Tech

The EHR Debate: Fighting the Last War?

Right now there’s a fierce debate going on for the hearts and minds of health IT. Finally American health care (well, half of it anyway) is using electronic medical records. But it’s not the panacea we were lead to believe. Costs haven’t gone down, health hasn’t markedly improved and the taxpayer/Chinese government is poorer. So too are many doctors and hospitals, and the main beneficiaries appear to be construction companies in Madison, Wisconsin.

Worse, those who promote the impact and importance of EMRs (Farzad MostashariAshish Jha) are being attacked by Ross Koppel, Steve SoumeraiScott SIlverstein and others who essentially say that EMRs are more dangerous and inefficient than paper.

This reminds me of the World War One British Army preparing to fight in the mud of Flanders with cavalry charges suited to the Boer War, the French Army in 1939 retreating to their WWI style trenches while the Germans flew over them, and (dare I say it) today’s TSA strip searching grandmothers looking for boxcutters.

Yes, we’re having the wrong fight by focusing on old problems. The EMRs that are producing the studies we’re fighting about are the current equivalent of 1990s EPR implementations. In general they’re hard to use and require lots of money and training to produce halfway decent results. The real improvements from IT came when user-centered tools came to consumers and then to business with Web 2.0 and new devices like the iPhone.

It may take months of training on Epic or Cerner to get a doctor or nurse to be three-quarters as productive as they used to be, but my two-year-old daughter can fire up an iPad and play games and watch videos with no training.What we’re seeing every day at Health 2.0 is a whole new generation of data-driven applications and devices that are going to make the health care user experience much more like the one my daughter has.

When we get there, the real improvements in both productivity and safety, as well as in quality and even cost, will emerge and we’ll wonder why we ever were having this fight.

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TariqDrabuMatthew HoltRoss Koppel, Ph.D., FACMIalan t falkoff, md, faafpBobby Gladd Recent comment authors
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TariqDrabu
Member

Excellent Wrk..
Source:http://tariqdrabu.co.uk/

Ross Koppel, Ph.D., FACMI
Guest
Ross Koppel, Ph.D., FACMI

Matthew Holt made the debate about HIT vs. pencil and paper. That’s not what anyone is talking about. HIT offers thousands of advantages over pencil and paper. Mr. Holt made that straw man argument for his post, and then won the debate with himself. But it never part of anything Steve or I ever said or contemplated. The issue is not about going back to paper or even going back to wet clay tablets and cuneiform. The issues is what can we do to make HIT better than it is? Than the clunky, non-user-friendly systems we currently have. But no… Read more »

Matthew Holt
Editor

Not sure why you’re responding today Ross, nearly a year later. But we agree! Need better technology, not pen & paper.

One good piece of news. We had 4 biggies in the world of EMRs (Cerner, Allscripts, athenahealth Practice Fusion) on stage our HxRefactored last week in NYC. All 4 have gone from 1-2 in their human/UI design depts 3-4 years ago to over 20 now. So your messages are resonating….slowly

alan t falkoff, md, faafp
Guest

It is 2013, I’m shocked that this debate is even going on. Emrs have been around since the late 1980s. How many of you are driving cars that old or cars that have technology, software and hardware that old? Having watched this industry since the early 1990s I can honestly say what we have in 2013 for the most part is far advanced from that time. The pen & paper vs electron debate has been going on way too long. There is way much more you can do with computers than pen and paper. There really is no comparison. Though… Read more »

Bimbo
Guest
Bimbo

@Carter “Overstating the case for or against EHR systems leads to arguments, not progress.”

I would not want my records on an EMR. Whenever money is involved, the cas is overstated, though the case against EMR is issued because it is a known fact that they cause errors, injuries, and deaths and no one is making a profit from insisting that the truth be known.

Bobby Gladd
Guest

” it is a known fact that they cause errors, injuries, and deaths”
__

And, you can document this precisely how? With legal specificity? A comparative specificity scientifically, forensically proving that Health IT is worse than paper overall?

“known fact” LOL.

Jerome Carter, MD
Guest

One very interesting thing I have noticed in reading about MU and HIT on the web is how quickly the discussions devolve. The fact is that no technology is ever neutral in its impact—there are always good and bad consequences. Antibiotics save lives and create super bugs. With any technology, prudence requires that one study the effects and attempt to maximize the good and minimize the bad. Looking at user surveys such as the one conducted by the Medical Group Management Association, reveals that some say they are better off after implementing an EHR, some say they are worse, and… Read more »

Boris Katz
Guest

I would suggest that the main goals of a good medical software (routinely called EHR even it does not reflect the goal) is to help (faster and withh less mistakes) physicians and their staff to get from point A (when a patient makes an initial problem related appointment) to point B (when problem as completely cured or – in case of a chronic desease, patient dies). That is it!. Everything else – MU specifically, is nothing more than intermediate goals, correctly or in case of MU incorrectly set.

Jerome Carter, MD
Guest

Agreed. HIT/EHRs should make healthcare processes more efficient and efficacious.

BobbyG
Guest
BobbyG

“Overstating the case for or against EHR systems leads to arguments, not progress.”
__

That has always been my position. Great comment.

Jerome Carter, MD
Guest

Thanks.

