Yves here. While this post on electronic health records may seem a big far afield of usual Naked Capitalism fare, it illustrates some of the themes we’ve seen in other contexts. The first is code is law, the notion that underlying, well-established procedures and practices are revised to conform to the dictates of computer systems, with result being crapification of the activity. Second is the distressing way that health care is becoming all about the money, with patient outcomes taking a back seat. This article describes in considerable detail how electronic health records, which in theory should reduce errors and allow for more consistent delivery of medical services, were instead designed only with patient billing and control over doctors in mind. As a result, they are if anything worsening medical outcomes.
By Informatics MD, a medical doctor, and medical informatics professional via NIH-sponsored postdoctoral fellowship at Yale School of Medicine. Expertise in clinical IT design, implementation, refinement to meet clinician needs, and remediation of HIT projects in difficulty in both hospitals and the pharmaceutical industry. Former Director of Scientific Information Resources and The Merck Index (of chemicals, drugs, and biologicals) at Merck Research Labs. Faculty, Drexel University, College of Information Science and Technology, Philadelphia, PA.. Originally published at Health Care Renewal
The Citizen’s Council for Health Freedom (CCHF) is an independent 501(c)3 non-profit organization with a mission “to protect health care choices and patient privacy” (www.cchfreedom.org/about.php).
Its president, Twila Brase, wrote this piece about Electronic Health Records in the CCHF newsletter of June 18, 2014, observing some “inconvenient truths” and highlighting one of the most asinine statements I’ve ever seen about computers made by (of course) a venture capital official who happened to play a significant role in formulating the Affordable Care Act a.k.a. “Obamacare”:
http://healthenews.cchfreedom.org/newsletter.php/148
The Truth about Electronic Health Records
Propaganda only works for so long. Pretty soon truth catches up to it. This is exactly what’s happening with electronic health records.
If you’re a doctor you know how bad the government-mandated electronic health record (EHR) is. But if you’re a patient, you may not realize that EHRs are endangering your life and jeopardizing medical excellence.
The EHR is nothing like what Big Government, Big Data, and Big Health said it would be. They promised convenience, coordinated care, fewer medical errors, more efficient medical practice, and portable medical records. They never meant it and it hasn’t happened. These data systems were created for billing, data collection and government control of doctors, not patient care.
From all I have seen over the years, I must agree with the last two sentences above. The pioneers who explored this technology back to the 1950’s warned against the nightmare that exists today, but I don’t think they believed we would ever get to where we are in 2014.
Further, while Politico did not explicitly mention risk to life and limb caused by these systems, Twila Brase did. “EHRs are endangering your life” is the elephant in the living room that the industry and its well-captured (and perhaps lubricated?) “regulators” simply will not address in a serious manner.
It has been my belief this reflects self-serving willful blindness, gross negligence and/or pecuniary motives, but I also believe that a fundamental malevolence on the part of people and organizations who know better increasingly needs to be considered as a contributor to the recklessness in the health IT sector. These are experimental technologies of admittedly (by the regulators) definite but unknown risk, due to impediments to that knowledge. Demanding their rapid diffusion under threat of penalty while knowing about the risks, and the uncertainty about magnitude, certainly does not reflect a benevolent disposition.
For more on the above points see my April 9, 2014 post “FDA on health IT risk: reckless, or another GM-like political coverup?” (http://hcrenewal.blogspot.com/2014/04/fda-on-health-it-risk-reckless-or.html) and its 11 points and hyperlinks. This post and its linked brethren represents an indictment of sorts against the health IT hyperenthusiast culture and the unprecedented regulatory accommodation enjoyed by this sector.
Arthur Allen at POLITICO Pro eHealth (http://www.politico.com/story/2014/06/health-care-electronic-records-107881.html) says government-imposed EHRs are:
- Driving doctors to distraction
- Igniting nurse protests
- Crushing hospitals under debt
“In short,” he writes, “the current generation of electronic health records has about as many fans in medicine as Barack Obama at a tea party convention.“
I guess that’s Politco’s way of saying “not very many at all.”
Doctors forced to use these EHRs say:
- “They slow us down and distract us from taking care of patients.”
- “We’re basically key-punch operators, transcriptionists having to input the data ourselves. It has essentially tripled the time to complete a medical record.”
- “That’s why I’m retiring.”
- “Before I took notes, wrote what I wanted to say. Now I write and I click. If you just click, the person who reads the record gets no idea of what the patient was going through, your thought process.”
- “Anything that in a normal world would take at most two clicks, here it takes four or five.”
In fact, doctors and nurses forced to use this technology say far worse (e.g., see my posts on candid clinician feedback at http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html , http://hcrenewal.blogspot.com/2013/11/another-survey-on-ehrs-affinity-medical.html , http://hcrenewal.blogspot.com/2014/02/ehrs-real-story-sobering-assessment.html , and http://hcrenewal.blogspot.com/2013/07/candid-nurse-opinions-on-ehrs-at.html).
Proponents falsely promised privacy. The real goal of Big Government, Big Data and Big Health was NO privacy. Data is valued as a tool of control and a means to profit. And today, 2.2 million entities today have legal access to your medical records without your consent because of the so-called HIPAA “privacy rule” and the 2009 HITECH Act. In addition, untold numbers of computer thieves, identity thieves and hackers have illegal access.
Not only that, but our data is sold in, in essence, data broker “back alleys” (e.g., see “Health IT Vendors Trafficking in Patient Data?” at http://hcrenewal.blogspot.com/2009/10/health-it-vendors-trafficking-in.html ).
Worse, the phenomenon of mismanagement of the “sales” is international in scope (e.g., see “NHS slammed for MAJOR data blunders as scale of patient info sell-off is revealed” at http://www.theregister.co.uk/2014/06/17/nhs_blamed_for_major_data_blunders_with_sale_of_patient_info_to_private_outfits/).
Every doctor and hospital must use EHRs by January 1, 2015 or face financial penalties. This was part of Obama’s 2009 Recovery Act, and the foundation of Obamacare. The sheer cost of the mandate has forced many doctors to shut down private clinics and become health system employees, susceptible to being told by outsiders how to practice medicine.
