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We will be made out computers before we have electronic medical records

robothangingout.JPG

To say one more word on electronic medical records, the fact that it's 2010 and we're having a conversation about how to move records from paper to computers is evidence of how screwed up the American health-care system is. In part, you're dealing with the fractured incentives in the system: It's good for patients and good for insurers if doctor's offices spend money setting up computer systems, but it's not necessarily going to make doctors any money, and the doctors themselves are frequently older and don't want to learn a new system. That's one reason why systems where the insurer and the provider are the same -- think Veteran's Affairs or Kaiser Permanente -- tend to be ahead of the curve on electronic medical records.

But even if the economic analysis makes you sympathetic, the end result is still absurd. Imagine walking into a bank where clerks scrawled all your information in a giant ledger book. You'd run out and tweet all your friends about this hilarious bank from the 18th century. But we actually let people do this with our medical records, and then some of us die or have serious problems because our records get lost or our doctor's handwriting is illegible.

Right now, one of the top stories on the New York Times site is about how human beings are going to become people-computer hybrids and live forever and that vision actually seems semi-plausible until you realize that all the information about the operation to download your memories into a Macintosh will probably be kept in a manila folder in a large filing cabinet, and then it doesn't seem so likely.

Photo credit: Thomas Peter/Reuters.

By Ezra Klein  |  June 14, 2010; 3:50 PM ET
 
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Comments

"You'd run out and tweet all your friends about this ..."

Not a chance.

Posted by: ostap666 | June 14, 2010 4:23 PM | Report abuse

"Imagine walking into a bank where clerks scrawled all your information in a giant ledger book. You'd run out and tweet all your friends about this hilarious bank from the 18th century."

Unless that was the only bank that your employer was willing to deposit money into. Then you would just have to suck it up.

I'd be interested in knowing if non-insurance paid medical services (i.e. Lasik) are further along on electronic medical records than the traditional insurer paid practices. It would give credence to Paul Ryan's idea that "This sector isn’t immune from free-market principles."

http://voices.washingtonpost.com/ezra-klein/2010/02/rep_paul_ryan_rationing_happen.html

Hard to believe that interview was only four months ago. Feels like a lot longer.

Posted by: jnc4p | June 14, 2010 4:24 PM | Report abuse

Ezra, don't forget that paper records are actually safer as far as privacy is concerned. It's much easier to crack into someone's computer system from over the Internet than to physically break into their office. I know one doctor who opposes electronic records for that reason alone.

Posted by: tyronen | June 14, 2010 4:34 PM | Report abuse

this is sad and pathetic and everything you say. What needs to be done is there needs to be a financial incentive on each of the parties to make this. And not so much a financial incentive to go do it but a financial hardship (and a serious one) to NOT do it. That's the only way it gets from a good idea to a good job and good practice.


Jnc4p,

one doctor isn't a study but a couple years ago I investigated going to have Lasik done and that doctor (who seemed to be cutting edge on the technology of Lasik) was not cutting edge on the medical records front.

I think this will have to be something like HIPAA that gets forced upon us all and we grump about it but in the end its a great idea and more importantly it'll save a ton or money and even more importantly still it'll save lives.

Posted by: visionbrkr | June 14, 2010 4:35 PM | Report abuse

Man. That article is horrible! The author seems completely confused about the distinction between transhumanism and the Singularity.

Posted by: adamiani | June 14, 2010 4:54 PM | Report abuse

A few mostly related points for your consideration:

1. Medical records are different in that there is not as much need for them to be shipped around as there is for, say money. A large percentage of people spend a large amount of their lives handled by one records-keeping agency.

2. Records are harder to convert to electronic form because there is a large prose component to many records: annotations, descriptions and so forth. For these types of components, the presentation of the record is important, crucial even and it is not easy to transfer this property to an electronic form especially since most application developers tend to think in terms of database tables for storage.

3. A person's entire medical history is rarely needed at any given time. That time I came in with a minor viral infection back in 1962 is hardly relevant to my current situation, but the fact that it was discovered that I'm allergic to penicillin back in 1962 probably is. The decisions about what is important and what isn't is a hard problem to solve in a generic fashion. Clinicians each have their own way of handling the problem that can be deeply embedded in their records keeping processes.

Posted by: stand | June 14, 2010 5:24 PM | Report abuse

Unfortunately health care systems with much more government involvement have also hard time bringing in electronic records. Canadian provinces have sunk billions into it with next to no results, the NHS isn't doing much better, and it took the Dutch 10 years and a lot of resources. Big government (and private sector?) IT projects seem to cost a ton of many and lead to lots of waste.

Posted by: SimonCox | June 14, 2010 5:41 PM | Report abuse

As a patient at Kaiser Permanente in northern CA, and at a dental clinic where everything from patient consent signatures to digital x-rays are completely electronic, I find your article a bit puzzlingly pessimistic.

You might want to spend some time checking out some of the major institutions that are already doing what you doubt can happen.

Posted by: allanbrauer | June 14, 2010 6:40 PM | Report abuse

Let's hope that if/when we are made out of computers that they are better tested than Kaiser Permanente's untested/untestable electronic health record... which should scare the heck out of anyone who gets care at that mediocre institution.

Posted by: johnincalifornia | June 14, 2010 7:07 PM | Report abuse

Something to keep in mind is that EHRs are still tightly coupled to particular implementations, and thus conversion means a full-blown systems rollout. Sure, doctors are terrible when it comes to accepting electronic systems, but there are barriers to development that are worth keeping in mind.

