1-2 years of data from whole hospital. On the other hand, introducing PACS and RIS is so much more widespread, but the volume of data makes project harder in the long run. After testing almost a dozen of PACS/RIS demonstrations, one free PACS amazed us with results, holding test data (0.5T of images) and working better than some very expensive solutions.
Re:Electronic Health Records is very hard (Score:5, Informative)
Re:Electronic Health Records is very hard (Score:5, Informative)
I would imagine the picture is very different depending on the country. I work on long term conditions monitoring systems in the UK and obviously our main client is the NHS. Even though our systems (or similar systems from other companies) will save the NHS a lot of money in the medium term it's been very slow to adapt due to the layers and layers and layers of management and middle management which also has a high rotation rate. It's not phobia to tech but politics (ie predecessor project on hold while I get mine to completion type of thing) for the most part.
About the article, it's fairly misleading and uninformed in my experience:
Too bad the medical industry has a vested interest in inefficiency.
Please spare me the conspiration theories. A sizeable chunk of the medical industry is composed of small companies whose main selling point is precisely efficiency and subsequent cost savings. This, the big medical companies can't provide anyway, there's no conspiration, you wouldn't believe the amount of paperwork you need to keep up to date to comply with regulations in this industry and especially with new products, therefore they simply sell same old.
No... it's because of the software quality (Score:4, Informative)
Go to any doctors office and ask how much they like their software. There is so much crap out there it isn't even funny. I know for a fact, one software company that services more than 20 hospitals and 200 doctors office recently discovered that they had a rounding error in displaying pharmaceuticals. Obviously nothing extremely dangerous... but the fact is there just isn't that many affordable quality software companies out there.
Hell, http://www.physiciansehr.org/index.asp [physiciansehr.org] and companies like it make it their sole business to find software suitable for your office, and help in the transition. It's huge business.
I don't honestly believe most medical practitioners are worried about that being used as medical malpractice fodder when weighed against the benefits. The problem comes with the cost and quality. Most doctors don't understand nor care since they have little interaction with it.
I've evaluated over 20 small doctors office software apps that are rated high and let me tell you... 99% of them suck ass. I officially dub "suck ass" a technical term meaning, someone was smoking crack when designing the user interface and knew more about making an annoying, non-user friendly piece of trash than making ANYTHING remotely useable by the medical field.
The transition will happen eventually but some standards need to be in place and universally accepted accreditation certificates need to be available to say "Yes... this software meets these standards". We all know that this will be abused and the bare minimum met... but you have to understand... the standards are SO low... that companies release bugged software knowingly...
Just ask E-Cast. I can't wait for a federal investigation to happen to those guys.
Disclaimer: I do not work for E-Cast, nor have I ever worked, contracted for or through any group associated with E-Cast.
Re:Electronic Health Records is very hard (Score:3, Informative)
Re:Electronic Health Records is very hard (Score:4, Informative)
Medical Doctors are in General very difficult to work with. There are a lot of factors...
1. Society says they are the smartest people around. They think that too. So when they go out of their area of expertise and they don't know exactly what is happening, they will avoid trying to learn about it but become defensive about it. And will not give respect to people who do know about such areas and let them ask the right questions so they can fix the problem. I have had Doctors yell at me, when I call them and say, "I hear you are having some problems with the system, could you explain them to me so I can see how I can fix it?" just as themselves will go to a patient and ask a similar question even when they have the problem written down as for the reason for the appointment. This makes them high maintenance and people don't necessarily want to deal with them. House may be a cool TV show, but you really wouldn't want to with him.
2. Doctors are trained in medical not business, they are MDs not MBAs. Yet a lot of them run their own practice and need to deal with all the business of running the practice and not working on the medicine. Many practices are so overworked that they don't have time to analyze or listen to ideas that will improve their practice.