It has also led medical centers such as the University of Arizona Health System, about to undergo the stresses of mass immigration of South American children no less, to sink $30 million into the red in large part in trying to fix EHR bugs (see my June 2, 2014 post “In Fixing Those 9,553 EHR “Issues”, Southern Arizona’s Largest Health Network is $28.5 Million In The Red” at http://hcrenewal.blogspot.com/2014/06/in-fixing-those-9553-ehr-issues.html).
Next Ms. Brase reveals a stunning fact about one of the architects of that 2009 Economic Recovery Act:
The arrogance of some EHR supporters is unpardonable. Bob Kocher helped write Obamacare, was trained as a doctor and is employed as a Venrock venture capitalist in health IT, but his credentials are those of a bureaucrat and profiteer (http://www.venrock.com/teammember/bob-kocher/).
Unpardonable arrogance indeed.
In other words, a speculator and profiteer in the health IT sector helped in the formulation of laws that pushed the technology onto physicians, nurses and hospitals with CMS penalties for non-adopters of “certified” systems. It would be interesting to know just how far such a potential conflict of interest went in the crafting of the ACA and HITECH itself.
Beyond that issue, this venture cap issues the following perverse statement, as cited by Politico and CCHF:
Per Politico pro eHealth, he says, “The reason so many [computers] are inefficient is that doctors are inefficient. If they redesigned their workflows, computers would work better.”
Readers of this blog are familiar with perversity in health IT, but that statement is literally stunning. It would make for a funny Saturday Night Live or Rowan and Martin’s Laugh-In (to us 60’s folks) skit if the topic were not so serious.
If they [doctors] redesigned their workflows, computers would work better?
Where, exactly, is the evidence for that assertion? Exactly how should doctors “redesign” their workflows, considering the poorly bounded, conflicted, highly variable, uncertain, and high-tempo nature of the field? [1]
How can one even have a well-defined and unvarying “workflow” in such a domain that would “make computers work better?”
Answer: it’s impossible.
(Perhaps patients should adjust the unpredictable nature of their illnesses and symptoms to make the computers work better, too?)
What Dr. Kocher seems to turn on its head is the recognition that:
“The reason so many [computers in healthcare] are inefficient is that they are grossly misdesigned for a domain like medicine. They are unfit for purpose. If they [the IT companies] redesigned their entire process in HIT production (from conception, design, implementation, marketing, and support) to be consistent with the needs of the field of clinical medicine and of clinicians, computers would work
better.” – Silverstein
The reality is that if the healthcare IT industry actually fired its ossified business-IT-oriented leaders (since business computing and clinical computing are two highly different fields, e.g., see http://hcrenewal.blogspot.com/2008/06/business-v-clinical-computing.html), or relegated them to managing accounting systems, and embraced the teaching of 50+ years of Medical Informatics in building good health IT (see definitions of good and bad health IT at http://cci.drexel.edu/faculty/ssilverstein/cases/), then we might actually get significant value and better safety from the technology.
Mr. Kocher, that’s an idea to consider.
As I wrote at that 2008 post on business v. clinical computing:
… The prevalent belief in MIS [management information systems a.k.a. business computing] seems to be that medicine is another area of transactional business subject to conventional modeling by generalists, to be followed by “business process re-engineering” and traditional information systems development processes and methodologies.
However, the belief that one could employ conventional business-oriented “analysis” in the clinical world always seemed to me to be oversimplistic, overoptimistic, and in fact not infrequently harmful to medical practice as a result of the simplistic assumptions. It is a belief that does not perform well even in the conventional business world where significant cost overruns, project difficulties, and project failures are commonplace, let alone in the unforgiving environments of medicine.
My fear is that many in business computing may lack the mental flexibility and capability to understand issues like that, that conflict directly with their linear-flow, business-oriented worldview.
In other words, Mr. Kocher wants doctors to practice according to the computer systems he helped impose, not the doctor’s patients. We must never let his agenda for medical practice prevail. State legislatures must act now to restore patient privacy rights and use Tenth Amendment powers to undo the EHR mandate.
Exactly. It’s certainly the simple way to big profits, and injured and dead patients be damned. Building good health IT is far more resource intensive.
Working to sustain an ethical patient-doctor relationship,Twila Brase
President and Co-founder
Thank heaven someone is working towards those ends.
Notes:
[1] Per Medical Informatics researchers Nemeth and Cook’s “Hiding in plain sight: What Koppel et al. tell us about healthcare IT”, Journal of Biomedical Informatics 38 (2005) 262–263 available at http://www.ctlab.org/documents/Hiding%20in%20plain%20sight.pdf)
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There is no free lunch, no free healthcare, no freedom from unintended consequences. Every action or inaction, regardless of people’s intentions, has positive and negative consequences. This is true of healthcare. This is true of medical technology, including EHR. I am personally involved with EHR, so I can tell you, EHR has both positive and negative consequences. The negative consequences, are the price we pay (and we struggle to minimize) to get the positive consequences. Of course not all consequences are unintended … but I don’t have any insight into what happened in smoke filled meetings that I wasn’t invited to ;-) Those of us involved in patient records, no less than your doctor, struggle to prevent malpractice from even happening … and struggle to correct any errors that occur, but malpractice in medical records has happened and will continue to happen, regardless if your medical records are on paper or are computerized. Each form of record has their advantages and disadvantages. But I am not claiming that anything, including EHR, shouldn’t be officially regulated beyond the professional ethics we all aspire to … that is a political, not a medical decision.
As a physician, I can tell you that EHR are a complete nightmare, primarily designed to extract maximum profit through controlling the entire process. It is financialization at its very finest.
I work with doctors et al in a large clinic … certainly EHR in a small practice is prohibitive, perhaps even with $24 billion so far in government incentives … y’all don’t have any room for overhead. Increasingly, both because of EHR, but for other reasons, small practices are forced to affiliate with big hospital chains. But then the days of Doc and his black bag visiting the sick at home on his buggy … are well past us. Large hospital systems like Kaiser can make this work … though of course a bad implementation is just as big a threat for them as it is for anyone. Typically everyone who is a “booster” never amortizes the down-stream costs either, they think that once implementation is payed for, they are done. In fact once on the IT treadmill, you are going to be facing maintenance costs for hardware, software, backup, training, emergency continuity of operations … in perpetuity. Those are some of the negatives of EHR.
