Health Care Information Technology: A Danger to Physicians and to Your Health

The causes of the crapification are legion, but one that is having a bigger impact on health care than is widely recognized is bad information technology implementation. And I don’t mean the website.

In case you missed it, the Federal government is in the midst of a $1 trillion experiment to promote (as in force) the use of Electronic Health Care records, or EHRs. Astonishingly, this program has been launched with no evidence to support the idea that rendering records in electronic form will save patient lives. From a Freedom of Information Act filing by the American Association for Physicians and Surgeons got this response, which was reprinted in their April newsletter (emphasis ours):

The American Recovery and Reinvestment Act of 2009 (ARRA) created the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. While our Office of E-Health Standards and Services works to implement the provisions of the ARRA, we do not have any information that supports or refutes claims that a broader adoption of EHRs can save lives.

Now of course, one might argue based on intuition that surely electronic data would help patient care. Think of all those illegible doctor scrawls that get misread from time to time. But you need to weigh those errors against those of bad data entry, difficult to read file formats, difficulty in converting records to electronic form, and greater risk of loss of patient data (hard disk crashes and faulty backups).

In fact, I’ve seen good health care information technology in action. When I lived in Sydney in 2002 to 2004, every doctor I saw had a little black flat panel screen in their office or examination room, and most would enter data during the session. The doctors I saw were in solo or small practices. Their fee levels (assuming a dollar for dollar exchange rate, which was not the case at the time) were 25% to 35% of New York City rates for comparable services. That suggests that the use of IT wasn’t a costly addition to their practice overheads.

But could the US adopt the sensible course, which would be to look for successful health care information technology implementations overseas and learn from them? No way. As Informatics MD notes at the Health Care Renewal blog (emphasis ours):

I know from personal development and implementation experience that when “done well”, that is, when good health IT and good implementation practices are offered and with patient safety as a priority, health IT can save lives and improve care. It’s just that the commercial for-profit health IT sector does not meet those expectations, due largely to its leadership model from the merchant-computing culture. Instead, bad health IT is the norm.

We’ll get to the lousy patient outcomes part in due course. But I wanted to focus on a less obvious but no less significant element of this health care information technology push: that it is accelerating the death of solo practices. Mind you, this was already well underway, as reader Juneau noted in our recent post on corporatized medicine:

Going from working for a large corporate healthcare entity to working alone, I have seen insurance rates cut by 40 percent simply for going from “group” to “solo” status. Those who can afford to “do it right” (maybe those without kids or a mortgage or 3 divorces to pay for) feel like dopes. Colleagues who put themselves first survive. Those who made sacrifices, provide free care to indigent patients, accept insurance, etc…..are now the low tier low status docs who work 60 plus hours to make overhead and stay afloat.

This article from UTSanDiego explains the impact of the health care information technology requirements from the doctor perspective:

…doctors who see patients under Medicare and Medi-Cal programs have been forced by the phase-in of a 2009 federal “stimulus” law to install expensive, complex software systems that sharply reduce time for patients….

Yet the unkindest cut has been the electronic records mandate.

Nearly 70 percent of physicians say digitizing patient records has not been worth the cost, according to a survey by Medical Economics magazine. This negative cost-benefit view comes even after $27 billion in subsidies to health care providers for the systems.

One big problem is the dozens of systems don’t talk to each other, because the feds didn’t mandate interoperability before the rollout.

So communication gains among hospitals, clinics and doctors offices aren’t happening. Adding insult, doctors can be criminally liable if hackers get hold of patient data.

Worse is the hit to productivity. Doug says he once aimed to see four patients an hour for normal office visits. Now he struggles to see three each hour, and colleagues report much the same.

The article concedes that the productivity loss should decline over time. But we have the hard dollar cost combined with the toll on doctors’ time….and worse outcomes from a medical safety standpoint. From a Sunday post at the Health Care Renewal website:

From a colleague, a physician and blogger and fellow AMIA member with an eclectic background, on the state of healthcare information technology. Reposted with his permission.

The fact of the matter is that the EMR remains in the United States a tool for maximization of reimbursement and as such is not a technological destination but rather a technological dead end. The driver for proliferation of this ‘dead end’ is the government being willing to fund its expansion with their fervent hope that it will be their magic bullet for finding the cheats and cheaters of Medicare….

The reality is the train has left, those of us addicted to patient care watch in dismayed horror as our productivity plunges and we struggle to restructure not our workflows but our clinical thought processes to badly designed, logically flawed, and obscenely overpriced documentation tools that distract the expert clinician from a high quality clinical encounter.

Quite honestly gentleman and gentlewomen of the jury, I don’t give a ‘rats a**’ about superior documentation, I am obsessed with superior outcomes, and as somebody who actually has to work with this junk, it all sucks………. and will continue to suck until such time as real world clinicians have veto power over the efforts of systems design teams with respect to their information design efforts…. What information design efforts? My point precisely…….

So in other words, the implementation of EMR had nothing to do with improving patient care. Nada. It was all about the money, supposedly improving doctor’s ability to get money back from insurers and helping the government catch cheats.

And if you think I’m exaggerating the risk to patients, the latest ECRI Institute report puts health care information technology as the top risk in its 2014 Patient Safety Concerns for Large Health Care Organizations report. Note that this ranking is based on the collection and analysis of over 300,000 events since 2009.

ECRI did an earlier deep dive on the health care information technology issue in 2012,. †he results were not pretty. The Institute found 171 technology-induced problems were reported in 9 weeks by 36 “facilities,” which were mainly hospitals. Eight of the incidents resulted in harm to the patient and three may have contributed to deaths.

Health Care Renewal gave a back-of-the-envelope calculation as to how to extrapolate these results to the US as a whole:

I note that’s 36 of 5,724 hospital in the U.S. per data from the American Hospital Association (link), or appx. 0.6 %. A very crude correction factor in extrapolation would be about x 159 on the hospital count issue alone, not including the effects of the voluntary nature of the study, of non-hospital EHR users, etc. Extrapolating from 9 week to a year, the figure becomes about x 1000. Accounting for the voluntary nature of the reporting (5% of cases per Koppel), the corrective figure approaches x20,000. Extrapolation of course would be less crude if # total beds, degree of participant EHR implementation/use, and numerous other factors were known, but the present reported numbers are a cause for concern

One of the basic concepts I learned many years ago was that managing was all about making decisions under uncertainty, and that there was a cost to obtaining information to try to reduce uncertainty. The gains in certainty had to be weighed against other costs.

