Ordering in Swahili at a French restaurant in Seoul

Bill Gardner at the Incidental Economist laments the state of electronic medical records today and contrasts it to a vertically integrated data exchange system that he used last week.

 the car has been worked on at several dealerships in several cities. And of course, I have no clear memory of what I’ve gotten done when.

No problem. The car has a VIN number. Dealerships are independent enterprises, but Toyota has an international database that has all the service records from all the dealerships. The service manager and I are looking at the records in seconds and we quickly make a decision about the needed service.

This is interesting only because I can’t do this for my body….

The engineering and legal work required to make electronic health records interconnect is harder than the engineering required to connect Toyota dealerships. Nevertheless, it is seriously stupid

I was able to speak with a medical informatics person for a while about this post and what she said was that right now most electronic medical record (EMR)systems are pretty good within their own silo. If you, as a patient, stay within one EMR ecosystem, the results are pretty decent.  Providers can see trends, they can see case notes, they can see allergies, and they can see any idiosyncracies about your medical history fairly easily.  Too many of the systems are still mainly focused on data management and not provider-patient interaction or even provider-computer interactions so too many appointments have the doc looking at a screen too much.  However, the back-end of any individual system on the market that has more than a couple major hospital groups using it is reasonably solid. 

The problem arises when you as a patient switch between environments.  If your primary care provider uses System 1 and your cardiologist just got bought out by a hospital group that uses its own in-house EMR system, the odds that those two systems will talk well with each other is slightly better than a Swahili speaking customer getting a perfect coq au vin in Seoul.  It is possible, just highly unlikely, that the righ set of crosswalks and translation protocol will be in place between the two systems.  Some of the larger systems will have rough translation protocols in place between systems, and there are developmental efforts to put a translation layer above a variety of EMR bases, but those systems are not widely deployed.

The big problem is simple for Toyota.  They keep everything vertically integrated and they make it a requirement that all the dealers in their network buy the same piece of software with the same protocols, the same data dictionaries, and the same agreed upon sets of meaning.  From here, it is just a nasty database management problem, and realistically, it is not too nasty as there is a unique key (the VIN) that already has external meaning.  EMRs in this country don’t have shared meaning, they don’t have shared data dictionaries, they don’t have shared formatting (for example,how do you write a date, as I can think of at least seven valid ways, three of which produce major screwups in other format systems), and they don’t share the same protocol. 

The VA gets around this problem because they are effectively in the same boat as Toyota.  Kaiser gets around this problem as they are a mini-NHS segregated from most of the US medical system.  Big players that own their own hospitals, doctors and insurance companies get around this problem as they can keep most of their patients in the same environment.  But crossing networks and getting the systems to talk to each other is an ugly problem.

73 replies
  1. 1
    Xantar says:

    Is this the kind of thing government regulation could address or is it so complicated that the only real solution is single-payer?

  2. 2
    Squiregeek says:

    Like the VA, our military is making great progress. When my wife was an air force physician, she treated returning troops at her stateside hospital. Long before arriving, their medical records were already on hand. Made it a lot easier to respond efficiently and appropriately.

    One of the many failures of our health care system was not requiring a common ‘language’ for medical records. Just as we are able to access all kinds of data from our browsers (because the protocols are fairly well standardized), so too should medical records have been required to conform to a common format.

  3. 3
    Jerzy Russian says:

    Kaiser gets around this problem as they are a mini-NHS segregated from most of the US medical system.

    What is a NHS? Given that, I can figure out what a mini-NHS is.

  4. 4
    Steeplejack (phone) says:

    @Richard Mayhew:

    “Informatics,” not “informatatics,” and “protocol” throughout.

    Great post, no need to detract with sloppy trim work.

  5. 5
    Barry says:

    @Jerzy Russian: National Health System

  6. 6
    RSA says:

    Too many of the systems are still mainly focused on data management and not provider-patient interaction or even provider-computer interactions so too many appointments have the doc looking at a screen too much.

    I’ve been in academic and industry meetings about medical informatics, and God is it complicated. Beyond technical issues, those participating in the process don’t even always have the same goals. A few anecdotes:

    I was talking with AllScripts about potential research collaborations for future interactive systems targeted at physicians. I outlined a system that would make it easier for doctors to explain to patients what was going on with their illness and treatment in a specific area, and after a while the rep told me, “Every minute a doctor spends with a patient is money out of his pocket.” They wanted to focus on more efficient use of doctors’ time rather than on the patient side.