Sounds like someone’s bought “the man’s” flawed logic for the current EMR paradigm. Have to agree completely with “imperanence”. Been part of many meetings where the crucial point with EMR’s in the integration with CPT and ICD codes to maximize reimbursement. Increasing the wellness of the patient is NEVER mentioned.
If programmers were required to write and fix code with the same limitation on data collection and testing of hypothesis as physicians, we wouldn’t be having this discussion as there wouldn’t be functional EMR.
There are two reasons to have electronic medical records – to maximize reimbursement or to assist medical personal in healing patients. The first supports the excessive medical infrastructure. The second could potential result in true improvement of health.
Aside from the politics, even something as mundane as medical records face profound ontological questions (part of the standard tables in our EMR includes, as part of a hierarchy of medical terminology, an underlying ontology … think of it as axioms of jargon) … for instance … is the nature of software descriptively or functionally incompatible with the nature of medical practice … you mentioned the “limitation on data collection and testing of hypothesis as physicians”. Software isn’t even empirical, but ideal … “the idea aka algorithm comes before the thing” in programming, but medicine is empirical … “the thing comes before the idea aka diagnosis etc”. Probably worth an endowed joint department professorship at some medical school ;-)
For a good overview of EHR today that doesn’t hide the problems …
http://www.govhealthit.com/
This covers both the public and private sectors for the last several years. Though with a caveat … they are pro-EHR … so you won’t find a balanced presentation here … though I don’t think you would find a balanced presentation on an anti-EHR blog either. Are both optimists and pessimists to be barred from commenting on things … or are only pessimists allowed? Hmm?
And no, I have nothing to market or sell, I am in operations directly supporting clinical and admin staff.
You read very much like somebody trying to rationalize his or her livelihood. You have my sympathy. Time are tough and work is hard to find.
I just visited a new doctor in a small group practice. I noted their lack of EHR’s and the doctor told me that they had just discussed the issue and decided against due to the problems involved and lack of patient interaction they entail. They have decided to take the financial penalty rather than use them at this point. Words for my ears!
Doctors are fighting back, but not enough of them. It is reminiscent of the statements made when Obamacare was launched. In the long run, can you fight city hall? I hope so as I do not see a good end to this. Combine EHR’s with the requirements for ICD-10 coding and disaster looms.
This is a biased rant. On the bad side: EMRs are clunky, waste time, etc. On the good side: eprescribing has made prescribing easier and more user friendly to patients and docs alike, has reduced errors by automatically monitoring for e.g. drug/drug interactions, and have reduced abuse of schedule II meds. Another good thing: in the next few years interoperation of emrs will become the norm. That means EMRs will talk to each other. That means if you are in an ER while on vacation in Alberquerque, the ER doc will be able to get your med info immediately. That means cost savings from no duplication of tests, etc.
The implementation of EMRs is painful and a mess. But the black and white picture is intellectually lazy and does not reflect the realities of EMR implementation in the US.
Oh, really? Just because EHR can produce better medical outcomes (I’ve seen good implementation in Australia) does not mean that that is what is actually taking place.
In case you missed it, the author is a recognized authority and provided citations. He also has ample experience in the field. And he has reports from clinicians and data to back up his views, while all you appear to have is faith in technology. From an earlier post:
So in other words, the implementation of EMR had nothing to do with improving patient care. Nada. It was all about the money, supposedly improving doctor’s ability to get money back from insurers and helping the government catch cheats.
And if you think I’m exaggerating the risk to patients, the latest ECRI Institute report puts health care information technology as the top risk in its 2014 Patient Safety Concerns for Large Health Care Organizations report. Note that this ranking is based on the collection and analysis of over 300,000 events since 2009.
ECRI did an earlier deep dive on the health care information technology issue in 2012,. †he results were not pretty. The Institute found 171 technology-induced problems were reported in 9 weeks by 36 “facilities,” which were mainly hospitals. Eight of the incidents resulted in harm to the patient and three may have contributed to deaths.
Health Care Renewal gave a back-of-the-envelope calculation as to how to extrapolate these results to the US as a whole:
http://www.nakedcapitalism.com/2014/04/health-care-information-technology-danger-physicians-health.html
Geoff Gray’s longer post, below, reads like an ad or press release. I wonder whom he works for.
Where is the ‘up-side’ if patients can’t get in the door? If you question the ‘Glitch’ possibility just follow the perk:
Canada: Province-wide electronic medical record computer system ‘glitch’ causing patients to be turned away from care
“Originally to encourage physicians to move to electronic medical records, the government gave a monetary incentive. Alberta Health selected TELUS Health Solutions Wolf EMR after a request for proposals in 2008.
There was a requirement for the service to be available 99.9 per cent of the time between 6 a.m. and midnight with financial penalties for failure to do so.”
http://medicinehatnews.com/news/local-news/2014/06/10/system-failure-has-docs-patients-upset/
In a “few years”? Doubt it. I use EHR software. When I receive a patient from another healthcare system that uses the exact same software comes to me with medical records some of the information transfers in and some does not. I then have to go and manually enter everything that does not transfer, such as a patient’s allergies and medications. This is because the software is customized for each purchasing system and if the information does not exactly match what my system has as a clickable option then it chokes on the information. I have to go in and enter the data in a way my system accepts. The patient often cannot remember exactly what they are taking or how they reacted to something on their allergy lists so I put in my best guess. The patient will receive medications in hospital based on the data I enter, hopefully I guessed well. That is the reality of implementation of EMR.
There is no question that there are positive aspects concerning EMR [legibility, in and of itself, is a wonderful thing], but the bad things are SOOO bad that it makes their implementation analogous to taking out the proverbial sledge hammer to kill a gnat.
The insurance companies [banks, by any other name] crave complete control. In order to extract the maximum amount of profit, how better to achieve this end other than controlling the actual care provided. THIS is what EMR is really about. Whomever controls the design of the record itself, controls the care.
