[y66]

Excerpt from NY Times story about electronic health records

Quote

Two articles published on Thursday in the New England Journal of Medicine, point to the formidable obstacles to achieving the policy goal of not only installing electronic health records, but also using them to improve care and curb costs.

One article reports that only 9 percent of the nation’s hospitals have electronic health records, based on a survey of nearly 3,000 hospitals. The government-backed study found a far lower level of use than some earlier, less rigorous surveys.

“We have a long way to go,” said Dr. Ashish K. Jha, an assistant professor at the Harvard School of Public Health who was the article’s lead author. “And we did not measure effective use. Even if a hospital does have electronic health records, it does not mean it is sharing information with other hospitals and doctors down the road.”

In a second article in the journal, two experts in health information technology at Children’s Hospital Boston assert that spending billions of dollars of federal funds to stimulate the adoption of existing forms of health record software would be a costly policy mistake.

In the article, identified as a “perspective,” Dr. Kenneth D. Mandl and Dr. Isaac S. Kohane portray the current health record suppliers as offering pre-Internet era software — costly and wedded to proprietary technology standards that make it difficult for customers to switch vendors and for outside programmers to make upgrades and improvements.

Instead of stimulating use of such software, they say, the government should be a rule-setting referee to encourage the development of an open software platform on which innovators could write electronic health record applications. As analogies, they point to other such software platforms — whether the Web or Apple’s iPhone software, which the company has opened to outside developers.

In the Mandl-Kohane model, a software developer with a new idea for health record features like drug allergy alerts or care guidelines could write an application, and those could be added or substituted for a similar feature.

Google has taken an interest in this problem. Maybe now we'll see more progress along lines proposed by Mandl and Kohane and more rapid convergence on standards.

Do electronic health records lead to improvements in the quality of care?

Yes, according to this study: Effect of the Transformation of the Veterans Affairs Health Care System on the Quality of Care

Quote

Conclusions

The quality of care in the VA health care system substantially improved after the implementation of a systemwide reengineering and, during the period from 1997 through 2000, was significantly better than that in the Medicare fee-for-service program. These data suggest that the quality-improvement initiatives adopted by the VA in the mid-1990s were effective.

[helene_t]

At the Acamdemic Medical Center in Amsterdam, they have a database platform called ZOUGA which allows developers to plug in databases (any jdbc compliant database would do although it may take some work to make ZOUGA "understand" which fields mean what) as well as applications (can be written from scratch in javascript, or you can use the building blocks they supply). This is a really good idea although when I worked with it in 2001 ithe development environment still wasn't quite of commercial quality.

[Aberlour10]

y66, on Mar 28 2009, 09:42 AM, said:

Do electronic health records lead to improvements in the quality of care?

The testing stage of the central data base in german health service is already very advanced. Every patient will recive soon a digital card with his medical basic data and history of the case, for more details there will be fast access to the central server. This should increase effectiveness in emergency cases, reduce costs ( no double check-up's needed) etc. But there are still serious concerns about the security of this system.

Robert

[kenberg]

This security issue mystifies me a bit. I don't deny its importance. However, I have various financial things that I can access online. Banks do electronic transfers of large sums. I can pay my taxes online. When I was teaching I could access student records online, Why is security a significantly more difficult problem when dealing with health records instead of with finances and other matters?


Around here the medical community is proud of having discovered that when a referral to another doctor is needed, it is actually possible to do this electronically. Six months ago I would have to drive over, pick it up, and carry it with me. Progress, I guess.

[helene_t]

Agree, Ken. Here in Europe, inefficiency in health care can be explained by lack of competition. I suppose if people had to pay more at paper-administration hospitals than at ICT-administration hospitals they wouldn't care so much about their computerfobia. Btw electronic systems are generally safer, the paper records are very leaky.

[Aberlour10]

kenberg, on Mar 28 2009, 12:40 PM, said:

This security issue mystifies me a bit. I don't deny its importance. However, I have various financial things that I can access online. Banks do electronic transfers of large sums. I can pay my taxes online. When I was teaching I could access student records online, Why is security a significantly more difficult problem when dealing with health records instead of with finances and other matters?

In case of paying taxes or online banking there is a sort of "one way" communication strictly between you und your bank or revenue authorities. No others are allowed to access. In health service is the situation much complicated, the access to the circulating data widened, so possibilty of misusage bigger.

Robert

[hotShot]

kenberg, on Mar 28 2009, 06:40 PM, said:

This security issue mystifies me a bit. I don't deny its importance. However, I have various financial things that I can access online. Banks do electronic transfers of large sums. I can pay my taxes online. When I was teaching I could access student records online, Why is security a significantly more difficult problem when dealing with health records instead of with finances and other matters?

