Some doctors think EHRs are hurting their relationships with patients
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I just had a patient transferred from an outside hospital for abdominal pain and somehow their CT scan was lost in transit. Because it was an emergency we had to CT scan them again which doubled their radiation exposure and their risk for a kidney injury from the iv contrast. It was midnight so it would have taken until business hours to obtain the scans from the hospital.
Things like this happen almost daily.
I'd read about CT dosing and realized that we had just increased this girls lifetime likelihood of ovarian or endometrial cancer by perhaps about 1/1000. For absolutely no reason other than the fact we couldn't get the images 8 miles down the road from the Duke ED, and the attending wanted to 'just be sure'.
I asked the resident why they couldn't send them digitally and they just laughed. That was 2009.
It's 8 years and a few hundred billion of national EMR spend later - and you know what? We still can't send an image between the two EDs. UNC and Duke were the first two nodes/servers on Usenet back in 1980[1], and 37 years later we can barely exchange medical data using our combined 1.3 billion dollars of Epic EMR implementations.
This problem harms people needlessly every day. Please use your voice as a provider to remind people whenever possible.
As a patient here's what gets me: UNC has one EMR system, my GP has another, and Duke has yet another. I've been a patient at all 3 at various times. I also use Strava, Fitbit, and the like. Now you would think that it would be trivially easy to use an API and export and aggregate all of my lab results, for things like blood pressure, cholesterol, etc., so I can graph, say, my blood pressure and my Strava activity together. But nooooo... all of these EMR systems either have no export functionality / API, or if they do, it's something byzantine and just-short-of-impossible-to-use.
Of course not every patient is a data geek who's going to use machine learning, statistical analysis and visualizations on their own data. But for those of us who want to, the roadblocks to doing so are infuriating.
I just had a patient transferred from an outside hospital for abdominal pain and somehow their CT scan was lost in transit. Because it was an emergency we had to CT scan them again which doubled their radiation exposure and their risk for a kidney injury from the iv contrast. It was midnight so it would have taken until business hours to obtain the scans from the hospital.
The doubly sad part is that this is almost 100% a policy / business issue and not a technical one. We've known how to share data for a long time. Heck, IIRC, a scenario much like the one listed above was used as an illustrative example for justifying the WS-Federation[1] protocol way back when.
Edit: Yep, this document[2] explaining WS-Federation actually uses an emergency room scenario to justify the need for WS-Federation. Not the exact same scenario as above, but the point stands. We've had protocols and technologies for doing this stuff for a long time.
[1]: https://en.wikipedia.org/wiki/WS-Federation
[2]: http://download.boulder.ibm.com/ibmdl/pub/software/dw/specs/...
Also, Fitbit data is medically useless beyond establishing that you do or don't exercise.
Unless a patient some specific chronic illness like diabetes or asthma, most patient recorded data isn't medically useful.
If you're talking about diagnosing a particular disease, you're probably right. That's not what I'm talking about. I'm talking about having an overall holistic view of my health and fitness related data, and being able to combine it so I can look for interesting correlations / patterns to suit my own interests.
They weigh you at any doctor's office, on a more accurate scale. Weight trends are important, but at a granularity of a handful of measurements per year.
The "more accurate scale" part is irrelevant given that your bodyweight can fluctuate 3 or 4 pounds from one day to the next, based on hydration levels, undigested food in your stomach, etc. Trends over time, even if measured on slightly less accurate scales, are really more meaningful.
Anyway, I'm not really sure why we're even having this discussion. Are you arguing that EMR systems shouldn't make their data easily available to the end user? Because otherwise, this whole thing about Fitbit data is a red-herring. What I do with the data, what other data I mash it up with, etc. is really not what's at issue here.
EHR companies have bigger incentives on selling than on making shit better. Worse, if I was to make an EHR startup with amazing UI and all around amazeballs features, I'd never get into a single hospital convincing their CTO to replace the current EHR system and re-train doctors. Never gonna happen.
Welcome to the problems of Enterprise tools, we've been having these for decades and nobody has solved it well yet.
The only real solution is for a hospital to take say 5 doctors of various tech and age levels, and create a mini EHR (regardless of cost) and test it. Then switch to another. The doctors would be EXPECTED to be inefficient, but they will be the scouts of the hospital. But hospital CTOs don't think in this way. Rarely are they technical people.
In your situation with CT scan, it sounds like there was no electronic way to share the digital version of the CT scan. Furthermore, if there was an electronic way to share it, your ER where the patient presented would need to be connected to any and all other facilities they could be transferred to.
