IT and Health Care 294
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samzenpus
from the broken-by-design dept.
from the broken-by-design dept.
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."
Hanlon's Razor (Score:4, Insightful)
Re:Electronic Health Records is very hard (Score:2, Insightful)
The biggest danger, manually you might make one mistake, electronically you can repeat that same mistake thousands of times before you catch it. Next up of course are software warranties, typical M$ warranties categorically states the software is "unfit" for any purpose, so if using it results in an error occurring it immediately leaves the hospital liable for criminal negligence as the software EULA stated it was unfit for the use to which is was put and the hospital "choose" to ignore that warning and use that software at the patients risk.
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. In the medical field, it is life or death and manual system continually checked, and immediately reviewable by any concerned parties do have a considerable safety advantage, this can certainly be augmented by electronics but replacing it requires extremely reliablly hardware and of course software with warranties that actually warrant the quality and reliability of the code in the software.
Re:Some insight perhaps? (Score:5, Insightful)
Government hospitals (like VA hospitals) have NO money to even fix aging equipment, let alone buy new or have fancy things like IT.
HUH ????
The VAs electronic health system is called VistA, and it is the EMR in the largest health system in the US. It covers all veterans, it is used nationwide, and it is so prevalent that most everyone who talks about standardizing medical records and medical data all talk about matching the VistA system in doing so.
Re:one word: protectionism (Score:1, Insightful)
When physicians are required to interact in electronic, shared systems, they can't lord over all the responsibility in care environments
As patients, we often forget that most diagnoses are really just a SWAG. A doctor usually can't be 100% confident that his diagnosis is correct, but does his best based on his expertise and the training he has. If I were a doctor, my daily concern would be malpractice suits. I don't even want to know how many incorrect engineering decisions I make in a year. If I had to be concerned about being sued for every one of those incorrect decisions, I would be lording over the data as well because I know there is always multiple ways to interpret the same data set.
Re:Electronic Health Records is very hard (Score:4, Insightful)
A very large HMO has spent Billions on an EMR, with major IT consulting involved, and little to show for it.
I assume you are talking about Kaiser Permanente's HealthConnect here? I think the key is that the groundwork has been laid. It takes a long time and a lot of money sometimes to be a pioneer in the healthecare industry. Ultimately it will likely benefit KP, as it will takes years for other systems to catch up if it's even possible for them to (most lack the integrated delivery system that made this possible for KP).
Doctors (Score:2, Insightful)
Quite simply it is that Doctors believe they are the most intelligent people in the room whenever they walk in. They will accept no management advice, no time allocation advice, no parking advice, no dietary advice . . . no advice.
They believe that they are already operating in the most efficient manner and that any change will put patient lives at risk. Well . . . actually they don't believe this, but this excuse is used every time they don't like something. A quick "OOooooo - patient lives at risk" and any progressive idea is already on the back foot.
This ideology permeates through the health care system with consultants at the top right down through the chain to the nurses.
Getting these people to agree on ANYTHING is a Herculean task.
A friend of mine (a Doctor) was on a committee trying to bring more IT into the healthcare system in Scotland. He is very IT minded (read geek) and was keen as mustard to help push things along. Within a handful of months, he was at the end of his tether due to the sheer deluge of nonsensical crap that was being floated purely to waste the committee's time and ensure that nothing got done.
Re:Electronic Health Records is very hard (Score:5, Insightful)
Why blame computers (and why go the lengths to blame stray neutrons) when humans themselves can screw up far more often and far better [smh.com.au]?
Conspiracy? (Score:4, Insightful)
There's ample room for conspiracy in the murky world of health care, but I don't think it is in IT - instead, look at medical companies and the way medicine is prescribed and used, if you are looking fopr conspiracies.
There are many good reasons why computers aren't used universally in health care. Two of the biggest are education and resources - doctors and nurses aren't really taught to use computers in their work. And while having a well designed computer system can be a huge advantage in any line of work, that is actually only true once everybody is fully trained; until that has been done, it is actually less efficient. And the situation in most countries is that there are too few medical staff anywhere, so where would one find the resources to make it happen?
On top of that comes concerns with incompatible, existing systems, privacy issues etc. Not to mention the fact that nearly all public IT projects so far have been hugely over budget and behind schedule. I think that perhaps the only realistic way this can be solved is by creating a good, open source health care system and let it mature and grow into general use from the grassroot up.
