Comments on: Dragging health records into the Digital Age

Federal funding and new tech are speeding efforts to digitize America's medical practices. But are they ready to forge into a paperless existence?

[karora]

Interesting!!

[masonx]

The medical arts have now become just another high pressure and complex marketing driven business. Medicine as it is practiced today is about as artful as used car sales and its' relationship to science has been so corrupted - it's almost as close to science as used car sales. Bringing the medical business into the digital age is 20 years overdue and while it might make it more efficient than current paper practices, it isn't going to change the fact large corporations own the government health care offices (FDA, etc.) that preside over all of health care, they own the insurance companies that own the hospitals that own the doctors that own the patients. Being the lowest rung in this monopolistic and parasitic food chain will keep the humble patient in growingly compromised health position - where he has little or no choice other than to be financially raped or to die without treatment. Somehow we have to break this monopoly that has turned medicine in the largest extortion racket in history - digitized or not.

[doublebullout]

Wow -- your comment couldn't be more off base, masonx. I've got over 20 years of experience in nearly all areas of health care delivery, including EMR systems design and implementation. Your frustration with health care seems genuine enough, but the situation is not anything like what you imagine it to be.

[Crunchy Doodle]

I am a software engineer with a Master's degree in Computer Science. I even read the ACM Journal most of the time. With the exception of one oral surgeon I've seen, all of my medical providers are quite satisfied with their clipboards and paper medical charts. They are reliable and easy to deal with in the sense that everyone in the office can handle paper charts with no special expertise and minimal training. Until wireless digital tablets replace paper in the general world, doctors will prefer their ancient technology. So be on the lookout for the Kindle 400 in the local grocery store hanging on a pegboard display for $4.98, That's when my dentist will consider replacing the ancient paper billing system he's been using for over 40 years.

[doublebullout]

Doctors prefer paper charting over EMR software primarily because paper charting is faster and more intuitive. EMR software is the key, not the hardware. Unless vendors greatly improve the speed and ease of use of their EMR products, doctors will continue to resist moving to EMR. (And rightly so.)

[Vegadan_Man]

Kindle? Are you kidding? We have to wait for Microsoft to innovate an alternative that runs on Win Mo. That is the only way to be sure our data will be secure. Advocating non-Microsoft products shows ignorance.

[carlbdc]

Ask your doctors who use paper records three questions:

How many records do you have? They never know.

How do they know when they've lost a record? When they need it.

When a patient calls you at night or on a weekend, do they ask the patient what meds they are on, when they were last in, etc., or do they have some way to know this? They ask.

Paper records lack consistency and structure.

I once reviewed 100 post op reports for cataract surgery. They were dictated, transcribed and reviewed by the surgeon. Everyone was different.

Some reported what was tried and failed. Others only had what succeeded. Some were terse, others verbose, even though done by the same doctor on a patient with the same degree of difficulty.

As for confidential information in an office, just about every EHR system provides for masking sensitive data. Please tell me how that would be done in a paper system?

Paper is great until it's your record that gets lost, or it's your after hours emergency that depends on your memory.

[jake_n]

This is ludicrous. Why would we want our medical records in a file that is easily accessed by anyone determined to get at it. If you were diabetic would you want a perspective employer to know this? What about mental problems or a family member with a costly ailment. There are no secure digital files.

As a software developer with over 30 years of experience this is not an easy or cheap solution. That $19billion might be just a down payment. Also, do you want you records on the internet. I don't think so. I don't want to vote on the internet and health care records on the internet is just as STUPID.

[zeroplane]

I have built several enterprise business systems in my time and I have reviewed several software packaged used at our local hospitals.

1) Hire a usability expert
Almost all and I mean all of the vendors providing software for the health care industry don't provide usable software. My sister who works in a trauma center has routinely stated that they just stop using the 30 million dollar software package because it is impossible to use efficiently. Especially when they are dealing with life and death situations they don't want to have to click through five layers of menus and screens to issue medication. (sad, really sad)

2) Define national technology standards for data sharing
Require vendors follow a industry standard (industry being the technology industry) for data access and data design. Better yet institute a standard cryptography strategy that all vendors must follow for data archiving and retrieval.

