kitchen table math, the sequel: doctors on electronic medical records

Tuesday, February 5, 2013

doctors on electronic medical records

As a veteran of the public school system, I've never seen electronic medical records as the great white hope where medical costs are concerned. "Technology" is expensive.

Sure enough:
The conversion to electronic health records has failed so far to produce the hoped-for savings in health care costs and has had mixed results, at best, in improving efficiency and patient care, according to a new analysis by the influential RAND Corporation.

Optimistic predictions by RAND in 2005 helped drive explosive growth in the electronic records industry and encouraged the federal government to give billions of dollars in financial incentives to hospitals and doctors that put the systems in place.


RAND’s 2005 report was paid for by a group of companies, including General Electric and Cerner Corporation, that have profited by developing and selling electronic records systems to hospitals and physician practices. Cerner’s revenue has nearly tripled since the report was released, to a projected $3 billion in 2013, from $1 billion in 2005.

The report predicted that widespread use of electronic records could save the United States health care system at least $81 billion a year, a figure RAND now says was overstated. The study was widely praised within the technology industry and helped persuade Congress and the Obama administration to authorize billions of dollars in federal stimulus money in 2009 to help hospitals and doctors pay for the installation of electronic records systems.


But evidence of significant savings is scant, and there is increasing concern that electronic records have actually added to costs by making it easier to bill more for some services.

In Second Look, Few Savings From Digital Health Records
Published: January 10, 2013
Mickey Kaus has posted emails from physicians describing their experiences with EMRs that are fascinating. This one especially:
I once reviewed a hospital record from a large national medical center that I can’t name, but [you've] heard of. The patient had a major operation. The operative note was incredibly good. Page after page it recorded in exquisite detail exactly where the surgeon cut, exactly what he retracted, exactly what he saw, exactly what detailed care he took to avoid injury to this organ and that one. I was impressed. I remember thinking, “Wow. No wonder this place has a national reputation.” This was the best documented operation I had ever seen.

In spite of this operation, the patient got worse. Four days later she went back for a repeat of the same operation. And the second operative note was the exactly the same as the first. Identical. Page after page, word for word, exactly the same. Leave aside the impossibility of having two multi-hour operations go exactly the same way, it is not possible to dictate or write two multi-page op notes that are word for word identical. The op notes were frauds. They were templates, worked out with the hospital risk management department to describe what should happen, and entered in the EMR with one click of a mouse. What actually happened? No one can tell.
More on Obama’s Great Health Leap Forward
Talk about 'always worse than you think.' Yikes.

We experienced a comic version of the prefab clinical observation several years ago when we took Andrew and Jimmy to the hospital for extensive speech testing, resulting in extensive reports. When we read Andrew's, we discovered that the report characterized him as 'deaf.'

Andrew is not deaf.

The rest of the report seemed to be about Andrew, not some other kid, so we assumed somebody must have hit the 'deaf' macro by mistake. That was mildly annoying, but it didn't occur to us to ask ourselves whether anything in the report was specific to Andrew.

Then there was the time C's middle school math teacher selected "Finds math difficult" from the Comment Bank....which reminds me of the then-assistant principal telling parents that teachers were no longer allowed to hand-write comments on report cards because you never knew what they'd say. (They might say something inappropriate, like "Finds math difficult.")

Meanwhile here's the latest news from the coming Disruption that is the MOOC: Crash Sinks Course on Online Teaching.
The six-week course, called "Fundamentals of Online Education: Planning and Application," was created by Fatimah Wirth, a Georgia Tech instructional designer. The emphasis of the course, which began on Jan. 28, was to teach students how to create online learning materials and manage an online class.

Students were asked to sign up for groups using Google Docs, but a spokesman for Google Inc. said the program allows only 50 people to edit a document simultaneously. When the crush of students tried to sign up, the system crashed, said Debbie Morrison, who was in the class.

Ms. Wirth emailed an apology, but when things didn't improve she, in conjunction with Georgia Tech and Coursera, pulled the plug on the course.
Kaus's other post on EMRs: Obama's Great Health Leap Forward

The Ups and Downs of Electronic Medical Records
Medicare Is Faulted on Shift to Electronic Records
A Shortcut to Wasted Time
Abuse of Electronic Records
Uneasy About Online Medical Records


GoogleMaster said...

Irony! I'm taking a couple of courses on Coursera right now, and I was browsing just this evening to see what I could take when these are done. I noticed the FOE class and thought about signing up for it, but I guess I shouldn't bother, eh?

One of my courses started with 41,000 students; the other has started with 92,000.

lgm said...