    I was in a meeting a while ago with IT people and physicians. The IT people were all about the details of data management, while the physicians were interested in having good access to relevant information; most of the time it seemed to me that they were talking past each other. At point point the subject of patient-centered medical care came up (I might have the terminology wrong, but the perspective should be clear), and one of the doctors said, “We tried that and it didn’t work.” WTF?

    I should also add that I’ve talked with a fair number of doctors who think their hospital IT systems are ungainly monsters from which it’s very difficult to get the right information.

  7. 7
    Steeplejack (phone) says:

    @Steeplejack (phone):

    Also “indepedent” and “for instancy.”

  8. 8
    Richard Mayhew says:

    @Steeplejack (phone): updated, and thank you

  9. 9
    Tommy says:

    @RSA:

    I was in a meeting a while ago with IT people and physicians. The IT people were all about the details of data management, while the physicians were interested in having good access to relevant information; most of the time it seemed to me that they were talking past each other.

    I made my living by being able to understand and talk to IT folks. Then walk back to non-IT people and explain shit. I don’t mean to build myself up but kind of a rare thing.

  10. 10
    raven says:

    I got an “apology” letter from the VA last week telling me they were sorry it was taking so long to process my claim.

  11. 11
    Starfish says:

    @Xantar: Possibly. Government could create an API and say “This is the information that all of these systems have to communicate with each other.”

  12. 12
    RSA says:

    @Tommy: In my experience it’s a rare thing as well. IT culture is partly the problem. I can’t think of any other area where non-experts are so often called stupid simply for not knowing what to do, often with a badly designed system.

  13. 13
    Jerzy Russian says:

    @RSA:

    “Every minute a doctor spends with a patient is money out of his pocket.”

    Christ, this is some fucked-up kind of thinking. So doctors who have exactly zero patients come to their office are rolling in the dough?

  14. 14
    cmorenc says:

    My wife, an ob-gyn physician, is a partner in a group practice that is currently transitioning through two of the big fundamental structural changes affecting medical practices generally:
    1) Electronic medical records – the learning curve is arduously time-intensive, even for folks as talented and experienced at guzzling and quickly sifting through high volumes of information as physicians are (which you have to be to make it through medical school). For the last three or four months, she’s been staying an hour later at her office than she used to, not because the hours the practice stays open for patient appointments has changed, but purely to stay caught up with properly entering patient info from exams etc. in electronic medical records. She’s progressively getting better and more efficient at it, but the irony is that all the physicians in her practice are finding the learning curve and time overhead of properly entering and maintaining electronic patient records is more time consuming, not less, than the old pen-and-paper method. This has to get better, and it is – I’ve noticed that finally, within the last month, she’s having to stay late to catch up the day’s electronic record=keeping a little less long, a little less often, but this is definitely at least a six-month learning curve to get to the crossover point where electronic medical records are more efficient and less time-consuming than the old manual way, from the originating physician’s viewpoint. There’s also the progressively growing efficiency benefit to her as a user of previously entered electronic patient records – the portion of patient records in electronic form is growing and she’s getting more skillful in using the system, which seems from her comments to just now be reaching the crossover point to being more efficiently useful than paper records.
    2) Her practice has joined a practice management group that negotiates network affiliations and rates with insurance companies, rather than doing this themselves. In theory, the better net reimbursement rates this management organization is able to negotiate with insurance companies will more than offset the %fee the management organization takes for its services – and fortunately, this seems to be proving out a few months into the arrangement after a relatively lean initial few months. Although this sort of thing existed pre-ACA, clearly the structural changes in medical practice and insurance flowing from the ACA are amplifying this trend.

  15. 15
    Anonymous At Work says:

    Well, as a recurring theme, the Obama administration has started us down the path, with HITECH (a HIPAA revision in their initial stimulus package) improving the incentives for electronic health record adoption by providers of all sizes. In 2008~2009, companies were slow to move away from their old system and to a new one for a variety (and some legitimate) reasons. That’s Stage 2 (HIPAA was Stage 1, getting uniform standards for electronic billing systems). Stage 3 will be providing incentives to unify medical records systems, not just for patient care but for big data projects, both research and quality improvement, as well (look at PHIS for example to see what pediatric medical centers are doing to unify their medical records for research and quality improvement purposes).