Compter illiteate & overstretched staff more l (Score:5, Insightful)
In most healthcare systems, staff are very busy, and computer illiteracy is rife. To get good with these electronic systems you've got to use them constantly, and when half the staff or more don't understand why they're doing a particular thing in a particular way. There's also a workplace culture of written notes, and often a limited number of computer terminals per staff member. So with queuing for terminals, fairly high friction processes for retrieving data and so on and so forth, there are quite high barriers to entry from a human point of view.
Don't get me wrong, EHRs have potential, and can reap benifits (especially for management - they can also make floor staff's job harder). Some kind of robust iphone-like device which is a secure platform for data entry and retrieval, might make it sufficiently easy and efficient from an end-user's perspective to decrease implementation barriers.
Re:Doctors (Score:2, Insightful)
Or maybe we IT guys are so incredibly annoying with our demands to computerise every last bit of everybody's lifes? I can only assume at some point you just fade out all this "integrated this and that"-"workflow bullshit bingo" crap that consultants regularly throw at people.
I'm a software engineer and I'm fed up with all the bullshit consultants and marketing people throw around. Have you looked at the product websites of applications from big companies? They are a load of hypothecial catchphrases and marketing dribble that sounds nice but once you actually have their Crap(TM) in front of you, it does NOTHING of the vaguely advertised stuff. It's just another complicated system that you have to get used to and that fails whenever you need it.
Re:one word: protectionism (Score:2, Insightful)
Sorry, but as a physician, you come to the table with a prior of zero credibility in a discussion of financial matters.
Most physicians ought to try working in any other profession besides the guaranteed-high-salary-MD-world before commenting on who it is that lives in a parallel universe.
Physicians in the US have created a closed system that requires a *state license* to enter, and then they earn 3-10+ times the median salary:
http://www.payscale.com/research/US/People_with_Jobs_as_Physicians_%2F_Doctors/Salary [payscale.com]
commensurate with remarkably low unemployment (while the rest of the US are now around 9.4% and rising).
I'm a strong supporter of anyone who creates high value earning as much as possible. When one builds value or manages high responsibility, they get the money.
Unfortunately, physicians in the US are not creating significant value despite the costs and their salaries. The costs to the US society have gone now above 17% of the nation`s Gross Domestic Product (GDP), and rising at rising four times faster on average than workers` earnings since 1999. That means more than 1 in 6 of *EVERY* dollar of value created in the US goes to this racket (sic). High cost, by itself, not a problem: health is extremely important BUT, health results in the US are not very good, on a cost comparison basis with other 1st world countries:
http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2006/Sep/Why-Not-the-Best--Results-from-a-National-Scorecard-on-U-S--Health-System-Performance.aspx [commonwealthfund.org]
For all this expense, and all those salaries, US health is not as good. Why?
Becuase care providing is a controlled, state-sponsored monopoly. In any other industry physicians would all have been fired and improved long ago for such a horrible financial mess coupled with such poor comparative results. As a physician you and your peers created and profit directly from the high costs in the system.
I agree with any of your assessment of EMRs. They are dead on - but interested physicians driving this technology forward with a sincere interest in human health and not solely on protecting their business and on profits would have made EMRs a priority more then 30 years ago when research in this area first started, and solved all those issues.
And as for "Medical care in most locales in the US has long been collaborative, team-based system" - that`s comic. A physician`s definition of "team" and what everyone else in the work world means with that word are miles apart.
Re:one word: protectionism (Score:2, Insightful)
This might be news to you, but it's pretty much the same as in the other first world countries, which are getting better medical outcomes at lower overall costs.
Re:Too much testing required (Score:3, Insightful)
Agreed.
All I'm saying is that if the level of validation for medical software/hardware is along the level of that required by Nasa, then we should expect rates of innovation and total cost to be commensurate with the IT Systems used in space shuttles rather than IT Systems implemented in other fields.
This stuff moves slowly because we make it move slowly. Is that bad? Probably not; but it shouldn't come as a surprise.
Too few computers, too little bandwidth (Score:5, Insightful)
I can't speak for the US or private medicine but I've seen numerous electronic record systems piloted in the NHS.