Did you have access to your students criminal record or their financial data?
It's not about a technical security problem (although that is an issue to) it's about who has access to what part of the data.

Do you think it would be a good idea, if your (future) employer has access to all health records of your lifetime?
Would you want to risk a job, because you were treated one night in hospital for alcohol abuse when you were 18?
Maybe you had a cancer therapy 10 years ago, and your future employers heath insurance rates for you are higher than those of an other candidate.
If you break your leg, is it really helpful or necessary for the doctor (and all of his team) to know about a sexual inflicted disease you had during your army days?

What informations does the pharmacist need before he can give you your prescription?

[hotShot]

All this talk about avoiding double examinations is useless, because even if you have your results with you where ever you go they think the can do it more accurately or more reliable.

And by the way, there are paper documents from 1000 years ago, but data on disk, tape or optical storage are often unreadable after less than 2 years.

[Aberlour10]

hotShot, on Mar 28 2009, 01:45 PM, said:

All this talk about avoiding double examinations is useless, because even if you have your results with you where ever you go they think the can do it more accurately or more reliable.

I dont think so. For example... if somebody made a check up a short time ago, and the Doc see it on his screen, he won't do it again...because the insurance company will not pay for it, if there is no need for repeating in so short time.

Robert

[kenberg]

hotShot, on Mar 28 2009, 01:36 PM, said:

kenberg, on Mar 28 2009, 06:40 PM, said:

This security issue mystifies me a bit. I don't deny its importance. However, I have various financial things that I can access online. Banks do electronic transfers of large sums. I can pay my taxes online. When I was teaching I could access student records online, Why is security a significantly more difficult problem when dealing with health records instead of with finances and other matters?

Did you have access to your students criminal record or their financial data?
It's not about a technical security problem (although that is an issue to) it's about who has access to what part of the data.

Do you think it would be a good idea, if your (future) employer has access to all health records of your lifetime?
Would you want to risk a job, because you were treated one night in hospital for alcohol abuse when you were 18?
Maybe you had a cancer therapy 10 years ago, and your future employers heath insurance rates for you are higher than those of an other candidate.
If you break your leg, is it really helpful or necessary for the doctor (and all of his team) to know about a sexual inflicted disease you had during your army days?

What informations does the pharmacist need before he can give you your prescription?

Who should have access? Definitely an issue. Let's look at one of the items you bring up:

Should a future employer have access to my medical records? What is the current practice? I have Medicare supplemented by private insurance. Between them they probably know every doctor's visit I have had for at least the last twenty years. So there is already a paper trail. If a prospective employer is denied access now to that information, it seems he could be denied access to computerized information. Maybe the future employers already have access to too much info and maybe that should be fixed, but I am not seeing how this is a new issue.

I do not wish to minimize privacy issues. My life would bore a snooper silly, but I do regard privacy as important on general principles. My life was not always so straightforward, I even think my phone was tapped once long ago. But it seems to me that these issues can be solved, and I can't really see why it should take five years and billions in government help to do so.

When it comes to privacy I think the folks that I distrust the most would be in the government. On any given issue they can often make a strong case for prying (we really do need to catch crooks and terrorists), cumulatively it comes to a large assault on privacy. This seems like the biggest problem to me. Private employers could just be told to buzz off, I should think.

[helene_t]

well said, ken.

[mike777]

when it comes to privacy many...90 out of hundred will sell it for a price.

I just think too many discount how powerful price is overtime. The rest die overtime and your children sell your privacy.

Keep in mind over 4 billion live on 2 bucks a day.

[Lobowolf]

mike777, on Mar 28 2009, 07:50 PM, said:

when it comes to privacy many...90 out of hundred will sell it for a price.

99.9 out of 100. The only questions are, how much privacy, and at what price?

I suspect most people are glad airports have metal detectors that everyone walks through. I'm also pretty sure most people wouldn't want them to have mandatory strip searches for everyone.

[mike777]

Lobowolf, on Mar 28 2009, 08:13 PM, said:

mike777, on Mar 28 2009, 07:50 PM, said:

when it comes to privacy many...90 out of hundred will sell it for a price.

99.9 out of 100. The only questions are, how much privacy, and at what price?

I suspect most people are glad airports have metal detectors that everyone walks through. I'm also pretty sure most people wouldn't want them to have mandatory strip searches for everyone.

Agree what price......I suspect that price will be smaller than many expect.

strip search...sure...just pay me......

which strip search line do you wait in...at what price over what timeline?

Btw this may be an argument....you cannot sell privacy at any legal price....

