The Tyranny of Electronic Systems

Some eight years ago the media was excited that Hillary Clinton and Newt Gingrich had formed an alliance about reforming health care. In 2005 Dana Milbank wrote in the Washington Post about a joint appearance in gushing terms –

Clinton, asked about electronic medical records, deferred, again, to her friend. “Newt has a very dramatic way of saying this,” she said, “which is ‘Paper kills.’” Gingrich sent the praise right back at her, hailing Clinton’s legislation on medical records as a “major breakthrough” in Congress. “This is absolutely the case that Hillary is making,” he said.

Of course, they were not alone. President Bush had already embraced the idea in his State of the Union speech to Congress.

Later, President Obama built the HITECH Act into his 2009 stimulus package and appropriated some $20 billion to make it happen. All promised to get everyone’s complete medical records in digital form by 2014.

Man, this is going to be GREAT! A model of modern efficiency! Bipartisan support! Interoperable! WOWSA!

Now, of course there were the usual naysayers and Gloomy Gusses. I was one of them in this research and commentary I wrote for the Heartland Institute. Dr. Bruce Landes, who comments here frequently, was another. Dr. Scott Silverstein at Drexel University was also skeptical. And Dr. Deborah Peele was very concerned about patient privacy in a digital era.

Most of these concerns were not about whether digital technology is a good thing. Of course it is, or can be, a very good thing. But the track record of top-down, politically imposed solutions is abysmal. And when you add vast amounts of money to the mix, chaos is inevitable. Great Britain went through a similar, though more modest, exercise and recently concluded that the whole thing was a failure, but only after spending some $12 billion.

But we skeptics were not able to overcome the hordes of advocates who were eager to get their hands on a bit of the $20 billion.

Now the results of all this are coming to the fore. The Washington Post recently ran an op-ed piece by Dr. Dan Morhaim, who is also a Democrat member of Maryland’s House of Delegates. (One of the refreshing things about bipartisan ideas is that the opposition can also be bipartisan.) He writes –

These systems tend to be fantastically complex. One doesn’t have to be intimately familiar with, say, Hertz or Enterprise to rent a car online. But many electronic health record systems have pull-down screens listing each of the 68,000 possible diagnosis codes in the World Health Organization’s International Classification of Diseases and 87,000 possible procedure codes.

Or consider what happens when I write a prescription: Every potential drug interaction or side effect listed generates a warning prompt. Inevitably, recognizing that the warnings are generally inapplicable and take time to sort out, clinicians start to bypass the alerts. Sooner or later, ignoring one will lead to serious complications.

Dr. Morhaim concludes –

Perhaps the most pernicious side effect is the erosion of the provider-patient relationship. When I first began working with electronic health records, I caught myself staring at the computer screen instead of engaging patients, who rightly felt ignored. Like many colleagues, I’ve reverted to the practice of talking with the patient and taking notes with pen and paper. After the evaluation is over and the patient has left, I type in the data. This takes much more time, but it is the only way to complete a proper history and exam.

The result is decreased productivity and frustrated providers — and a lack of meaningful data to manage patient care.

And The American Journal of Emergency Medicine published a study finding that ER physicians are now spending 43% of their time on data entry and only 28% on direct patient care.

So we have spent well over $20 billion (that was the appropriation for the first year alone), and are left with a system that reduces productivity, fails to provide “meaningful data,” and destroys the patient/physician relationship. From 2011 to 2012 there was a 21% reduction in the number of family physicians who had “meaningful use” of electronic medical records, according to the American Association of Family Physicians. Yet the mandate to use this system continues.

Boy, isn’t it great to have policies with bipartisan support?

Meanwhile, I don’t know about you, but I think it would be swell to have a simple wallet-sized card that listed my emergency contacts, personal physician, allergies, and current medications. But that isn’t grandiose enough for the Washington elite.

Comments (55)

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  1. Ralph Weber says:

    Just another way to lost medical privacy and allow DC to upload all of our health data so they can implement Politi-Care

  2. Dewaine says:

    “But the track record of top-down, politically imposed solutions is abysmal. And when you add vast amounts of money to the mix, chaos is inevitable.”