At present, the insurance companies achieve this by deciding reimbursement levels for various exams/tests/procedures. What they really wish to control is is the process by which you arrive at said exam/test/procedure. It is the record which is your road-map, that is, you must show a, b, c, before you can do d. If they control the record, they can make sure that the map is changed to insure that detours are inserted that favor their financial positions. The possibilities are limitless, and just think about the bidding wars that will ensue among the technology companies to have their ‘stuff’ included [or have others eliminated].
Health care is one area where it should be obvious that technology is NOT the answer. Real health care is about human compassion, only achieved through getting to know the patient and their needs, counseling and empowering them to take care of their own needs.
Again, the notion that you can repair everybody’s body parts is absurd, a utopian corporate fantasy playing on the ignorance of a population completely obsessed with momentary pleasures, and with a tremendous fear of that which is inevitable. Only when people begin to take responsibility for their own health [care], will they begin to see that, like everything else in life, the answers lie in their own behavior.
Computers are ruthless by design. They can account and respond and supervise but they can’t “care”.
Next week, I have an appointment with my physician. I will RESPECTFULLY ask her not to enter data or look at the computer screen during my visit. I have noticed that during my last four visits, she has interfaced (looked at, touched) the computer much more than she has my body!
do insurers already have access? it would make perverse sense in the us system to allow insurers to see the data: greater efficiency in quality control, transparancy in contolling, improved care. and cherry-picking.
Yes. I believe under the ACA if your insurer pays (as in you hand over your insurance card at the time of the office visit), they get the data. I’ve been making a point of paying myself and submitting for reimbursement. Since I have an indemnity plan and operated that way on this same policy for over 20 years, you’d think it would be OK, but it now creates all sorts of havoc if I see providers in their network.
Yves,
Great article. Can you elaborate on what you mean by “but it now creates all sorts of havoc if I see providers in their network.”
Only 2% of the insurance plans now in force are indemnity plans. That means I don’t have to go to someone in a network. I can see any doctor with no gatekeeping. So in my case, I can see non-Cigna doctors as well as Cigna doctors.
When I see non-Cigna doctors, the claims are processed correctly (when they are processed…..Cigna has this trick of not processing some claims and hoping I don’t notice). When I see in-network doctors, they try getting the network discount (which I am not certain they are entitled to given that my plan is not a “network” plan) and wind up imposing other restrictions on what is covered that aren’t in my plan (like on preventative care, when my policy doesn’t distinguish between preventative and therapeutic treatment).
This is just like MERS. What is administratively convenient for Cigna is trumping my contract. I’ve taken this up with my state insurance bureau. NYS tends to be tough, but they are also totally backed up, I assume due to Obamacare.
Technically under HIPAA … if a lab or other entity is a “business associate” … and perhaps some insurers are counted as such … then they are under the same restrictions as the original provider. That is as much protection as one can currently get under law. Also a patient has to sign a “disclosure” agreement as part of their care … which basically covers the original provider’s legitimate internal use, as well as reasonable (the rule is, the smallest amount of patient information as necessary for the function) sharing with “business associates”. Have you ever signed a “disclosure” agreement?
If an insurer needs more info from a doctor to see if a treatment was necessary and customary, I believe insurers could always get that info. HIPAA may have formalized that and could have liberalized it some. The provision I am talking about came about via Obamacare, and I believe it allows for transfer of all patient medical info to the insurer. But I can’t find where I saw this described, so my recollection may be off in key details.
American health care is very complicated, and Obamacare made it more so. I would certainly oppose complete medical record sharing with an insurer (or any other non-physician) under any system … as it is I was just told that the new medicine my mother was prescribed … displeases her health insurer, and they want her doctor to “explain himself” before they will back it … sounds like a Maoist re-education session to me ;-( The old medicine wasn’t working very well, and the doctor agreed to a different medication as an experiment. Good thing all the health insurers are licensed doctor police ;-(
A problem with the article is it leads you to the conclusion–throw the whole thing out. Rather, what is needed is an assessment that looks at the shortcomings of EMRs. And you shouldn’t have to look to the footnotes to make the argument. One of the big complaints of docs is that EMRs don’t help them in everyday practice. Surveys show that one of the things docs want is interoperation–which would liberate data, enable coordination of care, take information out of silos, etc. (BTW big EMR companies have been slow to adopt interop because it would empower smaller EMR vendors). That is now being implemented in the next wave of Meaningful Use. My point is that this is not black and white. And that the writer is a “recognized authority” doesn’t work for me.
Having had Chief Information Officers as clients, that is typically the only remedy. You just don’t want to hear that.
And what basis do you have for your cheery views about integration? Doctors are not driving this bus. And integration across systems that weren’t built with integration in mind is a very difficult and costly task. To wit: In Fixing Those 9,553 EHR “Issues”, Southern Arizona’s Largest Health Network is $28.5 Million In The Red (http://hcrenewal.blogspot.com/2014/06/in-fixing-those-9553-ehr-issues.html).
Citations of successful examples, please.
I suggest you read his site. He’s addressed the integration issue as well.
Some typical comments:
Finally, note that EHR oversell and exceptionalism has been going on for decades. Donald A. B. Lindberg M.D. (http://www.nlm.nih.gov/od/roster/lindberg.html), Medical Informatics pioneer and Director of the U.S. National Library of Medicine at NIH, observed in 1969 that:
Yves, one suspects that there are numerous Electronic Health Record implementations world-wide. If we are convinced that the one prevalent in the US is bad, why not just pick the best of the rest, bring it into the country, and roll it out. It is just code, after all, and working code wins.
Of course, make sure it is Open Source so that it can be maintained by the community rather than some proprietary rent-seeker.
little evidence available that the us learns from others, especially in the health care field. the status of insurers within the system is arguably decisive as every interaction has a price and those who pay ultimately want to influence pricing. in this regard the us has no referents. contending models run some variant on single-payer or public health insurance. interestingly public models run blind admission as efficiencies result from demographic breadth, not from cherry-picking. therefore participation is mandated – everyone must be in, and we won’t ask any awkward questions while processing your registration.
1. The US does not every learn from how other countries do things. I’m not making that up.
2. No other country has private insurers inserted in medical care the way we do, and that means any software program would have had to be substantially rewritten to allow for that.
3. As the post indicates, the object of EHR is billing, cost, and management-of-doctors related, not care related. It’s been presented as having something to do with patient care to make the recording of detailed patient information look acceptable to the public.
