We've Spent Billions to Fix Our Medical Records, and They're Still a Mess
motherjones.com
motherjones.com
If the existing EMR companies don't manage to subvert its goals, the problem of data interoperability will be largely solved within the next 5-7 years.
I want record from my GP? FollowMyHealth.com
I want records from my cardiologist? UNC's EMR system.
I want records from my bariatric doctor? Duke's EMR system.
I want records from my dermatologist? Yet another system.
I want records from my othopaedist? You guessed it, yet another system.
What I want is to be able to put ALL of my medical records, AND my "fitness" information (stuff from Strava, Fitbit, etc.) into one freaking place. This current setup is horrible. :-(
9/10 they don't want to look. I know there's lots of valid reasons why so I understand that part, but there's a bigger problem it speaks to. To me the greatest failure of modern medicine is that we have a word full of doctors (specifically, general practitioners) who have no time to stay current in their medical knowledge or to learn anything beyond the superficial details of a patient before pronouncing their diagnosis and moving on.
I truly miss having a GP that not only dealt with my medical matters for the first 24 years of my life, but 26 years of both my parents, and close to 20 and 15 years for my siblings as well. There's no way to replace this knowledge now he retired.
Likewise, I just started visiting a new internist who specializes in diet/lifestyle who supervises people going on a ketogenic diet. He asked if I had recent bloodwork, and as it happened, I'd just had a physical about two weeks before at my GP's office. So I fired up the "Follow My Health" app on my phone, pulled up the relevant test results and handed him the phone. He took the notes and says "Great, you just avoided having to have blood drawn today".
Any doctor who's not interested in this sort of thing when relevant should be fired on the spot; remember, whatever the "God complex" or the like they require to stay sane making decisions that will inevitably sometimes be wrong and harm or kill a few of their patients, they still work for you.
Note that absent a really difficult medical history, no doctor has time go back through a long history by (many) other doctors trying to find what's relevant and what's not. A "just the facts, mam" summation of your history is a much better start.
I fact, that's exactly what my current psychiatrist got from my previous one who'd seen me for a decade before I moved back to/retried to my home town. Probably took the former a few extra minutes. but he preferred that approach and I'm sure it was easily condensed to a page or so, even a paragraph or two would be sufficient.
That said, my mother was an RN and my father managed the business affairs of a bunch of doctors while I was in middle and high school, and one was our primary hunting partner. And I was on a biology track before I discovered how much better I liked chemistry. So I'm on top of this sort of stuff a lot more than most patient will be, but I suspect this sort of "just the facts, mam" approach could be more generally applied to our current system with benefit.
And if I were you, I'd fire those 9/10ths of ... overly focused doctors until I found a good one like your old one. Did just that after I found a very good one who then went to work for the man in the ER room before the multi-doctor practice he was in failed, then I had to fire two doctors who would not stop forcefully pushing statins, and finally found one who was willing to rationally discuss them, e.g. respect that I had enough of a biology background to balance the picture presented to him by the usual suspects.
"Billions" is a scary sounding number that doesnt mean much anymore. Show me 10s and 100s of billions.
This is what you get when you lookup the word "finger"
https://www.cms.gov/medicare-coverage-database/staticpages/i...
It contains hundreds of entries.
Here are just a few selected at random:
S61.352S Open bite of right middle finger with damage to nail, sequela S61.353A Open bite of left middle finger with damage to nail, initial encounter S61.353D Open bite of left middle finger with damage to nail, subsequent encounter S61.353S Open bite of left middle finger with damage to nail, sequela S61.354A Open bite of right ring finger with damage to nail, initial encounter S61.354D Open bite of right ring finger with damage to nail, subsequent encounter S61.354S Open bite of right ring finger with damage to nail, sequela S61.355A Open bite of left ring finger with damage to nail, initial encounter S61.355D Open bite of left ring finger with damage to nail, subsequent encounter S61.355S Open bite of left ring finger with damage to nail, sequela S61.356A Open bite of right little finger with damage to nail, initial encounter S61.356D Open bite of right little finger with damage to nail, subsequent encounter S61.356S Open bite of right little finger with damage to nail, sequela S61.357A Open bite of left little finger with damage to nail, initial encounter S61.357D Open bite of left little finger with damage to nail, subsequent encounter S61.357S Open bite of left little finger with damage to nail, sequela S61.358A Open bite of other finger with damage to nail, initial encounter S61.358D Open bite of other finger with damage to nail, subsequent encounter S61.358S Open bite of other finger with damage to nail, sequela S61.359A Open bite of unspecified finger with damage to nail, initial encounter S61.359D Open bite of unspecified finger with damage to nail, subsequent encounter S61.359S Open bite of unspecified finger with damage to nail, sequela
Everyone's unfair favorite is "V97.33XD: Sucked into jet engine, subsequent encounter."
Unfair because that doesn't mean you were stupid enough to do that twice, but had to see a doctor after the first visit.