    This is the fundamental problem of a lot of good ideas that government champions. It isn’t that they ideas are bad, rather that fundamentally the implementation saps efficiency.

    • JD says:

      Right, making choices reveals preferences. A top-down government system usurps that choice. Sure, most people might be just as well off because that is the choice that they would’ve made anyway, but it creates an inflexible system that doesn’t adapt to the needs of people. That always hurts some.

      • Dewaine says:

        And in fact, they aren’t “just as well off”. If 90% of the country would’ve chosen the option that government championed, they are going to pay higher prices for that service because of the 10% who are now added to the demand. So, everything is thrown off.

        • JD says:

          Good point. Meddling in the market is tricky and should only be performed in the most dire of circumstances.

  3. Sabal says:

    “Great Britain went through a similar, though more modest, exercise and recently concluded that the whole thing was a failure, but only after spending some $12 billion.”

    History is a good guide. We have been forewarned.

  4. Andrew Thorby says:

    Paying an industry to computerize was an idiotic policy from the outset. Instead of changing the prevailing fee for service incentive model that rewarded inefficiency and encouraged value chain fragmentation the government could have saved $20 billion and instead waited until value based pricing kicked in. The industry would have computerized of it’s own accord after it had re-organized itself around integrated delivery and managing pricing risk.

    Now we have thousands of provider centric systems that are of basically zero value in terms of supporting an integrated delivery model spanning the care continuum. Talk about paving the cow path.

    • Dewaine says:

      Exactly. Things evolve as people are ready, pushing them too soon causes calamity.

    • Wanda J. Jones says:

      You are correct: as one of the most serious gaps in the healthcare system is not having the customer in the system at all, because of fear of being known (illegals), fear of doctors, fear of hearing the diagnosis, lack of knowledge of how to find a doctor, ignorance of the meaning of symptoms, fear of needles, and cultural fear of certain diagnoses, such as first generation Latinos fear of diabetes, which they equate with a death sentence. With all of those potential customers out of the system, the data generated by providers mis-states the value of the healthcare system. Advancing the social network’s ability to snare data through voluntary customer response will generate some new ideas of where to modify the system.

      In addition to the time-wasting effect on doctors, computers in the patient care event also cause additional staff to be assigned. I just had a hospital admission where nurses rolled in a stand-up cart every time they had to do a nursing task, such as check on my pain status and possibly change the saline drip, and she spent about 7 minutes with the computer, never once approaching my bedside and talking with me directly. I estimate that the nursing staffing during my 6-day stay was at least 25% higher than it needed to be for simple patient care. And, there was a computer still bolted to the wall behind my bed from an earlier attempt, so instead of one machine per patient, there was one machine per staff member.

      My endocrinologist mutters under her breath when she is seeing me, about how the EMR does not save time or improve care. But to be part of a contracting group, she has to use it.

      An orthopedist dictated to a staffer during his physical exam of my back–higher costs, and not much efficiency gain.

      Supposedly, all these data will be mined and interpreted for the good of future patient: Who will do this?

      Patients could assure “meaningful use” if they got their own copies of their records.

      Greatest long time value would come if there was continuity to show the progression of disease and the emergence of co-morbidities. An episode of illness isn’t much, but 5 – 10 years could be valuable.

      Everyone should be aware that the CEO of Epic, a major vendor of electronic medical records, is a significant donor to Obama, and was on the President’s advisory council. Another instance of crony capitalism.

      Wanda J. Jones, President
      New Century Healthcare Institute.

  5. Dewaine says:

    We should be worried about deterioration of the physician/patient relationship. The consequences are severe.

    • JD says:

      “The result is decreased productivity and frustrated providers — and a lack of meaningful data to manage patient care.”

      More money, worse health.

    • Perry says:

      This is exactly why I don’t use them in my practice, and thank goodness I don’t have to.

      Trying to navigate medical records that are EHRs is horrendous, all of the pertinent info is mixed with all of the orders and it’s hard to tell what is what. Also, there is no leeway to modify the records to always clearly say what you want to.