  16. 16
    Gin & Tonic says:

    A pet peeve: “VIN number” is redundant. The “N” in “VIN” stands for “number.”

  17. 17
    Ruckus says:

    @RSA:
    This sounds like the kind of thing that government is going to have to step in and set guidelines as there are too many players, each with their own agendas, to do it. And there is no real industry authority to handle it.
    On the other hand I do use the VA and while I think it is great that they have a system and that the docs do look at it all the time, it seems to be rather complicated to look up history. A huge amount of info is presented and segregated by subsystems, tests, operations, etc. But 2 months ago it took the doc quite a while to find my one operation which was just a yr ago. She had to look through my entire last yrs history to find it. The VA docs will/can take the time but that does cut down on the number of people that can be seen in a day. I want good care but I also want others to be able to get that also.
    So this needs to be concise, segregated by some protocol that presents info in a meaningful and useful way, fast, and universal. That’s a very tough order.

  18. 18
    RSA says:

    @Jerzy Russian:

    Christ, this is some fucked-up kind of thinking. So doctors who have exactly zero patients come to their office are rolling in the dough?

    I left out some context: There’s a view of medical practice (I’m guessing much more on the management and IT side than among physicians) that seems to be similar to patients being sort of an assembly line, at least in my interpretation. So if a doctor treats a patient and the patient gets better, that’s all that’s necessary. Explaining what’s going on is overhead, by this view.

  19. 19
    raven says:

    @Ruckus: I want fucking hearing aids! (:

  20. 20
    Ken says:

    (for example,how do you write a date, as I can think of at least seven valid ways, three of which produce major screwups in other format systems)

    At least six of those ways are in fact not valid (http://xkcd.com/1179/), and if the system is using them internally it is non-conforming.

    However what is more likely is that it’s trying to support several formats for input, which is almost guaranteed to cause problems. The input dialogs should be structured with separate year, month, day fields, preferably in that order to secretly train the primates humans users to follow the ISO standard.

  21. 21
    cmorenc says:

    Medical residents-in-training are especially burdened by the differences in electronic medical records at different hospitals, precisely because in many (if not most) residency programs, they rotate every several weeks to a different practice focus at a different hospital, and have the dual stress of both the medical learning curve of the different subspecialty practice area AND learning a different electronic medical record system. My older daughter is an anesthesiology resident in a major-city university program, and last year rotated through four different hospitals. The first week at a new hospital is especially stressful because of the extra overhead of becoming familiar with a new electronic medical records system, but she’s a fast learner. But apparently no one is a fast enough learner to be immediately facile with a new electronic records system.

  22. 22
    RSA says:

    @Ruckus:

    So this needs to be concise, segregated by some protocol that presents info in a meaningful and useful way, fast, and universal. That’s a very tough order.

    Amen to that. I don’t see it happening very soon, unfortunately.

  23. 23
    GHayduke (formerly lojasmo) says:

    I don’t know about all this. The Mayo Clinic couldn’t figure out I had a drinking problem, despite elevated liver enzymes, excess body weight, a fatty liver on ultrasound, and me being fairly forthcoming about my drinking habits.

    /grumble

  24. 24
    WereBear says:

    As a database professional, I can testify that moving the data from one system to another requires formatting and reconciling that is labor intensive… and so, never gets done properly.

    Then, kludges get written that grab most of the improper data, but not all, so they add another kludge.

    If they had just transferred the data properly in the first place, they would not need to write kludge upon kludge. But nobody listens to me. And the data lies there, getting sicker and sicker.

  25. 25
    different-church-lady says:

    No problem. The car has a VIN number. Dealerships are independent enterprises, but Toyota has an international database that has all the service records from all the dealerships. The service manager and I are looking at the records in seconds and we quickly make a decision about the needed service.

    NSA! PRIVACY RIGHTS! SPYING! WHO KNOWS WHAT THEY’LL DO WITH THE DATA!