But that isn’t what is operating here. It’s not hard to see that this is an enormously expensive exercise relative to the promised gains in billing efficiency and in catching cheaters. Even before you get to loss of doctor productivity or the harm done to patients, this IT boondogle doesn’t remotely pass muster as an investment to lower costs. So it should be no surprise that it was thrown in the 2009 stimulus package, as something that on a superficial level sounded like it was worth doing and wasn’t as controversial as other spending options. After all, throwing money at white collar workers is not a hard sell, particularly if you pretend you can increase government efficiency, rather than helping struggling borrowers or *gasp* poor people.

And our latest example of crapification is well beyond the point of no return. High levels of disapproval by doctors and bad patient outcomes are irrelevant, since each group’s welfare was never the object of this exercise. This is kleptocracy, designed and executed to occur where the grifters were confident the public would never take notice.

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  1. mikkel

    I am a programmer that has worked with research physicians. Properly designed and implemented IT could save thousands of lives and billions of dollars — if it was physician/nurse oriented with good programmers using best practices. I know of at least a half dozen use cases where the combination of EHR and ICU monitoring would revolutionize care.

    A colleague implemented a custom monitor display that cut the rounds in her unit from 2 hrs to 10 minutes and reduced mistakes by 90%. It enabled her team to quickly figure out who needed intervention on the metrics they knew were important. This is in an ICU with brain trauma where seconds count. She did it with the help of two undergraduate programmers and a technician — probably spending about $30k on development.

    She is now interested in how to link to EHRs to calculate stroke probabilities, which will allow her to triage proactively. However, this is impossible because the medical software market is a cartel meant to extract as much as it can while providing negative benefits to everyone except for insurance companies. I’ve heard stories of $150 million deals sold on fancy demos that then led to software which was completely broken but the administrators would not pursue damages.

    It’s so bad that it was a major factor in my decision to move out of the country. At a medical conference everyone kept saying that OZ/NZ (and much of Europe) has a shot of adopting these good practices while the US was beyond hope due to entrenched for-profit interests. So I left and have found things much better across the board.

    I wish that all the amazing health care specialists and programmers would give up on the US and contribute their skills to places that aren’t so politically dysfunctional; and that investors funding start ups would look outside the US instead of wasting their money.

    An untold number of the world’s brightest and tens if not hundreds of billions of research dollars (let alone the infrastructure dollars) is being wasted on this completely dysfunctional and sociopathic system and everyone on the inside knows it. The $1 T was seen as the last chance to change course but it looks like that hasn’t happened, so the opportunity will be lost more or less forever.

    1. mike

      I can remember implementing an EHR (EMR) over a decade ago in one of NYC’s public hospitals. What I remember most was the Director of Radiology hugging me in the hall for supporting transitioning to EMR. That, admittedly, was only one service component of the EMR, I retired before all services were rolled into the EMR. I would not gainsay some of the real concerns about an EMR, all well stated, but the effort should be placed on marshaling the talent and will to make it work, not give up on it.

      1. Yves Smith Post author

        I have to disagree with you on your: “we just need to keep at this” posture. As they say in Maine, you can’t get there (good IT) from here (bad large scale IT already in advanced state of deployment) without throwing pretty much everything to date out, which is not going to happen.

        I stinted on the underlying information in the interest of keeping the post to a manageable length. Structrually, there is simply no way the patient/health care deficiencies will be fixed because doctors are not involved in the design process

        See this news story that we linked to:

        Ways EHRs can lead to unintended safety problems

        Wrong records and failures in data transfer impede physicians and harm patients, according to an analysis of health technology incidents.

        By Kevin B. O’Reilly, amednews staff, posted Feb. 25, 2013.

        In spring 2012, a surgeon tried to electronically access a patient’s radiology study in the operating room but the computer would show only a blue screen. The patient’s time under anesthesia was extended while OR staff struggled to get the display to function properly.

        And it isn’t cherry-picking to highlight a radiological study. See the list below at the Health Care Renewal website, from the ECRI report:

        The 171 events documented, break down like this:
        53% involved a medication management system.
        25% involved a computerized order entry system
        15% involved an electronic medication administration record
        11% involved pharmacy systems
        2% involved automated dispensing systems
        17% were caused by clinical documentation systems
        13% were caused by Lab information systems
        9% were caused by computers not functioning
        8%. Were caused by radiology or diagnostic imaging systems, including PACS
        1% were caused by clinical decision support systems

        He also adds this, which I did not belabor in the post:

        Note that ECRI Concerns #2 and #3 also may involve electronic medical records systems.

        CONCERN #2: Poor Care Coordination with Patient’s Next Level of Care (page 8):

        … Electronic health records (EHRs) can facilitate communication about a patient’s care among providers, but organizations must establish procedures that address accessing, reviewing, and acting on the findings in those records. For example, what happens if a provider who is viewing a patient’s record discovers that results of tests ordered by another provider have not been acted upon? EHRs could become a barrier “if physicians are second-guessing one another,” says Possanza. Organizations might find it helpful to develop a policy specifying procedures for a provider who finds an abnormal laboratory or pathology result with no indication that the abnormal result was acted upon.

        CONCERN #3: Test Results Reporting Errors (page 10):

        … Callahan observes that breakdowns in test results reporting, particularly in physician practices, typically have one of three causes or a combination of them: (1) technology limitations, such as an inadequate interface between an EHR system and a laboratory system that provides the results electronically; (2) provider-to-provider communication gaps, such as those that occur when no backup plan is in place to designate a provider to review test results for another provider who is unavailable or on vacation; and (3) staffing and training failures, such as requiring a staff member to periodically check an EHR system for test results but not informing the person of what to expect in terms of the volume of test results typically reported to the practice.

        As more healthcare organizations adopt EHR systems, Callahan warns against being lulled into thinking the systems are a panacea and can prevent test reporting failures. “It’s another tool,” she says. “It won’t improve test results reporting if it’s not used correctly.”