[luke warm]

kenberg, on Mar 28 2009, 06:42 PM, said:

Should a future employer have access to my medical records? What is the current practice? I have Medicare supplemented by private insurance. Between them they probably know  every doctor's visit I have had for at least the last twenty years. So there is already a paper trail. If a prospective employer is denied access now to that information, it seems he could be denied access to computerized information. Maybe the future employers already have access to too much info and maybe that should be fixed, but I am not seeing how this is a new issue.

per hipaa laws, your medical history can't be accessed without your permission (supposedly)... a future employer has no right to such information, although if that employer offers health insurance there may be a preexisting condition clause that applies, which means that for a certain length of time every doctor/hospital visit you make is subject to a medical history search over a past set length of time (although portability applies)

Quote

When it comes to privacy I think the folks that I distrust the most would be in the government.  On any given issue they can often make a strong case for prying (we really do need to catch crooks and terrorists), cumulatively it comes to a large assault on privacy. This seems like the biggest problem to me. Private employers could just be told to buzz off, I should think.

i agree, especially when it comes to the gov't

[kenberg]

For the last few years when you go for the first time to a doctor or lab there is a privacy document. It says blah blah blah, blah, more blah, then there is a place to sign. I sign. Someday I might actually read the damn thing.

We live in an extremely non-private age. Recently in Starbucks I told a cell-phone aficionado to please hold it down. He told me to mind my own business. I told him I would love to but his loud voice was making it impossible for me to do so. You regularly get the details of sexual adventures, financial transactions, kid's troubles in school and just about everything else.

Still, medical records do need to remain private. At least it should be at the patient's option to breach this privacy. Only if concealment puts the public at risk should this trust be broken.

So I very much favor privacy. As technology advances, we need to push back hard on the importance of privacy. But computerized medical records are not the enemy here as long as we are clear about hoow they are to be used.

A couple of recent examples of mishandled technology:
1. I mentioned this thread to my wife this morning. As it happens she has a knee problem, is seeing a doctor on Tuesday (she says i can tell this!), and had an xray. The lab said they could fax it, she said she will come pick it up and bring it with her because on a recent appointment the faxed material got misplaced and was not available to the doctor.
2. A couple of years ago I awoke with sharp pains and went to the emergency room. I have been very lucky with my health and this was my first overnight stay in a hospital since I had my tonsils out in 1945 or so. They did a lot of things and then referred me to a cardiologist. After reviewing my records, he suggested an echo cardiogram. It's an odd name and so I recalled that I had actually had one during my stay. Another sort by the doctor through the various paper records proved this to be true, saving time and expense for everyone. (I'm fine, btw)

Diagnostic medical technology is truly impressive. It's long past time for the medical community to get its act together on the use of technology for medical records. Currently, they suck.

[helene_t]

kenberg, on Mar 29 2009, 02:20 PM, said:

Recently in Starbucks I told a cell-phone aficionado to please hold it down. He told me to mind my own business. I told him I would love to but his loud voice was making it impossible for me to do so. You regularly get the details of sexual adventures, financial transactions, kid's troubles in school and just about everything else.

Lol. Once while I was traveling by train a young lady entertained the whole wagon with a phone conversation about the details of the lawsuit the child protection agency was running against her and her husband for mistreating their kids.

[y66]

Quote

It's long past time for the medical community to get its act together on the use of technology for medical records. Currently, they suck.

Mos def x 2. Will start asking my doctors, labs and insurance company about this.

[Winstonm]

Having worked in the health industry it is my experience that health records are a disaster for the most part. This is especially true when one has two or more physicians, as each physician is an independent contractor and not prone to spend a lot of time and effort notifying another physician of changes - these details are left to the patient or the patient's family to narrate.

It is amazing how difficult it is to simply get an accurate medication record when two or more physicians are involved - one would think there would be a master patient record that all physicians could access and update but no, each physician has his own private record of the patient. To get an accurate list of current medications means contacting each physician and obtaining each individual list or relying on the patient to furnish a current, accurate list.

There is no doubt that a centralized patient record would improve health care.

[helene_t]

In most (all?) European countries, patients generally have a single "family doctor" who maintains the master record of the patient. When I shift from one doctor to another, the records will be forwarded and I think it generally works OK, except when I moved from NL to UK and my British doctor couldn't read Dutch.

It is a major mess in hospitals, though. In Scandinavia, patients have a single record associated with their social security number, which is still accessible the next time a patient is admitted to a hospital in the same region. Dunno how smoothly it works if one is admitted to a hospital in a different region, though. But in the Netherlands, patients are registered by name and day of birth, and it may prove impossible to link records between hospital stays, especially for married women who may or may not use the name of their current husband. The costs and morbidities associated with redundant tests performed because the results from the last test were not accessible, and the costs and delays associated with paper records that get lost, are significant burdens on the health care system.