    Last week a friend was telling me a medical procedure was held up by his new — repeat NEW — doctor sending some important paperwork to an address he had for about six months over twenty five years ago in spite of the fact that he had provided all the current info to them.

    Every single time I go to my own doctor, they can’t find my insurance information. For the first two years I had insurance they would bill me as though I did not. For years when I didn’t have insurance I would pay at the time of the visit and a month later a bill would arrive anyway.

    I have never experienced a business sector that is run as poorly on the administrative level as the medical field. If a cable TV company ran things that badly they’d be out of business in a year. Yet this is just par for the course in medicine. Why we accept it I have no idea.

  26. 26
    raven says:

    @cmorenc: We just had a big dustup at the local hospital:

    Former ARMC CEO and President James “Jamey” Thaw resigned in May following the dissemination of a letter signed by more than a dozen physicians affiliated with Athens Regional protesting the implementation of an electronic health record computer system the doctors called dangerous and a hazard to patients.

  27. 27
    different-church-lady says:

    @RSA:

    So if a doctor treats a patient and the patient gets better, that’s all that’s necessary. Explaining what’s going on is overhead, by this view.

    Has it not occurred to these imbecile-assholes that if the patient has a better understanding of whats going on in his/her own body, the odds of getting better go up significantly?

    Or is it just another case of MBAs fucking up everything they touch?

  28. 28
    Dave says:

    @raven: I got one last month. That’s apparently an improvement.

  29. 29
    Dave says:

    @raven: I got one last month. That’s apparently an improvement.

  30. 30
    Stella B. says:

    Things may have improved in the two years since I retired, but what a mess. The user interface was beyond difficult to use — and no, physicians are not computer fearing Luddites* — built with 1980’s style interfaces, not the right-click, left-click, “save”, “cancel” interface that everyone uses without thinking. The charts never get lost! However, extracting past history from them was a frightening requirement. Every “note” generated by the system was a seven page fest of boilerplate and redundancy. Want to see when a medication was first prescribed — hah! No, can’t be done, but billing and collecting productivity metrics for management is easy. We were never able to see the same number of patients after the introduction of the EHR that we were able to see before the EHR. The $2M system finally got scrapped and replaced with Epic (corporate motto “We suck less.”)

    * I was a software engineer who wrote code for a living prior to medical school.

  31. 31
    Violet says:

    If the guy took his Toyota to the Chevy dealership he would not have the same seamless experience. Same if he took it to the Honda dealership or the local repair shop down the street. Each of those might have records for his car for any work they’d done on it, but they would not be able to access the Toyota dealership database.

    That’s more similar to where we are now with our medical system. Within a closed system like Kaiser the records are available. Even with small practices the doctors keep records of your visit. But unless your GP and your Endocrinologist are in the same practice there’s no way to share records unless you specifically authorize it by filling out forms to have them sent. HIPAA laws prevail.

    For this to work for human medical issues, to put it in car terms the guy seems to want all cars to be Toyotas and the only option for repair and service is at a Toyota dealership.

  32. 32
    AnonPhenom says:

    Really? He’s using his car’s repair history as an analogy for his healthcare information?
    I’d be able to hear him grinding that ax from the dark side of the moon.

    Financial statements and tax returns maybe?

    Yer’ getting warmer!

  33. 33
    raven says:

    @Dave: A hearing aid or a letter?

  34. 34
    shelley says:

    Ordering in Swahili at a French restaurant in Seoul

    Sounds like a good title for a Duran Duran song.

  35. 35
    raven says:

    @Stella B.: There ain’t no other kind of history cept “past” history.

    pp

  36. 36
    Dave says:

    @raven: Letter in the past people would have no clue what the status was. So it’s sorta an improvement if you look at it a little skewed.

  37. 37
    raven says:

    @Dave: This is my first rodeo with them and I really don’t care about a disability rating, I juts hope for the aids. Supposedly if you were “in country” they are a cinch but, after the first test, they asked me to come back in 3 months to make sure it wasn’t an allergy!

  38. 38
    Commenting at Balloon Juice since 1937 says:

    The guvmint should not have made EMR a requirement without establishing an open standard that all the systems must comply with. Other industries/fields do this. I am slowly learning about Geo Spatial information systems and it turns out there is a consortium with a web site and everything. There are still some proprietary dominant vendors but there is also a rich ecosystem using the open standards.