"W55.41XA: Bitten by pig, initial encounter" is OK, it happens. But "W61.62XD: Struck by duck, subsequent encounter." WTF??? I'm from a hunting family, and I've never heard of smallish birds like ducks harming people in this way. Ditto "W61.12XA: Struck by macaw, initial encounter" and "W59.22XA: Struck By Turtle" (now, being bitten by a big snapping turtle is horrific, but being struck by any turtle???).
But this remains the most bizarre of all I've heard: "V91.07XD: Burn due to water-skis on fire, subsequent encounter."
OK, at least we can laugh about ICD-10. For now.
The wide range of codes is a great setup for coding errors: errors of omission, imprecision, using multiple codes to describe an event when a more accurate single code exists, etc.
In the best case scenario, every doctor/nurse/PA/etc would have a technician follow them around just to manage the coding on EMRs.
https://www.cms.gov/medicare-coverage-database/staticpages/i...
Has Monty Python taken over the ICD?
I'm still trying to figure out how that could be a legit code. Jet skis, of course. But ... ah, while trying to see if anyone else had a brainstorm, I found a better one that eliminates a lot of possibilities:
V90.27XA: Drowning and submersion due to falling or jumping from burning water-skis, initial encounter
Got that from http://skepticalscalpel.blogspot.com/2011/09/icd-10-codes-dr..., which suggests:
I have come up with an answer. Someone, possibly an actor from the Jackass series of movies, sets up his water skis on milk crates in the back yard. The skis are positioned over a kiddie pool. He mounts the water skis while an accomplice sprays them with gasoline. The skis are lit, and the man jumps or falls from the burning skis, submerging and drowning himself in the process. Luckily there is an ICD-10 code for that.
Maybe we're being trolled? You know, there are trolling motors, but they're (all?) slow, battery powered ones to avoid disturbing fish, not at all suitable for water skiing.
/weird but true
And ICD-10 codes are used for a variety of purposes -- statistical, billing, etc. -- so if its important for one of those uses, its going to get added. Especially since, with the degree of automation preferred now, if it a distinction could reasonably affect any decision in any of the roles that the code set is used for, it needs to be represented in the code set.
And that's where it goes off the rails, this revision is trying to serve too many masters, in which actual health care is subservient to collection of data for the usual nosy suspects. Did anyone even contemplate the trade-offs?
And even then, look at all those codes for bites of fingers. Are you really insisting they will provide anything other than fancy looking statistics for self-important bureaucrats?
While I don't know the history of the particular codes, a lot of the hyperspecific codes are driven by needs of insurance payers (public and private) and their desire to incorporate elements that would otherwise be identified in (comparatively costly) non-automated review and provide the necessary resolution in coding that they can be identified and distinguished without that review and the associated cost.
Driving down that area of administrative costs is a different thing than providing fancy looking statistics for self-important bureaucrats.
What type of review - automated or manual - requires the categorical specificity of distinguishing between 359+ different types of marginally varying finger trauma from bites? This is just madness. That anyone would even suggest that that level of specificity was even useful, never mind required, is bureaucratic madness.
Step back from the tree and you can see the forest burning.
Or S61.355D Open bite of left ring finger with damage to nail, subsequent encounter ???
And with such specificity, why include this code:
S61.359D: Open bite of unspecified finger with damage to nail, subsequent encounter
I'm assuming "other finger" is the one between your little and middle ones, and we'll all sleep easier knowing that, while not found with jhulla's search, your left and right thumbs have not been neglected.
There were enough fraud claims where someone was wanting to be paid for a third leg amputation that we joked we needed LL (left) R (right) and M (middle) as our designations instead of just L and R.
Whether a payer accepts that the specific services you billed for are medically appropriate and thus pays them depends, often, on the diagnosis they are treating. (And, often, there are three possibilities: the payer pays the claim directly, or the payer requires additional supporting documentation which is manually reviewed before making a decision, or the payer denies payment outright.)
The more detail diagnostic coding provides (and, for that matter, the more detail procedure coding provides), the more an automated system can move cases that would otherwise be in the manual review category (which adds costs for all parties, and delays) to an automated decision (which is quicker and cheaper for all parties.)
Quite likely, review for medical necessity of the particular treatments billed for those bites. Which probably have wildly varying costs, and different indication; precision of diagnostic coding reduces the degree of circumstances in which it is necessary to require additional supporting documentation to be sent and have a human review it; manual review adds time and cost to claim processing, and is something everyone -- payers, providers, and patients -- benefits from reducing.
> That anyone would even suggest that that level of specificity was even useful, never mind required, is bureaucratic madness.
Only to the extent that medical insurance is inherently "bureaucratic madness".
Whether you are "struck by turtle" while playing Mario Kart, or smother yourself with a pillow [1], most codes are derived from recorded events. Then there's the algorithmically appended first, second, etc. encounters.
[1]: http://www.icd10data.com/ICD10CM/Codes/S00-T88/T66-T78/T71-
Not as unfair as it seems! Someone got sucked into an A-6 Intruder on a carrier with only minor injuries due to his helmet shredding the engine. https://www.youtube.com/watch?v=5jxcSY1AwrM
Could mean lovestruck? :)
> Struck By Turtle
Eagles have been known to drop turtles from flight, in order to crack them open. The ancient Greek playwright Aeschylus is supposed to have been killed by a tortoise in this manner.
