Archive for the Electronic Medical Records Category

More potholes on the road to digital medical records

Posted in Electronic Medical Records, Health Care Policy with tags , , , , , , , , , , , on April 14, 2009 by drbobbs

Brandon Glenn at Modern Medicine talks about a problem inherent in Google’s PHR (Personal Health Record):

Google’s PHR problems apparently stem from their reliance on coding data to describe patients’ medical conditions in the PHRs. Health IT leaders from Google and Beth Israel Deaconess Hospital (where deBronkart, the patient, receives treatment) say PHRs are a new technology and “will improve as more precise coding language is adopted in the coming years.”

This reminds me of a “kicked back” claim I once received on a urinalysis I’d obtained on a patient.  I’d used code 788.1 (Dysuria).  Somehow, what the third party-payor got was 798.1 (Instantaneous Death).  Of course, even when this sort of data entry error doesn’t occur, there’s still a lot of coding nonsense out there.  Glenn concludes that this “doesn’t bode too well for the federal government’s stated goal that all American citizens have an electronic health record by 2014.”  No, it doesn’t.  Worse still, unrealistic government-mandated electronic record compliance mandates will incentivize many physicians to opt out of Medicare.

And Dr. Wes discusses another problem related to the lack of electronic record interoperability: The Health Information Legacy Problem:

“While every one’s talking about developing a fully-integrated nationwide electronic medical record, no one give a damn about the old systems that exist out there. They’re not worth supporting. No one cares about the data they contain, even though for the doctor, they contain critical documentation about patient’s prior health care and are vital documentation to prevent litigation.

“So I ask you, when the government decides on a single electronic medical record system that suits their needs and is all-encompassing, what’s going to happen to all the data on the other systems?”

Physicians’ notoriously illegible handwriting notwithstanding, paper and ink does have the virtue of being “interoperable.”  But these technical problems with medical health information technology (HIT) are no problem at all to HIT vendors who simply want to sell their products whether they are practical or not.  Nor is it a problem for politicians who have never had careers as practicing physicians, hospital administrators, or information technologists.  It’s easy to be boundlessly optimistic about the solution when you are utterly clueless about the problem.


EHRs: The Road to Serfdom?

Posted in Electronic Medical Records with tags , , , , , , , , , on April 12, 2009 by drbobbs

Big BrotherWhile I’ve been skeptical about the cost-effectiveness and readiness of EMR/EHR technology, Dr. R. Wayne Porter or Terrell, Texas sees something more sinister:

The Electronic Health Record is a Trojan Horse which will open the gates to an invading army of bureaucrats and central planners and give them the tools with which to enslave us. Using it they will track every physician’s practice and compare it to their mandates (which is what “guidelines” will become). Dissidents will be punished. Those who fail to conform will be dropped from insurance company and medicare panels and/or have their licenses revoked. We must reject this poisonous “gift” and resist every effort to implement such a system, not only for ourselves, but for the sake of our patients, the citizens of this Country, who will be ensnared as well.

Why do we lie meekly still as, one by one, the threads of third party and State control are fastened over us? They are not yet so numerous that we cannot break free of them. Do we fear the loss of our comfortable lifestyles or our position and prestige (whatever may be left of it)? We have only to stand up and cry “Enough!” and they will be forced to scatter like cockroaches in the glare of the light.

That’s a pretty strong indictment.  I think EMR/EHR technology will produce cost savings, fewer errors, and better patient care…some day.  The technology is not ready.  But when it is ready, physicians should embrace it more than fear it.

As for third party and State control, are there large numbers of American patients who are burning their Medicare and private insurance cards out of frustration with third party-payors denying treatment and overriding physician decision-making?  This would seem to be a far greater source of both patient and physician dissatisfaction with the third party-payor system than whether one’s office notes are on sheets of paper or in a hard drive.  Everyone seems to hate health insurance companies, but is that hatred taking the form of large numbers of patients telling them that they will no longer pay their premiums?  We may one day see such a backlash, but not anytime soon.  For now, patients by and large seem to find it equitable or at least tolerable to pay enormous monthly insurance premiums to health insurance companies that will often deny coverage and stick them with the bill.  It is the unwillingness of the vast majority of patients to pay for their own health care that empowers both the state and private third party-payors.