As an activist who focused ten years of my life on this issue after the medical-industrial complex killed my husband, I now respectfully suggest that way too much time is spent analyzing, dissecting, and explaining all the grotesque shortcomings and outright crimes of the US healthcare system. Why not spend our energies on changing it to a public single-payer system instead?
Oh. Because corporate personhood. Well then, let’s focus on changing THAT. http://www.movetoamend.org
Any EHR system primarily designed to reimburse and/or supervise providers inherently places patients as subordinate stakeholders.
If physicians are whining about the problems in EHR technology adoption, it is probably because as a group they have yet to subordinate that technology to their pecuniary interests, as they have any number of new medical testing, procedures, pharmaceuticals, and devices.
If medical records are so crucial to a physician’s efforts, why have the myriad medical professional associations abdicated a collective responsibility to create a patient-first oriented EHR system, instead leaving the task to those individuals, institutions, and corporations possessing no professional duty or financial self-interest in doing so?
So three dentists fund a computer company…
An average bespoke line-of-business ensemble application for the small to medium business costs on the order of USD100k to complete using domestic labor. Compare this with the average practicing professional’s means and imagine how many of them are likely seed investors with some whole percentage of skin in the game. Personal responsibility first!
In the overall scheme of things, ‘interoperation’ is a rather trivial side benefit which is being heavily touted to obscure the Big Data objectives that are really driving this campaign.
Its Orwellian deceptions are symbolized by the ubiquitous HIPAA form thrust on patients by doctors offices, which purports to be about privacy, but in fact is about destroying it.
Since I object like hell to Big Data, I always monkey-wrench the system with scrambled SSNs, specifically to defeat interoperability, Nasper, and the rest of their toxic medical spyware.
As an IT professional I can assure you that the phrase ” liberate data” is Orwellian to the core.
Dehumanization of patients and healthcare givers is a feature, not a bug. Can’t have those pesky human relationships gumming up the system. Think: Divided and conquered.
21st century health care cannot continue with its 20th century paper records. Sharing, data collection, consultation, help with diagnosis, communication with health care insurance companies can only be done electronically. The virtual demise of the paper checks was not opposed by many. The attendant finalizing you flight detail at the airport mysteriously types in for minutes on end is not attacked as distraction and inefficient.
EHR are a must and will stay. Since medicine is more complex than individual banking and buying a ticket, EHRs are way more complex. Most of the EHR products are lousy, most physicians are set in the old ways and Ford’s Model T is not similar to Ford Escape.
There is no choice! There is no way back! We as patients, with our negligible rights, and our physician should demand fast improvements in EHRs. It’s more than doable. I see my share of physicians, undergo more than enough tests and even get to the ER every few years. The care I get was not negatively affected by EHR. The major negative aspects in the care I get now as opposed to a decade ago are: it costs me way more and the health insurance company has cut down on the time spent on care by providers and the number of allowable providers.
The financial and institutional incentives for creating a workable EHR system currently are against the ideal doctor-patient relationship, and therefore against best health care. If it’s a simple matter of making records available in a more convenient form (not the case in every situation) that’s a good sales pitch. But the incentives dictate maximum complexity, minimum security, and maximum cost. So that’s what’s being built.
Using a computer net to replace a records clerk sounds reasonable to our information age ears. But if the agenda of the system builders is entirely financial, the system will be created to maximize financial control and therefore benefit. The practice of medicine being by nature non-financial, there will be in conflict. We’ve been pitched information science as a servant, yet it ends up being the master.
Information efficiency is a lovely dream. One of the hallmarks of a tyranny is that the dream world of the rulers counts more than the real world of the ruled. A lot of people end up surprised which world they live in.
The clerk is replaced by the doctor.
There is no free lunch.
The amount of time spent by doctors looking at and clicking on their little pads is getting ridiculous. I suspect it would drive me batty to do that as a doctor. I’d want to hire an “apprentice” to do all that pointing and clicking–of course, that ain’t gonna happen because the big hospital or big practice would call that an unreasonable cost.
1. there is not one ehr in the marketplace. ehrs are not one gigantic system. there are hundreds. the market will kill some off. maybe the govt promotion is premature. and maybe the system needs to evolve more organically in response to docs and business.
2. but progress because of standardization has been significant. and limited integration–communication about a patient via interoperation–has been achieved using standard protocols, irrespective of the ehr used.
70% of docs now use EMRs. in some states like Mass > 80%. to interoperate (i.e. exchange information) you need a critical mass of docs using emrs that can talk to each other. MU 2 (2014) requires communication protocols. by 2015 all EMRs in the US that are ONC certified will have the ability to interoperate.
interoperation will be fairly simple at first–sending a basic clinical summary e.g. dx, problem list, meds. this first iteration will/is being rolled out now and will become universal by the end of 2015. more sophisticated querying of medical record data bases will probably not come about until 2017 at earliest with MU3.
see
http://www.healthit.gov/buzz-blog/electronic-health-and-medical-records/direct-implementation-guide-support-interoperability/
http://ehrintelligence.com/2014/03/17/will-and-how-will-interoperability-be-achieved-this-year/
http://www.healthcareitnews.com/news/mostashari-3-interoperability-questions
Physicians and especially highly-paid specialists have been hollering “government control” ever since the government sought to implement public healthcare. They have been one of the major opponents of single-payer health care but continue to get their annual Congressional doc-fix to Medicare/Medicaid rates while still refusing to see Medicare and Medicaid patients — and insisting on co-pays and balance billing.
This Politico article smells of an attempt to use concerns about NSA’s data gathering to frustrate healthcare reform.
EMR systems are a good as the providers want them to be. And most providers are not willing to delve into the details of their operations enough to get good systems. Which is why the nurses and doctors (the “users” of the systems) hate them.
And then there’s the sunk costs of existing poorly constructed, custom-developed legacy systems that have frozen the provider’s past idiosyncratic ways of operating that make adapting new best practices difficult or impossible.
As far as the indebtedness it is causing providers, major health systems could deal with that by reducing the pay of its top level executives.