My colleagues would love to have fast access to up-to-date clinical notes rather than play pass-the-parcel (or more often, hide & seek) with a patient's paper case-file(s), but wards tend to have one or two computers per ward and community services may have one computer between three to five staff. So at the end of a shift, when ward staff would be writing their notes, there'd be a queue for the computer. Similarly, before setting out on their visits at the start of the day and after returning from their visits at the end of the day, all community staff want access to the computer at the same time. Also, security dictates that as little information as possible is stored on the user's machine, so the intranet is swamped at these times and users face frustrating lags (I've been unable to access records in time for an appointment as the system was "oversubscribed").
To increase computer access to usable levels in my former service would have required a 3-400% increase in the number of computers provided to healthcare staff. I have no idea what the resource implications would have been for the service's intranet, but I imagine that a commensurate increase in server capacity (and in the IT department staffing, to take care of all of this) wouldn't be cheap. As a health service manager, having to decide between enough hospital beds or enough computers, which do you suppose is more likely to keep you in your job?
Medical IT sucks (Score:5, Insightful)
As a medical interpreter, I see health-care IT up close all the time. (I'm writing this in an ER, on an overnight shift.) TFA has a lot of good points, but think the biggest single reason the IT sucks is the sheer complexity of medical information, but also of our byzantine and baffling health system in general.
All the health systems in town use the same medical-records company, because it's local. Its design reminds me of Windows 95, and the nurses know more about the workarounds for the bugs than about the intended use. The thing is, few of the doctors and even fewer of the nurses are interested in computers. They're interested in medicine, and computers are a pain in the neck even *before* they break down. They can't tell when the computer is behaving unpredictably, because as far as they're concerned, the computer always behaves unpredictably.
Am I trying to blame the victims, here? No. I'm saying this is a detailed and ongoing focus group, and they're telling us that the whole IT system is a disaster. And as far as I'm concerned, the most damning critique is that no one I've talked to wants them to change it, because, almost to a person, they're convinced the upgrade will be just as, if not worse.
Re:Electronic Health Records is very hard (Score:5, Insightful)
The premise of the the original article appeals to conspiracy theorists, but I have to say I have never seen any evidence that supports it. The author also fails to provide any. Rather than look to greed, it makes more sense to look at the UI failures of most commercial systems and the inadequate attention given to training and support during implementation.
The Many Layers of Complexity (Score:5, Insightful)
The simple idea is to have a system that records the patients history of illnesses and treatment (including medication, obviously) and which is easily communicated across different places of diagnose and treatment (GP, specialists, consultants, hospitals,
This specific problem could easily be solved with standard software like Lotus Notes, Microsoft SharePoint and similar systems, but that is where the simplicity stops and the layers of complexity start.
Sorry if I am going down a well-travelled trail here.
Firstly, it is very difficult to get people and organisations to standardise on a single system for good and for bad reasons. (Like "We've already got Lotus Notes, why should we get a Microsoft product?" -- plug in whatever conflicting product/system names you can think of.) This means that a single system probably is out of the question, which leaves us with a standardised interchange format instead.
OK, now we have a gazillion systems happily exchanging information in a standardised format, so everybody is happy, right?
Wrong!
Because secondly, who is responsible for the safekeeping of the data? This is two-fold: Who is responsible for storing the data and who is responsible for who has access to the data?
So 2a, Responsibility for storing the data: If every place of diagnose and treatment is responsible for storing own data, how can a patient be sure that any specific institution treating her has access to all the information? This needs some centralised storage or at least "mediating" (much like peer-to-peer systems, e.g. torrents, need a "meeting place", like The Pirate Bay, where they can find the trackers so they know where to find the peers). Either system suffers from the problem of connectivity dependence, i.e. if they cannot get access to either the storage, the "mediator" or the peers, information cannot be retrieved. This is still better than paper-based systems, if you are treated in different places, geographically.
This leads to 2b, Responsibility for who has access to the data: I would obviously like for my GP to send information directly to the hospital and for the nurses, doctors, consultants and surgeons treating me to see my records, but -- being the famous person, I am
Thirdly, who would be responsible for correcting errors and mistakes in the records? This problem is not really an issue relating only to electronic records, but is a general issue, which crops up all the time. Should you, as the patient, be allowed to correct mistakes you know about? If that is the case, how do the professionals make sure that you are not trying to tamper with the system for some ulterior motive (everything from trying to cover medical problems for insurance purposes to hypochondria)? If you are not allowed to correct mistakes, how do you tell them that you did not receive a certain medication two years ago and, in fact, is allergic to it?