If physicians stand up and cry “Enough!” will they will be forced to scatter like cockroaches in the glare of the light?  Since only 4% of American physicians currently use fully operation electronic records systems, it sounds like physicians have already cried “Enough!” yet the cockroaches seem undisturbed.

Hospital EMRs/EHRs: the plan versus the reality

Posted in Economics of Health Care, Electronic Medical Records with tags , , , , , , on April 6, 2009 by drbobbs

The Plan: Obama wants full EHR by 2014

The Reality: Only 1.5% of nonfederal hospitals report having full EHRs:

Only 1.5% of nonfederal U.S. hospitals use a comprehensive electronic health record system, and only about 8% use a basic EHR in at least one unit that includes physician or nurse notes, according to the study. The report, which based its findings on survey responses from nearly 3,000 hospitals, appeared in the March 25 online version of the New England Journal of Medicine.

The unexpectedly low levels of EHR adoption rates in hospitals suggest that policymakers face substantial obstacles to achieving health care performance goals that depend on implementing health information technology, the study’s authors said.

EMR/EHR technology is still too expensive, too non-interoperable, and too user unfriendly for widespread use.  It’s a good idea, but it’s still in the early adopter stage which is itself fraught with peril:

Early adoption does come with pitfalls: early versions of products may be buggy and/or prone to malfunction (such as the Commodore 64 or Xbox 360), overpriced (iPhone), or prematurely obsolete (8 track tapes, Betamax, HD DVD). Furthermore, more efficient, less expensive versions of the product usually appear a few months after the initial release.

Advocates of EMR/EHR implementation should recall the wisdom of the old maxim “Make haste slowly.”

EMR panacea under attack

Posted in Electronic Medical Records, Medicolegal with tags , , , , , on April 4, 2009 by drbobbs

I’ve argued here on Dr. Bobbs that EMRs are not ready for prime time for most practices and will not result in increases in efficiency or cost reductions for practices that are not ready for them, that is to say, most medical practices.  It appears I’m not alone in this assessment.  Brandi White at the American Academy of Family Physicians’ Noteworthy Blog:

Electronic medical records are being touted as an essential ingredient in health care reform. Most recently, the Obama administration proposed the national adoption of EMRs on the grounds that it would save $80 billion a year and improve the quality of health care.

But not everyone is drinking the Kool-Aid.

Drs. Jerome Groopman and Pamela Hartzband, faculty of Harvard Medical School (and, notably, both Obama supporters), recently called EMR adoption “an overly simplistic and unsubstantiated part of the solution” and had this to say in The Wall Street Journal:

“The basis for the president’s proposal is a theoretical study published in 2005 by the RAND Corporation, funded by companies including Hewlett-Packard and Xerox that stand to financially benefit from such an electronic system. And, as the RAND policy analysts readily admit in their report, there was no compelling evidence at the time to support their theoretical claims. Moreover, in the four years since the report, considerable data have been obtained that undermine their claims. The RAND study and the Obama proposal it spawned appear to be an elegant exercise in wishful thinking.”

While there are real benefits of EMRs – such as medication alerts, reminders and increased legibility – it turns out that, despite all the hype, there’s no evidence that EMRs actually save the system money and improve outcomes. (They also can’t share data with one another and are cost prohibitive in many cases, but that’s another blog entry.)

Groopman and Hartzband cited several studies demonstrating the problems with EMRs:

“A study of orthopedic surgeons, comparing handheld PDA electronic records to paper records, showed an increase in wrong and redundant diagnoses using the computer – 48 compared to seven in the paper-based cohort. … A 2008 study published in Circulation, a premier cardiology journal, assessed the influence of electronic medical records on the quality of care of more than 15,000 patients with heart failure. It concluded that ‘current use of electronic health records results in little improvement in the quality of heart failure care compared with paper-based systems.’ Similarly, researchers from the Brigham and Women’s Hospital and Harvard Medical School, with colleagues from Stanford University, published an analysis in 2007 of some 1.8 billion ambulatory care visits. These experts concluded, ‘As implemented, electronic health records were not associated with better quality ambulatory care.’ And just this past January, a group of Canadian researchers reviewed more than 3,700 published papers on the use of electronic medical records in primary care delivered in seven countries. They found no solid evidence of either benefits or drawbacks accruing to patients. This gap in knowledge, they concluded, ‘should be of concern to adopters, payers, and jurisdictions.'”