Simply declaring that the problem exists between the keyboard and the chair is a bit of IT snark that covers up bad interfaces, unrealistic expectations, and often, poor implementation. It’s more office politics and lading on hidden costs. But we’re Americans and we like to blame the victims.
We’re talking about providers who already have a job. It doesn’t matter to the patient if a doctor or nurse can operate a feature-heavy system, it only matters to the layers of managers who feed off health care. The insurance industry drives most of this information-gathering, along with health-care managers.
It’s a common-sense reality that health insurance isn’t health care. It’s also obvious that the health care industry isn’t really about health care, it’s about industry.
Thanks for addressing this. There are at least three major problems with the current EHRs.
First, they interfere with doctor communication to other doctors. The billing driven data entry, the clicking of boxes related to different organ systems that often have nothing to do with the chief complaint and needed care creates a report for the next provider that drowns out the needed information to provide and coordinate good care. See e.g. here, http://www.kevinmd.com/blog/2014/04/brevity-soul-good-emr-note.html and here http://www.kevinmd.com/blog/2014/04/brevity-soul-good-emr-note.html.
Second it eats time in already shrinking patient appointments and does interfere with building relationship. Without that trust, information may well not be shared at all. Again care suffers.
Third, the financial and administrative burden of providing and managing these records could be deadly for small practices. There is a huge market opportunity for an it provider who could sell a simple EHR with technical support at a price point that worked for a small practice, but that’s not what’s currently on offer.
We no longer have independant pharmacists in the US by and large. The vast majority of farmers are in hock to the seed companies. The independant retail store has shrunk beyond belief in the last 50 years. Doctors are afraid they are next.
Another issue of interest is who owns and profits from the consolidated medical practices. Attorneys have laws to protect them, usually something like only licensed attorneys can hold ownership interest in a law firm. The policy justification is that a business person who is not an attorney would fail to respect or comply with ethical obligations and would instruct attorney employees to violate them. There really should be a public interest movement lobbying to get the same or better protections for doctors.
Excellent comment. It is fundamentally an IT design issue. It is a business process issue to the extent that micro-managed fee-for-service accounting to squeeze maximum revenue drives the inclusion of non-relevant checkbox options.
No there my friend – it is at the root a PATIENT issue first. Tech be damned in this instance!!
On balance EHRs offer opportunity for higher efficiency, better care and better value per health care dollar spent, regardless of the naked capitalists that will implement it (and they will surely be involved because that is the way our country does things). This particular essay raises some questions worthy of attention, but is also one-sided, rather than balanced (it mostly cites political sources rather than public health peer review studies). It’s not wrong to point out negative outcomes, but the authors sure left out all the positive benefits and driving reasons for the EHR. Not having it is one of the reasons the USA has fallen behind other nations in health care efficiency and outcomes. By itself EHR cannot overcome all our problems, but they can sure help us when implemented well.
Here are some more likely outcomes privacy advocates might feel weird about … your care and outcome might be pooled with that of others to conduct evidence based research studies (but – hey – that already happens without your knowledge believe it or not by hospitals, insurance companies and Medicare). In rural areas of the USA, primary care physicians will be able to share your patient record with specialists halfway across the country saving you a 500+ mile trip. You’ll be able to access the results of your own tests online, getting the full details and becoming better informed about your treatment choices if you’ve the mind for it; you can even print out these test results and share them with another physician of your choosing for a second opinion. Your doctor’s decisions will be more transparent (or did you think this was unnecessary?). If you have complex conditions, they can be better coordinated. You, too, will be a direct financial beneficiary.
Smaller doctor offices may have the greatest hurdle with this change though as it requires a capital investment and careful selection of the implementation. Quite true.
It really isn’t about EHR, it is about training the health care workforce to better manage patient care through transparent records, the adoption of evidence based science and stuff like that. If doctors and workforce only see the part of EHR that is extra work for them personally, an inconvenience for them, an opportunity to bill the heck out of someone or other, then they have seriously misunderstood the purpose, opportunity and utility for better patient care and better value; there is an educational gap — wrong program, wrong staff or wrong attitude such that somebody truly does need re-training.
What really upsets me more than EHR is how many physician/hospital errors have killed/injured people in the past and then been swept under the rug with non-transparent systems and claims by hospitals that they must maintain patient privacy – oh yeah, when family and/or lawyers come to inquire about an unexpected bad outcome, but not when it suits them to mess with your records and bill your procedures in the most costly way conceivable to the Medicare fee for service program. By some estimates, one in 5 deaths are caused by physician/hospital errors. Don’t be so quick to get huffy about a little more access and light into hospital decisions/behavior/procedures. It could save your life.
Who do you work for? This sounds like an ad.
On balance the theory of information efficiency sounds good but the reality is pretty messy. It generally turns the user into a slave, requiring jumping through lots of hoops irrelevant to whatever job the user’s really doing. Gathering management/accounting information becomes just another work duty that generally takes away from the primary duty. Non-operational managers don’t see anything wrong with that.
The dramatic anecdotes of lives lost for lack of one bit of information are rare, when they’re not fiction. Most doctors kill their patients with good old fashioned incompetence, along with standard practices that don’t work or are actually harmful. That bit of information won’t save any lives.
The dream that a high capital spend will pay off with more efficient operation has been sold for decades. And, some day, it might really pay off.
Ya know folks – this world we live in is utter madness – Thinking that databases, MOAR information, more tech and the endless stream of information will somehow solve our problems and make things all better is fallacy – we live in madness and it is getting madder and madder everyday!! Wake up – slow down – live abundantly and f….the slavemasters who would want you to live curled up in a corner where they can simply keep an eye on you.
Wake UP!!!!
The tail end of this article is oddly, but understandably, naive about business “informatics.” He seems to think it’s actually well fitted for use. Evidently he’s never seen bank tellers struggling with the latest version of their software.
My son is a computer jockey, specifically in Computer Assisted Drafting for a large engineering firm. He uses two different programs, both long-established in the field and presumably highly refined. Both drive him crazy; he can spend hours trying to make the system do what it’s supposed to do. His biggest complaint is with updates that screw up a feature that was working (“crapification,” yes).
Maybe EHR is just a bad idea, though the allure is pretty obvious. For instance, anyone who’s changed doctors has struggled with records transfer. Of course, if you make that too easy, the whole world has your medical records.