To further complicate matters, and electronic CT scan isn't really EHR functionality, it goes straight from the CT device to a PACS (picture archiving and communication system). There may be integration with the EHR, and definitely with the RIS (radiology information system), but outside of those two, you're talking about transferring 100s of MBs to GBs of data to the other hospital.
If I ran your hospital IT team (or rather the hospital you're referring people to) I would prioritize integrating the two. Duplicate scans cost them money, and if you have choice over where you refer patients - the integrated hospital will always be preferred right?
A family member just was hospitalized for a serious issue that requires rehab, and the default from the hospital is to get you into an affiliated facility (a nursing home). The better facility (a rehab hospital) for this person's condition is in a different network. We handled data transfer by putting the records in my hands and delivering them to the physician hands at the rehab facility.
If you're not aware of these differences and pushy, you'll get sent to the default and likely have a worse outcome. So my family member gets stuck with a worse quality of life, and the taxpayer via Medicare gets to spend exponentially more on providing care.
Seems unlikely. A few years ago I was given a CD-ROM of the scan of my jaw and was able to download a free DICOM viewer to look at it. These things seem to be standardized.
Wasn't really excited to take that much dose to my head but at least I have the souvenir of a 3D view of my jaw...
The problem is that the digital scan is isolated to his ER's network, and without a business relationship between the two parties, a CD is the only way to transmit the data.
It seems the most common answer is attempt to call the patients pharmacy or rely on the best info at the time. I'm working to solve this problem at least for Medicare chronic care patients - we basically instantaneously provide physicians a pharmacy created medication history and 6 months RX claims data - and while we are focusing on primary care, ACOs, and transitional nursing care...maybe this might be of value in the ER.
My GP migrated to a pretty good EHR in 2007 as an efficiency measure when he was a partner in a ~<10 doctor practice. That was awesome because it reduced friction and improved continuity if you had to see a NP or another doctor. That solution wasn't fully Medicare compliant, so they moved to another system that definately sucked, but wasn't much different from a patient perspective.
Now they got gobbled up by some mushrooming health network centered on one of the hospitals. They just migrated them to yet another EHR that is cloud hosted (Athena?) -- except they forgot about the "R" part of EHR. They literally migrated nothing and the medical staff needs to re-enter all information from billing to health history. It's just irresponsible as people don't necessarily remember all of their health history.
You can't even leave as like 75% of GPs near me are in this network and affected by the same thing. The other network in the area concentrates on a different geographic region.
This is the money quote right there. EHRs are purchased by hospital administrators, the people who are worried about cost and compliance. They are the ones who get to dictate the features to the EHR vendor in the selection process. Yes clinical staff is consulted but usability is only ever a consideration when a high-enough ranking doctor goes on a rant about it.
The same thing happens in finance, warehouse work, etc etc.
Instead of:
Coder: Hey, end-user, does this data model / interface makes sense for your work?
End-user: Nah, something more like ... would make more sense.
It's:
Coder: I'm not sure which of designs A, B, or C would make more sense for detail X of feature Y (see ambiguous specification, section 2.2.2.3.a.alpha).
Project owner: Ok I'll check with the client. writes email
Client's project owner: Hmm I'll ask my people.
2 days later
Project owner: I've updated the specs.
Coder: checks specs That... doesn't answer the question.
I have mixed feelings about all of this, and think the problem with EHRs isn't really the EHRs, it's the systemic problems underlying the EHRs. The EHRs are just a tangible way to vent about them.
First, the way these EHRs were rolled out, under federal mandate, was a fucking fiasco. I am definitely not anti-government when it comes to healthcare, but I do not think EHRs should have been mandated. People forget that in all of this. Administrators did not want to purchase them, because they were huge cost sinks (the rollout of one EHR at a hospital my wife works at was 2 billion dollars over what they initially estimated it to be). So, you have these systems which weren't purchased because they were appealing solutions, or cost effective, but because the hospitals had to to avoid losing reimbursements. This led to systems being rushed early, without adequate hardening, and all sorts of things. Before EHRs, records were done in-house by people who were highly trained in this area. My guess is that if markets had been allowed to progress naturally, you would have seen more in-house open-source implementations that would have happened more gradually, at much lower cost, and with more back-and-forth with providers.
