Last night I realized that I actually do like having a computerized medical record system.
I have had a love hate relationship with our computerized medical record system since we adopted it in January of 2007. We decided to make all of our records and billing electronic in 2006 and tried out several systems before deciding on General Electric’s Centricity product. It was expensive, over $100,000 for our 9 physician group, not including the loss in production as we learned how to use it, and not including many of the laptops and desktops and printers and other hardware. When the system “went live” we all slowed our history taking and record keeping to a snail’s pace and were hard pressed to see half as many patients as we had before the system was in place. We all stayed late and came in early. Eventually we adjusted to it, and after a year, we were not as fast, but almost as fast as we had been before. We lost 2 physicians who really couldn’t deal with it and had trouble retaining a couple of newly hired physician because it was difficult to use. We kept better records, eventually. Some of the nurses and other office staff couldn’t adjust and left.
Sounds bad, I guess.
But there’s more. It would freeze up when we did certain things that were supposed to work, like faxing a prescription, and stay frozen for 5 minutes before resetting itself. There would be system updates which caused new bugs to appear. If one person was using a document, another person would not be able to use the document until various closing rituals were performed, and if they were performed wrong, a chart could be in a state of limbo that only the IT guy could fix.
Now these problems are only a bad dream. There were other ones too which I thankfully can no longer remember. We are left with only the bugs that seem to be completely resistant to all attempts to treat them, and bugs that are intrinsic to the system.
There is no back button. There is no automatic spell check (though you can spell check manually). Once a document is electronically signed, it can’t be changed, and it is easy to accidentally sign a document. There are no autocomplete functions. My cursor jumps, and so when I am typing, all of a sudden I am no longer creating text and I have to manually put the cursor back where it is supposed to be. Sometimes the jumping cursor will randomly highlight text and then when I start typing again it deletes the highlighted text. Occasionally vital signs are entered and just don’t appear on the final document, but you can make them appear by re-entering any value into the form. Documents are much longer than they need to be and look awkward. I can’t look at a patient’s medical record in the same window that I am using to take their history.
When I tell people this, they say, “oh, you just have a bad system.” Well, yes, obviously that is true. Nevertheless, this General Electric product is one of the most widely used medical record keeping systems, and being able to communicate with other medical offices and hospitals by way of shared software is one of the major reasons to computerize records. The obvious solution to bad electronic medical records system is to create a great electronic medical record system and make it inexpensive or free, perhaps supported by a government grant, so it out-competes all of these other really-not-very-good systems that we have adopted for lack of a better options.
But that was not the story that I wanted to tell.
I actually wanted to say that providing medicine the way I think it should be done, at a time that is appropriate and in a place that is expedient, has been made much easier by the fact that I can access a patient’s medical record from my laptop, anywhere I have internet access, and can send prescriptions and keep records in a way that lets me review what has happened, and later to remember what I have done.
Yesterday when I got back from backpacking, where there was no cell phone service and even google earth couldn’t find me, I found a message on my answering machine from a patient who needed help. I was able to sit down at my laptop, see what medications she was taking, see what, if anything, other doctors in my practice had done for her, and discuss medications, side effects and interactions with her. I was then able to order the appropriate change in medication and relay it to her pharmacy, which would get the information the following morning since it was 9:30 at night. It was good medicine, practiced at the most appropriate time for me and the patient, and there were minimal associated costs.
Electronic communications have expanded the way that medicine can be practiced, including the possibility of web based communications to patients with shared problems, e-mail communication, video chatting and efficient communication between doctors of different specialties. I don’t use even a fraction of what is available, but I can certainly see what powerful tools exist.
Many things get in the way of making these electronic tools acceptable in our practices. The difficulties in buying functional software like I described in the first several paragraphs is one barrier. Issues of protection of privacy are another. Not least, however, is the fact that the majority of physicians are still paid only for face to face contact with patients, and there is no easy way to change that without fundamentally changing the business of medicine.
We could, of course, simply start charging for all forms of communication, and remain in the “fee for service” model. This would involve more complex billing plus long and incredibly irritating negotiations with public and private insurance companies. We could also fundamentally change the way health care providers are paid, and pay people like me salaries to do the jobs we now do without the complexities of scoring each problem solved, procedure performed or patient seen.
I think that electronic communication and record keeping can, at best, provide an excellent backdrop for community funded health care. Most physicians loathe the complexities of billing for the minutiae of our work, and we would love to be able to put all of our hearts and energies into the actual care of patients. If communities were able to hire the services of hospitals, doctors, nurses and other staff, we would be able to care for people using all of the appropriate and available technology. Our present system of billing keeps most of us firmly entrenched in communication technology that is many decades old.
It is hard for me to understand why the US government has not commissioned, on behalf of all the MDs in the US, the most perfect of all computerized medical record systems ever… a true public good. Seems we have to wait for some blackberry APS to solve it.