Electronic tech cuts out the physical mail delivery system. It also allows the physician to chart data and run statistics quickly.

Auntie Ann said...

Medical staff also loathe the pull-down menus. They are prone to error--how many times have you tried to select your state on a website, only to have it end up on another one? And they are incredibly slow to use! (Click on the down arrow, roll down the list, find the right entry, then click it.) They are especially hard to use when working on a laptop's touchpad.

At the hospital I work at (admin, not medical,) they've found them to be a major time waster and expensive in practice--it is particularly bad when the time being wasted is an expensive MD's or high-level RN's. They've needed a large number of support staff to help them with months of training or to do stupid computer data entry.

And paper systems don't crash, electronic ones do. Crashes mean you have to also plan for a back-up, paper-based system to kick in immediately upon a crash occurring. You can't put all your hospital's activities on hold while your computer technicians track down the problem and reboot the system. Then, when the system comes back online, you have to clear the backlog of missed data entry.

What a headache!

momof4 said...

Just this morning, I was talking with a nurse whose office is transitioning to EMR - unwillingly, under O'care mandates. She said the EMR wastes time, costs more money and can communicate only with those records on the same program. She also said that there are lots of things that pop up spontaneously when something else is clicked. A rehab medicine relative of hers, who is often involved in court cases, said he's seen several instances where male patient records have data on menstrual cycles; thus invalidating the entire record, for legal purposes. I also read of serious problems with auto-generation features of operative notes, which override or cancel the actual surgeon's note, even if one was done. GIGO

Anonymous said...

Not to mention the nightmare scenario of the office employees taking laptops/thumb drives home and having them lost/stolen from car/home.

momof4 said...

lgm: The various EMR systems can't talk to one another and that's a huge stumbling block; staff time, paperwork and money.

It's exactly like foreign languages; A hospital system speaks/understands only A, B hospital only B and independent groups/practitioners/hospitals C through ??? speak only C through ???. Since patients see practitioners and use lab/rad facilities from any combination of the above, records still have to be faxed around (usually after at least one reminder call prior to patient arrival in clinic awaiting records and another call after patient arrives in clinic). I've been doing that for years.

And it's all unnecessary, since the federal government already owns/has paid for the well-tested and user-friendly CHCS. It was started in the military in the 80s and spread to the VA - no reason it couldn't have been made available to everyone. Used nationally, it would facilitate care in situations where patients become ill or injured on vacation, on business trips or during snowbird winters; unlike the current situation. Also, since most physicians have rotated through a VA during training, they already know the system.

AmyP said...

"We experienced a comic version of the prefab clinical observation several years ago when we took Andrew and Jimmy to the hospital for extensive speech testing, resulting in extensive reports. When we read Andrew's, we discovered that the report characterized him as 'deaf.'"

We work with a very fine child psychologist who may be guilty of similar--there was a section of the report on our daughter that used "he" rather than "she" repeatedly and a friend of mine who had a child evaluated by this psychologist also had some non-relevant boilerplate show up in the child's report. This is a very good, intuitive psychologist, but she's not careful enough with these reports. I suppose there is a tendency to just throw the kitchen sink into these reports, thinking that overdiagnosing does little harm.

I had no idea that this was going to be the future of the medical profession generally.

That said, I definitely have seen my family's care improving over the last five years (which coincides with the rise of electronic records). When I see doctors, they walk in knowing who I am and what I'm there for and what I was in there for last time, which has not always been the case. (Maybe the electronic records improves good doctors and makes bad doctors worse, because it allows them to camouflage themselves?) I definitely feel that it's a more seamless system now. Just out of habit, I try to make sure to overcommunicate with medical people, but more and more, I'm finding that they are already up to speed.

Anonymous said...

-- no reason [why CHCS] couldn't have been made available to everyone

If you think EMR was about what was good for patients and their care providers, then I have a bridge to sell you.

It was, and is, and will be, about control. The feds will now control the medical staff, and doctors will get to be public sector union members of local #1926. They will be told what they can do and when, and they and we will get treated accordingly.

Anonymous said...