Second, I'm a little tired of griping from physicians about having to do paperwork. Sorry if this comes across as hostile, but a lot of it is narcissistic bullshit, frankly. Records in high-stakes settings is not just about documentation, it's about checks, and making sure you're following protocol. Studies have shown this increases safety. We all have to do it. Someone asked about scribes, but wait until some lawsuit happens because of ambiguity about whose responsibility it was when some instruction or note was done incorrectly. This way, it's ultimately the provider's responsibility, coming directly from them. And yes, you can still do transcription for lengthy notes. I know this because I've done it. One of the elephants in the room when it comes to healthcare costs is that there's too much top-down authority, too much monopoly, too little competition in provider models, and people feed into this when they start going down the route of suggesting it's too much to ask physicians to be responsible for their own damn communication with the rest of the providers in healthcare.
Finally, going back to my original point: the real problem in a lot of cases isn't the EHRs, it's the business-model administrative hierarchy that's taking over all sorts of fields. Regardless of whether or not this should be the case, physicians want to be in charge, to have autonomy and authority, and suddenly they're finding themselves being treated like widgets in a vast healthcare machine that benefits administration primarily. They have to use some system they didn't approve of, and they realize that the decisions in some sense aren't coming from them, they're being told what to do by administration. So rather than feeling like they're the top dog at the hospital, they're feeling like cubicle workers. That's what I suspect this is mostly about, not the time with patients, or whatever the hell the complaint du jour is. Note that on this point I sympathize with them--this administrative hierarchical model that's squeezing workers, whether it be healthcare, or IT, or education, or whatever, is fundamentally flawed. It's just new to physicians, or something they didn't think they'd have to deal with.
This is my little tangential rant, but I'm sick of healthcare discussions in congress being so focused on costs, and not on deregulating healthcare and increasing transparency. There needs to be less of this kind of EHR red tape, more use of EHRs that is driven by their utility, more competition among provider models, greater consumer access to drugs and healthcare options (and I don't mean by giving them more money, I mean by letting them do whatever the hell they want), and more transparency about costs. Right now, we have a model where you have an extremely small number of people telling everyone else--including different types of providers, as well as consumers--what they can and cannot do with their own healthcare decisions, and billing them without them even knowing or agreeing to the cost of a service. Imagine if the government said that only accountants they approve of, with doctoral level finance degrees, could do your taxes, and that those accountants could charge whatever they want without telling you the cost ahead of time. People would be in an uproar. We spend all this time assuming that our healthcare system should basically stay as it is, but that we should reorganize how we pay for things, when the discussion should be about both.
Bingo.
I was in an administrative heavy medical lab and most attempts to streamline processes were met with a lot of backlash from the doctors. My director was told by several of them that he was "undermining and ruining medicine."
Yes, it was a land grab sparked by ARRA stimulus money. As long as some of these rollouts took, I argue they didn't adequately capture the needs in healthcare environment. The healthcare process is very complex and many assumptions were made on the vendors in order to meet deadlines, leading to many hiccups in an already complex process.
> I'm a little tired of griping from physicians about having to do paperwork
Again, yes! There are plenty of physicians who consider anything remotely clerical as beneath their level and insulting to their position. Unfortunately, poor UX has only given them a louder voice. This results in abherations, eg. CPOE done by the physician logging in with his credentials then offloading to nurses or MAs for the actual entry.
> There needs to be (...) more use of EHRs that is driven by their utility, more competition among provider models, greater consumer access to drugs and healthcare options
Unfortunately the tendency is in the opposite direction, with massive consolidations. Big groups took the ACO model and realized they could just buy out the small practices and be one big group.
To your last point, its an interesting thought that in our supposedly free market healthcare, we have more clinical micromanagement by various bodies (JCHAO, AF4Q et al.) than some other countries with supposedly "socialist" healthcare.
Expecting competitors to share data is a non-starter. Fed's carrot vs stick stratgey is not sustainable or economical.
You say regulation and I'm thinking unbridled bureaucracy. eg What drove ICD-10? Not patient care or improved outcomes. Maybe jobs program for consultants, or plausible deniability for insurers. But no one can deny the ever increasing admin overhead in the US, with or without govt involvement.
On the other hand, I do think that an EHR can be a good thing. Because we work closely with the doctors we can tweak things to their liking. Some departments spent a great deal more time on tweaking the software (mostly younger doctors) and that pays off for them. They lose less time with the software and the software becomes an aid for them - as it should be.
It does not happen in every department of all of the 20 something hospitals, but it _can_ be good.
From what I have seen in this industry - the worst thing you can do as a hospital is buy an EHR package by a company that is not working closely with others in the medical field. You need communication between the departments and the engineers, and a short release-cycle surely helps.
Aka do you work for Epic
Healthcare is harder than any other domain. One would expect its supporting IT would reflect that.
I can't believe we let some of best doctors in the country waste hours each day fighting with terrible software instead of treating patients. My partner spends more time trying to figure out the EHR than she does treating patients.