  6. JD says:

    “Meanwhile, I don’t know about you, but I think it would be swell to have a simple wallet-sized card that listed my emergency contacts, personal physician, allergies, and current medications. But that isn’t grandiose enough for the Washington elite.”

    That would be wayyyy cheaper too.

    • Sabal says:

      I like that idea, it would be easy on everyone and effective.

    • Brett says:

      No need to wait for the government to provide this for you, just do it yourself. I put all this information on a half sheet of paper that I fold up and put in a plastic bag to carry with me when I go biking.

  7. Studebaker says:

    There is an area of psychology that looks at human factors and ergonomics (i.e. industrial psychology).
    In a nutshell, this has to do with whether or not the user interface works with the way doctors interact with patients. The people designing these systems were not allowed to make them user friendly. Ease of use was not the primary consideration. Practices are being required to capture more data than needed because bureaucrats got to decide what data they wanted to see.

  8. Eric S. Graber says:

    Concerning Dr. Morhaim and AJEM’s conclusion as reflected in today’s post:

    Let us not be discouraging about the vast potential of digital record keeping in doctors offices for improving healthcare. I have personally experienced successful, unobtrusive implementation of digital record keeping by doctors in their offices at time of medical care. Records of the notes are readily available to me online shortly afterwards. AJEM’s findings suggest that doctors and patients would benefit by further training of medical personnel. Perhaps, younger doctors are relatively adept at employing the new technologies.

    ESG

    • Allan (formerly Al) says:

      “Perhaps, younger doctors are relatively adept at employing the new technologies.”

      Perhaps younger doctors should be trained to communicate better with their patients than they can with the computer.

    • Dewaine says:

      There is definitely potential and expect that as time goes on EHR will become the standard, but forcing everyone to use them before they are ready will certainly create inefficiencies.

    • S Silverstein MD says:

      Gee, yes, I guess medical personnel do need more training, over the many years they already have, in how to adopt bad health IT prevalent today – instead of IT personnel being trained in medical needs and being held accountable.

      The Obamacare computing disaster is really a microcosm of the health IT world – to use a simple Yiddish word: Drek.

      I’ll bet the system your touting is also suffers many deficiencies.

      See my site, linked in the article by Mr. Goodman.

      BTWL:

      Bad Health IT is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.

  9. Perry says:

    Part of this tyranny is that these are designed to capture specific information, not necessarily relevant to treating the patient at hand. Additionally, there are so many different systems out there, they cannot communicate to one another easily.
    Doctors are now becoming data processors.

  10. Allan (formerly Al) says:

    John G. writes: “I think it would be swell to have a simple wallet-sized card that listed my emergency contacts, personal physician, allergies, and current medications.

    In the ~1980′s there was such a company that I used especially for those with abnormal EKG’s.

    I would send out the necessary information and the EKG to the company along with the patient’s check of $3 (maybe $5). The information contained allergies, medications, serious medical conditions and physician name on one side and the EKG on the other. It was then laminated by the company. I received no compensation despite the fact that it imposed some costs on my office.

    Too many people think everything should be free so the number of people willing to pay that price was extremely low. The complaints required too much of my office’s time so eventually I abandoned the service.

    However, there is no reason any individual cannot simply take the basic medical record to Kinko’s and reduce it in size and create a wallet size card. That can also be done with disc, flash drive or other technologies such as the cloud. That is the information along with serious medical conditions that are needed immediately in times of emergency.

    Since my records were partially on computer since the 1980′s I would provide for free a type written sheet containing allergies and medications on every visit for those requiring such information. The only reason my office did not communicate with my lab and elsewhere was because of government intervention and the Stark laws. EHR’s are good if developed from the bottom up, but a tremendous waste of money and time if developed in any other fashion.

    • Greg Scandlen says:

      Right, but let’s see — $20 billion was spent on the IT mess. At 300 million people in the U.S., that amounts to nearly $70 per person. Think we could have paid for these cards for $70 a pop?