  39. 39
    Shakezula says:

    There’s also the issue that your multilingual dinner order will not cause a HIPAA violation. It seems that the process of going electronic or shifting systems creates a lot of risk because you have more people with access to your information and it is being moved around, sometimes to the internet. That’s not to say it shouldn’t happen, just that it is one more reason a practice or facility might decide not to bother.

    And, to pick up on what other people have noted, if you want doctors to stop giving a damn immediately, give them information that has nothing to do with their paychecks or patient care. And their definition of “nothing to do with” is really broad.

  40. 40
    martha says:

    We are patients (customers?) who have come to fully appreciate EMR systems. Our providers have used the EPIC system for at least 10 years, given that we live in the city of its founder and corporate home. I guess we (and they) were the early adopters (aka guinea pigs). A medical emergency in a far away state a few years ago was made so much easier when we learned the ER used EPIC. My DH’s condition was treated much faster because the Doc could immediately access his records and decide which course of treatment made sense. On the privacy question, I have no expectation of privacy. But I had none before EMRs either. I’m cynical that way.

    I think Kaiser is an EPIC customer. Not sure about Mayo.

  41. 41
    Stella B. says:

    @raven: “history of the current illness” vs. ”history of previous illnesses”. It’s jargon.

  42. 42
    martha says:

    @Commenting at Balloon Juice since 1937: Great point. I think part of the problem is, I know that at least EPIC was founded in the early 1980s I believe. So well before most envisioned the need for EMRs or the value of open source coding. Hard to put the genie back in the bottle I think.

  43. 43
    JCJ says:

    @raven:

    There ain’t no other kind of history cept “past” history

    True, but a patient’s past medical history is different from their family history

  44. 44
    RSA says:

    Long excerpt from a book I wrote a couple of years ago. Things may have changed in the past decade, but I suspect not enough.

    From 2002 to 2004, Ross Koppel and colleagues studied a system for hospital personnel to enter orders for medication and to track when patients receive their medication. The goal was to reduce errors with a system that puts relevant information together and makes it easier to access. We can assume that such a large-scale system would be built using the best software tools available. What could go wrong? Here’s a sampling.

    The interface for looking at the information for a specific patient makes it easy to choose the wrong patient. Patient names are listed in alphabetical order for the entire hospital, not grouped by hospital unit. The names are small and crowded together, to show more information on a single screen. Once a patient is selected, their details are shown on a new screen that may use a different size and color for the text, and the information doesn’t always include the patient’s name.

    Seeing all the medications prescribed for a patient can mean looking at up to 20 different screens of information. Doctors and nurses can be uncertain about the medications and dosages for a patient. This makes it possible to enter incorrect, duplicated, or incompatible prescriptions.

    Some kinds of information can’t be entered into the system, such as specialized tests to be run before a medication is given. For other kinds of information, the system is too flexible. A surgeon performing an operation late in the day might note that the patient should receive some medication “tomorrow at 7:00am,” but this information could be typed into the system much later, by another doctor, even after midnight. The medication would be delayed by a full day.

    Some information is stored in several places, in the system as well as on paper charts and paper records; making sure that all the information is consistent takes extra time.

    Some information is simply confusing: the system might display a drug as being available in 10 milligram doses, leaving it ambiguous whether this is the usual dosage or the units in which the pharmacy stores the drug.

    The hospital system also crashes several times a week, leaving doctors and nurses to work without its help.

  45. 45
    raven says:

    @JCJ: see, there is an exception!

  46. 46
    Violet says:

    @Commenting at Balloon Juice since 1937:

    The guvmint should not have made EMR a requirement without establishing an open standard that all the systems must comply with.

    Yes. This. The way they’ve done it leaves it wide open to be a big mess. Which it is at the moment.

  47. 47
    Shakezula says:

    @Commenting at Balloon Juice since 1937: There are meaningful use requirements but that’s within the system. If you mean they should be able to communicate with one another you’re getting into the Most Anciente History of Medical Software Systems. It wasn’t uncommon for a doctor to create a system and share or sell it out right. When it looked like Medicare was going to make these systems obsolete, people did not respond well, so requirements had to be built around the existence of these one-off systems.