Fourthly, a system relying on doctors, specialists and consultants to type would probably be doomed, at least for now. It seems that doctors, etc. at all the hospitals I have seen, rely on dictation, having a pool of secretaries typing it in and updating the records, which introduces unnecessary delays and adds an extra risk of introducing errors.
These are some of the many problems facing such a system and I am sure I have left out many, just as relevant. I honestly do not believe that the fear of transparency regarding the treatment is the major stumbling block for the introduction of electronic medical records, but rather the diverse types of problems facing the system.
wrong answer (Score:5, Insightful)
"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"
Besides being perhaps the most ignorant thing I have read this morning, this statement reminds me of the irony inherent in listening to tech people whine about how medical caregivers have no trust or knowledge of IT, while the caregivers complain non-stop that IT has no idea how to design a decent medical record system.
Re:one word: protectionism (Score:5, Insightful)
"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. "
Whenever this topic comes up, the same answer always eventually comes out to address "4", which is of course VA's VISTA/CPRS. Not only is it customizable and extensible, but the program and code are free to anyone who wants it. And I don't see the programmers from the VA winning any Nobels any time soon ;-). Read "The Best Care Anywhere." Even if you disagree with the premise, Longman presents an interesting section on how VISTA, and later CPRS came into being. It's his position that an important (if not primary) reason there is not adoption of electronic medical records in the private sector is because it can actually create a competitive disadvantage.
Massing huge amounts of electronic, easily accessibly medical information on an individual is really only advantageous to the patient, provider and system if the patient remains with the same providers and same health care system, which of course is true for the Veterans treated by VA. Long term, detailed information on a patient is advantageous on the patient level because you can monitor more easily preventive health measures and track health status over time; for the provider it means decision making can be more informed which should improve outcomes; for the system it means better outcomes and presumably more competitive advantage. But here's the rub: patients don't stay with the same providers or same systems. Health care has become so complicated that person's change their care plan, and hence their providers and health care system often. If I'm Blue Cross, I can guarantee you I know exactly what the rollover of the person's in my panel are from year to year. If I'm a hospital administrator, I know exactly how many person's come and go through the plans I have contracts with and how many are seeking care at my facility. As you point out, unless a facility takes a stab at VISTA/CPRS, EMR's can be insanely expensive to develop. And deployment, penetration and compliance within a facility/system is a herculean task requiring a major change in culture to ensure adoption. So, as some sort of health care system administrator, for every patient that moves to another plan and hence gets care from other providers in other hospitals, I have just given my competitors an enormous advantage in their care of this patient. The patient is able to bring them their complete, beautifully printed out and organized medical record to aid their providers in the care of this person.
Now, of course, it also says I would have the same benefit when patients come to my system. The problem is who is going to budge first? And if someone else budges, and I can attract those patients to my system, then maybe I don't have a good incentive to develop an EMR for my facility in the first place. Maybe I should spend more money on a finely landscaped, aesthetically beautiful, modern bed tower? Because, really, the patient is going to leave and go elsewhere eventually. When they change jobs, their health care plans change. When life circumstances change (e.g. they now need a family plan), their health care plan changes. There's a ton reasons person's change health care plans, and very few of them have to do with actually wanting to see a certain person or get care at a specific facility. Without these lifelong relationships between patient, provider and system, it's hard to convince a facility of any size, be it a small practice of primary care providers to large health care systems buying up hospitals, to invest the time and energy in an EMR. And it will remain this way until there are clear financial incentives to do so; or the health care system is totally revamped such that lifelong relationships between patients and providers is again feasible.
later,
jeff
Re:Electronic Health Records is very hard (Score:2, Insightful)
U.S. Department of Veterans Affairs developed VistA - for everyone.
I am surprised the open source pundits dont know about this one.
http://en.wikipedia.org/wiki/VistA [wikipedia.org]
disclaimer: i work for the dva on vista every day
Re:Too few computers, too little bandwidth (Score:1, Insightful)
Re:Electronic Health Records is very hard (Score:3, Insightful)
Absolutely (Score:4, Insightful)
It's not protectionism or any of that other trite conspiratorial nonsense that keeps physicians from using EMR (you can't get ten physicians to agree on damned-near ANYTHING, from what PACS software to use, to what size coffee cups to keep in the surgery waiting area... how do you expect them to engage in any kind of organized conspiracy to keep using paper?) You want to know why physicians dread EMRs?
Well... being one (and a tech geek to boot), I'll tell you:
It's the UI.... that and the cost. If you can make it fast, user-friendly, intuitive, lightweight, and inexpensive, the world will beat a path to your door.
