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."
one word: protectionism (Score:3, Interesting)
The nugget of this is not explained really in the article:
Cost is *NOT* the barrier, but "lucrative business model hidden" what they mean is the intrinsic structure of how medical care is delivered and who gets to be responsible for care delivery.
In my opinion, refusal to openly adopt electronic medical records is a direct result of overt protectionism by physicians and surgeons. For good reason, society has left medical care in the hands of competent, trained people. However, competency and training has been industrialized to only 1 kind of person, with one kind of standardized training: the MD, and basically no one else, regardless of training or ability is allowed by license to practice medicine, or reap the financial rewards of such extreme responsibility. NPs have wiggled their way in a bit and DOs are close, but basically no one else.
When physicians are required to interact in electronic, shared systems, they can't lord over all the responsibility in care environments, and then they won't be the only ones who run all the medical care and take home most all the money. They will lose their self-created and maintained monopoly on responsibility for care.
Anyone who has worked a hospital environment learns in the first few weeks exactly what the MD care delivery scheme is all about.
Re:one word: protectionism (Score:3, Interesting)
Who keeps the records? (Score:5, Interesting)
I had an interesting experience in China. In 1996, when I received treatment, I kept my own records (they gave me a little paper booklet). This eliminates all the record keeping costs of the doctors and hospitals.
It might be an interesting model to look into here.
Re:As someone who has worked on it... (Score:4, Interesting)
Your reasons 3 and 4 contradict each other.
Re:Electronic Health Records is very hard (Score:4, Interesting)
re (Score:1, Interesting)
Some things people fail to account for: ...
A) Cost. Some of these data entry systems are pricey! Some physicians who only have 5-10 years of practice time left and with private practices do NOT want to invest the time or the money to adopt such a system. The software runs thousands of dollars. You assume each and every physician is just REAPING in the cash and has 30,000 to invest in a computer system. Plus the cost of inputing old records into the data system on top of that. Granted its a system of healing people and what not, but everyone is out there to make a good living for themselves as well. You invest a lot of time and money to have an opportunity to treat people. A lot of delayed gratification as well. Most of ya'll probably went to work right after college/masters, assuming you did one at all. Some doctors don't get out and make money till they turn 30. Some even later than that. A neurosurgeon has 9 years of residency training at least.
B) Time of entry. Having used some of these systems. They are a pain in the butt and not that quick. In private practice. Its much easier to write out a note than spend 15-25 mins trying to write an electronic note. Time is limited and using these data systems are not efficient for most physicians! Especially with all the overhead costs of providing care, most doctors do not have the time to spend more than 10? mins per patient. Anything more and they can't pay the rent or the staff, etc.
C) None of the systems are compatible with each other. For these savings to be realized, Every doctor and point of medical care would require the same software and access. That is not going to happen without any intervention from a big brother.
D) HIPAA sucks. Adds a lot of overhead, headache and costs.
E) DOs are MDs, just a different philosophical background on the cause of the disease. But in the end they are physicians. Nurse practioners are not doctors and will never be. They do not receive the same amount of knowledge and training. Average primary care physician spends 4 years in college, 4 years in medical school and 3 years in residency. NP does what? 2 or 4 years max? BIG difference.
F) Doctors are not the big problem here. Granted some do over order exams. Some do it to protect themselves legally. You know its not there,but you need a way to document that its not there when you get sued.
G) HMOs and insurance... can't be sued for making business decisions. Setup a lot of roadblocks to not cover patients and create as many road blocks to keep from paying doctors for service. I worked with a urologist. HMO basically said we think this procedure was worth $150 (used to be he got $1500 for it 10 years ago). Its a take it or leave it proposal. Then if he wants to take it, HMO requires that he personally call in and go through a convoluted phone system that costs him/her time and money. They want to make it as long as possible so that the person calling in will just give up that money and move on. Like a mail-in-rebate essentially
Re:Who keeps the records? (Score:2, Interesting)
I actually took part in a trial of a system like this at my local GP's when I was still at school. I've still got the credit card sized optical card that has a store of all my patient records at that time.
Don't know what the reasons for the demise of the project were, but carrying your own data around with you is exactly what people don't like about ID cards. It could also scratch easily and doctors had no access to the data unless you were actually in the practice with your card.
Centrally stored universally accessible (with applicable restrictions if you ABSOLUTELY need them) are the only way forward. Been knocked over by a bus in a strange city? Have medical complications that it would be just great if the Doctors treating you had access to?
NHS IT: last year's hardware at next year's prices (Score:3, Interesting)
So why not have the ability to "skin" the interface to keep the primadonna clinicians happy? Provide a 'reasonable' default interface and a tool kit that enterprising folk can use to charge the clinicians for making a bespoke interface for that clinician. The clinician then owns his own interface that he can carry around with him (on a thumbdrive maybe).