Amongst other problems, the HIPAA and HL7 protocols (based on the creaky X12 EDI specs) are obtuse, expensive to access, and difficult to develop to; the business rules for medical coding and billing are incredibly complex; the security issues surrounding HIPAA compliance are significant; and -- just to top things off -- the AMA charges absurdly high prices for developers and medical staff to use the Current Procedural Terminology (CPT) codes, which are required by federal law and standard industry practice. (Every other code list is open and royalty-free, while AMA receives the majority of its operating budget -- some $70m per year -- from selling access to CPT codes.)

If the HIPAA, HL7 and CPT specs were open-access (which, as government-mandated specs, you'd hope they would be), we'd see a much larger systems ecosystem in the clinical space. However, as long as it costs tens of thousands of dollars to simply get access to the specifications, I think conversion will continue to be a rather arduous and expensive process.

Posted by: TWBr | June 14, 2010 8:32 PM | Report abuse

"Imagine walking into a bank where clerks scrawled all your information in a giant ledger book."

I'd be at Gringott's Bank from Harry Potter, and I'd think it was awesome.

The point about complexity. Only now, with stuff like the iPad, are we really approaching the point where electronic medical records might be more of a help than a hindrance. And even then, there needs to be something that doctors can legibly scroll their signature on.

That having been said, there's plenty of decent electronic record keeping for medical offices out there. My daughters' pediatrician comes in with his laptop, and is wirelessly networked with his office computers and the office printers. Prescriptions are done on the laptop and simultaneously sent to the pharmacy on our account and printed out at the office printer by the door, to be picked up on our way out. He has immediate access to all my daughter's records, all her visits, images of X-rays and more.

It's happening, just slowly. My daughters' pediatrician is a young man. Most of the offices I go to, run by older doctors, aren't nearly so modern (though some are clearly trying). And this is in Bartlett, TN.

I'm amazed Ezra can't find any networked, prescription-emailing, records-at-his-or-her-fingertips Doc in DC.

Posted by: Kevin_Willis | June 14, 2010 8:35 PM | Report abuse

"scroll their signature" . . . I meant, "scrawl in their handwriting". Oopsy.

Posted by: Kevin_Willis | June 14, 2010 8:36 PM | Report abuse

Amazingly enough, this is an area where I'd think market preferences might actually work. I know I am MUCH more likely to prefer a young doc, especially for primary care, based largely on this consideration.

I'm actually surprised insurers haven't taken more of a leadership role on this. If EHR's save lives and reduce physician error, they have to also save MONEY. You'd think that would translate to higher reimbursements to EHR-using docs or lower costs to patients comfortable with younger, but more tech savvy docs. It will be interesting to see if they start pushing physician practice differences like these more after the Affordable Care Act stops their ability to compete on health status.

Posted by: NS12345 | June 14, 2010 9:01 PM | Report abuse

@NS12345: It definitely would save money in the long-term. Unfortunately, it would cost money in the short-term which would impact the stock price and result in the CEO getting a smaller bonus this year.

Insurers aren't in the business of providing health care - they exist to take the biggest cut they can and nothing more.

Posted by: lol-lol | June 15, 2010 9:51 AM | Report abuse

I own a small Health IT company that sells EHR software to small/medium medical practices. Dealing with doctors I live with their reluctance to implement EHR. Their concern for impacting their relationship with their patients and the initial impact on the number of patient visits is understandable. What I don't understand is their lack of grasping the productivity savings a well implemented EHR can provide.

When you look at the productivity savings a practice can realize by doing away with charts it blows away the relatively small amount of stimulus funding available. Practices not only pull charts for every visit, but just about every query from a patient. This involves not only finding the chart, forwarding it to the proper provider, provider review, and then refiling the chart.

For some EHRs, once it is implemented it is a simple option to offer patients on-line access to their records. This "self-service" model, which is table stakes in most businesses (as Ezra points out in his banking analogy), also yields tremendous savings to a practice. According to national surveys about 60% of patients want on-line capability with their provider, but less than 10% enjoy this feature. The majority of the "10%" receive this service from the insurance plan.

Doctors need to realize that if they don't provide the services that their patients demand then their "friendly" health insurance company will. This will tilt the playing field even more in the favor of the insurance companies.

Posted by: mpd777 | June 15, 2010 10:56 AM | Report abuse

"...That having been said, there's plenty of decent electronic record keeping for medical offices out there. My daughters' pediatrician comes in with his laptop, and is wirelessly networked with his office computers and the office printers. Prescriptions are done on the laptop and simultaneously sent to the pharmacy on our account and printed out at the office printer by the door, to be picked up on our way out. He has immediate access to all my daughter's records, all her visits, images of X-rays and more."

That sounds good, initially. But there's still the question of interoperability and security. Just because your pediatrician can send documents around his practice does not mean that he's fully immersed in EHR. Being able to transmit and receive records from other facilities and practices, plus being able to conduct insurance claim transactions, plus remaining compliant with HIPAA transaction/privacy/security, HITECH, NCQA, Federal Reserve rules, etc is a very expensive proposition -- and that's the main reason why most independent practice physicians haven't transitioned to EHR yet.

Posted by: LoCoChick | June 15, 2010 3:29 PM | Report abuse

my doctor's office is all-electronic now. all the Drs and PAs carry laptops with them when they visit patients, and they can pull up old patient records, enter new records, and even electronically send prescriptions to your pharmacy - all from their laptop. no paper at all. and they're just a small local practice in Durham, NC.

very nice.

Posted by: smallest | June 19, 2010 1:32 PM | Report abuse

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