Title translation: the effort to create Electronic Medical Records (EMR) will be a lot bigger than the Y2K effort to make the world’s computer systems survive the arrival of 1 January 2000. Virtually everybody in the US will be impacted, and it will provide a treasure trove of stories about fabulous failures and super successes in the software industry.
If you doubt the truth of the title, consider two facts:
- The US government will attempt, and probably succeed, to control the EMR development and usage process.
- There is no 1 January 2000 – no deadline by which it has to be good enough.
What are the potential problems with EMR? Consider the amount of information about each of us that already exists. Consider just your credit rating. Personally, I think the major credit reporting companies do about as good a job of keeping accurate data as is possible today. Yet there are errors throughout the system, some caused by the deliberate actions of criminals stealing your identity, some caused by some inadvertent screw-up in the literally thousands of companies that send data to the credit agencies. A real universal EMR solution will have even more of your data:
- Much of your financial data allowing you to be billed or more likely just have your accounts debited.
- Information about all your insurance policies.
- Even more identity information than exists today.
- Plus all of your medical records, including test results, X-Rays, doctor visit summaries, ….
It will be a substantial increase in the data that the government, and all of those companies, has about you.
The Health Information Portability and Accountability Act (HIPAA) will become a joke. It will prevent your best friend from finding out how you are doing in the hospital, but will enable any aspect of the medical-insurance-government complex to freely access, and update, any of your information.
Since there will be thousands of companies and agencies that will need to access and update your data, this will have to be the ultimate Cloud Computing solution, with your data spread around the world. See my earlier blog on Data in the Cloud if this doesn’t scare you.
As an aside, we will need a real national ID card to make it work. A couple of decades ago I worked on a student records system. As we were doing some database maintenance, we found up to four different students sharing the same social security number. We guessed they were different because they had different names, genders, and birth dates differing by decades. We also found students with multiple social security numbers, or at least multiple social security numbers all referencing a person with the same name, address, gender and birth date.
There is a fascinating article from the Association of American Physicians and Surgeons (AAPS) titled “Myth 32. Information will improve efficiency and safety.” One of the main points is that EMR systems are inherently very complicated, and thus error prone and hard to use. Again, I suggest you read this article if you think this isn’t a very serious problem. One study reported in the Washington Post and cited in the AAPS article showed that more than one in five hospital medication errors were caused at least in part by computerized systems.
No problem. We’ll simply legislate that the system must be simple to use and increase efficiency. Back in 1897, State Representative T.I. Record of Posen county introduced House Bill #246 in the Indiana House of Representatives that pi should be 3.2, thus simplifying engineering calculations. Fortunately, this bill did not pass.
Personally I believe that EMR is a necessary part of a real solution to cost-effective medical care in the US. I’ve watched an older friend as she deals with a handful of doctors and a pharmacy. There are sometimes communications gaps that could be filled if they all knew what each other was doing. At the moment, the pharmacist has the best view of what she is taking and periodically issues warnings and suggestions. The pharmacist has access to all of her prescription history, and cares.
The AAPS article states a number of problems with using information technology to improve the medical delivery system. In some sense, I believe it is a little too optimistic. The short term (i.e., next 20 years) result will be that we will have a 100GB of medical data on every person in the US. That is except for the 10% which will have more than one set of inconsistent data, and the 25% that will have only 5% of the appropriate data. The data that is there will be about 95% correct, and hopefully the other 5% won’t kill you. This is a lot of data. If my estimate is close, the medical data for a thousand people will be about the same as all of the data in the Library of Congress in 2009. We won’t have any idea how to secure it, nor we will know how to make it available to the “right” processes and people at the right time, nor will we have all of the processes and procedures to do everything we should with it. Even if we get to the point that we solve those minor problems, we still won’t have enough data to determine if this particular John Smith will benefit from a treatment that has a 10% chance of success on average, or will be harmed by a treatment that has a 95% chance of success on average.