3. Most practices are small business. Good EMR and PM (Practice Management) system are not cheap (like most professional apps), and there is a sticker shock for paying thousands of dollars for software, even for a glorified access database. They feel like they are getting ripped off by paying such high prices for software. So they will go with their crappy methods before getting ripped off.
4. Open Source is not an option. Sorry Open Source fans. In a career where you can get sued in an instant you need somewhere to point the lawyers away from you. (Hence part of the high cost for medical software) Yes this is a lame excuse for Microsoft (who makes general use software) but for specialty software companies they are under the guns of lawyers all the time.
5. MD are known to make a lot of money. This doesn't always attract good, nice, or even smart people. Remember "What do you call the person who graduated with the lowest score in Med School?" answer "Doctor". A lot of people are just in it for the money. They may say they like helping people but they are in it for the money (How a lot of doctors in California will prescribe "medical marijuana" for "problems sleeping") They will be so tight with their money and be blind to all benefits such systems will have, and will not pay unless things work the way THEY want it to.
6. Uneducated staff. For most practices you will have 1 or 2 doctors 1 or 2 nurses (with Associates or BA degrees) then a staff of 4 or 5 with High School degrees. That staff runs the business for the most part. They lack the patience or discipline to learn such technologies and to use it for its best advantage. Also many of them feel sub adequate (as they need to deal with the high egos of the Doctors) so they are afraid to ask questions or point out problems.
Re:Electronic Health Records is very hard (Score:1, Informative)
What you say is largely true. As an MD I've participated on a group that developed a standardized XML EMR format 10 years ago -- despite being available this has not been widely implemented by Healthcare IT vendors -- so don't blame the doctors!
In my experience, Healthcare IT vendors produce crappy software for $$$ that often doesn't help the MDs do their work more efficiently. Don't blame the doctors for this situation.
IT and Medicine are a Bad Fit (Score:5, Informative)
One thing everyone seems to be missing here (including the author of the article) is that medical data is an odd duck that just doesn't fit easily into a digital record. (I'm an MD, a medical informatics guy and CTO at a medical software company)
If you're running a McDonalds you can easily computerize everything: You have a fixed menu your customers can choose from, and every purchase can easily be stuffed into a relational table. Medicine isn't like that.
Trying to enter a patient encounter into a contemporary medical record system is an extremely unsatisfying experience: Humans are just weird and idiosyncratic and every time you treat someone there will be parts of the patient visit you can't represent symbolically in a piece of software. This is still largely an unsolved problem- If you read the literature on Description Logics you'll see that even PhD logicians have a hard time symbolically storing this kind of abstract data into a piece of software, let alone a doc with little computer training.
Because of this, most current record systems use a lot of "free text" for storing medical info, which is a pretty ugly hack and everyone realizes this.
I think this is a major reason for the problems people have with digital records: They don't work very well right now for fully capturing a patient encounter in a rigorous, symbolic fashion.
An EMR story... (Score:4, Informative)
My surgeon was running late due to complications in an earlier procedure, so when 10 AM rolled around, both the septuagenarian and I were still waiting for our procedures. For me, it would clearly be a matter of time. From overhearing the family, the doctors, and the nurses, however, it was fairly clear that the old man would not have his surgery that day, because he was presenting symptoms that suggested he may have bronchitis or pneumonia.
As is standard procedure, each surgical patient has a pre-operative screening with his or her regular physician, to ensure that the patient is well before the operation. This man had his visit, including a chest x-ray, but those records never made it to the surgery center. The man's clinic had EMR technology, so one doctor suggested that they just pull up the records. That's where they ran into some problems. The only terminal with EMR access at the nurses' station in the surgery center could not access the records for that patient. Multiple people tried their logons on that terminal, but none of them could pull up the records. There were discussions as to whether or not the clinic was on the same EMR network as was the hospital. One nurse commented that she had cared for a patient in the main building and accessed records from the same clinic system. Finally, another nurse mentioned that there was another terminal in a records room in the surgery center, so she and a doctor headed off to try to access the EMR from there.