The system should obviously provide an interface that attempts to provide standard information in a standard way, but should also have the ability to step 'over' the standard way when the clinicians feel it is preventing them from correctly/accurately/fully writing up the patient notes. These occasions should automatically flag themselves up to someone in the "office" who can manaully glean the correct info to fill in the "standard info". It could also notify the writers of the software, providing a feedback loop to help to improve the software for future versions.
My experience of "IT in Healthcare" is the closed shop encouraged by the NHS which means you HAVE to buy from a very small set of approved vendors who then provide last year's hardware at next year's prices!
Why would anyone want to use lousy software? (Score:2, Interesting)
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.
I speak as a general practitioner of many decades, and I've been playing with computers since the early 70's. The main reason medical records software is not accepted is that it sucks.
My 24" screen holds far less information than a bunch of scribbled A4 pages. Time is what I lack, and scrolling through pages & sections on a screen is just not very efficient.
Yes, there are some great aspects in most of the software I have used over the last decade, but as far as being a place to store info that I want to easily access & collate later, all too often it is too bloody slow & awkward.
Except for one feature of electronic records, I would go back to pencil & paper.
The only really successful feature was the first; writing scripts & recording the fact that a script was written. In the 'old' days, you would write a script, then the phone would ring, on hanging up, you forgot to record what you had just prescribed, leading to problems down the track. Software to prescribe & automatically store a record of that transaction has been fantastically useful for both myself & the patient.
I have sat here for some 10 minutes, and the only other feature I like is that my notes are more legible to me down the track. As a computer nerd, I want to love these systems, but so far they are not very good.
Health Care vs FedEx (Score:3, Interesting)
Well, Fed Ex is a private entity with very little government regulation, while medicine is subject to government involvement all over the place. The government either pays for medical care (medicade, medicare), determines how it will be paid for (tax incentives) or mandates that it doesn't need to be paid for (get wheeled into any emergency room and they must at least stabilize you, or so I've heard). Government then regulates the tracking of information (privacy regulations - no such privacy regulations apply to FedEx package locations). If something goes wrong, government is involved in deciding malpractice verdicts and awards. From start to finish, government has its hands in the mix.
I remember reading about the difficulties the IRS had with automation due to the complexity of the tax code. Is it any wonder the medical profession would have trouble automating given the complexity of the rules associated with health care in this country?
A couple other key differences between FedEx and Health Care. First, most people feel no moral obligation to provide package shipping to everyone in the country.
Second, it is far easier for consumers to evaluate the effectiveness of FedEx than it is for them to evaluate the effectiveness of their medical care. With FedEx, you can verify that the contents weren't broken, and you can compare the speed similar shipments sent by other companies. That's easy. With doctors, well, recently someone I care about had an abscess in his neck. The doctor was thinking the pain was just lingering effects of a sore throat. But when it didn't clear up. he theorized an abscess and sent the person to the emergency room for an MRI. The abscess was found and removed by surgery that night. Did the doctor nearly cost this person his life by not recognizing the abscess until it was close to breaking through a vein causing blood poisoning? Or did the doctor save this person's life by recognizing the abscess in time? It's not so easy for someone like me to know.
Re:Electronic Health Records is very hard (Score:1, Interesting)
US only problem (Score:1, Interesting)
In countries with sane health care systems, the government forces the hospitals and practitioners to do exactly what you say: "making medical records available for data analysis might expose redundancy, over-testing, and other methods of extracting profits from the fee-for-service model".
They can do this, because the government is the one paying the bill. Optimizing the quality/cost ratio is an important part of keeping health care payable.
I guess the US has some catching up to do to stop all the abuses of private health care.
US EMR / POE experience - cynicism & skepticis (Score:1, Interesting)
The initial article's analysis of these complex issues is infantile and myopic. Referring to conspiracy theories to explain why everyone doesn't jump to the commands of those who push EMR is just paranoid, and gets about as much respect from me as the schizophrenic ED patient's reports of what the voices in his head are saying.
Disclosure:
I am an MD. After 4 years of college (undergrad degrees in math & chemistry), 4 years of med school, 5 years of general surgery residency, 2 years of fellowship training, and 3 years of bench research, I now have been an attending surgeon for over 10 years. Despite the below experiences, I was and am still an advocate for mature, reasonable, responsible, and efficient EMR and POE.
As an intern, I and my peers were subjected to the introduction of the first-ever system-wide "physician order entry" system. The best comparison might be the African-American patients "enrolled" in the Tuskegee syphilis studies.
