We have no idea what we're missing

Mar 05 2011 Published by under Medicine

The ongoing health care crisis in the US is so pervasive and yet so invisible.  It is a smog you and I breathe in every day, everywhere.  It is manifest on so many levels, so overwhelming that it is nearly invisible.

In primary care offices, doctors struggle to see more and more patients, many of them medically and psychologically complex.  We order all manner of complex studies, and if we've taken advantage of a current subsidy, we record this all in electronic health records (EHRs).  This subsidy, which helps pay for EHRs, is slated to turn into a penalty over the next few years, as practices that hold off on the risk of such a large purchase look to which will be worse: spending a few hundred thousand now with the promise of a rebate, or having payments withheld for failing to buy a system which may very well be obsolete in five years.

Information technology in medicine is stuck in the 1980s.  Individual hospitals and practices purchase their own systems, customize them, curse, bless them and operate them as if they were simply electronic versions of paper charts.  The technology has existed for decades to give every person their own comprehensive and portable health record, one that could be accessed by any health facility.  Whether held in the cloud, in a USB stick, or a magnetic card, a personal health record, or even a unified national medical informatics system could save millions, perhaps billions, in unnecessary testing, treatment, waiting.  It could streamline preventative care.  It could help us track the real results of interventions on a population-wide level, as is commonly done in Scandinavia, England, and other industrialized nations, nations that spend less and get more for their health care Euro, Pound, or whatever.

Privacy concerns are real, outside of the paranoid rantings of various libertarians, but these problems can be minimized, and the price we are paying simply isn't worth it.

17 responses so far

  • WhizBANG! says:

    I personally am amazed by some BS. We get a number of tests covered every year by the Uni Med Center. They get sent to the regional lab, which happens to be our Uni Med Center. The results do not get entered into our EHR, though, because our lab acting as "regional lab" doesn't do it. If insurers audited my chart, it would appear that the only testing I have had for a few years are vitamin D levels, which are not part of the health benefit package.
    Fuckwittery for damn sure.

  • Stephanie Z says:

    As I go to my doctor on Monday to ask for a test I should have had about 10 years ago, let me just add easy (consensual) access to family health history to the list of things we're missing by being out of date.

  • Peggy says:

    I've seen how the lack of easily portable records can result in tests being unnecessarily repeated or treatment being delayed when multiple practices are involved. It's an update that has to happen eventually.

    I'm wondering, though, what this means for the old-fashioned family GP with an independent practice. If they can't afford the new technology, will they be driven out of business? That would be a serious loss, I think.

    • D. C. Sessions says:

      I’ve seen how the lack of easily portable records can result in tests being unnecessarily repeated or treatment being delayed when multiple practices are involved.

      Umm, yeah. As in, I had an out-of-town ER visit a few years back for a tibial fracture. Sent out after an x-ray ("No? Really! I had no clue that it was broken. I always thought they were supposed to rotate there!") and a splint. Couldn't get the X-ray on the spot, since you have to get it from an office that's closed on weekends -- and so when I call up the next day so my orthopod can have a copy, it turns out that for patient confidentiality reasons they need me to pick up the DVD personally.

      Yeah, like I'm going to drive 400 miles with a fractured right leg.

      EHRs would be nice -- but even without them it would be nice for providers to stop treating my records like Mickey Mouse. That way maybe we could avoid a few redundant doses of ionizing radiation. Save them for the covert backscatter scanners, maybe.

      • We had to hand-deliver the DVD of my son's Xrays from the local rural hospital to the major children's teaching hospital two hours away. Then we had to wait at length while the jpeg-reader software specific to the local hospital and included on the DVD decided whether or not it was compatible with the system at Children's and would allow the specialist to actually view the images. It seemed as if the local hospital built in extra barriers to sharing records by writing their own in-house software (probably a decade ago)... why not just save the Xray images as jpeg files that any system can read?! Someone at my local hospital is getting paid to maintain this program that effectively prohibits sharing critical patient information...

        When the pediatric orthotist finally say my son's Xrays, he decided to take his own anyway because the local hospital hadn't used current best-practice measurement methods.