The implication here is that Obama’s push for EHR is yet another example of outright financial corruption: what sounds like a good idea is really make-work for software companies that aren’t nearly ready for prime time.
What a surprise.
As a healthcare professional in the blood transfusion area, I can only provide my experience that the systems that I have worked with that are interfaced with system wide IT are wonderful. As people are living thru tramatic incidents – planned or unplanned, they require transfusion. After that, they can developed antibodies, that can kill people. Today we see more of these folks and the amount of work to provide a safe transfusion increases. No, O Neg blood is not the panacea that is floating outside my sub speciality. Having the patient’s history available immediately via electronic record actually saves lives.
There is no perfect world – some IT systems are better than others. Take a gander at the ICD billing codes – anyone who believes that they are a walk in the park, either manually or electronically are being disingenuous. And demanding that they be done by hand is absolutely BS. Physicians will always complain and have repeatedly about EHR. Interestingly, if they worked with IT, they can set up their own special set of differential diagnosis tool, they can set up a specialized set of comments – that more suit their most common pathways. (yes they do have a way of thinking / processing information).
Are EHR’s perfect: NO! what is? Now if you want to revisit the 50-60’s please feel free, should you also expect 21 century medicine wrapped in that visit – nope! Think of the physician complaining about data input and then complaining when they don’t have instant access to results – which is data input by others or via electronically linked testing systems.
I went to a new (to me) physician three weeks ago, and as part of the new-patient intake process was asked to read and sign a “Notice of privacy policies.” The document was two full pages single-spaced and the section entitled “Our right to notify third-party institutions and agencies about your health information when necessary” had some interesting clauses. These included: “We may disclose your health information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. We may disclose your health information to authorized officials so they may provide protection to the President and other governmental leaders, or conduct special investigations.” I brought this stuff up with my doc who said he was unaware that these disclosure assertions existed in his firm’s new-patient paperwork, and that he thought the government would have to present a warrant to collect data on a specific patient. I didn’t agree, but the doc was a good guy, and after a fairly long discussion I ended up commiserating with him, telling him that being a data collector for the government was probably not what he signed up for when he took the Hippocratic oath. He agreed with that!
With EHR and our government’s apparent surveillance philosophy of “collect it all,” I assume that before too long they’ll know even when my allergy medication dosage changes. I will certainly assume there’s no guarantee of confidentiality when I discuss my health with my doc’s.
I and my household have been Kaiser members here in the DC area for 4 years now. I have no complaint. The doctors handle entry, the records are well designed, and communication with those on my panel of docs has been good–quick, certain, and complete. No problems. Ask the doctors.
Bespoke software is a more affordable item than you might think. It’s within the means of a half dozen doctors in a joint practice to commission an app perfectly tailored to their own use. A firm like Kaiser would be silly not to do this unless there were a perfect fit right off the shelf.
Kaiser is way ahead of any other US healthcare major, because it’s the only one. Other majors are insurance companies that happen to do health. Kaiser has a mock hospital in Oakland (CA, their hometown) where they test new tech and train people.
My first Kaiser visit, my doctor got two other docs on the speakerfone (different specialties) and we lined up a prescription regimen. Then I waited for the ‘roving dermatologist’ who does not do appts., just wanders around the complex on call. Whole visit took about three hours. I walked out in shock.
And, yeah, I’m in healthcare IT now but way deep in the billing end. Don’t blame me!
Another concern I have about EHR is that all when data is not stored locally there are more system vulnerabilities. In theory there are more ways to have backups, but my confidence in all our infrastructure is nevertheless declining. Just like we assume the availability of food on the shelves of our stores, and power coming out of our sockets. As a society we take a lot for granted, and don’t recognize that our current vision of “progress” forces us to take rely more and more on the things we take for granted.
I’m one of those resistant docs healthcare IT people always blame for their failings.
My specialty is entirely computer-based; we interpret the heart’s electrical signals and manipulate them to make them clear, treat them with sophisticated computer systems to generate 3D pictures of the inside of the heart and find their “short circuits”, use RF energy to burn their short circuits out inside the heart, or implant and program microchip-based pacemaker and defibrillator devices that treat them automatically. And you know what? These systems are unbelievably good.
So I am considered computer savvy by my group in part because I find it so interesting, and no one was surprised when I was the only one in my large cardiology group happy to embrace speech recognition as something fun to learn…and have been struggling with it ever since.
It’s ludicrous. I retrain constantly. I can’t even get it to consistently put periods at the end of my sentences, whether I ask it to do so automatically, (periods land in the middle of the sentence), by saying “period” or “dot” when it just prints the word period or dot or just gives me a question mark, or any other way. In the meantime, they are paging me to take care of a real patient with a real problem, like a cardiac arrest, while I struggle with punctuation. Some of my colleagues have put an automatic disclaimer at the end of their dictations to the effect of “take this document with a grain of salt because it was generated with speech-recognition software, and is prone to non-sensical phrases and statements”.
I always assume there is a better way to do I just don’t know of. But I call our IT people at the hospital, and often the answer is “we have been struggling with this, you are not alone.” And sometimes there is a solution which works, a workaround, but it is not intuitive.
The same goes for all of what they commonly call “healthcare IT” out there. It’s terrible. It’s obvious no one paid attention to medical design when the computer asks me what dosage form to give a common drug…when it can only be given orally. Or asks me if I want to save data, when I just did. Or asks if I want to close all tabs, then makes me do it anyway, click after click after click…..it was just stupidly designed, that’s all. Nor is there any real attempt to provide user friendly interfaces; we can see all our ECG rhythm strips online, but we have our staff print them out because it’s too time consuming and counter-intuitive to get them on the screen.
I want to re-iterate. I can thread a catheter into someone’s heart, find and eliminate a short-circuit making it race at 200 bpm , then send them home the same day, all with gorgeously-designed computer systems. Then I step out to write their discharge orders or dictate a summary, and struggle with it. Because that software completely sucks.
Clearly, there are people out there who can anticipate clinical needs and design a program around those needs. They just don’t predominatek in healthcare IT.
And they are making everyone use it.