I am a physician at a large medical center in Los Angeles that recently installed EMR. The program favored by the government is called EPIC, and the installation has taken well over a year so far and there are parts of the program that are still being installed. The company that produced the software sent out legions of people to train the hospital, and we now have an in in-house crew of IT people numbering in the hundreds. IT specialists have to be available 24/7, in case log-ons fail or there are other computer problems. The system required doctors to undergo a minimum of 8 hours of training. Nurses were required to attend three days of training sessions. All spent countless hours working with the trainers who were brought in for the installation while working on the clinical service.
The system is cumbersome and time consuming to use. Notes and physicals take much more time to enter than the old paper charting. Physicians can import lab data, x-ray reports and other reports directly into their daily notes, so the notes have become much longer. Templates also add to the length of the notes. Medical students, residents, fellows, nurses and attending physicians all create these lengthy notes daily, all with repetitive information, lab data etc, imported into every note. Most of this is done for legal and compliance purposes, and the notes become virtually unreadable.

Everything done by providers is coded for reimbursement and compliance purposes so that the data can be mined later by administrators and insurers(mostly the government). Compliance requirements are enormous, with countless audits and statistics required for participation in insurance contracts and government certifications. It amounts to an enormous administrative burden transferred from insurers to providers. There is now a small army of administrators collating data on efficiency, compliance with government regulations and patient safety and submitting the required reports. None of the cost of all of this known or reported. From the perspective of the government and insurers, it's all free! Look forward to it getting a lot worse. I suspect that in a few years, 25 to 30% of reimbursements to providers will be going to this kind of administrative activity. Insurers are now limited in the amount they can be reimbursed for administrative overhead, but there is no limit to the administrative costs that they can unload onto care providers.

Anonymous said...

The bulk of the data entry is done by nurses, who have now become "HIP"s (human interface persons). They tootle around with mobile computers called "COWS" (computers on wheels). Hips with cows. Not much attention being paid to patients anymore.

Glen said...

And then there's the PMR system: Paper.

I go into the local emergency room in terrible pain and get an interview with triage. "Have you ever had A, B, C, ...Z, AA, AB, ...?" "Are you allergic to anything?"

"Yes, silk adhesive tape makes my skin blister." "Okay, just a few more questions, a couple of forms to fill out and sign. Won't take but a minute, Hon'."

Then I go into the exam room. In comes someone with a full six-page questionnaire to fill out. "While you wait."

Page after page of: "Have you ever had A, B, C...?" I'm in a lot of pain, answering the same background questions I just answered in triage, describing my problem again but in writing, and once more with the allergies.

I write that I'm very allergic to silk tape.

I finish writing about the problem and in comes a doctor who asks me to *tell him* about the problem. "Uh huh. Uh huh. Mmm."

In comes the finance lady. "We have a few papers for you to fill out."

"You were here a couple of years ago," she announces. I agree and add that if she knows that, she must have found my records and should still have the papers I filled out last time for finance. Nothing has changed.

"Oh, we have a new system. The paperwork is different. You have to fill it out again."

The ER doctor comes back and tells me I need to be admitted and introduces me to my new doctor. They take me upstairs and give me more papers to fill out. "Have you ever had A, B, C...?"

"Didn't I already do this several times?", I ask. "No, whatever you did downstairs was for [them], this is for [us]." My new floor has its own paperwork. My new doctor has his own paperwork. I fill in forms acknowledging that I know all my rights. I sign papers waiving all my rights. I have to write about my problem all over again. I ask why I can't just photocopy it. Because the photocopiers are only for staff. "Okay, you photocopy it." Fat chance. [Apparently timesaving devices are for people whose time is worth saving.]

I write about my silk tape allergy one more time--maybe two more times, I lose count.

In comes "my" nurse. She just has a few questions, all of which I've repeatedly answered in writing. "Oh, but we don't have those papers here, so I need you to tell me again."

In comes another nurse who tells me to lie back and look out the window while she slaps and thumps my arm, looking for a vein. "You might feel a little pinch." When she stops pinching me, I look at my arm and see that it's striped with white tape.

"Is that silk tape?" I wail.

"Yes, why? Is that a problem? You should have told somebody."

Anonymous said...

At MGH, where I go for everything, electronic records management has been working very well for more than a decade. I have a primary physician within the system, but I rarely see him except for physicals every few years and any major or chronic problems requiring referrals. If I need something I see a different doctor or nurse at a clinic. And every time I do it goes into the system. When I see my doctor for a physical, he goes over what's been happening with me medically since I've seen him because he sees it all on his screen. If I've had any X-Rays or MRIs, they're on his screen too. Any diagnoses or prescriptions are on his screen. It's easy, seamless, and the way medicine should work. My entire medical life is in one place - as long as I never go anywhere but MGH.

froggiemama said...

My practice is completely computerized and I love it. When I see any specialist, or go to the affiliated urgent care, the information flows to my PCP right away. If he sees something that concerns him, he calls me or emails me. This has happened a couple of times now. I totally appreciate it.

