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The Parable of the Wicked EMR

Preface by e-Patient Dave: This is a story of bad data gone wild, wrong info that spreads. It starts with a story from the 1600s, which applies all too aptly to our EMR situation today, in which there are inadequate controls on data quality, and errors that leak can be impossible to contain.

It was a scandal. In 1631 two London printers published an edition of the bible that omitted “not” from the seventh commandment. [It should have said “Thou shalt not commit adultery,” but it didn’t.] The public outrage over what was dubbed the “Wicked Bible” was loud and immediate. King Charles I heard about it, and was incensed. This simple mistake by print compositors landed their employers in the Star Chamber before the infamous Bishop Laud, where they were tried, found guilty, and fined 300 pounds. They also had their print licenses withdrawn; the fine was directed to be used to for a new set of print typefonts and to oversee new quality control practices to prevent such a mistake from ever again occurring in the future.

The episode of the Wicked Bible has historical importance because it demonstrated how the new print technology allowed printers to create “standardized” errors, something impossible in the scribal era when all books were the product of hand copyists. Textual drift – the result of small copyist’s errors in single books, which were then repeated in the next copy, and so on – was no longer possible, replaced by the textual fixity of print type. If printing presses could greatly lower the costs of producing books, and make them available to whole new classes of people to read, they were also capable of mass producing errors!

Enter e-Patient Dave. As we all know by now, Dave asked to have his hospital’s electronic medical record system upload his health data to his Google Health account, only to find that the diagnoses transferred were claims data that were largely unintelligible and meaningless to Dave, and some of the problems listed were downright inaccurate or false.

Wicked EMR! How is it possible that that such mistakes could be made? Not exactly the Word of God, but most people trust that their health information is accurately recorded inside the EHR technology of the hospitals where they are cared for and treated.
Plus, since insurance billing records are transferred to the MIB, an insurance industry database that insurers use to check patients for pre-existing conditions, errors in billing records can have serious effects, as the Consumer Reports blog reported last August. A truly wicked consequence of a propagated error.

Hundreds of blog posts later and two articles in the Boston Globe, here are my takeaways from the Parable of the Wicked EMR:

  • Hospitals must recognize that more and more of its customers will want their medical records in electronic format, and help filter and organize these data, rather than just “dump” them to the patient’s chosen PHR, in this case Google Health.
  • Dave’s healthcare providers need to help keep the data and information available in terms that patients can understand, along with coded data, and be aware that reconciliation at discharge in CCR or CCD format will be valuable to them. This will help them check for errors (free quality control!) and empower them to be increasingly responsible for their medical information.
  • And the PHR companies need to continue to help bridge the gaps that exist between health data in EHRs and IT systems, some of which is largely incomprehensible, and organized sets of information available in patient-understood terminology on the Web.
  • Finally, as Dave is proving every day, the patients/consumers have to take some responsibility for feedback and additional commentary until we all get this right.

The good news in all of this is that so many people actually care about e-Patient Dave’s experience getting better. It’s lit up the blogosphere because it’s important. This isn’t about blame – it’s about improvement to the point that patients get accurate and up-to-date summary health information about themselves at every point in the health care system.
A few questions that we might want to answer before this is all over:

  • How can it be that a doctor’s list of problems/diagnoses and those that the hospital uses are not the same? Is this an error, or is there upcoding and possibly abuse of the system going on?
  • If Dave’s doctors had acted on the data sent from the hospital to Google that was incorrect, and Dave was harmed in some way, would he have a legal cause for action against the hospital? Against Google?
  • If these billing data are inaccurate, wildly so in some cases, then why are we using them for analytics and quality research? For disease management?
  • If Dave’s billing data in the hospital EHR/EMR system is actually data from someone else, ie. another patient, then is Dave prohibited from seeing his own chart due to HIPAA privacy rules?
  • Isn’t it time for there to be a patient right to summary health data that is digital, up-to-date, and accurate?

We don’t have access to the same recourse King Charles had; we’re not likely to arrest and fine those who mismanaged the “sacred” data. But if you ask me, we ought to have the same sense of indignation, and the same commitment to hunt down and eradicate the Wicked EMR.

This posting was originally published on e-patient.net and is republished on THCB with permission of the author.

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ManojDeepakHANNAH'S HEALTH BLOGGeneric CialisMedInformaticsMD Recent comment authors
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Manoj
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Security for EMR is a major concern. EMR solutions providers must adhere to strict guidelines. Doctors and practitioners must take this seriously and thoroughly investigate security of their data before implementing a solution. This is where value provides can help physicians.
http://www.informed-inc.net

Deepak
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Buying EMR or EHR directly for the software manufacturers is frought with fault. You need an IT partner on your side. We at Informed Inc. are here to help. With our healthcare and IT specialists, we can help you navigate the EMR landscape to identify the right solution at the right price for you.
We know how important is your practice for you and we ensure we keep that trust through the entire implementation process. Please visit us at http://www.informed-inc.net

HANNAH'S HEALTH BLOG
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WICKED EMR… HAHAHA….such a big mistake…… LOLz

