It’s In The Computer

Did you know that people are fixing to cut funding to Graduate Medical Education? Yeah, you know, the thing that actually allows us to make new doctors, while we’re in a PHYSICIAN SHORTAGE?!

Yeah, I know.

Everyone’s trying to cut costs.

But cutting primary education, infrastructure, and the funding that allows us to pump out the people who make sure you don’t die when you are in a car accident seems like a stupid, stupid move.

Here’s a better alternative.

You know what would take a significant chunk out of health care costs? In one fell swoop?

Standardize electronic medical records.

That’s right. All you private companies with your New! Improved! EMR Systems! need to take a bow and just disappear…instead of the doctors who use them. Cerner, Quadrumed, Sunrise, and all of you other overcomplicated, hypofunctional EMR systems…I’m sorry, but we just need to end this relationship. It’s not me, it’s you.

Do you have any idea how much time, money, and resources are spent repeating workups? A lot. A. LOT. This problem is exacerbated by the fact that patients now have a tendency to bounce from hospital to hospital, shopping for who knows what. At every hospital, basically the same workup is done. And it’s practically impossible to get records from previous hospitalizations, even if a patient signs himself out of one hospital and goes straight to another one. (This happens all. the. time.) So what does hospital number two do? Exactly the same thing that was JUST done at hospital number one.

But Dr. Grasshopper, I hear you saying. Why can’t the patients just fill you in on their medical history when they come to the hospital?

I’m sorry. I barely heard you through the millions-of-voices-strong chorus of that cringe-inducing statement: “It’s in the computer.”

What medications are you taking? I dunno. It’s in the computer.

What illnesses have you had in the past? I dunno. It’s in the computer.

Have you ever had any organs removed? I dunno. It’s in the computer.

This happens even at hospitals that DON’T USE ELECTRONIC MEDICAL RECORDS.

Okay, okay. I’d be a fool to expect Americans to take responsibility for their own health history. It’s absurd to ask someone to write down their medication regimens on a piece of paper when they go for a doctor’s appointment or present to the emergency department. It’s pure idiocy to expect people to remember whether or not they ever gave another human being permission to slice their bodies open and fiddle around with their insides.

But if we’re going to allow patients to abdicate their responsibility toward knowledge of their own bodies and make the healthcare providers solely responsible for the information required to treat people correctly, effectively, and inexpensively, then THERE HAS TO BE A RELIABLE WAY OF COMMUNICATING INFORMATION BETWEEN PROVIDERS.

And there just isn’t.

Except in one sector: The Veterans’ Affairs hospitals.

Why, you ask? (Don’t pretend you didn’t ask. I heard you through the computer chorus.)

It’s because of a program called CPRS.

Let me be the first to acknowledge that CPRS is an imperfect EMR program. But it is far LESS imperfect than any other system I’ve worked with. The biggest advantage of CPRS is that the medical history, imaging, and previous test results of any VA patient who presents to any VA hospital in the country is immediately accessible, no matter which VA hospital they had been to previously. I could go into details about the time, energy, and healthcare errors that are saved by such a simple thing, but I just don’t have the time or the energy to try and convey that kind of ENORMOUS MAGNITUDE.

Here’s my proposal: extend CPRS to all hospitals that use electronic medical records. All of them. We’ve already paid for the development of this system; CPRS was taxpayer-funded. So make the investment that would be needed to dump all of the other overpriced systems-of-marginal-utility and transfer them over to one, centralized repository of patient information whose design and development we have already paid for. And then just do it.

It has to happen. Electronic medical records are awesome, but like everything else in medicine, you can’t get a benefit without a side effect. And the biggest side effect I’ve noticed from EMR systems is that everyone outsources their knowledge of their own medical situations to some amorphous, all-knowing Computer. And from what I’ve seen, that’s not likely to change any time soon.

So why not just make it a reality? It would make life easier for everyone, doctors and patients alike.

Some immediate effects:

-Shorter wait times in emergency rooms, as doctors won’t have to sit and painstakingly try to reformulate by trial and error the magical sequence of questions that will drag useful information from forgetful, uncommunicative, or unengaged patients and family members. Doctor/patient time can then be spent with far more meaningful and fruitful interactions.

-Drastic decrease in healthcare spending; you’d be horrified at how often the same tests and imaging are repeated, just because the results of previous tests cannot be found in time to contribute to medical decision-making. Well, you might not be horrified, but I am. On a multiple-times-daily basis.

-Fewer medical errors, since medical providers will be able to make decisions based on the most complete set of information possible, instead of the slapdash patchwork of patient recall, previous records (if you can ever find them), and possibly-misleading-test-results-that-wouldn’t-actually-terrify-you-and-lead-you-to-do-a-full-panicked-workup-if-only-you-knew-that-the-patient’s-result-has-been-at-that-same-bizarre-level-for-the-past-fifty-years-and-it-has-never-made-any-trouble.

Everyone currently employed by the useless-and-now-defunct-if-this-proposal-takes-hold EMR companies can devote their energies to the security and functionality of the centralized repository.

What other single piece of policy change would have such a drastic positive effect on this broken, broken system?

I dunno. It’s in the computer.

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Published in: on November 15, 2011 at 4:14 am  Comments (11)  

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  1. “Why can’t patients fill you in when they come to the hospital”? People seriously ask this?
    Why can’t someone who’s sick,injured. shocked, exhausted, or just out of their comfort zone, recall the details of tests from decades ago, or the exact sequence of pills their insurance has compromised on and when, or the names of tests that they never understood in the first place….

    assuming the patient’s conscious in the first place?