The bottom line: Once again, physicians are being told to invest their time and dollars in an unproven strategy on the hope that it will eventually pay off. An alternative approach, one advocated by the Network for Regional Healthcare Improvement, would be to create a system that rewards physicians and pays them fairly for achieving the desired outcomes regardless of the specific technology or tools they employ.

It is a constant source of amazement that self-proclaimed health policy “experts” seem to accept as a matter of faith that replacing hundreds of dollars worth of paper in every medical office with tens of thousands of dollars of EMR hardware and software will cause health care costs to plummet.  Of course, our government appears to think that we can spend our way out of a recession and big business sees nothing amiss about being flown into Washington, D.C. in a private jet to beg for taxpayer money to prop up the corporation they’ve run into the ground.  It all seems to be of a piece with the Alice in Wonderland logic of our time.

Moreover, while EMRs are good at quickly generating large, detailed notes, they are less adept at producing concise, actionable information as noted by Grider, et al in Medical Economics:

In April 2008, a study published in the New England Journal of Medicine reported similar problems, pointing out that “Notes that are meant to be focused and selective have become voluminous and templated, distracting from the key cognitive work of providing care. Such charts may satisfy the demands of third-party payers, but they are the product of a word processor, not of physicians’ thoughtful review and analysis. They may be ‘efficient’ for the purpose of documentation but not for creative clinical thinking.”

The study also reported an example of the consequences of these problems: “A colleague at a major cancer center that recently switched to electronic medical records said that chart review during rounds has become nearly worthless. He bemoaned the vain search through meaningless repetition in multiple notes for the single line that represented a new development . . . Ironically, he has started to handwrite a list of new developments on index cards so that he can refer to them at the bedside.”

It gets even better.  From a medicolegal standpoint, those big, impressive EMR notes may be less of a shield than a lightning rod:

[C]ertain types of data-entry functionality…result in “cloned documentation,” in which the records of every visit read almost word-for-word the same except for minor variations confined almost exclusively to the chief complaint.

Physicians have long been counseled that a well-documented medical record provides the best defense in the event of a claim of medical liability. The June 2008 issue of the Journal of AHIMA quoted EHR legal expert Patricia Trites on the potential danger of electronic systems that permit copying of near-identical documentation into large numbers of patient records: “From a medical-legal standpoint, what would [lawyers] do when they [see] this chart?” she asks. “They are going to rip it apart.”

Of course, physicians can already do a lot of dubious documentation with check box sheets, or by having a template for their transcriptionist (e.g. “Physical exam: insert normal gynecologic exam into note.”).  And much of the documentation from patient encounter to patient encounter is repetitive:  Most heart exams reveal regular rate and rhythm, normal S1 and S2, no murmurs, gallops, or rubs, for example.  But third party payors have a built-in incentive to try to avoid paying for claims and lawyers will often twist the facts to favor what they are trying to prove:  An overly brief encounter note or a massive, templated encounter note can both be used to argue that the physician is trying to hide something.

I suspect the EMR backlash will continue and grow.

Another point of view on the readiness of EMR/EHR

Posted in Electronic Medical Records with tags , , on March 27, 2009 by drbobbs

I’ve argued that electronic medical and/or health records are advancing but still not ready technologically or economically for widespread implementation.  Steven Kern disagrees.

More headaches for Mr. Obama’s EMR plan

Posted in Electronic Medical Records, Health Care Policy with tags , , , on January 18, 2009 by drbobbs

Robert Pear writing in The New York Times:

In a speech outlining his economic recovery plan, Mr. Obama said, “We will make the immediate investments necessary to ensure that within five years all of America’s medical records are computerized.” Digital medical records could prevent medical errors, save lives and create hundreds of thousands of jobs, Mr. Obama has said.