The experience has been reported by Dr. Massaro, although a number of points are missing:
Massaro TA. Introducing physician order entry at a major academic medical center: II. Impact on medical education. Acad Med. 1993 Jan;68(1):25-30.
Massaro TA. Introducing physician order entry at a major academic medical center: I. Impact on organizational culture and behavior. Acad Med. 1993 Jan;68(1):20-5.
The so-called "pilot" project took all of the feedback from the resident physicians, which was 98% negative, and cherry-picked out the 2% positive responses to justify a full roll-out of the system.
To state that there were confrontations with the housestaff is putting it mildly. Many of us were computer-literate. The obvious inadequacies of the system and inefficiencies which dramatically took us away from patient care were persistenly NOT addressed for YEARS. Documentation of adverse patient outcomes and events rooted in the inadequacies and check failures of the system was universally spun around and regurgitated as a failure of the end-users to "understand" the system. The only way the end-users (residents, NOT attendings or administrators or nurses) were finally able to get any audience with the company representatives and the hospital administration was through confrontation.
The inefficiencies of the initial system were disastrous. As an intern on a busy surgical service, a typical day consisted of over 8 hours inputting orders at light-pen-enabled computer terminals located at central nursing stations and visible to the patients, who often remarked how their doctors did not have time for them but instead were "playing computer games". Shifting a SINGLE intern from putting in orders from the preconceived structured pathways (e.g. IV fluids -> D5NS, 1000 mL -> rate: 100 mL/hour -> start: now) to instead a simple free-form type-in (e.g. please start IV fluids: D5NS @ 100 mL/hour) shut the in-patient pharmacy down in a single day, as they had eliminated the capacities to handle any exceptions.
The housestaff voted to go on strike when we reached the point where we felt that continuing with the system was causing more harm than just shutting everything down; in the state of Virginia, we were classified as state employees and did not have the legal right to strike. Our initial access to free legal counsel options from the University's Law School students (imagine a free legal clinic run by the students) was terminated by the administration, so we assessed dues from all housestaff and created our own independent legal fund.
Ultimately, the only things that seemed to work to finally get our grievances with the system heard were:
1. the adverse patient outcomes attributable to the system being leaked to reporters for both local and national newschains
2. resident complaints to the ACGME and RRCs resulting in site reviews of all the residency programs
The system was revised, and by the end of my residency, was efficient and flexible to the point that it was
Re:Too few computers, too little bandwidth (Score:3, Interesting)
1) It is the software licence that make up most of the cost, not the hardware.
2) The second highest cost following the software is not hardware, it is the trainning
3) The third highest cost would be.... still not hardware! It is support
4) Ok, what about the fourth highest? Depends on department (Radiology have really fancy monitors, those don't count) it is usually networking and management
5) Finally we got to hardware, but vendors tend to have big issue with their software running on unqualified or untested hardware. You risk voiding your support or paying a premium for reusing old computers.
When he said "Computer", he really means "Computer, the software, the training to use those software, connection, and support when shit hit the fan". Not just computer.
Re:Electronic Health Records is very hard (Score:3, Interesting)
I would imagine the article submitter doesn't understand the concept of "other countries".
I could imagine providers overtesting in a US style pay-as-you-go system - the incentive is clear. But why would the NHS in the UK (OMG!!! teh sosherlizzum!!!!) do such a thing? And as you hint at, the NHS has a long record of failed IT implementations too.
I suspect the problem is to do with medicine itself - every case is different and partly the attitude of its practitioners - doctors are set in their ways and often arrogant.
Because the requirements are hard (Score:3, Interesting)
You have the following requirements:
1) Data integrity. This is very hard. Your typical programmer doesn't understand it. This is a disaster waiting to happen. I personally do not want my records in electronic format. See the disaster called electronic voting as an example now increase the complexity.
2) You need tight security of records. Electronic security is a joke. And who is liable? How many breaches have there been in the private and government sector in the past few years see this article: http://hardware.slashdot.org/story/09/06/25/0243221/Reporters-Find-US-Govt-Data-In-Ghana-Market?art_pos=5 [slashdot.org]
And security is orthogonal to ease of information sharing.
3) Ease of data sharing. A major selling point of electronic data is the ease in which data can be shared. But this is orthogonal to point #2. Also if data integrity is violated and the data stream becomes polluted, as in point #1, this is a major liability.
Getting all three of these major requirements is hard. Very hard. Probably harder than running tests or doing many surgeries. A simple screw up here can have ramification not just for one patient but for millions. See the nightmare called electronic voting to see what will happen.
AFAIAC, electronic medical records will cost more in lives and money than they will save.