In spite of all of that, I firmly believe that we need to aggressively more forward with implementing EMR. According to a story I can’t verify, Napoleon wanted a main road to Paris to be lined with tall trees to shade the troops as they marched triumphantly back to the capital. Some colonel told him that it would take 40 years for the trees to grow to make shade. Napoleon said “Then you’d better get started immediately.” Whether the story is true or not, two hundred years later, the trees are still there providing shade.
The last word:
According to Wikipedia, the world wide cost of the work done in preparation for Y2K was over US$300B. The US government is expected to initially invest something on the order for $45B to encourage or more likely compel doctors and hospitals to use electronic medical records systems. This doesn’t count the billions private companies are spending already on developing their own components and systems, and the billions more that will be spent making them work together. If you are a young software developer looking for a career, I have one phrase for you: “Electronic Medical Records.”
Comments solicited.
Keep your sense of humor.
Walt.
Of course our current medical record situation is fraught with requirements to act without access or knowledge of existing medical information stored with another hospital, doctor, pharmacy etc. This brings a set of risks.
With the prospect (or probability for the foreseeable future) of an imperfectly implemented EMR system, we have a real risk our doctors will have ready access to erroneous or mis-information. I’m not qualified to assess the relative gravity of the two risks, but it seems likely the current medical profession has experience functioning with the risks of missing information. How quickly will the develop a practical set of procedures to act with potential false bravado.
Nice synopsis of the scope of this endeavor.
Walt –
There is just one small problem — the database, although not quite in the entirety of the EMR already — does exist. It’s called the Medical Information Bureau (MIB). MIB was started by — the insurance companies. Like a credit bureau, it keeps scads of information on you all of which is collected through those nice little insurance reimbursement codes that the doctor or hospital or pharmacy fills out. The insurance companies use this information to rate or deny life and health insurance.
Ask how many people know about MIB! It’s a very small number. I haven’t found a physician yet who knows what it does or even what it is. Why do I know about it? I’ve been in the biomedical field for a long time and have battled with insurance companies for people regarding rare diseases. But its extent really hit me when I was told by a life insurance company that I had had cancer — which I never did. None of my docs would ever say that I did. So, where did this information come from? That’s when I discovered MIB by being persistent and a real pain in the butt to the powers that be.
MIB will tell you that they are just like a credit-reporting agency. Yes, they do make mistakes, but you can have them corrected or challenged just like with a credit bureau — if you know the MIB exists; and insurance companies will not tell you this.
They will just tell you that the “underwriter” — some just-out-of-college-kid with a formula tucked into his computer — would not approve it. Ever try to talk to an underwriter? Kidnap the insurance company’s CEO and you might get there.
But they work on MIB data.
As you well know, where I went to school they taught us how to WIN not to lose. It was that attitude and train of thought that broke these characters down. First, I found out that I supposedly had had cancer. THEN I found out the MIB exists. HIPAA? It’s worthless now. You don’t need EMR. The MIB will only make expansion to the EMR so much easier.
I wonder if it’s just a coincidence that MIB can also stand for “Men In Black?”