  48. 48
    JCJ says:

    @Stella B.:

    I had to use iCare for many years before the hospital system switched to Epic. I think because of this I am much more tolerant of Epic than if it was the first EMR I had used. I do like the fact that I can access records from other hospitals in the area.

  49. 49
    Pharniel says:

    The Automotive Repair Industry is coupled with the Automotive Insurance Industry and portability of data, particularly estimates, comes up all the goddamned time.
    It’s so pervasive that there is an industry group dedicated to creating a bedrock claim format – CIECA.

    Unfortunately like RSA found because it’s a ‘generic’ format that hasn’t been updated in 15 years (Version 2.6 is the latest supported by…well the industry as a whole. It’s at least got the option for ‘cell phone’, the more commonly implemented standard, 2.01, still only has ‘Work’ and ‘Home’) and each stakeholder has different needs for the information. And that’s without any sort of privacy regulations to worry about.

    It’s something that needs to be done but you’re going to have to wait for Medicare or someone with massive purchasing power to push it.

  50. 50
    Violet says:

    And then there are data breaches.

    Community Health Systems, which operates 206 hospitals across the United States, announced on Monday that hackers recently broke into its computers and stole data on 4.5 million patients.

    Hackers have gained access to their names, Social Security numbers, physical addresses, birthdays and telephone numbers.

    Anyone who received treatment from a physician’s office tied to a network-owned hospital in the last five years — or was merely referred there by an outside doctor — is affected.

  51. 51
    numfar says:

    @Stella B, I can personally attest to E pic’s motto.

  52. 52
    🚸 Martin says:

    The reason this is a problem is very simple, actually. Cars have a universal, unique ID. The VIN is almost universal. There are actually 4 VIN standards, but they are mutually exclusive and therefore as a set are unique.

    People have no such universal, unique ID. SS# is the closest we have in the US, and we’re not allowed to use it for this. We have recognized the problem and tried to solve it (which would also have given us a unique, free ID for voting purposes, etc) but the GOP thought it was the mark of the beast and that Clinton would use it to stuff conservatives in FEMA camps. Part of the anti-immigration drumbeat is that a national ID would be introduced so that Obama could track how many times you flush your toilet.

    So there’s little point trying to build a universal health care data system because such a system would necessitate a unique identifier, be it SS# or something else, and the GOP won’t stand for it. Better to keep everything keyed off of your insurance account number so that only your giant insurance company can track your every movement.

  53. 53
    Violet says:

    @Violet: And this:

    No industry has been hit harder by hacking and data breaches than health care.

    Recent numbers show 90% of health care organizations have exposed their patients’ data — or had it stolen — in 2012 and 2013, according to privacy researchers at the Ponemon Institute.

    The medical industry faces more breaches than the military and banking sectors combined.

    Why are medical records so attractive to hackers?

    Illegally purchased medical records fetch huge sums of money on black markets — about $50 a pop. By contrast, credit cards fetch $1 each — tops.

    Criminals can use medical records to fraudulently bill insurance or Medicare. Or they use patients’ identities for free consultations. Or they pose as patients to obtain prescription medications that can later be sold on the street.

    And data isn’t safe:

    Doctors and hospitals also rarely encrypt all of the data they keep on us. The federal health records protection law, the Health Insurance Portability and Accountability Act, doesn’t demand that hospitals and physicians use encryption.

  54. 54
    WereBear says:

    @Pharniel: Not to mention that what goes wrong with cars is a creature of standardized parts and hourly labor charges. We wish that were so with people!

  55. 55
    Shakezula says:

    @Violet: Oh don’t worry, they’ll steal paper records as well!

    The federal health records protection law, the Health Insurance Portability and Accountability Act, doesn’t demand that hospitals and physicians use encryption.

    This is another compromise between the ideal and what was going to happen. When people first started talking about encrypting devices, the cost was high, encryption was clumsy and providers were very resistant to the idea, especially for their personal electronic devices. For one thing, they didn’t see the breach as that big a threat, in part because of the way HIPAA was structured.

    So now the compromise is you don’t have to do it, but if you do encrypt and someone walks off with your computers, it doesn’t count as a breach. As the cost has gone down, encryption has become more user friendly and providers see that Holy Shit, people are stealing data left and right and I’ll be in trouble if it happens to me, more people are moving to it.