  11. Gary Alan Mohr MD says:

    I am a board certified family physician. I can see the potential for computers to improve medical care, there are some valuable applications such as being able show a patient their CT scan images from my exam room.
    But the commercial programs are so huge and unwieldly that they consume more of my time than they are worth.
    My first computerized medical record was a simple word document that fit my needs and had features that the fanciest $80,000 systems do not include. But they don’t satisfy the pinheads so I can’t use them.
    Government intervention into a private market is always fraught with peril, to physicians as well as patients.

  12. Charlie Bond says:

    Hi John,
    I began speaking to physicians about electronic medical records in 1993. Every speech I have given since then on the topic includes the sentence: “The state of the art isn’t.”
    We simply have not developed a templated method of standardizing the myriad of observations a human can make about the infinitely variable condition of another human.
    As you know, I am a strong advocate for the patient-physician relationship. Without question it is being dehumanized by the drive for data. To ameliorate this, there is a project using Google Glass to at least maintain eye contact with the patient. But even that project is in its infancy.
    The drive for data is not so much about improving individual care as it is about creating standardized units of care with acceptable outcomes that can, in turn, be given a price tag. Presumably, given massive amounts of data, the true price of cost-effective medicine can be derived. ACO’s and gainsharing are just a step along that path. The question is who will own the data and set the prices at the end of the day? Wouldn’t it be best if it were the patients operating in a free market?
    Cheers,
    Charlie Bond

    • Perry says:

      Well said Charlie.

    • Wanda J. Jones says:

      “standardized units of healthcare.”

      Yes, that is an underlying assumption, or several, that are weak or wrong.

      Wrong: “More data equals an ability to judge outcomes and compare “quality” or “value” among providers.” [But there are no data about the patient's own presenting factors that could affect the outcome.]

      Wrong: ” If outcomes vary, it indicates variation in cost.” Theoretically, better outcomes cost less. [No, they may cost more. And costs are mostly fixed, not varying much with variations in quality or outcomes by individual patient or patient type.]

      Wrong: “Medical IT systems are worth the money.” [Not when the money is huge, and a change can cost $100K a page, and when installation means hiring new staff to input starting data on current patients as those already in the system.]

      Wrong: “Medical IT has value for both clinical care and management of groups of patients.” [The greatest value from Medical IT is from the knowledge-based systems that help with medical decision-making. Those are in addition to the medical record.]

      Wrong: “Electronic Medical records will help providers demonstrate to payers that they are cost-effective.” [No, as the up front costs are real; the future value, if any, comes slowly so that the installation costs are amortized over decades What is saved is the space and staff dedicated to paper records.]

      The downside of all this is the mis-use of data by government staffers who do not know medicine, who do not understand the limitations on their power, and do not perceive the action-reaction effects of medical computing on medical manpower and access.

      A few decades ago, I sat next to a staff member of a government committee that had just passed a new law: “Comprehensive Health Planning,” a replacement for the Hill-Burton Act. He and his colleagues had just lectured on all the organizations who came out against that law. I asked “Who came out for it?” His answer was; “I guess we were.” (Committee staff.” Exactly.

      Wanda J. Jones
      San Francisco

  13. Jim Morrison says:

    Greg,
    Great article. There is an old axiom in the computer world: “Garbage in, garbage out”. I think it is applicable here.
    Jim

  14. Jan Peter Ozga says:

    Well, then I guess we should be grateful that the DoD and VA earlier this year scrapped their plans to create a single electronic record for its respective constituents(which on the face of it shouldn’t have been that difficult)…after investing a billion dollars.

    That said, I’m not sure I’m with you on this one. Health care is the least automated industry in the US and, by its own admission, the least efficient. I’d say that’s a pretty good cause and effect.

    Yes, bureaucrats can butcher things up and the cost of anything goes rises when the government is in charge. But the fault there lies with the operators not the machines.

    If the electronic age has enabled all other industries to be more efficient, there’s no reason health care couldn’t benefit from IT. It should enable doctors and other health care workers to spend MORE not LESS time with patients. Sounds like most of them need to learn to use computers better. Much diagnoses and an increasing number of treatment techniques involve automation/computers. Certainly, more IT should help reduce medical errors.

    Resisting such progress makes opponents look like they are wedded to the status quo…for their own, not their patients’ sake.