But the part I really like is that I have access to most test results online.
And since Kaiser is a self-contained HMO and doesn't generally do referrals outside of their system, interoperability isn't really an issue -- when I get referred to a Kaiser specialist or move to a new area and start seeing a new doctor, I know they'll have access to my records.
In a previous system, I had to see a specialist, and though they requested that my original doctor transfer all records, not all of the records were sent and I ended up having to reschedule an appointment so I could pick up the missing records and take with with me.
How did he know? He started seeing records from certain docs where they did the full workup on every single patient. There is no way they could do this, a full workup takes between 5 and 7 hours (he said).
So what was happening? Someone at these offices had filled out the 'full workup' form for their EHRs and then discovered that they now literally had a button that would print money (paid out by insurance companies).
If you give someone a tool that lets them print money at the click of a button even if it means they didn't actually do all the tests to fill it in they are going to click it.
While I've built few nifty tools (chrome extensions and macros) for her to simplify some of the cumbersome tasks, I am envisioning and planning to build a whole new EHR solution from scratch that puts doctors first, as my side project. It's a daunting task and requires expert domain knowledge. Hoping to get an MVP by end of year.
As a result when you need an appointment what you hear is that nothing is available for three to five days. Numerous times I was unable to get my Dad in for over a week when he needed to be seen. Sometimes progress is not progress for everyone.
I should add that while the extra data capture may now seem like an issue, when federated access is better supported it will be a boon to healthcare.
Aside, since when does PBS write such clickbait? The article clearly gives advantages and drawbacks with the current system compared to old. Why not give a professional quality title?
It is likely that these issues are also geographical in nature as some areas are not experiencing the physician shortages or patient loads that other areas and physicians are experiencing.
On a serious note, though, two things I think about when I'm at the doctor and they're just typing in what we're talking about:
* It's an evolving tech; it'll slowly change * How happy the doctor and patient are with the system isn't measured, and therefore "doesn't matter".
EHRs are a farce. They've made a few people very wealthy at the cost of widespread misery for patients and doctors.
And also, how does that lead to your conclusion that they are a "farce"? Do you mean to suggest that we would be better off without EHRs, or do you specifically have issue with the implementation of EHRs as is right now?
I'm surprised by you calling them a "farce" and causing "widespread misery for patients and doctors" because my understanding was that the clinical data collected by EHRs permitted improvements in the quality and delivery of care for patients within an institution.
I will admit that - as mentioned elsewhere in these comments - lack of interoperability is a huge issue which drastically reduces the effectiveness of EHRs.
But even though it isn't a perfect system -- 1) It is an improvement over the previous form of paper records, and 2) The industry is iteratively moving to resolve these issues.
There are a lot of reasons for why these problems exist such as misaligned incentives, etc. but we have been trying to address this through both policy (e.g. the rise of accountable care organizations and how the ACA experimented with physician reimbursements). There also exist middleware solutions that I believe would help ensure that this data is not silo'd, and in doing so improve interoperability.
Maybe I'm just misunderstanding something but if I am, could someone please point it out? I'm not saying that EHRs are perfect -- they have a way to go (both in UX design/interoperability). But, they were a step in the right direction and I am not convinced that they are as bad as you claim they are (though I recognize their limitations). What am I missing?
EDIT:
I've also heard from physicians and patients that because EHRs easily allow a doctor to read up on a patient's notes from their previous visits, it can actually improve their relationship because the doctor can go into the room for subsequent visits knowing something (or in some cases, everything) about the patient and speak to them with that information in mind.
NOTE: My comments are only applicable to the US medical industry.
This statement highlights your lack of knowledge about the general EHR/EMR landscape and current implementations. As someone that works parallel to a hospital operation, I both know and interface with people that have to use them on a daily basis and this could not be further from the truth.
EMRs have helped to collect and make more data accessible, this is true, but they are not necessarily an improvement over the previous form of paper records. In most cases, they are simply a different representation of the same data. Take EPIC for example wherein you can search for a patients name but then you are provided with the digital representation of an analogue patient folder and/or chart. I think that most of the people on HN would have their opinion of the medical software landscape changed if they were ever granted the opportunity to use most of the current implementations for only a couple of minutes...
It is also not true that the "industry is iteratively moving to resolve these issues". I was most put aback about 2 years ago when I heard that while every hospital may have EPIC, Cern, etc installations, that none of them are universal. Every hospital will have a customised EHR/MER installation, and therefore custom templates for each doctor, or unit. This means that the installations are almost never updated, or allowed to have new features introduced. In most cases, a patch, or update will require a field tech being sent from the providing company to the hospital where he will work with the onsite customized installation to complete the work.