Except in that, as I note elsewhere in this subthread, it has no more to do with providing better healthcare than the myriad insane variations of finger injuries that started this subthread.
When I was a neuro tech, I remember doing a nerve conduction study on a patient, on one arm only, and the patient had no abnormality, when went into my report. The doctor doing the final report for the record copy/pasted from his list of stanzas, and forgot to switch 'left' in his copypasta to 'right', which I caught. This particular doctor was perfectly competent; it's just that there's a thousand ways to make errors like this (and yes, copying from a list of stanzas isn't the best method, but neither is individually typing out the same diagnosis paragraphs again and again).
Being unambigous with which side of the body and which body part is very important in medicine.
Although I'd say this is still an experiment in which will result in the fewest mistakes. Maybe someone should have paid Kaiser or the like to try this out first to find out some of the consequences?
Oh, and if you think your code's good enough to fix healthcare, we're hiring ;D
Epic has made major strides in supporting connectivity between EMRs. Partially, through standards like direct - http://directproject.org/. This problem will be largely solved in three to five years. Actually, a growing number of geographic regions of the US already have seamless EMR records exchange
"Moving on... It's been a fantastic ride"
And there are many related stories about doctors focusing on their computers instead of their patients as they fight with these systems (I kinda saw that once, but in all fairness the doctor had lost all her paper records in a tornado, I don't think she had anything left but her appointment book). In one worse case I read about, fighting the system until there were enough lights turned green.
In general this is a very hard field, e.g. the U.K. NHS more ambitious effort was an abject failure: https://en.wikipedia.org/wiki/NHS_Connecting_for_Health
In addition, the doctors I know who continue to practice have had to reduce their patient hours due to the amount of time EMR takes up.
How do the French do it? Well, it's not that hard. All other developed nations using the Bismarck Model (like the US, feel free to google that or any of this) have a few structural differences from the US. The first is a particularly obvious one: insurance companies are non-profit (though privately held and operated). Fees are entirely standardized and printed for all to see ("reference pricing", structurally like medicare/aid). Doctors and hospitals make a lot less money (Doctors drive volvos not porsches). Doctors don't pay for medical school. Claims are never denied. Doctors are rarely sued. Doctors are paid very quickly (3-14 days). I'm not making this up. In essence, the system squeezes all of its players to be as efficient as possible.
In the US, the exact opposite is true. Most of the players are incentivized to drive costs up. A private FOR PROFIT insurance company (which no other developed nation allows) by definition wants to suck all the money it can from the system and pay none of it out (to wit: when an insurance company pays a claim, it is called a "medical loss"). Hospitals are in an arms raise of acquisitions (to better negotiate with insurance companies) and over-built, fancy facilities (to attract patients and justify the exorbitant costs). Doctors start their professional career by having to pay off huge student loans. Insurance companies, hospitals, and (to a much lesser extent) doctors collude, in effect, to steal money from all the other employers out there (in insurance premiums) and from patients (co-pays, denied claims, and an ever-growing number of out of pocket expenses).
None of this is the fault of insurance companies, hospitals, or doctors. It is entirely the fault of our incompetent no-account and utterly failed political system. US healthcare is corrupt because the US political system is corrupt. To fix it, we need to fix that. Entrepreneurs cannot fix US healthcare in the current regulatory environment. The incentives are completely wrong.
EDIT: added a missed "system" after a "political".
EDIT2: I forget to mention the most relevant piece. The French, since 1998, have had 'La Carte Vitale'. It is an electronic medical record they carry around with them. Every doctor's office has a reader. It is a government standard, government owner, and government operated. Epic makes money by _NOT_ sharing its data if it can get away with it. Switching costs are its friend. It's called 'vendor lock in' and its why the government should be doing this small piece of it. It's like building an interstate highway. It lets commerce happen.
I've only heard of HL7 which is basically paying money for a bunch of XSDs (of course)
Plus, the whole thing about identity is even more difficult, you can't go by name, SSN, and DOB alone.
As far as I know, HL7 is mostly used between internal systems within an organization.
For sending actual patient data, allergies, conditions, CCDA is usually used for communication with non-Epic EMRs belonging to other organizations.
As an aside, CCDA and HL7 don't support rich data well, so they usually end up as base64 encoded PDFs.
{OBX,ORC,etc.} |data|||more data|number|||identifier| Which is basically a member of the multimap with the first word as the key, with an indexed map of text.
It's not really a standard like HTML, at least no EMRs, interface systems, instruments, and so on abide by them.
So, whenever systems hook up, there has to be setup / build to map what text means what to each other--although the positions are generally agreed upon.
When interfacing systems together, there is both a legal and a technical cost that must be dealt with. With highly configurable systems on both ends, figuring out who's terms / categories equate on the other side and back is not an easy task and most organizations hesitate to go through with it unless necessary.
The tools are there, it's just that when everyone customizes their own universe, it's unlikely to work out of the box. You can stick a german and a guy from holland together in the same room, they might have some shared words, but whether they can hold a coherent conversation in their native tongue is a different matter.