  56. 56
    sempronia says:

    @Xantar:

    It’s not a problem fixable by single-payer. As Stella B said, all the EMRs out there are already good at extract billing data – it’s obviously a major selling point for hospitals. But there’s no financial incentive for them to talk to each other; better care isn’t an incentive. There are a few exceptions though. When we moved to Epic (also known as EpicFail), the data from the old EMR got imported into Epic; somehow they were able to translate much of it over directly. Some of the older notes got scanned, but apparently they paid students at the U to type up other notes in Epic-friendly format, for $50/hour. Imagine brute-forcing your way through all the medical records in the country to get everyone on one system.

    Also, some hospitals in the same region on different EMR systems have info-sharing agreements. I’m not sure how they formatted things to make them readable by everyone else.

    Seems to me that Epic is on its way to majority status in this country, in terms of number of patients covered. Epic hospitals don’t share info now, but it seems possible that they could, fairly easily.

    There was so much belly-aching when the ACA required everyone to install an EMR, even though it provided major financial grants for setup (the redder the doctor, the more complaining, ha ha…). I would laugh so hard if single-payer and a new national EMR were simultaneously foisted on my red colleagues.

  57. 57
    Stella B. says:

    The difficult of communicating records between providers was an existing problem before EHRs, but the EHR designers did nothing to provide a method for merging non-system data into the record. In the system that I used to use, outside records showed up as a file with the data on which the file was scanned into the system. In order to find the colonoscopy report, for instance, you had to open every file in the list until you got to one that had the colo report. There was no way to search, no way to label the file “colonoscopy” or “Dr. GILuvMuny”. A patient with a significant, er, past history would have dozens of files, to open, l o a d and scan through.

  58. 58
    Jim says:

    Amen to the post. Every time I have to see a (new) specialist, it’s “fill out the forms,” which started out a few years ago at one or two pages, but is now more like a small book of forms. The doc’s office then has to *transcribe* the damn things. And after all that, nobody other than the doc, including me, can access the information. Each time I ask about it, I’m told that interconnectivity will happen “Real Soon Now” (that’s an old programmer’s expression for “it ain’t gonna happen).

    Same with my dentist, but at least I can fill out those forms online. Quicker for me, and doesn’t require transcription and the inevitable typos.

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    Steeplejack says:

    @Richard Mayhew:

    I sent you an e-mail, in case you don’t check your Balloon Juice address, or do so infrequently.

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    Southern Goth says:

    There’s a lot of stuff in here that’s just wrong.

    A certified EHR system does require some common exchange documents for example Transition of Care and Clinical Summary documents. A certified EHR system would be one that healthcare providers/organizaations can attest to “Meaningful Use” compliance.

    A “Stage 2” certified system requires an encrypted email system (at a minimum) to exchange documents between organizations.

    Healthcare organizations are not required to use encryption among internal systems. They are supposed to be encrypting data when exchanging or exposing data over the internet.

    There’s a lot wrong with the way that the Meaningful Use specifications have been written and the lack of guidance on implementing. But the basics are there.

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    jl says:

    thanks for another useful column.As I understand it, the horrible lag in integrated and efficient electronic health record system is fear of Big Brother and Death Panels. Any such system will be the last link needed to get soilent green really going in high gear. Yeah, that is the fear, where the information security and integrity of the private provider and insurance system has been rotten.

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    Southern Goth says:

    When I first read the title to this post, I thought Tom Friedman was guest-posting here.

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    JaneE says:

    @Jerzy Russian: Kaiser is a HMO – one of the biggest. It is just a miniature version of the National Health system in the UK. All Kaiser members have access to all Kaiser facilities (there are regions, mainly for admin purposes). Your primary physician plays gatekeeper to most specialties, but they have almost all of them available. Worst case is you have to drive about 75 miles to see the right specialist, which is really bad enough in Southern California, where I am.

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    Joe Frost says:

    I designed medical IT systems for living for 20 years. We do have a universal standard for data interchange, but each new implementation using HL7 was free to interpret the use and meanings of the fields as needed for the moment. We also had to deal with limitations on storage, so we cut corners where we could. There was money behind improving billing data, but it took stratagems and fast talking to slip in extra medical data.