    Finally, there’s no reason consumers couldn’t have the type of card Greg advocates AND health care providers could have access to information that would help to reduce over medication, enable timely collaboration, and otherwise provide high quality care. A country doctor operating in isolation is a quaint concept but antiquated in this information age.

    Maintaining privacy and confidentiality in electronic records should always be a priority but that’s why user names and passwords are created.

    • Greg Scandlen says:

      Jan,

      That is why I said in the piece that IT can be a very good thing. And in fact I know quite a few Docs who use and love their EMRs. But here’s the thing — they begin with their clinical practice and then look for ways that HIT can improve the way they work and build up from there, gradually expanding what they do with it — start with their own patients, add the colleagues they work with, add the labs they use the most, add in the hospitals they use, etc. That’s why I am convinced it has to be built from the ground up. At some point, yes, someone needs to come in and figure out how to smoothly integrate those systems. But that happens to improve, not dictate, the clinical practices.

      Far from resisting technology, we need to master it. But WE should be the master, not some tech whiz kid who knows nothing about clinical practice.

      • Vince says:

        Greg makes a great point. As a healthcare provider I read a ton about the emergent ACO’s. Most of these pieces are from IT guys touting how IT will help manage patient care without any input from physicians or other providers. The IT people think data and technology is the solution to the problem. Providers needed to be brought into the equation much more than what we have instead of some IT guy telling us what we need.

    • Allan (formerly Al) says:

      “there’s no reason health care couldn’t benefit from IT”

      What makes you think healthcare doesn’t utilize what the electronic age has to offer? I know government has inhibited some of the developments possible in the electronic age, but you realize computer type equipment and other hi tech abounds all over the health care industry that has increased its efficiency many fold?

      Its hard to automate when person to person services are being provided. That is the nature of medical care. …But what about CT scans and MRI’s that take the place of surgeons cutting through the human body to find out what is there? What about the computers that direct radiation therapy to the spot that needs it preserving good tissue? What about the computers that run the machines that do testing greatly minimizing the work force? What about physicians that go to their computers to look at x rays both on site and off? What about the computers used to monitor pacemakers and defibrillators? What about the computers in the pacemakers and defibrillators? I can go on and on, but you have focused on something medical records that are used to enhance the treatment of patients where each physician and patient encounter is unique.

      Maybe you should start evaluating the EHR’s pushed by government so that you can recognize that they don’t exist to enhance medical care. Maybe you should look at the advancements in this area that were inhibited by government through rules and regulations such as the Stark laws. As a physician, who was using a computer since the 80′s to maintain portions of patient’s records and be able to obtain that information off site, almost everything I have seen pushed by government and rejected by physicians is contrary to good care and interferes with the doctor/patient relationship.

      “Maintaining privacy and confidentiality in electronic records should always be a priority but that’s why user names and passwords are created.

      I guess you are not familiar with Wiki Leaks and all the break-ins to our own companies and governmental offices.

    • Rebecca Burke says:

      I would have to agree with you. While I am very concerned about the privacy implications, I think that physicians’ offices are poorly prepared for the digital future. The immediate consternation with typing in patient interaction notes will be soon replaced with voice recognition. Creating digital records will be a as simple as dictating notes of just a few years ago. As a patient I remember sitting quietly while my physician dictated notes on findings and treatment plan. It was helpful to listen to what he was concluding. Records will be the same. There is much angst about this, but newly trained physicians will come out of medical school with great facility with this development. The only real issue to address is how to protect privacy and secure these records. That is a big question, but one that has to be solved. Electronic records, as in all businesses, is not going to go away.

    • S Silverstein MD says:

      re: “If the electronic age has enabled all other industries to be more efficient, there’s no reason health care couldn’t benefit from IT.”

      This statement suffers from what Scott Adams calls an:

      AMAZINGLY BAD ANALOGY
      Example: You can train a dog to fetch a stick. Therefore, you can train a potato to dance.

      “No reason” – take a few graduate courses in healthcare and social informatics, and you might learn there’s hundreds of reasons why healthcare is not by light years as amenable to cybernetic fixes as is, say, selling potato chips and pretzels, or other areas of manufacturing, mercantile, and management sectors.