My kids see a ped whose practice is still paper-based. WHile I like the ped, the practice is a nightmare. Things are constantly lost, and the information DOES NOT FLOW. When my kid sees a specialist, I know the only way to get the results back to the ped is to do it myself.

Anonymous said...

Allison: You are absolutely right; it's all about control. That's the issue that is behind the hospital/government push to make all physicians employees, not independent practitioners. There's also the push for various companies to profit from their EMRs.

ANONYMOUS: AS LONG AS I NEVER GO ANYWHERE BUT MGH"; THAT'S THE PROBLEM. Large numbers of people take vacations, travel for business and go south for the winter (the latter are seniors,large users of medical care). What about my relative's physically disabled son, who (1)lives in the Northeast, (2) travels for business, (3)visits family in FL at least a couple of times a winter and (4)summers in a fourth location? Complicated medical history and no one can talk electronically to one another. It's even worse in the rural areas in the Midwest; lots of distance, small towns with only one clinic and the necessity to drive long distances to "the city" for anything other than routine primary care. People who live in cities (and I used to) don't understand the issue; care for "everything" is simply not available at one location or from one system.

Anonymous said...

Other Anonymous, the failure here is that you're blaming your problems on the wrong thing.

Yes, it's true that the medical care you receive if you are transient or live in an undeveloped area is inferior. This is not caused, however, by use of electronic records. The same thing happens when you use paper records. It's too bad that electronic records can't necessarily fix your problems, but electronic records are not the problem here.

I don't use any other services but those from MGH in my area. If I need medical services while traveling (and I've probably traveled a lot more than your relative), I bring the information home with me for my physician to enter into my record.

It is true that people who live in cities can't understand a lot of things. For example, we can't understand why people who separate themselves from an economy of scale feel disgruntled when they receive inferior services.

Of course rural services are worse. I get one-day mail delivery and your post office will be closed. I can get anything I want picked up on the curb, and you have to drive to the dump and pay per load. My tap water is delicious and yours is undrinkable. I have the best medical care in the world, and you would too if you lived here. No electronic brilliance will cure the lack of service caused by lack of a market.

Electronic records work very well in the appropriate setting, implemented in a large network by competent people. If you live in Possum Holler, Kentucky, you might never see such a thing. But don't blame that on electronic records.

Anonymous said...

I said nothing about rural services being worse. In my place of current residence, the medical care is excellent,and so ranked. (the tap water is also excellent, as is the trash collection) For most things, the care is easily comparable to that provided by MGH (with which I am familiar) and for the few and rare others, there is a well-established referral system to a number of big-name facilities. What I did say, accurately, is that EMRs do not easily accommodate care from more than one system and that issue could have been avoided.

Your attitude is typical of Northeast city-dwellers; a population with which I have been well-acquainted for many decades. Contrary to your belief, civilization does exist outside of the boundaries of your world. My family and friends from that area will enjoy reading your comments. Cheers!

cranberry said...

Our family's experience with electronic medical records in the greater Boston area has been wonderful. If we must go to the hospital, doctors at the hospital can call up our pediatrician's and GP's records, as they have admitting privileges at area hospitals.

Prescriptions are also in the system; my GP, or her nurse, can see if I refilled a prescription, and order a new prescription sent directly to our pharmacy.

FedUpMom said...

Here's my story of the interplay between medicine and technology:

I have asthma, and I use inhalers as a normal part of my routine. I go to my friendly neighborhood pharmacy for refills of my inhaler prescriptions.

For a stretch of several months, every time I received a new inhaler, it came with a neatly printed label that gave the instruction: "Insert in right ear." I kid you not.

I let it go at first, thinking naively that someone at the pharmacy would notice the error, but after several months I finally pointed out their mistake. It turned out that someone had entered the code "AD" ("insert in right ear") instead of "AS" ("Use as directed.")

Unknown said...

I understand people's concerns about EMR software and its potential security and error issues, but isn't this the way it is with all technologies. There are always risks. We have to adapt from these risks and learn how to prevent them rather than give up on a technology that has many positives.

GoogleMaster said...

My concern is not with the technology; my concern is with the people using the technology.

Unknown said...

I agree that in the beginning EMR software wasn’t perfect, but like anything else the kinks have to worked out and approved upon. Today many practices are thrilled with the use or electronic medical records. Wait times are faster than ever, checkups have become more routine and patients are now even using email as a part of communication with their physicians.

Anonymous said...

Cecilia, thank you for the spam that was not so cleverly disguised as an actual message.