For example, when I was an intern, we were evaulating a hospital-based order-entry system from TDS. It was the old light-pen system, and the damned thing took 14 screens to order an Xray.
I'm now a practicing ER physician... nobody is under greater time pressure than I am, and the EMRs that I've seen so far will slow me down. My colleagues at a nearby hospital who use one of the tablet-based systems complain bitterly about how slow it is.
Make it faster and easier to use than paper. Make it... you know... an actual upgrade? Not some ugly, unwieldy kludge forced by some data-mining, numbers-obsessed bureaucrat. Doctors generally aren't geeks... they care about ease of use. A system that doesn't make it easier to take care of patients will be universally despised, and resisted by everyone on the medical staff.
Physicians have enough to do, and enough to worry about. Want to have medical staff buy-in? Make the EMR an asset instead of a liability.
Re:Electronic Health Records is very hard (Score:1, Insightful)
I read your post and the first thing that came to my mind was that it was very easy to change 10k+ patient records to be whatever you wanted. Yeah... Sounds like a good idea to me.
BTW, what form of version controlling or auditing do you utilize on your database? I mean, what if they change the definition again and you have to go back to the original start date? That would be easy, right?
Are doctors truly necessary in most circumstances? (Score:2, Insightful)
In my experience, in most situations, a simple algorithmic deterministic decision tree (with the right medical tests at the nodes) is sufficient to correctly diagnose and treat most diseases. I've seen my highly paid doctors I've been to under my snazzy uber-exclusive insurance plan repeatedly go to a *.nih (I think) page and reading about the various possible conditions. The human doctor is only important when dealing with the exceptions and the hard / rare cases, not with the bulk of minor, commoditized afflictions that affect mankind.
It is purely a matter of personal preference that the current generation of middle aged baby boomers are so attached to the personal touch of another human reading them a website. However your kids, raised in a webcentric era, might feel differently when asked to choose between paying $1,200 for 60 minutes with a reputable doctor (most of which spent filling paperwork and waiting) and $89 for going to a modern clinic where they follow an automated set of tests administered by a nurse, with results feeding into a computer (a doctor is called only if an exception is triggered).
And yes, don't give me the sob story of that one time where sheer human genius saved someone's life. First, there will always be a doctor on standby to deal with exceptions, and complications. Second, you cannot drive policy off exceptions like this. Third, the high price of current practices drive many people away from medical care early in their afflictions, possibly outweighing the benefit of customized care.
Also, customized care means you are relying on your knucklehead doctor to be up to date with all the medical research not only in his field, but in all related fields. Put it this way - who would you rather ask your random general knowledge questions: wikipedia, or a single smart educated professor?
In conclusion, the best thing to do might be to offer people both alternatives (at appropriate price points) and let them choose.
Re:Electronic Health Records is very hard (Score:2, Insightful)
Re:Hanlon's Razor (Score:3, Insightful)
Anyhow, this article is about Medical IT. I would guess that the slow adoption is at least partly because doctors and nurses are not bureaucrats and hate the bureaucracy, so even though computers are great for organizing information, doctors and nurses thrive on stressful "save the world" scenarios. I think it's just a mindset, not covering their butts.
Re:Hanlon's Razor (Score:3, Insightful)
And by that you mean AMERICAN hospitals are a business and "need" to be run like one. Perhaps... that's wrong? Perhaps they shouldn't be run like businesses, because of the aforesaid well-nigh impossible balancing act? Perhaps... they should be run like a social service? Perhaps they would benefit from a sweeping serious thoughtful re-imagining?
I know I'm whistling in the dark here...
Re:IT is only one facet of healthcare (Score:3, Insightful)
Your example is a good one, but after having all these arteries clamped and fixed, how many patients then go on and die because some nurse adminsters the wrong drug - or the drug that the records say is the right drug but that was due to some kind of clerical error?
My concern is that for every miracle life saved there are probably 500 lost or otherwise shortened through the medical meat grinder. Quite a bit of pain and suffering too as patients take needlessly long to recover from less critical problems.
Medicine seems to be optimized to handle these kinds of major trauma scenarios and less optimized to handle some poor guy with sepsis who is about 95% likely to recover with prompt and correct treatment and about 50% likely to die if there is much delay in getting them the care they need, but in the meantime there isn't any blood pooling on the floor.