  15. Bill says:

    Good stuff, Allan.

    Docs were early, not late, in the use of computers–when they were useful. E.g. we began, in our lab, using a PDP-8 [8k of memory!]to manipulate lab data in 1970.

    The problem with the total electronic record will be unfortunately solved by litigation. Every significant side effect of a given drug and all interactions between drugs will have to be mentioned as the doc implaces his orders. They will be seen in pop-up menus to remind him. An attorney who mines these big data resources will find whatever his wallet wants and whatever his imagination filters. “How many people who used clindamycin later got C. difficile?”

    I think the theoretical problem with the EHR is that it is digital and not analog and, as such, it has less information….just as the analog audio systems of yore are theoretically better. The hand written chart shows much more than simple textual data. It is a scrapbook: it has heavy lines. It may have colored pencil or ink. It has meaningful pauses and spaces. Some phrases are underlined. It has all caps here and there. It has notes written by the patient. It has scribbles. It has foreign bodies that the patient brings in ["this was stuck in my throat"] and the doc glues into the chart. And it has pages that a desperate patient might want destroyed [e.g. a surgical abortion D&C record--all initiated by a paramour].

    As the learning curve ascends patients will demand we go back to written charts.

    • Allan (formerly Al) says:

      Thanks Bill. Your charts seem to look similar to mine. I could look back decades and from my chart remember an encounter that I could never remember had it not been for all those extraneous lines that are scheduled to disappear.

      What I note from an over reliance of electronic records is that suddenly diseases appear that didn’t exist or some disappeared when they did exist as the physicians relied more on the electronic record than the patient.

      Where did that murmur disappear when one referral didn’t hear it and all others relying upon that note didn’t hear it either? How did it suddenly reappear again in my office? The practice of medicine is like an ecological experience where when one changes the environment even slightly there are big repercussions down the road.

    • S Silverstein MD says:

      I also learned computing on a PDP-8, a PDP-8/S to be exact. 4K of core!

      I agree about the litigation aspect, and have been educating the plaintiff’s bar on medical errors where EHRs caused or contributed to the malpractice…and the use of the systems to alter the records.

  16. Karl Stecher says:

    This is what happens when you have non-doctors (the govt) making heavy handed decisions without the benefit of hearing from “troops on the ground.” Further, they have messed with doctors by forcing them to use this system, to invest (?) thousands of dollars ins systems which are of little value, added incentives for people who use them and punishment for those who don’t.
    Come on…EMRs are not safe, and everyone has seen massive computer data banks hacked..be it ins company, Mastercard, college records, etc. You could almost say that putting a patient’s record into EMR violates HIPPA.
    Electronic transmission of data is of value…lab tests, CTs and MRIs on your screen. But right now EMRs are terrible as a doctor searches through a chart, page by page, when using paper leads him/her to what the physician is searching for. We saw this same problem when hospitals, to save space, put records on microfiche…it took valuable time to find what you were looking for.
    This is the same government that is responsible for the utterly failed Obamacare/Abysmalcare.

  17. Ron says:

    Let me comment on my observations of the Newt-Hillary connection. (I worked with both: Hillary Care consultant in 1993-94 and a Sr. Fellow at Newt’s Center for Health Transformation). I always thought that Newt was in favor of Personal Health Records (PHRs) so that individuals could take control and own their health history. On a voluntary basis they could make that information available to other providers when changing physicians or in case of an emergency. Hillary, on the other hand, pushed for Electronic Medical Records (EHRs) so that a central source of information on every citizen could be available for political purposes and government data mining. I am not sure at the time there was much definitional difference between PHRs and EHRs.

    In any case, we may one day be able to track our health data much as we can our car repair and maintenance data – but only if it has enough value to purchasers that a free-market solution arrises. Remember, after Katrina many displaced folks were not able to know what medications they were on, but had electronic histories of their lost cars.

    BTW: I was an actuarial consultant on HillaryCare that helped to kill it by exposing the costs of the program.