So far, the only jobs created have been for a small army of lobbyists trying to secure money for health information technology.

Consumer groups and some members of Congress insist that the new spending must be accompanied by stronger privacy protections in an era when digital data can be sent around the world or posted on the Web with the click of a mouse.

In the last few years, personal health information on hundreds of thousands of people has been compromised because of security lapses at hospitals, insurance companies and government agencies. These breaches occurred despite federal privacy rules issued under a 1996 law. Congress is trying to strengthen those privacy protections and make sure they apply to computer records. Lobbyists for insurers, drug benefit managers and others in the health industry are mobilizing a campaign to persuade Congress that overly stringent privacy protections would frustrate the potential benefits of digital records.

The data in medical records has great potential commercial value. Several companies, for example, buy and sell huge amounts of data on the prescribing habits of doctors, and the information has proved invaluable to pharmaceutical sales representatives.

“Health I.T. without privacy is an excellent way for companies to establish a gold mine of information that can be used to increase profits, promote expensive drugs, cherry-pick patients who are cheaper to insure and market directly to consumers,” said Dr. Deborah C. Peel, coordinator of the Coalition for Patient Privacy, which includes the American Civil Liberties Union among its members.

Get ready for these and other kinds of problems if we go through with this.  If you throw enough money at an immature technology you can always accomplish something, but don’t bet on it being what you originally set out to accomplish.  We did that with space technology in the 1960s.  The result was not cheap and reliable access to space for the average person.  The result was a half-dozen very expensive flags-and-footprints missions to the Moon.  Since then, we haven’t been backto the Moon, haven’t made space travel a practical reality and have seen two space shuttle crews killed in accidents.

EMR technology is not ready for prime time yet.  Don’t forget futurist Paul Saffo‘s admonition about mistaking a clear view for a short distance.

Obamacare: Computerized Medical Records

Posted in Economics of Health Care, Electronic Medical Records, Health Care Policy with tags , , , , , , on January 13, 2009 by drbobbs

CNN reports on President-elect Obama’s plan to digitize America’s health care records within 5 years:

[M]any hurdles stand in the way. Only about 8% of the nation’s 5,000 hospitals and 17% of its 800,000 physicians currently use the kind of common computerized record-keeping systems that Obama envisions for the whole nation. And some experts say that serious concerns about patient privacy must be addressed first. Finally, the country suffers a dearth of skilled workers necessary to build and implement the necessary technology.

“The hard part of this is that we can’t just drop a computer on every doctor’s desk,” said Dr. David Brailer, former National Coordinator for Health Information Technology, who served as President Bush’s health information czar from 2004 to 2006. “Getting electronic records up and running is a very technical task.”

It also won’t come cheap. Independent studies from Harvard, RAND and the Commonwealth Fund have shown that such a plan could cost at least $75 billion to $100 billion over the ten years they think the hospitals would need to implement program.

That’s a huge amount of money — since the total cost of the stimulus plan is estimated to cost about $800 billion, the health care initiative would be one of the priciest parts to the plan.

I’ve noticed that enthusiasm for EMR systems seems to be greatest in EMR system manufacturers and politicians.  Real live doctors who actually deliver health care are a lot less sanguine about the whole thing. 

EMR systems have a lot to offer in terms of safety and cost effectiveness for practices and hospitals that are ready for them.  That means the early adopters.  Of course, even the early adopters are a heterogeneous group.  I once rotated through a practice as a resident where the doctors dictated their encounter notes into microcassette recorders so their transcriptionist could type them into the EMR.  The EMR should have partially justified its cost by the elimination for the need of a transcriptionist.

We’ll know truly practical EMR systems have arrived when relatively little training on the part of health care providers is needed to work it.  It’s like that with any mature technology.  Maybe one day every exam room will have a Microsoft Surface-type desktop where you touch and drag a virtual chart around and just set your handheld voice recognition dictaphone on the thing and it instantly downloads and transcribes everything.

One day.  Hopefully.

But Mr. Obama’s plan sounds like a very expensive excursion into the Beta Culture.