    When I retired last year, we were working on merging data from all the historical databases of four medical centers and three of the current major vendors into one master database that can be searched for trends and improve patient care. The data from the different vendors is still hard to share smoothly, but it beats scanning documents and saving them as PDFs.

    Epic and the other major vendors are scrambling to help their customers comply with the Meaningful Use requirements that are the little-known part of Obama’s healthcare reform. The government put money behind EMRs by hooking payment levels to compliance with adopting the new standards. Suddenly, CIOs remembered that the hospitals have a medical staff, too. All the myriad of databases built by different departments to track the details they see as important are now surfacing and being fed into the Federally Certified database(s).

    One of the problems that we can look forward to seeing addressed is that the US uses a version of medical coding that the rest of the world translated away from years ago. It isn’t quite as bad as metric versus English units, but the conversion will be about as big a disruption in medical informatics as metric would be to the auto industry.

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    grrljock says:

    This is the classic complaint about the state of health IT and health informatics in the US. Yes, healthcare lags behind other industries in taking advantage of IT to facilitate operations, and many factors contribute to this lag. One is the complexity of clinical processes in healthcare (patient encounters, consultations, submission of orders, routing and visualization of patient results), another is the fragmentation of the field, which means most effort is put into making sure the right insurance company is billed for the right codes.

    VistA (the VA system) was started by far-sighted doctors who understood the need for electronic management of clinical data. It uses a very stable, but old, and not “sexy” code. Epic (a dominant player in the EHR market) uses the commercial version of the same code, so it’s very stable, but hard to write interfaces too. Epic is also notorious for keeping anything related to its EHR closed, adding to the complexity of any interoperability efforts.

    The EHR field faces the same market pressures as the general healthcare field in the US, so as much as government-imposed standards (EHR, interoperability, and data exchange) are a logical move, the environment is not conducive for that. Instead, through the HITECH act the government is offering a mixture of stick and carrot to first increase EHR implementation and adoption, then on to the next steps of exchange and interoperability.

    This concludes your intro to Healthcare Informatics.

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    JaneE says:

    @cmorenc: I am a Kaiser patient, have been since 1979. We have been through 3 system updates since that I know of. I also know one of the people who worked on the first one in the early 80’s. The first ones were the most painful – now everyone uses the computer terminals like a pro. I see benefits for patients and their doctors, over what we had when I first started. But I know that they have been actively working on developing an integrated electronic information system for at least 30 years. As a patient, it took at least 15 to see any results at all – the first benefits were for their doctors.

    As a retired programmer, I know how hard it is to get things right, especially so when going from one system to another. I have also been there when some of the most vocal complainers and frustrated users have admitted that they wouldn’t have been able to increase production, improve quality, etc – without the system. It just takes a long time and hard work from everyone involved.

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    Richard Mayhew says:

    @Steeplejack: Received e-mail, and I appreciate the help, your suggestion on predrafting makes a lot of sense.

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    Zifnab25 says:

    Finally, something I know enough about to make an intelligent comment on, and it looks like everyone else bet me to it. :-p

    Standards do exist, they’re just not all that great. We’re supposed to be moving towards health information exchange sites that shuttle data between providers on-demand, and these vendors should force the EMR developers to adhere to a tighter integration standard. But it’s a long, hard road. And we’ve got a long way to go.

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    mclaren says:

    Once again, Mayhew is spewing horseshit.

    The federal government could demand that all medical providers store data in a standardized record format using plain text (as in linux.) No fucking binary blobs. No fucking proprietary data formats.

    This is done all over the net in lots of other formats, like LaTex for scientific papers. If Mayhew is telling us this can’t be done for medical records, he’s either brain-damaged, drunk, or lying.

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    Van says:

    @Stella B.: We’re using the EPIC system at the hospital I work at. It’s far from perfect but overall a pretty good system. As much of a hassle as EMRs are they seem to be significantly better then leafing through huge mounds of paper records.

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    @shelley: Or title for a Thomas Friedman column. (Sorry, I see Southern Goth noted this already.)

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    Lit3Bolt says:

    “You will each be given an identity disk.

    Everything you do, and learn, will be imprinted on this disk.

    If you lose your disk, or fail to follow commands, you will be subject to immediate de-resolution.”

    End of line.

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