  18. James R Chaillet, Jr. ,MD says:

    Yesterday, I saw a patient with a flare up of a skin condition. Strange because the condition is managed by a dermatologist. Come to learn, through the process of communication – back and forth-, that the concern was about a social disease and because of a bad (social) decision he made a few weeks before. Try getting an EHR to figure that out and try to get the info into the EHR using dropped down tables, templates and point and click and coming up with an insurance company acceptable diagnosis and have it mean anything. Oh, and if I focused on the computer instead of the patient, as many young physicians are wont to do, I probably would have missed the story.

  19. Wanda J. Jones says:

    Just a small concern: A lot of what goes into the medical record is from the patient: with a flood of people moving into their senior years, and experiencing their early memory problems, how accurate will be the medication list, the time when a chronic disease appeared, how often the patient takes his/her medication, and how many surgeries have been done. Doctors relying on that part of an EMR will be short-changed. Then there are customs among doctors of not recording that a patient is an alcoholic, drug addict, or wife abuser.

    Wanda J. Jones
    San Francisco

  20. Ron says:

    Actually, the medication history is available electronically for more than 80% of the population. Insurers have a common software system that allows them to access medication history for nearly every applicant they get for underwriting. They can tell in 15 seconds or less if a “heart medication” or other prescriptions have been missed or excluded from an applicants written history. This system can no longer be used for health underwriting under ObamaCare (it can be used for underwriting disability, life and LTC policies), but could be used for automatically populating PHRs.

    BTW: few know of the software and company offerring the service as few carriers wanted applicant to know. The company is owned by Milliman (actuaries to most Insurers) and the system is IntelliScript.

    • AbbysMom says:

      Don’t follow you. If the only health insurance you’ve ever had was employer-based, how would your medication history get into this database?

  21. Bruce W. Landes, MD says:

    Those who say ‘doctors just have to learn computers better’, only confirm the Landes EHR rule, that: “The enthusiasm for EHRs increases with the square of the distance from actual medical practice.”

    Why did digital watches and digital speedometers fail? Because they turned information into data. People don’t want to know exactly how fast they are going or exactly what time it is. They want to know how fast they are going relative to the speed limit. They want to know how long it is before a certain event. Analog meters and dials give this information that digital data doesn’t.

    Similarly, poorly designed EHRs strip the context from medical records and turn them into mere data.

    Data is not Information.
    Information is not Knowledge.
    Knowledge is not Wisdom.

    People without engineering degrees would not think of opining on how to build a bridge or a better brake system for a car, yet people without medical degrees don’t hesitate to opine on how doctors should work with EHRs. To practicing doctors, it’s like listening to chickens discussing how best to make an omelette.

    Am I alone in this? Listen to this recent survey of practicing physicians:

    “What makes doctors less than satisfied with their work? Not being able to provide top-notch patient care because of obstacles in their way.

    That’s one of the main findings of a survey on physician job satisfaction that was conducted by RAND Corp. researchers, in conjunction with the American Medical Association, and released this month.

    The report based its findings on data from 30 physician practices of various sizes in six states: Colorado, Massachusetts, North Carolina, Texas, Washington and Wisconsin. Researchers surveyed 656 physicians, of whom 447 responded, and interviewed 108 physicians and 112 staff members.

    Report co-author Dr. F. Jay Crosson, group vice president for professional satisfaction, care delivery and payment for the AMA said the major driver of physicians’ satisfaction or dissatisfaction revolved around one general issue: “Was there a sense at the end of the day that they were able to do the right things by their patients and deliver high-quality care?”

    One of the main obstacles cited by the doctors: electronic health records. “We didn’t think we’d be focusing on this to such a great extent,” Friedberg said, “but we realized it’s a major factor.”

    Doctors who use electronic health records generally said they wouldn’t want to go back to paper, Friedberg said, but they complained of frustration because of difficulty using the computer systems.

    “A lot of doctors are sitting there with their electronic health records thinking, ‘Is it me? Am I the only doctor who can’t pay attention to both an EHR interface and the patient in front of me?’ They should take from this that they’re in very good company.”