3) Use technologies within the last 15 years
My sister showed me a client/server application that they just bought (2009 here) that was a horrible thin client dos application for a old mom database/application server. 2009! and the vendor is using technology that is well over 15 years old.

We the people are getting ripped off by the Health care industry who is getting ripped off by the health care technology industry. And you know who ends up paying for it? Why Joe public, that's who.. either through high prices for health care of billion dollar bailouts from the Federal government.

Oh joy.

[hackingbear]

Before AI advances to a stage where doctor's cursive handwriting is recognizable by computer; this is mostly useless and counterproductive; or at best as useful as paper because the "electronic" document is just an image of the handwriting. For sharing of diagnostics? Why can't the patients just take their charts around like patients in many places in the world? Are American patients as dumb as children? Today, the reason records are not shared is that doctors afraid of liability. In fact, in this lawyer-infested country, you have to ask explicitly to view your own record. These are cultural and legal problems;

Neither the costs of health care caused by $20/hour staff pulling out your chart.

Of course, these do not stop the marketer from promoting something that solve nothing.

[memadmin]

I don't want my private medical information placed onto a public IT system that is maintained by a gigantic monopoly overseen by bureaucrats. My doctor uses computers and technology and I am (for now) free to choose a doctor who does things differently. Technology is fantastic, but if you put voters and bureaucrats in charge of medical technology you are going to get the medical equivalent of AMTRAK.

[jypeterson]

There are some great comments by individuals here. I would like to add a few more:
1) Healthcare is an extremely complex industry. Expense inflation in excess of reimbursement inflation has been the norm for more than 15 years (and more) in many regions of the country.

2) Most hospitals only have an operating margin of 2-3%, in a good year. Where are hospitals (let alone physicians) able to procure enough capital to purchase good EMR systems? (this is why it hasn't happened yet)

3) Community physicians are decreasing call services for hospitals. This causes hospitals to higher high paid Intensivists and Hospitalists to cover rounds -- reducing the amount of capital available for technology upgrades.

4) EMR data standards are non-existent. There are too many competing companies for EMR systems and no data standard to go by -- yet.

5) The tort system is out of control. Most large hospital systems now only have major medical malpractice insurance due to the exacerbated costs of malpractice insurance -- which only kicks in at a certain point (say, claims in excess of $5MM). I'm not saying that hospitals and physicians shouldn't be responsible, but the system is being driven by lawyers, not by healthcare, Congress, the Courts, nor by patients.

6) Move to industry transparency -- most hospitals now report LeapFrog, Medicare and Medicaid, and numerous patient quality information surveys. This is still in its infancy, but the trend is that information is available and free to patients on hospital quality.

Healthcare reform is an ongoing PROCESS, not a destination. It will take great amounts of communication, collaboration, and innovation to improve healthcare. EMR's are just a small portion of that -- but it will come at a short term price. Hopefully, we will see the results of innovations soon.

[jypeterson]

One more point, EMR's will help keep patients safe -- identity theft, drug safety, patient telemonitoring, automated laboratory systems, et cetera will all help patients be monitored safely and provide a SECOND CHECK to that of the patient caregivers. Good old clinical expertise will never be replaced by a computer, but these systems can give warnings to prevent over doses, track medical ID theft, and keep patients safe from falls and OR fires.

[johnwtucson]

I have received health care from a Veterans Administration Hospital for some years. They are, I think, the ideal model for digital health care records. And they have saved an enormous amount of money and cut down on errors while doing this. I could walk into any VA hospital in America and they could pull up all my medical records in an instant.
Is this what everybody else wants to do? Look, then, at the paradigm that the VA has become.