Walt:
I enjoyed reading your blog about implementing EMR’s. Your words evoked several emotions, even a little anger and resentment as you tactfully presented some truthful arguments for keeping the government out of the development and implementation process and even questioning the need for EMR’s. I kept thinking about “throwing out the baby with the bath water because the water temperature was not perfect”. I believe that EMR’s are important to the future of efficient medical care and by the end of your blog I realized that you do also. In the world of medicine, not too many years ago (40 years or so) health care revolved around a patient going to one physician most of their lives for only major illnesses. The most important medical record was that physician’s memory. Most people self-medicated or just lived with what health status they were given by good or bad genes, happenstance or circumstance. Over these last 40 years, we’ve seen an explosion of preventive care science turn our world into a constant race for optimum health by preventing or minimizing the effects of diseases that used to kill us. This new norm creates a plethora of patient contact with a number of different physician specialists, each providing a treatment within the specialists own “medical vacuum” and each specialist providing some sort of intervention (since we have a medication or an herbal remedy for everything that we were once told to “just live with it”). Take my own situation. Last year I saw a family practice physician, an urologist, a radiation oncologist, a hand specialist, a dermatologist, an allergist and a pulmonary specialist that my allergist sent me to for my asthma. Most of these doctors treated me with either a procedure or medication, sometimes both. In a couple of instances, medications were prescribed that should not have been taken with meds I was already on. I knew that and identified the mistake. Most patients would only be able to identify those drug interactions if they were diligent enough to use only one pharmacy provider (and a conscientious one at that) for all their medications. Many patients don’t see the wisdom of that practice. Professionally, when I owned my infusion pharmacy, one of the usual and expected delays in starting a homecare patient on service was securing an accurate medical history on the patient. Chasing hospital staff or a family member for current medication information, drug allergies and pre-hospitalization medical history was a nightmare. Often chasing that information caused a delay of 3 additional hours before initiating patient services. Sometimes, as a last resort, we secured accurate patient data only when the admitting nurse arrived at the patient’s home. How frustrating it was to find some piece of medical information that would prevent initiation of service (and billing for what we had already done) and then have to chase the ordering physician for new orders. How nice it would have been to have had a central source of patient information to begin to develop a patient profile.
What I’m saying is that the world of medicine continues to move into disjointed pockets of medical care as patients seek to eradicate minor medical irritations from their lives and we continue to evolve into more cost-effective, non-institutional medical care. This reality produces isolated pockets of patient medical history that often don’t follow patients as they move into a new medical adventure, and this creates a danger for additional medical mistakes through decision-making based on incomplete information. EMR’s are a way of bridging that information gap. Part of that process will have to include a component of patient and caregiver education to emphasize that it is the patient’s right, and even their responsibility, to access their medical data to review it for accuracy. I was so pleased that our family practice physician has implemented an EMR process that includes a yearly physical and is recorded on a small disk that I can carry in my wallet as I travel. In an emergency, I know I won’t be able to remember all the medical specifics important to any emergency medical care. Am I concerned that EMR’s will compromise my right to medical privacy? In some ways yes, but in reality I have no medical privacy at present. In spite of HIPAA, in order to get my insurance carrier to pay my claims, I have to assign benefits and allow access to my medical history and current status. And, I know this information is already being used to establish statistical data at various levels. That has been happening for years. I would rather have some new, appropriate safeguards be included in EMR laws to prevent the insurance industry from using this information to cancel my insurance coverage for extensive claims, or to prevent implementing new exclusions to my coverage, as well as preventing any statistical data gathered from being traced specifically to me (such as through community-based outcomes analysis initiatives).
EMR implementation won’t be perfect in the beginning and it will be a slow process, as was HIPAA. It took years for the medical community to embrace that simple concept and it took a government mandate to implement. I remember my fear as I read what new tasks my company had to implement to assure patient privacy. Once I pushed myself and my staff out of our comfort zones and we developed a plan of action, I realized it was doable and not so monumental after all.
Walt, modern medical care is a complicated process and will continue to become more complicated as expensive new technologies and medications are discovered to treat and prevent the debilitating effects of age-related diseases for our growing elderly population. Lifestyle changes, preventive care, and central data access represent a core beginning to addressing these challenges. Will the private sector be able to develop and implement the paradigm shift required to contain the explosive health care needs of our population? I wish I had the answer to that.
Thanks for letting me pontificate, Walt. It was cathartic.
Nice blog entry and great comments. Instinctively, I know I don’t want the government anywhere near me or knowing anymore than they already know about me. I have visions of big brother scenario’s running through my mind and can’t help but think, ultimately, EMR will cause more damage than good. It only appeases those that think others can do a better job of managing themselves than they can do. Everyone needs to take personal responsibility for all aspects of there life, especially their health and assocaietd records.
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