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Dragging health records into the Digital Age
Walk through a typical Kaiser Permanente doctor's office or hospital, and you won't find a paper chart lying around. Kaiser, with 450 hospitals and offices around the country, is almost entirely paperless.
But as the rest of the health care industry rushes to follow in Kaiser's digital footsteps, Kaiser's paperless success story--a 10-year, $4 billion effort--might actually serve as a cautionary tale.
By no means has the Kaiser e-health project failed. In fact, besides some hiccups, it has gone well: Kaiser said it has seen more satisfied patients and a slight dip in emergency room visits and hospital stays, which cuts costs. Even the doctors grumbling the loudest beforehand don't know what they would do if they were forced back to paper.
Unfortunately, the rest of the health care system looks nothing like Kaiser.
health care information within its hospital walls. It has
been using a desktop cart on wheels, but the tablet is
less intrusive and can run longer without needing a charge.
Kaiser is a rare beast: both an insurance provider and medical provider. Investing in digital technology was projected to create efficiencies in its medical services and boost the bottom line.
Most hospitals don't operate like that. They provide a service, bill the insurance company or the government, and move on to the next patient, efficiency be damned.
Nonetheless, the United States appears to be barreling ahead with a far-reaching health care digitization effort that even proponents say leaves many questions unanswered. The Obama stimulus package provides $19 billion for hospital technology efforts, which could go a long way toward prodding penny-pinching hospitals and doctors to finally leap into the 21st century.
But then what? Most experts believe that $19 billion is only a down payment on what it will really take to digitize American hospitals. What's more, successful digitization will require the reinvention of the rest of the medical industry--with insurance companies on one side and doctors on the other, in an often-nasty tug-of-war over patients and dollars. That means a change in policy as much as technology, and perhaps the most drastic overhaul of an industry in American history.
"What I worry is that there are some very, very high expectations that may result in significant disappointment," said Andy Wiesenthal, the doctor who helped set up Kaiser's system. Digitizing the whole country's medical records could take a decade of sustained commitment, and "as a country, our attention span is not lengthy," Wiesenthal said.
"Finding 50,000 high-quality professionals is going to be hard," said John Halamka, who serves as chief information officer of New England's CareGroup Healthcare System and also chairs the U.S. Healthcare Information Technology Standards Panel. "The one thing you do worry is that there are going to be a lot of fly-by-night companies. There has to be real vigilance to make sure people are actually getting what they are paying for."
Unfortunately, it's neither clear from where all those new workers will come, nor who will be policing for shoddy technology acquired in a government-funded buying spree.
In a three-day special report, CNET News will take a look at the rapidly digitizing health care industry and try to answer the question: What took them so long? In the process, we'll explain the dangers inherent in the digitization, what the stimulus plan and e-health legislation means to the average person, and maybe inch a little closer to answering one of the most vexing questions of American medicine: why are doctors such Luddites?
If the country's hospitals really are going to go digital, they would do well to be asking these questions and getting answers--fast. In the past, health care information spending has been like a steam train just sort of chugging along, said Patick Heim, Kaiser's chief information security officer. Now "we have a new engineer--Obama--dumping tons and tons of coal ($19 billion worth)," Heim said. "That steam train is driving faster and faster. Have we tested the rails to make sure we understand that speed? Do we have the brakes in place?"
Does spending equal efficiency?
Like most businesses in other industries, Kaiser benefits financially from efficiency. If people need less treatment because electronic records help prevent duplicate tests or enable doctors to spot issues sooner, Kaiser's bottom line gets a boost.
Most hospitals and doctors, though, get paid only when they deliver service, regardless of whether it's done efficiently. And in that environment, there's little reason to invest dollars up front in order squeeze costs out of the system over the long haul.
Nonetheless, Kaiser said it is a big supporter of what President Obama is trying to accomplish by providing financial incentives for the industry to move to digital records. It just wants to make sure that the money is spent with focus on improving care, as opposed to merely adding technology.
Although there is some debate, the consensus among medical professionals is that electronic records should be able to improve care, said Matthew Holt, the co-founder of the Health 2.0 conference and author of a well-regarded blog on health care technology. But he cautions that the speed at which the industry is moving may mean that more money is spent on older, readily available technology.
The problem, Holt said, is that many prevalent products were developed 10 or even 20 years ago. Most of the software on the market uses a traditional client-server approach, as opposed to the kind of Web-based hosted service that might make the most sense these days, Holt said.
Even companies lining up to land contracts in the digital push are urging care and caution over how the dollars are spent. Peter Neupert, head of Microsoft's Health Solutions Group, has urged the industry to put IT spending in the context of broader health care reform, saying medical records are a "necessary, but not sufficient," step.
"I'm trying to transform the discussion just a little bit," Neupert said in a January interview with CNET News. "Don't focus on spending money on tech, per se. Focus on what outcomes we want."
The outcome we want
In a perfect world, there would be a national system in which each hospital and doctor is connected. A patient would arrive at a hospital he had never visited, and all of his records would be available. That would mean that tests would not have to be repeated, and those tests that were ordered would be in the hands of doctors as soon as the results are ready. Doctors would have access not only to patient records, but also to software that provides recommended drugs and treatments. And patients would feel confident that their medical records are secure.
But even just basic digital health records could make a big difference.
Former U.S. Rep. Billy Tauzin (R-La.) said he learned that firsthand during his recent battle with cancer. For months, he was bleeding internally, and it took five trips to the emergency room and seven hospitalizations to nail down the problem.
"For six months, I had to constantly fill out the same forms," he said. "I had to go through interrogations to get the pint of blood I needed," said Tauzin, who now runs the drug industry trade group Phrma. One time, he said he found himself lying on the floor of an emergency room because he couldn't sit up as he tried to get through all the required paperwork.
Another time, Tauzin said he had an unnecessary operation because the doctor performing the surgery didn't know about an earlier procedure he had undergone--one requiring the use of longer surgical instruments than the ones the doctor had on hand.
Page 2: A full dose of what's wrong
Day 1: Dragging health records into the Digital Age
Microsoft, Google in healthy competition
Day 2: What you need to know about e-health records
Politicos prepping for another health care showdown
Day 3: Why are doctors such Luddites?
Images: Taking your health record with you
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.
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.
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.
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.
Is this what everybody else wants to do? Look, then, at the paradigm that the VA has become.
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.
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!
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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.
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.
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.