        The IT programs are designed to suit the beancounters. And once you have an installed base of lousy IT, it is just about impossible to turn it into a good system. You’ve got too much invested in the bad system to toss it and start over, which is what needs to happen. Doctors have no input int the design. Go look at the bio of the guy who is writing these posts:

        Medical doctor, and Medical Informatics professional via NIH-sponsored postdoctoral fellowship at Yale School of Medicine. Expertise in clinical IT design, implementation, refinement to meet clinician needs, and remediation of HIT projects in difficulty in both hospitals and the pharmaceutical industry. Independent expert witness on health IT-related medical malpractice and related issues. Former Director of Scientific Information Resources and The Merck Index (of chemicals, drugs, and biologicals) at Merck Research Labs. Faculty, Drexel University, College of Information Science and Technology, Philadelphia, PA. Architect of Drexel’s Graduate Certificate Program in Healthcare Informatics.

        You are being naive in minimizing his criticisms.

        1. Fair Economist

          Saying problems occur with computerized systems doesn’t even begin to show they’re a bad idea. You should know better, Yves. Paper files can be lost, swapped or misread too. The question is which produces better outcomes in general. I have to say if the showcase example of a horrible EMR problem is – a slightly longer anesthesia time, then EMR must not be causing serious medical problems.

          I’m finding it really nice that my hospital has the results of my last blood test at my doctor and my doctor can see the X-ray of my finger. It’s nice that the pharmacy is already starting to fill my prescription as I’m driving over. The doctors I see have avoided spending time doing data entry by having the nurses do it – they only enter treatment information.

        2. Nathanael

          Yves is correct. Most hospitals and doctor conglomerates are implementing *really really bad* electronic medical records systems — utter garbage. The results are awful. I could program better systems in a couple of weeks (of course, nobody would pay my rate, and my systems wouldn’t meet the desires of the beancounters).

          It’s arguably easy enough to fix this by throwing the systems out and starting over. But the grifter cartel doesn’t allow this to happen.

    2. worker-owner

      Thank you. IT has been THE productivity engine in most private and public sector enterprises. It is hard to understand, other than gross negligence and intentional obstructivism, how it could fail to bring similar benefits to public and private health.

      1. MikeW_CA

        Perfectly said.

        I’ve been meaning to snap a picture sometime of the massive wall of paper records that sits behind the reception desk at my doctor’s office, mainly because it is so fascinatingly anachronistic.
        Even the most technologically backward industries, such as law practice and mortgage lending have gone digital by now. Medical care is truly the lone holdout.

        That said, I’m not impressed with the software system my doctor is starting up with. I have real doubt that it improves quality of care right now. But hey, every other business has a 20 year head start on getting the bugs out and refining the user experience.

    3. John Yard

      I developed a medical records system for a pathology lab in the late 1970’s to track cytological changes in patients . The system worked technically. It did automate the tracking of cellular changes in patients that could be precursors to serious disease. But the system could not be implemented because over 80% of the patients seen were one-time patients, which meant this lab was investing in a system that yielded positive results to a very small minority of its patients.
      From this experience it seems that the ownership of the data is critical. If you own your own medical data, and it is stored in an open source or common standard format, then the implementation of medical records system(s) would be tremendously simplified. Also the costs of this implementation will fall dramatically. My understanding is that 35 years later ,
      we still have not achieved this standardization. Please correct me if I am mistaken.
      Further, a unified national medical records system strongly supports a single payer approach to medical care. And a national medical records system will promote analysis of the effectiveness of medical procedures and drugs undreamed of with the current system of isolated and expensive studies.
      But if you don’t own your own medical records there will be eternal turf battles and incompatibilities that nullify the potential rewards of maintaining this data.
      I am sure others have more current and more relevant experiences , and can share these with us.

      1. Lambert Strether

        “If you own your own medical data, and it is stored in an open source or common standard format….” BWA-HA-HA-HA-HA-HA!!! Stop it, you’re killing me!

        [wipes tears]

        * * *

        Of course, we can never do that because markets.

        1. hunkerdown

          Right. Taxonomies of billing codes are apparently just on the wrong side of Feist, luckily for the AMA. Too bad about public coding schemes like ICD-10 and its follow-ons that could be implemented right now if it weren’t for CMS siding with the rich kids’ union.

    4. Lafayette

      Nonetheless, here in France, when I wanted a medical file from a dentist, I had to wait for it to come in the mail.

      France has a fine law that protects civilians from the disclosure of personal financial/medical information – but if you walk into any hospital here, you will find the medical equipment of 1990 state-of-the-art. Why?

      Because everybody here is waiting, as the did when electromagnetic scanners that came on the market in the 1980s, for the government to buy them for hospitals.

      And today, the French government is broke.

      1. Lambert Strether

        I’d rather have dental treatment in Thailand from paper records than dental treatment in the United States with electronic records, and not only because of the arbitrage, but because I prefer to be treated as a patient, as opposed to being processed like meat, because I don’t like being ripped off, and I don’t like pain. YMMV.

        1. Orthomama

          Dentistry, except for Medicare claims (very few), has thankfully been left out of the EHR mandate for the time being, High volume Medicaid dental billers (many are corporate and/or serious scammers of the program) are eligible for incentive payments if they implement the EHR as well as complying with meaningful use.

  2. Middle Seaman

    Improvement and evolution of health care cannot and will not take place without EMR. Apple didn’t start with the iPhone. Of course, it would be beneficial to have EMRs exchange data, but a free software market does start with agreed upon data formats. There will be many awful products and piles of wasted money. Still, the move to electronically record health care benefits all of us in the long run. Even the opposition and doom sayers are expected and helpful.

    1. Nathanael

      There are no agreed on data formats, so this isn’t useful at all.

      An agreed on standard for electronic medical data would have been useful. That was NOT done.

  3. LAS

    Actually there is quite a lot of evidence suggesting EHR is a better strategy, although much of the evidence is based on implementation in other countries. Electronic records SHOULD help us achieve accountability because there will be a record trail for real evidence based research of procedures versus outcomes. Additionally, healthcare providers can better collaborate/check up on complex cases to keep persons out of the hospital with timely interventions.