Since working in healthcare IT I’ve learned something about Doctor’s Guild: it had total control over healthcare govt. policy but is losing it. If you can’t cut people open & prescribe drugs, doctors in govt policy won’t talk to you because you’re clearly unqualified to have any opinion about how healthcare works.
We’re seeing a general struggle to break the Doctor’s Guild, unacknowledged by all and possibly only funded by a few people. It’s the strongest union in the US because it’s not a union, workers & mgmt are all on the same side. Very German.
It’s fascinating to witness the tragedy of the petty bourgeois in real time. Even the very strong doctors’ profession is getting proletarianized and forced to submit themselves to the larger capitalists.
As a commenter from non US country which has EHR for a long time implemented, and as one who has plenty family members as doctors using it I can sum a few things, and please don’t take offense of those.
1. Doctors do not like technology. Period.
2. The older the doctors are, the less they like technology and the less they adopt technology.
3. Not all technology is great and there are a lot of problems, bugs and pitfalls with every software of large scale – EHR not excluded.
4. The added benefit for the common good, over the long run is much greater in EHR than the pitfalls.
5. With that said EHR requires the doctor to adapt the way they check patients to time constraints and to computerized models. The doctor can’t just write what he wants but also has to follow a standardized process which later on helps gain aggregate insights on treatments, mistreatments etc`.
6. Computer slow doctors down in the beginning, but as they learn (those who decide to embrace technology) to use them correctly they gain a lot in productivity.
7. For MOST common medical professions, physicans, pediatricians etc` in my opinion about 80% of the work is secretarial (excuse my English I might have needed a different word here) work – whether you like it or not, a pediatrician mostly treats kids having standard viruses with standard treatments and so does the physicans with grown ups. For doing work which is very similar over time, a computer can do and will do a better job than a person, and will be able to accelerate the time it takes to examine and “checkout” a patient. EHR will and does allow faster access to the medical history and can automatically raise flags instantly which the doctor might have caught or missed (all humans make mistakes some times).
With the above said I cannot say that every patient will benefit from the use of EHR, but overall this will improve the situation – whether you like it or not.
I can also say that doctors are mostly very conservative and HATE change, especially change which comes from technology – most doctors (all over the world) studied very hard and worked very hard to get where they are and are afraid of anything which might harm their status.
Given the above EHR are good, mistakes are probably made and will be made – but on the long run patients, doctors and service providers will benefit from them.
Since EHR in the US is a billing classification system and not a medical classification system, no. It won’t get better. You gotta know the territory, in the words of Professor Harold Hill.
Agree completely.
The reflex is to blame the doctor. The doctor hates technology.
I’m an older doctor and I love the technology, as do my colleagues, as long as it is useful and advances patient diagnosis and treatment.
If doctors hated technology, you would have heard us complaining when CT and MRI scanning became commonplace. We didn’t , because it opened up huge windows we’d never had access to before. It was not easy to learn, but the value was obvious and no one complained. In the cath lab we love good fluoroscopy machines and drool at the idea of getting a better one.
As I explained above, the sophisticated technology I use to crack the code on short circuits in the heart is
gorgeous and I love it. So do all my colleagues who work in the same specialty. That form of healthcare IT works. Our old radiology program lets us manipulate X-rays in so many ways I can see a needle in a haystack. I love it. That’s real healthcare IT. I deal with advanced computer technology for a living and most of it I love.
Then the EHR mandate came, and WTF?? Who designed this stuff?? I don’t know how to make this point without you blaming me for being a troglodyte doctor except to say; take it from someone who knows, it really sucks. It just does. I have no interest in offending the code writers; I don’t know the political mileau or instructions they received when it was made.
In its defense, I can batch out orders in a checkbox fashion that are rote much faster than I could write illegibly by hand. That works. For simple, rote order sets.
What’s missing is any sense that the user interface is important. All it would have taken is someone with a medical background to go along with the program writers and say “no, make this step like that because you will just slow the care process down needlessly”, or “make this result stand out in red, that lab result is very dangerous, can’t just be buried in a list” and so on. Then before these programs are released, doctors and nurses should have beta tested it extensively. At that point you would have gone completely back to the drawing board. It is just painfully painfully obvious when we work with this stuff that it’s stupid software. I don’t mean that offensively, really…..it’s just what I can’t help saying when I run into a new problem…”this software is so klunky and stupid.” And it makes me think that literally 20 or 30 times a day.
The only comparison I can draw is the old DOS programs that IBM had, in comparison to the apple. Anyone who used the apple would say “Why would you use DOS, it sucks” and they were right, and everyone knew it. Except at least DOS functioned once you learned it, in the way it was supposed to, and did better with scientific applications. But the EHR is that inferior in the user interface but without any of DOS’s redeeming values. And in addition, it just does such painfully stupid time consuming things for no reason, even after you learn the “code”. As if the coders chuckled when they made it and said, “this is funny…he’s going to spend 5 minutes doing this step but I could have written it for him to do it in one click. He’s going to be so ticked!!”
Of course when it’s too time consuming, I can’t think enough about the patients, the real reason for me to be here.
I don’t know if it can be fixed in the US, or as Yves suggests, may need a do-over.
I wrote an EMR in the early days when it was exciting and all of us were learning, but payers took over and that’s when the downfall started and it has not stopped with EMRs, it’s everywhere. Look who’s the #2 man at CMS, right from United Healthcare, and yes, they own about 3 medical companies too as subsidiaries. That appointment is enough to put the fear of God into doctors as they just use complex contracts and formulas to whittle away at their money.
http://ducknetweb.blogspot.com/2014/06/how-hard-did-united-have-to-lobby-to.html
Revenue cycle people have no clue how hard it is for a doctor to enter chart information today, it’s automated coding and SNOMED with patient problems now. If you mess that up if you are in a hospital, then all hell breaks loose. A little off topic, but a rant of mine today about a hospital buying data from Axciom..get this MDs are now supposed to soon rummage through the records they buy from them as well as your MasterCard and visa records , they also buy just what doctors and patients want and need-NOT.
http://ducknetweb.blogspot.com/2014/06/oh-crap-now-hospitals-are-now-buying.html
I can’t blame doctors at all as the medical records systems, like everything else has become so complex it distracts from patient care. I do think Google glass though is help for them to give them their hands back.