[ewliu88]

I'm a physician at a relatively well wired 600 bed hospital in the NE.
Hospitals have large enough budgets to afford EHRs. The advantages are easily accessible prior patient data from that hospital system (no more walking down to medical records office), medical error checking (medication interactions, dosage checks), legible and standardized (rather than handwritten) orders, easy access to other studies like ct scans, mris from the floor for the physician (rather than walking to the basement for the films). Much of medical charting is still handwritten by all the providers in a chronological fashion. This is the legal and medical record and only way to document what happens to the patient. Electronic progress notes are starting to become available but many are very limited. It's like an old DOS text editor rather than a modern word processor. Problems are getting tech phobic doctors especially older ones to use the system (most of them aren't employees and can't be coerced), server crashes (paper doesn't evaporate but electronic data does). Another problem is getting legacy systems to talk. The lab system has to talk to the EMR which has to talk to the pharmacy computer. Sometimes the interface between systems fails. Right now, data may be available within a hospital system but not outside the system. The VA is a good example since it is all government owned and run and was running a EMR back in 1999 when I was a resident. Private hospitals may share an EMR between hospitals within the system but not to local competitors who may run on another incompatible system. There was no financial incentives for hospitals (which are strapped for cash) or EMR vendors to expand the compatibility between different EMRs. Only if the EHRs communicate will you save money by reducing redundant expensive. But from experience there will be human tendency to repeat the test if the patient is transferred to a bigger referral center which may not believe the results of the referring hospital. Or may not want to make a big decision based on the written interpretation of a study at another hospital. If the actual images of the ct scan, mri, or cardiac cath are transmitted (lots of storage needed) then maybe that will reduce redundant tests.
The local physicians often do not use EHRS because 1) EHR are expensive for a small business, 2) many doctors are not comfortable selecting an EMR or investing time/money/staff to convert over from paper to electronic. Paper and pen works well for small practices if the the patient is a short term patient. Continuity clinics or offices may not be efficient if a person has 10+ years of data in 3 binders in a single practice. So EHRs are becoming more common in larger continuity practices with multiple sites. For example, a cardiology practice might have 3 offices and people don't want to be locked into a certain office. If you have a EHR linking all 3 then you don't have to shuttle paper charts back and forth. Scripts can be electronically sent which spares medical errors and checks for drug interactions and dosages rather than writing out scripts in bad handwriting. Electronic charts also can be checked at home when the ER calls you about one of your 500 patients at night. So there are definite advantages to EHRs in a practice.
Most EHRs for smaller practices are produced by small companies. Bigger players are paying attention but there will be attrition and massive consolidation from smaller and midsized EHRs. I'm sure some physicians will be on the losing end of a consolidation when their product goes belly up. Many smaller EHRs don't talk to hospital EHRs especially if there aren't well established data exchange format standards Also most physicians are essentially independent small businesses so they can't be easily pushed or forced into something they don't want. A major financial incentive from the government may be the first compelling reason for the smaller practice to purchase and use a EHR. It'll be interesting what develops over the next few years.

[jmdavis278]

I'm a veteran and my medical files have been deleted and modified by people I disagree with on important issues here at the VA hospital. Untill laws are passed against human nature, the lessons repeated everywhere, that, electrons should not replace paper in voting or law or medicine .

[gdusseau]

Record all of your medical information on a digital memory device.
Keep it in your possession at all times.
Buy a laptop upon which to display the data in the dmd--never
Never allow a doctor/hospital to download the info, and block your IR port!

[Jerry_In_Detroit]

By itself, digitizing health records isn't going to solve a lot and is already creating problems.
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Let's begin with ?The Law of Rewards?; Very simply people do what is rewarded. For the health care industry, the simple fact is that paperwork equals profit; Profit for the industry and all the agencies up and down the bureaucratic food chain. Digitizing health records will solve nothing and is likely to fail because there is no reward to the insurance provider or the governmental agencies that oversee them.
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The very least of the problems is developing a portable health data file format. If the software industry is as smart as they say they are, they will set up a working group now and develop their own standard before the government attempts to do it for them.
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One issue will be patient access. Like credit reports, the patient does need the ability to read their own health records and provide corrections when necessary. A lot of the more obvious mistakes could be detected by an AI program but there is no substitute for the patient occasionally reading thier own health records. By the way, did you know the insurance companies have a health care rating system not unlike the credit rating systems like Experian?
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Another issue will be losing health records or worse yet, someone editing out undesirable information. It is not unreasonable to take a flash drive along and request a PDF printout of all your health records once in awhile.
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The big problem will be patient privacy and abuse of the system. Already, there are stories of Obama's administration scouring VA records for anyone who has ever seen a psychiatrist or psychologist ever then entering their names into the FBI's National Instant Criminal Background Check System (NICS). This is, of course, a total abuse of the GCA 68 legislation but, hey, nobody likes gun owners anyway and we can trust the government to act on our behalf. Right? Without adequate & sensible privacy protections and strong protections against abuse, digital health records are on the short track to the scrap heap.
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Currently, digital health records and administration are a lot more common than people realize. Here in my Detroit suburb, my doctor's office is completely digital. Prescriptions are e-mailed to the pharmacy of my choice. It is happening. The need for a national health care database is questionable though.