    That vested stakeholders in the US may be able to corrupt virtually anything is another story and we should not let it dissuade us from what needs doing. Stakeholders want consumers to hear only select marketing, not outcomes based info that points up how expensive and ineffectual many procedures are and how you might be better off not using them. I think we need to hang in there and make the EHR transition even as vested stakeholders try to corrupt the execution.

    We are cynically taught to distrust the Federal government by major stakeholders claiming that government is subject to influence from vested stakeholders, even as they collect tons of federal dollars from the government (Medicare, Medicaid, etc.) as stakeholders. It is perhaps the most cynically argument of our time. However, as I see it, the government is less the problem for most of us than the market forces and their propaganda (not least the AMA). As the biggest financier of healthcare and primary fund provider of residency programs, etc. – the federal government has a right to demand greater accountability from the corporate/industry beneficiaries. It has every right to “means test” these affluent beneficiaries of federal dollars.

    1. Gerard Pierce

      The federal government is often the source of the problem. Years ago, I was invited to bid on some improvements to a system that tracked donor organs. The system had a very limited proprietary reporting subsystem. The developers of the system had no problem with giving me access to their system because the documentation requirements guaranteed that if I had developed a significantly better system, the government would not allow me to sell it without documenting the system and ALL of the components used to support the system. This was a stack of paper about three feet tall.

      The federal government guaranteed that no one would be able to compete with the existing crappy system and the existing client could not make any improvements at a reasonable cost.

      This was about 20 years ago and I suspect that in today’s market, the problem has not been solved, it has most likely been made worse.

    2. David Lentini

      You can’t divorce the federal government from industry the way one could decades ago. Industry and government bureaucrats have taken the military-industrial complex as the model for action. This is especially true in high-tech areas, where there is a lot of military and big science experience. Just as we see with Common Core and its huge requirements for collecting and using Big Data, the government is often driven by industries trying to create a mandated market for their products using the police and taxation powers of the government.

    3. Yves Smith Post author

      I don’t know how many times I am having to say this in this post. You have either not read up on or are in denial about the state of play. I suspect you have never have dealt with a failed large scale IT implementation. I’ve seen them at a distance (they happen often on Wall Street, but they can generally bury the bodies without the wider world taking much notice).

      There is no way to fix lousy IT. The only remedy is to scrap them and start over. That is NEVER NEVER NEVER going to happen with 5 years of Federal spending on this matter. No amount of patching is going to fix bad design, bad definition of data fields, IT processes that don’t map well onto underlying routines and procedures. This is like trying to build more floors on a building sitting on a bad foundation. It will not make matters better.

      See this comment for more detail.

      1. Nathanael

        The IT systems will be scrapped and they will start over. It always happens with every lousy IT system.

        Unfortunately, it won’t happen until the people involved in implementing the crappy systems have retired or quit. That’s how it works, culturally speaking. So we’re in for a couple of decades of crap.

      2. skippy

        Some advanced military aircraft have the same problem, projections for full operational capacity are around 2023.

        skippy… all that matters tho is they look sexy in the hangar or on the tarmac, scares the crap out of the bad guys…..

    4. Lambert Strether

      You write:

      [R]ecords SHOULD help us achieve accountability because there will be a record trail for real evidence based research of procedures versus outcomes.

      If indeed the EHR coding is a taxonomy of billing codes, and not a taxonomy of diagnostic (let alone narrative) data, is there any reason to think EHR will be useful in improving medical outcomes?

      I understand that a billing taxonomy will be useful in improving financial outcomes for the owners/users of the taxonomy, but that’s not the question I asked.

  4. Skeptic

    “It’s not hard to see that this is an enormously expensive exercise relative to the promised gains in billing efficiency and in catching cheaters. Even before you get to loss of doctor productivity or the harm done to patients, this IT boondogle doesn’t remotely pass muster as an investment to lower costs. ”

    I live in a rural area where there are a few cattle farms and small butchering operations. A few years back, the government tried to implement expensive regulations on the butchering operations. Many folks felt this was just to drive them out of business. WIthout them there would have been no small cattle farms, since they would not be able to process that meat. All to the benefit of the huge industrial cattle feed lots owned by conglomerates.

    Thus, I suspect also it might be with IT-Doctors. Make the regulations so onerous and so expensive that Doctors cannot profitably operate alone and thus become scalpel fodder for the Healthcare Racketeers. A cheaper and captive labor force.

    This is a 1% strategy devised by Armies of Lobbyists and Quants that is also at work in all other industries. Examine your own field of work for this.

    1. Orthomama

      Exactly. Why do you think the ranks of private practicing doctors are shrinking and the doctor employees of hospitals and medical chains are growing? EHR is part of that reason, along with Juneau’s example of payment schedules that pay large groups more than private docs.
      And don’t even get me started on the ‘facility fee’ that hospitals and hospital based doctors can change just for being tied to a hospital.

  5. Katniss Everdeen

    “The driver for proliferation of this ‘dead end’ is the government being willing to fund its expansion with their fervent hope that it will be their magic bullet for finding the cheats and cheaters of Medicare….”

    If the government is so “fervently” looking for Medicare cheats, they should start with the fetid Frist family and its evil spawn Bill, former majority leader of the Senate, and once mentioned as a possible presidential candidate.

    Or they could take a look in the Florida state house at the governor, Rick Scott. You could probably find him at one of his campaign offices. Having suffered no apparent reputational ill effects from his participation in the largest Medicare fraud ever as CEO of HCA, he’s running for reelection. In a state that has one of the largest populations of Medicare beneficiaries.

    No EMR or even much detective work required.

  6. John

    The concept of electronic health care records has been around for some time and the US government DOES have several good implementations. Look no further than at the VA and DoD. Soldiers use to have to carry their records every where they deployed. No longer. Military doctors can pull up a soldier’s record in the middle of the battle field, right on the computer. Records are updated in the computer logs without a single piece of paper.

    Since 2009, Obama has pushed to get the rest of the country to e-record keeping. The problem has been many vendors (a.k.a Wall Street) have lined up to get in the action, even when their platforms are not proven nor interoperable.