Government initiating isn’t the way it works my friend. You see we all know that government screws up everything and the last thing we would want them to do would become involved in developing a better system for keeping medical records.
The only thing more inept than a government worker of course is some egghead at a college. One’s lost and the other will never know where they are.
The only way we’ll get a good system like we need is when some business will develop it with the purest of motives, profit.
I never had first hand experience with electronic medical record systems, but any time that I had to deal with the VA, they always seemed to have organized, easy to read, easily updated, and, most importantly for my purposes, easily accessible medical records. Is the VA system available to other parties?
It’s exciting to see the possibilities that are created with new technologies. Is there anything that is slowing the pace of getting the software problems fixed? Those sorts of bugs seem like they should be easy to eliminate, at least from my non-technically trained point of view.
Of course we don’t want the government developing a system. Private enterprise will develop four or five systems and they will duke it out over the next decade while roughly 80% of everybody has to buy two or more systems until things settle down. Government might, heaven forbid, standardize things, so everybody would be able to communicate with everybody else. Can’t have that, can we?
yes, wired, I agree with your evident frustration. I think that there is lots of expertise out there, and I did use the VAs medical record system decades ago, and it was actually pretty good. I don’t know what my more refined take on it would be. I think facebook is a great product and a system using many of the same gadgets would be user friendly for both physicians and patients. I would like to see fresh thinking computer savvy folks like those who work for facebook or google charged with creating the best medical record keeping system, have it be supported publicly and then have it out compete the many incompatible systems we have now.
A very brief outline for an application of this type (recordkeeping):
1) It must have the highest standard of data integrity. The patient’s life depends on its accuracy.
2) It must offer every opportunity for the data entry to be stored in a fashion that later users will find accessible, immediately understandable (we call that “intuitive”) and in a fixed format. It must force every user to enter data the same way every time, in the same format when it can vary (like the different ways to express a date). Consistency is the short term for that.
3) It must be capable of transmitting (sharing) very large volumes of data between different platforms. A platform is the combination of hardware (mainframe, PC servers, some gradations in between), software (operating system), and the vagaries of manufacturer’s proprietary design (that big difference between the plethora of PCs and Apple).
User-friendly or usability is first on the list of secondary priorities, not making it unimportant but recognizing that it can add levels of complexity to the design that can be very expensive.
That said, find a financial investor and a group of physicians willing to make a similar investment of time and I (or a long list of veteran software developers) would jump at the opportunity to build that application. I would guess some millions of dollars and about three years to get the beta version ready for extensive testing.
If not also via the immediate medical profession itself, via the Medical Information Bureau (MIB) or descendant or alternative databases such a database will provide endless hours of interesting and amusing entertainment to any medical industry-connected underwriter, secretary, clerk, salesperson, executive, or friend or relative of the foregoing capable of being interested, amused, and entertained by any facet of your physiology, its functions or dysfunctions, and any lifestyle elements relating to those.
H. M. Stuart
Alexandria
A key issue that keeps us from getting integrated records, like they do in France, Germany and Taiwan, is that our hospitals are in competition with each other. Most docs are in groups in competition with other groups.
Next major problem is the issue of security, not so much for what HMS suggests, this is not happening in France et al. as far as I can tell, but rather that potential employers find out. If they know you have an expensive to care for medical problem they are less likely to hire you.
Like Janice, I would love to have nationalized, accessible records. I get tired of having to guess at people’s medical history.
Steve
That’s a critical point, Steve. I hadn’t thought of it, and it would seem to be an insurmountable wall. We can’t have universal record keeping without a universal coverage system/plan/program that prohibits punishing people who are sick.
Next major problem is the issue of security, not so much for what HMS suggests, this is not happening in France et al. as far as I can tell…
My good Steve,
It may not be happening in France as far as I can tell, either, but, then, my on-site experience with the amusement value of medical records in France is likely even less than yours.
However, in the U.S., in my direct experience, it is not uncommon at all for a bullpen of individuals to discuss such things as, for example, which most desirable alternate sexual positions to attempt with a named individual whose medical records indicated a congenitally tilted vagina and uterus.
Again, I am no expert on France, but I can confidently assure Americans that, if they think their medical details are now or will be in the future kept private from such pastimes, they are sadly mistaken.
H. M. Stuart
Alexandria
We can, actually, have universal record keeping without having a single payer system, but it has to be easy and financially attractive to all users. There is a single payer for almost everybody over 65, and that is already a powerful driver. What we don’t have is good leadership and consensus from within the field of medicine. The other point I was making is that communities can fund health care. This is not the same thing as “the government” funding health care. There are various experiments of this kind surviving and thriving in the US. Standardized, inexpensive, flexible and user friendly medical record keeping systems would make systems like this function smoothly and efficiently. Using all of the technology we have at our disposal would make a community medical system really effective, but will be really difficult to put into practice while we still pay only for individual face to face services.