David C. Kibbe, MD MBA
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David C. Kibbe, MD MBA

Dear Commenters All: Claudio said something very important, in my opinion. He said: “The applications aren’t to blame — we’re seeing the consequences of junk data being exposed without review. It’s just a taste of the skeletons that may lie in the data closet. It’s also worrisome, because it may make hospitals reluctant to adopt the level of transparency that 21st century medical data requires.” I love this description! “junk data” and “skeletons in the data closet” Isn’t this the problem, that we are using data somewhat recklessly, without review, and in “the closet,” meaning out of sight? What Dave… Read more »

Generic Cialis
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Excellent topic.Thanks for commenting. Indeed, most of these points are not new. Unfortunately they seem to be forgotten by a lot of people in health care.

rbar
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rbar

I wonder whether you exagerate these problems, for obvious reasons … or whether I just happen to practice in an area where things are not that bad (my own large MSG does a good job handing out chart copies, and I know that Mayo and most other area facilities do well). There are some offices/institutions that are slow or unreliable, I will admit that. The most straightforward approach to this would be to cite/fine those. But of course innovative solutions are great … I just don’t see the need, not to that extent (and some other problems if patients can… Read more »

MD as HELL
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MD as HELL

In general, a patient usually knows his or her own history. Compiling all your own records from all providers strikes me as unnecessary and not needed for care. It may be an exercise undertaken for another purpose. It would be extremely evident very soon that a rolling record from provider to provider would become so useless due to errors and perpetuated inaccuracy that any doctor would be negligent to rely on it. The doctor must start over and must verify everything that might be suspect. After five or ten years, a sick patient’s record could take a day to review.… Read more »

Merle Bushkin
Guest

rbar, You and many other posters have commented that patients can get their records from their physicians by merely asking for them, at least in part because the law (I’ll leave it unnamed) requires it. At the risk of sounding argumentative which I am not trying to be, I must ask if you have ever tried to assemble your own medical records. I have, and it was an experience I wouldn’t wish on my worst enemy! Each physician and hospital told me it would cost a considerable amount of money and take one or more weeks. When I agreed, they… Read more »

rbar
Guest
rbar

I generally agree that communication between providers is paramount. However, I refer about 2x/year to subspecialists at the Mayo Clinic, and they sent all data (to me as the referring doc), without the need for further requests. In fact, written communication to the referring provider is a prerequisite in order to bill for a consult. There still is substantial fragmentation of efforts in the US system, in part triggered by patients, some of which are wandering rather aimlessly from provider to provider. But in times of HIPPO, you can get the records that you want, as long as the patient… Read more »

MD as HELL
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MD as HELL

Mr. Bushkin,
I don’t send my patients to just any chucklehead. It is not random. Great patient care requires great people, not a great system.
The problem with the EMR is that it is only needed to accomplish what the vendors want, which is to sell me a product that controls and tracks patients. I think a flash drive would be fine for the patient to carry. But I don’t need a national, central, monolithic anything to take good care of the patient.

Merle Bushkin
Guest

MD as HELL, Two clarifications. First, the additional income is after any clerical costs. It’s what you or any other PCP would take home. Second, in the system I described, uploading a copy of your notes to the patient’s portable device doesn’t send the patient’s record to a “central planning database.” It merely puts it on the patient’s device — which the patient owns and controls. Even “big brother” can’t access them unless the patient lets them. On the broader issue of whether a patient’s record should be readily available to any care provider when and where they need it,… Read more »

MD as HELL
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MD as HELL

Mr. Bushkin, If I were the patient’s doctor I would know everything about him without any records, unless they were new to me. I would see him or her over time and know all about his family, his work, his habits, his life. I would know all that because I would talk with him or her. I would have a relationship with him. As for making more money, the $25k would not cover the cost of the extra assistant necessary just to interact with the central plannig healthcare database. There would be no extra money. I would retain as confidential… Read more »

Merle Bushkin
Guest

MD as HELL,
What if your patients came to you with copies of all their records that you could electronically sort and search to find whatever clinician-provided information you need, and you were paid for your assistant to upload your notes so the patient’s next care provider had similarly current information when they treat the patient — and the payments you received over a year would total more than $25,000? In short, you’d be able to provide better care and make more money, too! Or would you prefer to ignore such available information and plod along doing business as usual?

MedInformaticsMD
Guest
MedInformaticsMD

Wicked EMR! How is it possible that that such mistakes could be made?
See here.
http://hcrenewal.blogspot.com/2009/04/should-google-seek-resignations-of.html

MD as HELL
Guest
MD as HELL

All of this bruhaha over patients controlling their own records is unnecessary. An informed patient can simply write his or her own record. Who needs a doctor? In fact, they really want to subvert their doctor, so have at it. Write your own. Put it on FaceBook. The patient knows better than the doctor that they had procedures xyz on specified dates. They know they have illness abc. They know they take meds and what they are. As a doctor I would love a well thought out summary from the patient about medical facts. Please include a detailed family history.… Read more »