    The other problem is the government relies entirely on the private sector for policy and system design. A case in point was the roll out of the website. True to form Obama did not put any effective government CTO in charge to run the program. Instead, he commissioned several clueless government hacks appointees to oversee the deployment, which proved to be disastrous.

    As proven by DoD socialized medicine, the technology is effective in reducing paper trails and it is available where and when you need it. However, deep down we know we cannot expect such a thing for the rest of us. No, no, no! Instead, we’ve come to expect Team Obama to do their best at screwing it up to the benefit of Wall Street fat cats.

    1. Eric Sabety

      I wish I could agree but the DoD system is an example of the problem. It is designed basically to bill even though the government does not bill. The records storage function of any EMR system is good and better than piles of paper but one does as well simply using for that and nothing else.

  7. worker-owner

    Great comments, all, so far. The problem of intentional occultation of data-formats and the erections of barriers to interoperability is one of competitive strategy and delusions of dominance. At some point, The Money recognizes that the market is largely saturated, that groaf is really a zero-sum game (not a high enough hurdle rate for Wall Street and SiliValley VCs to throw gobs of money at) and the pressure in the balloon starts leaking out. At that point, folks start tearing down the competitive walls and standards emerge (for the faithful, think SAML, LDAP, and HTTP). Unfortunately, because of The Money and its enablers in DC, HealthCare is a groaf market in which lots of ambitious people think they are going to be the Bill Gates or Larry Ellison. IMHO, as it is not exactly a “Green Field”, disappointment sets in sooner, not later.

  8. ep3

    at first, to me someone that has a lot of drug allergies, medical records would greatly help because every doctor i see i have to recite every drug i am allergic to, which is a long list.
    But, what I see in this is data mining. The ability of the central medical records database to sell the data to drug makers who can then hire advertising agencies to market drugs to certain ppl. Good data mining would give doctors and researchers the ability to use the data to make better drugs and cure diseases. But this is always about the money. And the money is better in selling drugs and medical equipment.

    1. Jim Haygood

      ‘What I see in this is data mining. The ability of the central medical records database to sell the data to drug makers …

      Me too. Look no farther than Nasper, a national prescription-drug database which spies on us all, while allowing insurers and spooks to infer what ailments we may have from the meds we take.

      Monkey-wrench the Database State: give them scrambled SSNs; order meds from overseas.

  9. McMike

    Strikes me, as commenters said above, the theoretical benefits of better universal health records are significant, in terms of productivity, avoidance of errors, efficiency, and rapid response. Not to mention billing and fraud tracking.

    I go into the doctors offices and it is painful to go through the paperwork, over and over each visit and for every doctor. It screams the need for improvement. The only thing worse is ticket counters at airlines, where I am certain the agents are doing their hundreds of key strokes just for show. Surely these major industries can afford to get some slick software. Oh, and banking, working with a bank officer is beyond painful as they toggle from screen to screen (my god, is that a green screen crt mainframe terminal?)

    Anywho, given the proliferation of insurances and health care laws and doctor firms and specialties, it sounds like a nightmare.

    That said, it is my experience that crapification is fairly rampant in most aspects of software and technology. Surely medicine has no monopoly on that.

    1. Jim Haygood

      This painful, redundant paperwork is required by HIPAA, an earlier (and conflicting) federal law.

      Another federal law requires every water supplier in the U.S. to snail-mail an annual water quality report on paper to every customer, every year. Sometimes I forward it to my KongressKlowns for recycling, since they’re the ones who cluttered my mailbox with it.

      And so forth. Maybe the fedgov should just stay the hell out of our lives.

      1. McMike

        Well, my understanding of HIPAA was it was motivated to protect consumers from careless and invasive privacy attitudes by health care providers.

        In this case, the government got in our lives because the private companies were already in our lives and not being very neighborly. Of course, that was back in a magical time when the government occasionally acted in a way that could be construed as in the public interest.

        Besides, at the doctor’s, HIPPA is just one form that I sign without reading. Takes two seconds.

        The really onerous forms are the medical history, name/address/insurance info, etc. Which you must fill out every single visit to every single doc. And if I go to a primary doc, and then a specialist for the same complaint, guess what?

        Privacy concerns aside (which are substantial) I would not mind never filling out my history or name/address again.

    2. Lambert Strether

      My understanding — health care mavens please correct me — is that the EHR coding mandated by the Feds is for billing. Is there a reason to think that a billing taxonomy for disease would map cleanly to a health care taxonomy of disease? I’m guessing there’s every reason to think that an “impedance mismatch” between the two is quite likely.

      1. McMike

        A microcosm for the entire Obamacare genre: take a good idea (broader national care/universal health data), and then run it through the captive/crony corporatist crapifier, and what comes out is a simulacra of the putative intent.

        A system is sold under the banner of administrative efficiency, client care effectiveness, and ATGS, but what it really ends up becoming is a boondoggle for IT contractors, a Trojan Horse for data miners, and a bludgeon for utilization auditors.

        1. MaroonBulldog

          My new doctor wanted to give me a particular vaccination. I told him his predecessor had given me that vaccination a few years before, and I wasn’t due. A check of the billing records showed I was right. No way would the doctor have gone through the paper patient file to find that answer.

          So I conclude electronic billing records can mprove patient outcomes, to the extent they avoid redundant vaccinations.

      2. hunkerdown

        No, but it maps very cleanly onto an insurance taxonomy of disease: line items representing claims which can be (perhaps) mitigated by adding other line items.

        My reading of the Meaningful Use attestation worksheet seems to be oriented toward enabling recording of structured data which can then be mined: CPOE/e-prescribing, drug interaction alerts, allergy/Dx/Rx lists, demographics gathering, recording/presenting vitals, smoking status, implementation of a “clinical decision support rule” (basically, automation), ability to provide timely electronic copies of EHR to patient (for what that’s worth), clinical summaries for each visit (typically includes copy drawn from copyrighted databases), and security analysis/mitigation.

        There are a few other “menu” measures from which providers can choose to ignore some fraction of 10, including things like “drug formulary checks” (there’s your e-death panels!), checkup/follow-up reminders, e-registries for immunization (way to needle the far right, eh) and, as if they almost forgot, continuity of care.