        I was wondering how the military tracks healthcare delivery for combat troops? I recall reading something about how awesome their information tracking protocol is from battlefield to rehabilitation.

  • D. C. Sessions says:

    Those privacy concerns are extremely real in a country where your livelihood depends on keeping your HIV status private, where your health history can cost you your job (and thus medical coverage), or for that matter where your sexual history can cost you your life. Maybe in another country they'd be less of a concern, but today in the USA they're very real.

    What gripes me the most is that people aren't honestly discussing the tradeoffs here. On the one hand, we're told of the wonders of a system where caregivers can access my health history if I'm found unresponsive away from home, and on the other insisting that nobody can access that health history without my consent.

    Choose one. There are good arguments for both, but people aren't quite so stupid as they're being treated and from time to time figure out that they're being lied to.

    • OleanderTea says:

      Every piece of health information about you has been collected by your healthcare provider, your insurer, any third-party trading partners working with that insurer, AND a company that exists solely to data-mine your diagnoses (and then sell that information to potential insurers). So it's not like our health information isn't all over the place now.

      I'd much prefer my health information to be all over the place for a reason that might benefit ME.

  • anon says:

    It's worth pointing out good examples in the US. Last time I saw it, the VA electronic medical records are quite good and built on a public domain platform so that it has been used in multiple countries and by private providers:

    I've also been personally impressed by the Kaiser Permanente system. I can enter any Kaiser center anywhere in the country and they have all my records. I can view my test results and chart changes over time from my home computer.

    Lastly, Are you sure US is behind other industrialized nations on this? Scandinavia is way ahead of the curve of electronic medical records. Some quick internet searching seems to say that England set some high compliance levels for electronic records, but fell far short. You have other examples of industrialized countries with very high levels of electronic records usage?

    • PalMD says:

      It's not just about ehrs but also integration of services and data collection.

      • anon says:

        Both Kaiser and the VA have integration of services and data collection. Both my doctor and I can see the results of any test I've taken within minutes of it being entered into the system. For example, I recently got a strep culture since my throat was sore and my daughter had a positive culture. I got an email inviting me to look at my rapid culture results online less than 30min after taking the culture. My primary care physician (who hadn't authorized the weekend culture) emailed me the next day because he saw the negative culture, but wanted to check that everything was ok. I'd call that integration.

        As for sizes, Kaiser has 8.7 million people in the US and the VA has over 4 million (numbers from wikipedia). That means Kaiser is handling many more individual's electronic records than every Scandanavian country except Sweden. This isn't to say the US can't do better, but it's worth pointing out examples that are working.

  • Father in law is an internal medicine doc with an aging patient population and is currently converting over to EHR. Its amazingly expensive and he's wondering which vendor to choose as there is no standard EHR form developed yet. You don't want to be the doc that chooses the BetaMax version of EHR.

    Pal are you using EHR and if so, who would you recommend?

    • PalMD says:

      Hard to say.They are terribly expensive, but some systems are "certified" as being compliant with current health laws such as HIPAA and the new health care law. To be reimbursed from the gov't, it has to meet "meaningful use" criteria.

      There have been some articles in some of the medical mags like med economics. Some are better for small practices, some for large, and in some cases it may not be worth it at all.

  • Manduca says:

    The difference between practices with electronic records and those without is striking.

    In an emergency visit to my dentist (with electronic records), I entered the treatment room to find my most recent X-rays on the computer screen and the dentist studying them to find an explanation for the complaint I'd given on the phone, which he already knew about because it had been entered into the electronic record.

    In an emergency visit to my regular doctor (without electronic records), I had to answer the same set of questions* four times, the last time to the doctor who now had in front of him the answers to those questions in the notes of the first two people who asked me, on the form on which I'd written them, and in my medical records folder. I was noticeably sicker by the time I was treated than when I walked in, and the doctor obviously knew nothing about the case.

    *not birthdate and address questions to confirm my identity, but questions about medications, allergies, surgeries, and family medical history, as well as the timeline of my current symptoms.

  • William Wallace says:

    There should be an opt out.

    • OleanderTea says:

      You're already in, unless you've never filed any insurance claims -- once you do, MIB has your health data stored away in its databases.