    Friedberg said the report points to the importance of prioritizing the usability of EHR products, as well as the need for health care leaders and policymakers to focus on factors that are crucial to physician satisfaction.”

    http://www.healthbanks.com/PatientPortal/MyPractice.aspx?UAID={A830907D-8345-4AA5-A0D5-F8776BBC08BB}&TabID={X}&ArticleID=681257

    • Bruce W. Landes, MD says:

      I note that the above hyperlink was truncated in posting. If you are interested in following it, copy and paste the whole thing into your browser, it will work.

  22. Ian Duncan says:

    A timely posting by Jonah Goldberg about the UK’s attempt (I thought this had been killed some years ago but apparently it rumbles on):

    “A plan to create the world’s largest single civilian computer system linking all parts of the National Health Service is to be abandoned by the Government after running up billions of pounds in bills. Ministers are expected to announce next month that they are scrapping a central part of the much-delayed and hugely controversial 10-year National Program for IT.

    Instead, local health trusts and hospitals will be allowed to develop or buy individual computer systems to suit their needs – with a much smaller central server capable of “interrogating” them to provide centralised information on patient care. News of the Government’s plans comes as a damning report from a cross-party committee of MPs concludes that the £11.4bn program had proved “beyond the capacity of the Department of Health to deliver”.

    The Commons Public Accounts Committee (PAC) said that, while the intention of creating a centralised database of electronic patient records was a “worthwhile aim”, a huge amount of money had been wasted.

    “The department has been unable to demonstrate what benefits have been delivered from the £2.7bn spent on the project so far,” Margaret Hodge, chair of the PAC, said. “It should now urgently review whether it is worth continuing with the remaining elements of the care-records system. The £4.3bn which the department expects to spend might be better used to buy systems that are proven to work, that are good value for money and which deliver demonstrable benefits to the NHS.” A further £4.4bn was expected to be spent on other areas of the vast IT project.

  23. Alieta Eck, MD says:

    Read “Cutting for Stone,” a fascinating novel with story after story of sheer clinical judgment and minimal technology. No EMR– just history, physical exam, clinical diagnosis and treatment. We have lost something wonderful in our hi-tech world of medicine, and it will not end well. Centrally and government accessed EMRs are a lawyers’s dream and a doctor’s nightmare. It will not make for better patient care.

  24. S Silverstein MD says:

    Re: Alieta Eck, MD says: – ” Centrally and government accessed EMRs are a lawyers’s dream and a doctor’s nightmare.”

    Actually, they are a lawyer’s nightmare as well, both for the plaintiff and defense sides.

    The reams and reams of legible gibberish produced are as useless to attorneys as they are to clinicians.

    I know, because I assist attorneys in making sense of EHR output, and validating same as complete and free from alteration, in medical malpractice cases.

    A line of work I began after 20 years in Medical Informatics after my mother was seriously injured in 2010 and then died in 2011 of the toxic effects of bad health IT – despite my written warnings a month prior to the accident to the hospital in question of issues such as here: “Quality and Safety Implications of Emergency Department Information Systems”, http://hcrenewal.blogspot.com/2013/10/quality-and-safety-implications-of.html

    Docs, if bad health IT causes or contributes to medical error, it’s on you, not on the executives who foisted bad health IT onto you, or the IT companiers and personnel who designed and implemented it.

    Time to speak up. Loudly.

    Unless, of course, your employment contract calls for you to only extol EHR virtues.

    – SS

  25. AbbysMom says:

    Personally, having a EMR (electronic medical record) has enhanced visits to my primary care physician’s practice. For example, I recently had to see a different provider because she was on an extended maternity leave. The other provider (a nurse practitioner) had instant access to my medication history and so could easily tell if a new med she wanted to prescribe would have adverse interactions with any other prescriptions. Secondly, the NP could print an order for X-rays that was easy to read.

    Also, it is so easy for me to get a summary of each visit or test results any time I see my doctor. All I have to do is ask and the printout is ready at the front desk when I’m ready to check out. Much easier than with paper records.

    In case an electronic health record (EHR) is an electronic record that can be shared outside a medical practice group or hospital group. An electronic medical record is an electronic medical record (EMR) can only be used within a single medical practice with one or more locations or a single hospital or group of affiliated hospitals. This is a significant difference.

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