  10. Eureka Springs

    One TRILLION dollars! There should be one code… and a scanner which simply turns any old paper records into a very simple universal digital file.

    The last time I saw my general practitioner he spent far more time with the iPad than me… An iPad which was between him and his patient for 99 percent of the time. I had to beg him to touch a lump in my neck …and beg him to wait long enough for me to practically rip my shirt off so he would simply inspect a mole on my back. All to be told as he was half out the door… go get insurance and I will refer you to a specialist. I guarantee you whatever he put in the pad was useless… not based upon me or my my health at all.

    That was over two years ago… upon reading this post I think the word Care is as poorly used in the title as the word Health. I also think that people should be able to see their medical records entirely… online. No permission needed.

    Why do we need every medical professional to be able to view our records when insurance companies and government are making sure there are actually very few medical establishments who can see/cover us? Why are we the people subsidizing over a thousand companies plans/verbiage/code… ensuring complete gibberish are our records.

    Nearly three years later I’m at least 15k ahead (not that i had that 15k) for avoiding these corporate ipersons like the plague.

  11. TarheelDem

    The Congress in its eagerness to health the private IT industry did not do what it could have done–push for free open-source software for medical professionals that automatically built in patient privacy protections and facilitated medical procedure studies.

    That didn’t happen because of “private-sector jobs” in the proprietary US software industry, especially the boutique medical IT synecures. That didn’t happen because of the need to be backward compatible with a complicated and arcane fee-for-service system that just has to be grandfathered in so large medical systems can use their micromanaging for bigger dollars reports to figure out how to game the system. That didn’t happen because making better medical results data available runs counter to the proprietary medical device manufacturers, the overpriced medical supply cartel, and the huge global pharmaceutical cartel.

    In addition to IT costs and medical equipment costs, most physicians can’t go solo easily because of losing the payment on their medical education that most large medical systems provice (“golden handcuffs”) and the necessity to set up their own billing and collections function because the the still complex billings to individual insurers, government, and patients (who get balance billed, whether they can afford it or not, meaning writing off a lot of revenue and pricing other charges to cover the losses).

    But most of all, the inability over the last 70 years of physicians to take chickens, vegetables, and furniture that fell off the turnip truck has meant more and more patients do not have the dignity of paying for medical care. So they go without. Until there’s a free clinic.

    I understand medical professionals’ poormouthing; there are a lot of good reasons. But too often the attacks on the government are self-serving, miss the role that cartels play in their financial stuggles, reflect unrealistic status and income expectations, and ignore the consequences that universal healthcare requires that healthcare be treated as a societal infrastructure with social transfers of risk and pooling of funds. And the physicians who are members of Congress put more thoughtful physicians at a disadvantage in arguing their case.

    We will decide to have better health information technology it seems when our betters have the mercy to give it to us. Otherwise, it is just a means of making a profit, patients be damned. Or in the profitized government sector, another means of social control of the lessers so they won’t get rowdy.

    1. hunkerdown

      The Congress in its eagerness to health the private IT industry did not do what it could have done–push for free open-source software for medical professionals that automatically built in patient privacy protections and facilitated medical procedure studies.

      You forgot about synergizing the action items! FOSS and software assurance don’t play well together. How are you going to prevent the circumvention of patient privacy protections in FOSS? How are you going to ensure the code that’s running is the same code as has been audited and certified? This is a problem that reaches all the way from Ken Thompson to Tor and as yet has found no satisfactory solution (though, Tor certainly is working on it).

      You’re right; the government should have just budgeted for a team of programmers to write a national standard EHR (I think Canada has one) for maybe $20 million, but what does that have to do with creating rental streams (aka fulfilling the public interest)?

  12. The Infamous Oregon Lawhobbit

    And let us not forget – putting things in electronic format makes it easier for those nice people in the NSA to access. Not that there’s anything wrong with that, right?

    Just sayin’.

    1. McMike

      Something tells me the NSA has already got a pretty good triangulation on our health concerns.

      But it will fairly guarantee that insurers are able to find ways to screw us in advance.

      1. Nathanael

        The joke’s on them — most of my medical diagnoses have been completely wrong, over the years. The records are full of crap.


  13. washunate

    This is a fantastic writeup Yves. Brilliant combination of the general challenges of implementation and the particular wastes in our healthcare sector.

    The fact that doctors – who are some of the most highly educated and well-paid workers in our entire economy – are helpless to stop such obvious crap does helpfully demonstrate how thoroughly rotten and unsustainable our institutions have become.

  14. Ernesto Lyon

    A product that the government forces people to buy, or that is deemed so critical ( e.g. prisons, national security) that the government must spend deeply on it, is a luctative business model.

    Enjoy your late capitalist decline.

  15. Ed S.


    Spouse has had a difficult to diagnose and chronic condition for 18 months with no (or incorrect) diagnosis; 4 months ago she decided that it was time to go to the local university teaching hospital (note well: not a for-profit hospital).

    I am AMAZED at the EHR system used. It’s simply incredible. EVERY physician, NP, RN, etc. has access to complete and comprehensive information. Dr. Smith can see what Dr. Jones and Dr. Brown did and concluded. All test results (including graphics, scans, pictures) are available on-line. All blood tests. All allergies (food, environmental, pharmaceutical). Information and diagnoses are shared and care is coordinated. Oh, and need a referral to another speciality? Done automatically.

    And the patient portal is comparable. YOU can see all of your test results as well. Have a question? Email and expect a response (a detailed response) from the physician or assistant within 24 hours. It’s absolutely comprehensive (although does not contain the case notes).

    W/R/T Medicare, my 88 year old mother was in and out of a different hospital probably 6 times in the year before she passed away. Virtually every time she went in, the attending physician replicated all of the tests that the prior physician had done (sometimes only a few weeks before). Tests that at the “rack rate” were $5k – $10k each. On one memorable occasion, I was called and asked to authorize a test (which would have been EXTREMELY difficult for her to tolerate). I asked the attending physician a simple question: Have you talked to the physician who has been treating her for the past THREE YEARS for this condition that you want to test? 10 minutes of evasion and double talk later, I said: So you haven’t spoken to the other physician, correct? The answer: No, I haven’t. (and I never heard from that physician ever again).