What we don’t have is good leadership and consensus from within the field of medicine.
Simplistically put, if much more difficult that it sounds, six to ten representatives of the medical community would be enough to form that leadership and work towards consensus, that being not agreement that a universal record keeper was needed, but what it should look like and do.
Software comes in two general flavors: The ones that look great, and the ones that do what you want them to do. Think of your favorite website for content taking 3 minutes to load a page and another two minutes to get all of the ads out of the way. That’s your “looks great” example (ahem). Compare that to a website that take a total of 60 seconds or less to login and load the content you want to see (something BQO did/does very well). That would be my example of the latter flavor.
I design and create “back end” applications, databases, their loading and maintenance, and moving data from source to destination. In short, I do record keeping and creating the access to the data so it can be displayed, edited, deleted or updated from a user interface. With the appropriate restraint on the user interface design. your universal medical records system just needs two things: a confirmed list of all of the standard elements required, and the extent to which “free form” data is permitted and stored.
Once the hardest part is accomplished — that consensus — it’s just a matter of scoping the work and putting a budget around it.
and to HMS–I’m not really sure that privacy of a medical record has ever been achievable. The only way to make information truly private would be to make it un-shareable, as in the doctor gets a brain wipe after the patient visit. Paper records were perusable by the janitors after the staff had gone home, and “curbside consults”, which are one of the most efficient and inexpensive ways to get specialty input on questions, are easily overheard. We do need to make it difficult for recreational users to get access to medical records, but we will be fooling ourselves if we believe that our security is absolute. And as for accuracy of medical records, that is also very far from absolute, so even if spying eyes do read sensitive information, it might easily be wrong.
and to HMS–I’m not really sure that privacy of a medical record has ever been achievable.
My good Janice,
You are correct. The problem is now, which will only become worse, that digitized medical information can only become an ever more facilely manipulable commodity: illegal trading in medical identity already parallels illegal trading in financial identity.
As the utilization of medicine becomes ever more a universal mass commodity so will its information trail, in the same way and to the same degree that once private individual financial information has now become a mass commodity, easily available for access and sale.
H. M. Stuart
Alexandria
Application security, despite what we regularly hear about how easy it is for hackers to invade systems, is quite sufficiently mature to guarantee privacy by closely defining access.
I submit that we don’t need anything more than existing laws to cover the rare successful theft of data. Prison terms are an excellent response.
“The problem is now, which will only become worse, that digitized medical information can only become an ever more facilely manipulable commodity: illegal trading in medical identity already parallels illegal trading in financial identity.”
I suspect most of this goes away if we have true universal health care. Other than celebrity records, I am not sure what you gain be stealing most records unless you are an employer.
Steve
My good Steve,
If you were a data miner (or a military intelligence analyst) which would you seek more diligently and pay more dollars for in order to build a mass marketing profile(s) (or a soft war* economic assault** plan), a browser cookie or a definitive medical record indicating the subject might be a prospect for (or not for) X?
In point of fact, as the health care industry trends ever more greatly toward becoming the bulk of any economy itself, as it is doing right now in the U.S., such medical records as marketing aids in order to facilitate selling ever greater product and service into potential medical related need – in addition to my previously mentioned, already rampant market in “clean” medical identities – become progressively more desirable and valuable.
*Corporate or national
**Let us say one a) has obtained broad access to a population’s medical records, together with other personal data, and b) has an equally cost-effective way to reach the members of that population, say, electronically.
An easily compiled and easily communicated mass assault across a mass population [Option C3, of different, cybetnetically compiled and collated options A-Z times oo: "(Your female name here), we understand from (subject's physician's name or equivalent) you are probably tired of being rejected by people you would like to be closer to because of your embarrassing incontinence problem, blah, blah, blah..."] can easily disrupt and demoralize a significant portion of a population, enough to significantly dampen or diminish its collective economic or political competitiveness over a measurable period of time.
Targeted to an international competitor’s specific industry, significant changes in market share could easily be reaped, with no real pattern of assault ever being detectable.
I am just blocking out a crude example, absolutely easy to execute. A specialist in the field could achieve much, much more.
The reason nobody spends billions globally annually collecting and collating information of every sort is because nobody wants to do anything with it.
H. M. Stuart
Alexandria
There are actually two competing forces operating on medical records right now. The number of people/entities that have legitimate access to your medical records is probably higher than it has ever been before. But OTOH, the likelihood of any of these people actually reading all that stuff is probably smaller than ever. Do the docs here have any solution to this conundrum?
Re: brain wipes–I asked a psychologist friend of mine about the possibility of doing this, perhaps through post-hypnotic suggestion, as a way to protect proprietary info. He thinks it could be done, but would probably come with some messy side effects. Of course, the economic side effects would be even worse–if you deprive people of the memory of having seen a movie, they will feel no need to see another one, when they can just see the first one for the first time again and again.