All in all, it is true that there are people in the field trying to push medical technology forward. Take PatientBank, Sprig, Stitch, etc as evidence that this happening. But what is certainly not true is that the incumbents are pushing to make major changes. Additionally, the regulations with regard to medical software, as well as the legal incentives make it very, very difficult to develop a product, let alone to bring it to market.
I know that there is a distinction to be made from EMRs and EHRs right? (I thought EMR was the electronic version of the old paper medical record, while EHR was designed to create a more longitudinal view of the patient's care).
Yes I did know that though two hospitals with EPIC's system will still face interoperability issues due to varying data dictionaries, but I didn't consider the difficulty in updating features, etc.
I agree and recognize that the incumbents are not pushing to make major changes (after all, they don't have strong incentive to, right?). But I did notice companies like RedoxEngine which provide a layer of abstraction to address interoperability issues for health tech startups. And also projects like this which are moving to slowly consolidate rather than silo data: http://hospital-zsfg.medicine.ucsf.edu/research/homerun.html
Anyway I will dig more into it to inform myself -- appreciate your response.
"Before you can create interoperability, you have to create operability"[1]
I'll leave it to you to decide whether this was a wise philosophy to underpin a major national IT project.
[1]http://www.healthcareitnews.com/news/blumenthal-look-stage-1...
All the requirements are written as a numerator/denominator format. For example, 25% of all lab orders placed by a provider need to be resulted electronically. So there's an incentive to integrate some things, but not all.
Edit: here are the 2015 rules and accompanying underlying standards: https://www.healthit.gov/policy-researchers-implementers/201...
Of 50 state exchanges, most have collapsed, with only occasional use of the ad-hoc implementations and networks that remain. And people dying everyday while vendors like ECW get wrist-slaps for lying to CMS about their MU compliance.
-http://www.healthcareitnews.com/news/eclinicalworks-pay-155-...
When someone asks us to integrate with a small EHR, the first thing we look at is ONC certification. We at least know that they meet some base level of functionality.
[1]: https://en.wikipedia.org/wiki/Health_Level_7
[2]: https://en.wikipedia.org/wiki/Fast_Healthcare_Interoperabili...
If you're ever interested in learning more, my company builds the national reference implementation of SMART on FHIR for the Harvard DBMI, in support of the NIH 'Sync For Science' Pilot - happy to talk all about FHIR and data exchange standards!
The participating vendors will be launching pilots this year and things are proceeding well. If we can give them some positive attention for it, maybe we'll see some progress. I sure hope so!
[]https://www.healthit.gov/buzz-blog/health-innovation/nih-and...
I wasn't aware of this NIH 'Sync for Science' program though, very neat!
I also participated NHIN's first competitive interop whatever it was called. (We were sub to Northup Grumman. Our team won. Yay. That recognition plus $3 will get you bad cup of coffee.)
The secret to interop is to ignore the standards. No one else cares, so why should you?
For inbound, just capture whatever is sent, use web scrape style tools to extract the bits you care about. For outbound, manually create payloads that work (maybe with SOAP-UI and then tweak), turn them into templates.
If you're a monster org like Boeing or Toyota, you can rule by fiat. Everyone else has to fake it.
Mobility (iPad's for drchrono) are just starting to make a bigger impact on the market and I think over the next 5 years 80% of providers in the US will be using a mobile interface (probably an iPad) and not touching a keyboard/mouse while a patient is in the room.
https://discussions.apple.com/thread/4383886?start=0&tstart=...
I clean my personal iPhone/iPad once every few months. I think it's much easier and more possible to sterilize a glass/metal ipad than a keyboard (especially for onboarding of patients in a waiting room.)
The fact that it's electronic enables administrators (emboldened by EMR/EHR vendors) to claim that "it's convenient" enough to be done in the room (faster than writing it down by hand or transcribed via recording after the exam ends).
But, you doctor likely is scheduled such that they have less than 45 minutes per patient including reviewing records. Additionally, the relevant records may have been gather during intake by a nurse or MA, so they aren't available in advance. Better EHR UX could probably alleviate this problem.
A typical medical record can contain more than 100 pages of documentation. I've seen records that span more than 1500 pages.
While most medical records are electronic, systems do not interoperate with one another. So, you are forced to type in relevant information from a fax into your EHR system.
Most of the pain comes with documentation necessary for dealing with billing and insurance. In fact most of the language is super vague so that you can cover your ass if someone tries to sue you.
Disclosure: I run a start up that is working on solving a lot of these problems.
That must be someone who goes to doctors as a hobby.