    While each individual seemed caring and competent, the organization was disorganized and chaotic – systemically. And jaw-droppingly expensive. One bill for 5 days (in a room, no procedures done, no ICU, etc – just in a hospital room) was $150k+ at the standard rate. And all billed to Medicare.

    1. Nathanael

      Which hospital has the functioning system? I’d like to know which hospital is is, so that I can tell the doctors I go to to USE THEIR SYSTEM.

  16. afisher

    In this particular case, I disagree with the author. Anyone who follows AAPS should know that they are a politically motivated conservative group who refuse most FED dollars – aka Medicare – or as they say on their Wiki: fighting socialized medicine. There are about 2K members – and if they don’t have to sign-up / bill for Medicare – which is faster via electronic billing – then why should they actually care about CMS IT or electronic medical records.

    EMR are not perfect, but neither is attempting to read a physician scrawl. When EMR were implemented at my public hospitals – DR’s grumbled and then got over it.

    I a really perfect world – patient’s should be able to request their EMR on a thumb drive and be able to take it with them on vacation, etc.

    1. Yves Smith Post author

      Ad hominem and also off base. The AAPS article was a write-up of the ECRI study, and ECRI is a respected organization. And ECRI found, based on a three month study at 37 medical facilities, that IT was THE biggest source of patient risk. And causes #2 and #3 had significant IT components.

      You need to get past your belief in technology and deal with the facts presented. And the author of the Health Care Renewal posts is no Luddite, he’s a heavyweight authority:

      Medical doctor, and Medical Informatics professional via NIH-sponsored postdoctoral fellowship at Yale School of Medicine. Expertise in clinical IT design, implementation, refinement to meet clinician needs, and remediation of HIT projects in difficulty in both hospitals and the pharmaceutical industry. Independent expert witness on health IT-related medical malpractice and related issues. Former Director of Scientific Information Resources and The Merck Index (of chemicals, drugs, and biologicals) at Merck Research Labs. Faculty, Drexel University, College of Information Science and Technology, Philadelphia, PA. Architect of Drexel’s Graduate Certificate Program in Healthcare Informatics.

      Your fantasy of what EHRs could be is not what is being designed and implemented. And there is no plan in the works for patients to get access and be able to carry their records around either. How many times do I have to tell you that this system is not being designed with medical care outcomes in mind, but with procedure capture and billing as its biggest driver?

  17. Lambert Strether

    Relation between EHR and ObamaCare. HHS:

    Reducing Paperwork and Administrative Costs. Health care remains one of the few industries that relies on paper records. The new law will institute a series of changes to standardize billing and requires health plans to begin adopting and implementing rules for the secure, confidential, electronic exchange of health information. Using electronic health records will reduce paperwork and administrative burdens, cut costs, reduce medical errors and most importantly, improve the quality of care. First regulation effective October 1, 2012.

    Whenever you hear “reducing paperwork” you can be sure that’s not what’s going on.

    1. TarheelDem

      “Reducing paperwork” means only (1) I don’t want to have to keep buying reams of paper and file folders; (2) I want to downsize staff who are recording and filing records because the “professionals” are too busy to do it; (3) Our physicians have difficulty reading each others’ writing and sometimes their own but can follow their own logic and have a little memory of their own patients. Forcing handoffs and records that lawyers can read might lower malpractice risks; (4) My son-in-law is a salesperson/IT person/programmer for an established/startup medical records outfit; this looks like a good match for this healthcare organization.” They all are about reducing various kind of paperwork.

  18. Nero Pasternack

    The government’s financial incentives accomplished the following:
    1. PRODUCT PRICE – They inflated prices for HIT products and services by creating artificial demand for them.
    2. ADOPTION SPEED – They sped up the process, resulting in hasty adoption of solutions that were not ready to improve clinical care. The differentiation between competing products all but disappeared, as rising water lifted all boats, good and bad, resulting in much malinvestment in crappy IT systems that will have to be replaced with other, less crappy systems.
    3. LACK OF STANDARDIZATION – The money was poured into proprietary software, which is not secure, cannot communicate effectively with other software (a large hospital will have over hundred proprietary applications and an unwieldy patchwork of hundreds of interfaces), and requires expensive maintenance, support, training,etc.
    4. TURNED CLINICIANS INTO COMPLIANCE CLERKS – A checkup at the doctor’s office is like a compliance session – she tells me less than what I googled while I waited for her, and spends most of the 15 minutes documenting our conversation in the EHR. Then sends me a bill for $200. WTF? Never do that again.
    Now don’t get me wrong – I think most of healthcare is an overpriced consulting service by middlemen who are protected by outdated regulations, with very negligible consumer protections (do I really need a prescription for an ounce of antibiotic eyedrops, when farmers are feeding it to poultry and cattle by the tractor load? And when in almost any other country, you can buy it over the counter for pennies?). Healthcare delivery needs to be commoditized by information technology – in the age of internet, there should be no reason to walk into a hospital unless you need an MRI, deliver a baby or you are coughing up blood (got flu? google it – the doctor’s visit will do NOTHING for you). EHR may be the step in the right direction towards that commoditization, just not the way it has been implemented so far.

  19. Ray Phenicie

    I see from the overall gist of this article that I can give up on my dream of having EMR instituted before I ride off into the final moonrise. I have had much experience recently with medical records, having been in acute care facilities about six times in the last year plus a ten day stay in a subacute (rehab) care facility. During all of this I had approximately three to five practitioner visits per month and many trips to the local pharmacy. More visits to lab and testing facilities than I care to recount were and still are also part of my monthly regimen.
    “One big problem is the dozens of systems don’t talk to each other, because the feds didn’t mandate interoperability before the rollout. . .
    So communication gains among hospitals, clinics and doctors offices aren’t happening.”
    This lack of record availability is adding to patients’ dissatisfaction, much of that comes in the way of costs; for example, my local Social Security office had to request paper copies of my medical records on top of the reams of paper I sent them. Reams that cost me approximately $350 in fees and postage. Fees were collected from facilities and practitioners alike although many professional’s offices did not charge. I had gone around with my employer on collecting my medical records to send to them for approval of my long term medical leave (six years) before Social Security did their schtick on me. Both have approved my status as disabled -hip hip!
    In the course of my care I was in two different hospitals and the last one could not see what the first one had provided in the way of care. The same is true of professional offices, I have a list of my medications and treatment plans (for prostate cancer) that I have memorized as I have written it to 10 or 12 different offices. The system for patient care is broken in this country; medical records are only one of several ways that shows up.