    The answer seems kind of self evident.
    As someone who’s filled out way WAY too many doctor’s office history forms , I wholeheartedly support your plan. Every doctor asks for permission to request records from every other doctor; wouldn’t it be more useful for them to have that BEFORE they see the patient?

    Nargh nargh nargh…

  2. They’re in the process of doing that very thing here, at least in this health region. I’ve seen the program on my doctor’s computer. It looks complicated, but everything is right there at his fingertips. I’m sorry I can’t remember the name of the program.

    I suppose this sort of thing is easier in a public health system (in Saskatchewan, Canada).

    And the only medical college in the province keeps increasing seats in an effort to get more doctors who will stay in the province. Many move to the larger cities – some even move to the US to work at private hospitals – where they get paid more.

    I guess you win some, you lose some.

    But having worked in a library system where the regional libraries all use different computer systems for their cataloguing, I can tell you that one standardized system can save time (and sanity) and is much more efficient all around.

  3. Ah, you see, if they followed your suggestion then money would stop going to the private companies who produce the EMR systems. Instead, money would be going to the increased doctors who graduate and practice medicine. Money going to individuals who earn it instead of evil companies who hoard it? I’m just a distant observer, but that doesn’t sound American, to me.

    Also, the computer is your friend. http://en.wikipedia.org/wiki/Paranoia_%28role-playing_game%29#Setting

  4. That bit about the VA makes me happy, but not much else. I’m looking at separating from the military soon and the less time I have to spend in a waiting room, the better.

    That being said, I’ve probably existed in a different paradigm when it comes to medical care. Not knowing what you are taking or your medical history in greater detail is strictly unsat in the military, so when asked by a doctor what my history is, I rattle off ten year’s worth of history almost by reflex. Yet even this takes about five to ten minutes out of an appointment that is only supposed to last fifteen minutes, and appointment that is supposed to diagnose what weird and crazy thing is going wrong with us at that point in time. (I’m still convinced this is why I was sent to work while suffering a really bad case of the flu.)

    I’ve noticed a huge discrepancy with medical recording between mine and my dependents though. My medical record travels with me in a heavy duty folder whenever I go between medical clinics. All I do is drop it off at the records desk and that’s in. However, whenever I transfer my children’s PCM, I have to jump through hoops to match paperwork.

    In short, I agree with you.

  5. I’ve been told that in Australia – another public health care country – each person’s medical card includes a chip on which all their medical data is encrypted. Right there, with them, as needed. To which I say BRAVO.

  6. As a doctor (and sometimes patient) I completely agree with you. A universal system would also save doctors’ offices and hospitals the huge overhead costs of personnel whose job it is to track down medical records from other places and send it when requested.

    So here’s the problem I keep hearing; HIPAA. Now, I tend to think HIPAA is pretty dumb – most patients don’t seem to care, most medical employees aren’t perusing patients charts just for fun, and an ungodly number of people are already seeing you medical info over at the insurance companies. But still, it’s law, and medical practices take it pretty seriously. So I think universal electronic medical records will have a hard time taking off till someone can convince people that every person with access won’t be reading about their neighbor’s depression, weight problems, or sexual dysfunction.

    Thoughts?

    • My understanding is that the HIPAA problem with this isn’t on the access point (aka doctors and medical personnel) it’s on the data storage and transmission/encryption problem.

      How do you make sure the people who need to access can do so easily but make sure that others can’t? There are going to be a lot of hiccups in getting that system rolled out to wider use.. and those hiccups are all going to have HIPAA violations– and who gets charged with the violation? The unauthorized accessor? The software programmer? The network administrator? The internet service provider the information went through?

      I suspect the VA system works (or works as much as things can) because every step of the system is owned or run by the government. Which brings us back to panicked cries of socialism and Big Brother government.

      Sigh.

      • At least on the active duty side of the house, HIPAA is alive and well and strictly enforced. For example, due to the nature of the organization, certain medical diagnoses and medications must be disclosed to your command – but only a select few members of the chain.

        For instance, I recently found out that I’m pregnant. I only had to tell my LPO (Direct supervisor), my Chief (Divisional supervisor), the CMC (her boss) and the CO and XO.

        So in essence, I can wander around my command at nine months pregnant and not tell any but those I must. Its ridiculous.

        But when it comes to other things – mental diagnoses, problems of an intimate nature, etc. Those things tend to be very sensitive, but make for ripe fodder for the rumor mill. I’m sure that it’s the same in other communities too – and rumors can totally break your reputation and image. I saw a girl get separated from the military due in a large part to a rumor regarding her mental health, followed by people talking about the medications that she was purportedly taking. I think, that like many laws, HIPAA was created in reaction to the few rather than the many.

        Perhaps it isn’t so much HIPAA entirely, but how it is interpreted. And there are likely parts that need revised, regardless.

    • Canada has one of the strictest privacy laws in the world. Yes, that is a challenge our integrated system has faced, but I believe they’ve got it worked out now. Of course, it may be easier if run by our health dept. I’m afraid I haven’t looked into the details.

  7. And you know what? From a person working as a project manager for global clinical trials, whenever I hear EMS, I also start to cringe. Cause GCP-wise it’s also a problem. A hospital or clinic or practice doing a study uses electronic records? They either need to prove their system is validated and CFR compliant and everyone has their own password and the CRA can get read-only access, or else they need to print out every darn page relevant for the study patient and sign and initial it. And very often, investigators don’t want to do it. It’s a nightmare for anyone running a clinical trial. Auditors hate EMSs too.

    I can totally understand your frustration, even though I come from a different perspective. Still, with us being well into the era of electronization, there is no way we can stop it becoming the new standard. But what would really be neat is a harmonized system across the board. Because that would make it so much easier for everyone.

    • Why did I wrote EMS? That’s something different. I meant EMR. Anyway…


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