In the mean time, this poor old gent is starting to cough a lot, and appears to be in much pain. No one was able to reach his primary physician by phone, and the patient's home-town clinic was not open that day. The doctor and nurse returned from the records room, and indicated that they had no better luck. An older nurse then mentioned that she thought the main hospital had access to more healt-care networks than did the surgery center. Someone was dispatched to the hospital to try and pull up the records.
It turns out that my physician was havin a really rough time. His first patient, who was in for what was thought to be a minor rotator cuff repair, apparantly had old baseball injuries about which the physician was unaware. In the end, the doctor was able to patch him up, but three out of four of the primary ligaments or tendons were beyond repair. [That bit of information was picked up by my wife in the waiting room, when the surgeon came out to tell the other man's wife how things went and why they went long, and to tell my wife why I was not yet in surgery.] I'm just noting that so you'll understand why I was still waiting for surgery as the hour neared 1 PM.
The surgery center called over one of the on-call physicians from the hospital, who checked in on the man numerous times during the morning. He was convinced that the man was too ill for surgery, but the man insisted that his own physician had told him to go ahead. The family members were upset, because travel took a lot out of their father, and he made the three hour trip specifically for the surgery (a hip replacement). The on-call doctor made it clear that there would be no surgery that day. Why were they keeping him waiting is what the family wanted to know. The on-call doctor wanted to consult with the man's physician, because he felt the man should be admitted to the hospital. He was trying t
A few comments from a guy from this field... (Score:3, Informative)
1. HIPAA is a problem. everything you do, EVERYTHING, has to be HIPAA compliant. this means checking, rechecking, checking a 3rd time and then hiring an outside party to check your checking. if you screw up in any way, it's possible to be held criminally liable, personally. the HIPAA rule book was around 1200 pages long the last time I had to use it. My small company (150 employees) had a full time staff of FIVE that did nothing but interpret HIPAA and document changes everytime some politician lobbied some bullshit minor rule change thru the system. Each time this happened, we had a mere 90 days to version our software to match. This is a big deal when you have 3 developers working on 4-5 million lines of code. Summary: any screwups can land you in jail, so review and testing is off the scale thorough.
2. Mistakes can be fatal. During my time writing healthcare software, I had to opportunity to work on a system I'll call the Pill-Counting-Robot. It did exactly what you'd think it would do: scripts would come down the wire, the robot would count pills into a bottle and label it. Counting the wrong kind of pill can mean instant death for a patient. Counting the wrong number of pills can make a patient very sick or dead. Printing the wrong instructions on the label can also kill them. ZERO SCREWUPS CAN HAPPEN! None. Not one. We debugged that thing for months on end, trying as hard as we could to break it... we did testing with red and green M&Ms to make sure it never mixed medicine. You really don't even want to hear what kinds of scary mistakes that thing can make when it jams or crushes a pill or breaks a pill in half, etc, etc. Summary: a tiny glitch can kill people.
3. The final roadblock to quick progress is ancient standards. When scripts go over the wire, they use a format called NCPDP. This was made in the 70's for use over non-duplex modems. It is slow as snot. It cannot handle whitespaces in the wrong place, it can't handle variable length text, and it can't handle certain kinds of punctuation. It definitely can't handle long names or hypenated names (e.g. married folks who share names with eachother). And yet, as bad and old and broken as the standard was, we were required to use it because of a federal mandate. See Item 1. Summary: laws make the field obsolete and obtuse.
Re:Who keeps the records? (Score:3, Informative)
Have medical complications that it would be just great if the Doctors treating you had access to?
Buy a damn medalert bracelet. A million times faster than triage staff trying to figure out whether you've given your medical records to google or microsoft and what your userid is to get them back.
Why Ignore VistA (Score:3, Informative)
It works and docs find it helpful. I'm amazed that it's ignored in TFA.
Docs won't use EMRs until they need to do so to get paid. That's the long and the short of it.