[Centrifuge777]

The hidden issues of Electronic Health Records is what troubles me the most.
The patient has a right to their own records, they also have a right to store records on their own premises vs the hospital filing room.
These rights are necessary and crucial in protecting patients from the beast that has become the Health Care Industry. (Heal Care Industry = Making money from human suffering).

Your health information should be considered as intangible property that comes with mandatory sole ownership to the individual, assigned guardian, or relative in the case that the patient is unable to manage, or make decisions for themselves.

Electronic Health Records should only be forced, or even made available, if definitive law is put in place that allows individual patients to control all data and records stored regarding their health information. If this is not done first, then the intangible property of your "health information" will become the property of the IT industry and you will have no way to control, review, or correct errors. It should also be made law that no company shall offer or force a EULA for services, or access, to any individual or guardian, that forces an individual to waive their right of control concerning their EHR's. That way you force every entity storing EHRs to adhere to certain standards. Those standards are roughly, that the individual or guardian has a right to control how, when, where, and if EHR's are used for any purpose, and also the right to erasure, modification, or correction of any records stored.

[jerrymacGP]

I work in health care in western Canada. Although the issues surrounding health insurance and privacy are different in Canada, due to the universal single-payer model here (nobody has coverage for essential care denied due to "pre-existing conditions"), many of the other challenges discussed here are the same. Government policy, usability, and infrastructure compatibility are among the most important.

In the province of Alberta, seven of the nine Regional Health Authorities (RHAs) had signed an agreement to use a common system, which integrates patient registration, diagnostics, patient scheduling, utilization and workload statistics, payroll and HR management, and multiple other function across the entire continuum of care, from community health to acute care; however, the two largest RHAs, those centred around the province's two major metropolitan centres (Calgary & Edmonton) opted out of that system and chose to go it alone. Furthermore, providers outside of the publicly administered system, such as private physician practices, were not included in this system either. This year, the government of Alberta abolished all nine RHAs and created a single province-wide authority governed by a "superboard". It remains to be seen which way the new province-wide authority will go in advancing IT in health care.

Usability is another serious barrier to digitalization in health care. Many current systems do not fit well into a typical health care provider's workflow. A paper chart does not close itself and lock out if you don't flip the pages for a few minutes. You can carry it around from patient to patient, reading as you go, and have it open in front of you while talking to the patient or the family. You don't have to re-enter a complex password to move from one section of the chart to another. And paper never ever freezes or crashes. (Even in a power failure, a simple flashlight is all you need to use it). There is a reason why digitalization has increased the amount of paper we use in health care, rather than decreased it: systems are not stable. Many end users (myself included) print everything, just to be on the safe side.

Infrastructure compatibility: many health care facilities were built long before the digital age, and were not designed to accommodate a multiplicity of computer workstations in patient care areas. We shoehorn computers into workspaces not designed to fit them, without investing the capital funds and downtime to renovate, and then wonder why keyboards get broken and coffee gets spilled on them, and why we have to elbow each other aside to get access. Cable runs and network access ports are inadequate or unavailable, and there are never enough computers for everyone who needs to use them.

Finally, you also need to talk to other players in the health care system, not only physicians. Registered Nurses comprise the largest group of health care professionals in both Canada and the US, but you haven't quoted a single nurse in your piece. Physiotherapists, pharmacists, and dietitians, for example, will also have their own unique perspectives on this issue.