    1. McMike

      That couldn’t mandate interoperability; that would interfere with the free market. *snort*

    2. Lambert Strether

      Sounds to me like you’re becoming a “smart shopper,” Ray! Albeit retrospectively. But I’m sure you’ll be smarter next time! Remember: When you enter a hospital, it’s just as important to manage your financial health as it is to manage your physical health! And so what if you’re sick?

  20. mellon

    Here are two studies which show that EMRs DO NOT SAVE MONEY OR IMPROVE THE QUALITY OF CARE.

    Woolhandler, et al. “Hope And Hype: Predicting The Impact Of Electronic Medical Records,” Health Affairs, September/October 2005; 24(5): 1121-1123.

    Himmelstein, et al “Hospital computing and the costs and quality of care: a national study,” Am J Med, Vol 123, Issue 1, Pages 40-46, Jan 2010

    Here is a new report:
    TISA versus Public Services: The Trade in Services Agreement and the Corporate Agenda

    This study examines the adverse impacts on public services and public interest regulation of the little-known Trade in Services Agreement (TISA), quietly being negotiated in Geneva by a group of 23 governments, including Canada. Researchers Scott Sinclair of CCPA and Hadrian Mertins-Kirkwood from the Institute of Political Economy at Carleton University highlight how the TISA would make it difficult or even impossible for future governments to restore public services, including those instances where private service delivery has failed.

    The study also discusses how the TISA talks affect vital public policy issues only peripherally related to international trade.

    Despite disturbing revelations about spying and privacy, corporate interests are seeking to weaken national controls that protect data privacy.

    Even after the 2008 global financial crisis, the TISA includes talks to further liberalize financial markets.

    The TISA also promotes the temporary movement of professionals and workers, and in committed sectors would eliminate the legal onus on employers to hire local workers if they are available.

    The report stresses the importance of greater public disclosure and accountability in these secretive treaty negotiations.

    The report was commissioned by Public Services International, a global trade union federation representing 20 million public sector workers in 154 countries. It is available in English, French, German, Japanese and Spanish at

  21. MaroonBulldog

    The government spends $1 T on new IT to prevent and detect fraud and waste: absurd on its face. How much of that $ 1 T was wasted or fraudulently converted? All of it maybe?

  22. Mel

    “If you own your own medical data, and it is stored in an open source or common standard format….” BWA-HA-HA-HA-HA-HA!!! Stop it, you’re killing me!

    [wipes tears]

    * * *

    Of course, we can never do that because markets.

    There have been efforts besides the usual tentacular vampire squid ones. Rather successful one up here came out of the McMaster University Medical School.

    seems to be the most friendly introductory page. I hadn’t looked at it for a while, and the entry page has morphed to a slightly scary bureaucratic thing aimed at keeping some hard-won certifications. But yeah, owning ones own medical records is a thing, and there are places where it exists.

    Yes, Industry is really, really interested in generating momentum in a different direction.

  23. financial matters

    Just as one persons anecdotal experience from reviewing medical records for over 30 years there is no question that the EHR is very helpful. Previous medical records were a joke. Bad handwriting and insufficient documentation.

    Now if I need to review a record for pertinent patient care there is a much higher chance that I will be able to retrieve useful data.

    And yes many physicians don’t like it. It takes more time and people can understand what they said which is not always what they want. :)

    1. Nathanael

      The problem is that current EHRs are mostly just as bad as the previous handwritten records, and in some cases worse. For this we are spending money?

      A few hospitals are implementing things well. Mayo Clinic, I am told, is implementing a good system. Most places are implementing crap.

  24. Jim in SC

    I think the government has a two track mind in trying to find Medicare and Medicaid reimbursement abuse. On the one hand, they think that electronic medical records will allow computerized screening that will out abusive re-imbursement practices. On the other hand they’ve allowed Medicare and Medicaid HMOs to clawback payments from doctors pretty much at will: payments for procedures that are standard of care, which physicians have to perform if they want to avoid liability for not following standard of care. If a physician doesn’t like it, they have to appeal the clawbacks one by one. The clerks to whom they appeal may or may not be high school graduates.

    Who would become a doctor today?

  25. Steve Z

    Nice post, Yves. You captured some of my frustration and disappointment.

    I am a physician who uses Epic, a very commercially successful and, I think, “highly rated” system. (Think 800-pound gorilla.) In my opinion it is awful. It is buggy. Its UI is terrible. It is so NOT interoperable with other systems; it is not even interoperable with itself. I have used versions from two large health systems (we used a resold version from one health system and were bought by another). Transferred notes looked like unformatted word clouds. Med lists, I was told, could not be transferred at all. I was told Epic did not endorse that type of transfer, that it would be at risk of errors. So instead, our lowest paid clinical staff were paid overtime to rebuild the lists manually. Lots of human error ensued. The Feds have a standard for drug identification called RxNorm, but somehow no one mandates that EHR vendors use it or other standards. EHR vendors get CCHIT certified by demonstrating they can perform some basic interoperability tasks, but they cannot do these tasks in real world situations.

    We have building codes. We should have federal “building codes” for EHRs based on open source software and true interoperability. Switching costs keep us stuck with crappy systems. Data should be easily transferable. Vendors should compete on training, implementation, support, customer service, and UI design, but not with proprietary file systems and databases. We should have networks that communicate between health systems regardless of which EHR product they use. EHRs need to focus on improving quality. As others have said they focus on documentation purely for the purpose of reimbursement (based on a messed up scheme that has not been revised since 1997, but that is another rant).

  26. Gadema Quoquoi

    I remember in the early 80s, there were people talking about employees pllaying games with Word Perfect. That employees were waiting thier employers time.

    Word Perfect increased employess’ PRODUCTIVITY.

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