Bubbles
Guest
Bubbles

Nonsense above. Patients are not safer with HIT infrastructure in hospitals. Collect the data and get the systems validated and proven safe by organizational surveillance. The number of errors due to flawed drop down menues and tiny fonts are staggering.

Roger Collier
Guest
Roger Collier

Matt’s analogy with World War One tactics is interesting but incomplete. Cavalry charges were superseded by defensive barbed wire and trench warfare (which resulted in millions of casualties with no perceptible progress by either side) and finally in turn by tank assaults (which made the previous strategies instantly obsolete). So far as healthcare IT is concerned, it does sometimes seem as if we’re stuck in the second phase of the analogy – a grinding costly effort that has yielded very limited achievements. Unfortunately, Matt’s post provides no convincing proof that we’re on the verge of a third phase: a vastly… Read more »

Margalit Gur-Arie
Guest

This is not a “normal” war, Roger. It’s a Holy War. The outcomes are irrelevant. The only important benefit accrues to the powers to be from maintaining a perpetual state of war.
Full opinion here: http://onhealthtech.blogspot.com/2013/07/the-holy-ehr-wars.html

BobbyG
Guest
BobbyG

Now, THERE’S a worthy blogger!
__

“The non-believers come in many flavors and as always in history, are disorganized, fearful, delusional and in violent disagreement with each other. There are those who question only the particulars of the Technology, but basically believe in the Promise, and very carefully profess their deep belief in magic in every article or opinion piece criticizing the current state of Technology…”

Sorta like pols who have to preface EVERY gun control advocacy with their “unwavering support for the 2nd Amendment” — an Amendment I would repeal. (While we seem hell-bent on effectively repealing the 4th and the 14th).

Margalit Gur-Arie
Guest

Thanks, Bobby.

BobbyG
Guest
BobbyG

“you and Matthew would not be permitted to testify as expert witnesses in health-IT related cases, while I and similarly educated physician informaticists are, and do.”
__

And, we can assume you have an empirical case outcomes track record? Are you exclusively an anti-HIT witness? What’s your batting average?

40yearold doc
Guest
40yearold doc

Beautiful collection of meaningless endpoints.

Tavenner and Mostashari are both moronic self-righteous bureaucrats who have never used an EHR.

I don’t ask for advice on buying a new car from someone who has never driven one.

BobbyG
Guest
BobbyG

“moronic self-righteous bureaucrats” __ The Usual Libel. “…Dr. Mostashari served at the New York City Department of Health and Mental Hygiene as Assistant Commissioner for the Primary Care Information Project, where he facilitated the adoption of prevention-oriented health information technology by more than 1,500 providers in underserved communities. Dr. Mostashari also led the Centers for Disease Control and Prevention-funded NYC Center of Excellence in Public Health Informatics and an Agency for Healthcare Research and Quality-funded project focused on quality measurement at the point of care. He conducted graduate training at the Harvard School of Public Health and Yale Medical School,… Read more »

40yearold doc
Guest
40yearold doc

Read any interview with Mostashari: he seems incapable of understanding simple English.

He is asked about A, B, and C, and responds by talking about X, Y, and Z.

If he’s not a moron, he should stop talking like one.

BobbyG
Guest
BobbyG

That’s complete crap. I know the man personally. I have heard him speak in person on multiple occasions. And I am no reflexive cheerleader for all of his views (as he well knows).

But, y’all keep it up. Wasting bandwidth.

40yearold doc
Guest
40yearold doc

Maybe.

But the real miracle that should make us drop to our knees is that EHRs have sent out over 13 million appointment reminders, right?

BobbyG
Guest
BobbyG

“But the real miracle that should make us drop to our knees is that EHRs have sent out over 13 million appointment reminders, right?”
___

LOL. Yeah, and they overtly touted it as a “miracle.”

Take any one required reporting measure in isolation and mock it. Lather, rinse, repeat. A fun time.

BobbyG
Guest
BobbyG

apropos of Anger Management: __ EHRs ‘transforming’ care, says Tavenner Providers are increasingly using electronic health records, both to manage their patients’ care and to provide more information to those patients, according to new data published Wednesday by the Centers for Medicare & Medicaid Services… By meaningfully using EHRs, physicians and care providers have shown increased efficiencies while safeguarding privacy and improving care for millions of patients nationwide, the data show. “Electronic health records are transforming relationships between patients and their health care providers,” said CMS Administrator Marilyn Tavenner, in a press statement. “EHRs improve care coordination, reduce duplicative tests… Read more »

Al
Guest
Al

Bobby G., If your technology is better then the alternative physicians will adopt it just like they adopt new ways of doing things all the time.

It is you that has to prove your value and not the other way around. If you can’t prove your value then work harder on the programs and stop complaining.

BobbyG
Guest
BobbyG

It has proven worthy for many, many actual physicians. The Great Unwashed non-MD me tends to side with them.

Al
Guest
Al

No one doubts that there is variation in how physicians benefit from different things. That is fine. However, if you are in this sort of technology it is up to you to prove your value to the other physicians who will adapt when you make such adaptation worthwhile. I am one who likes the idea, but finds it distressing how you react to criticism. Understand, the primary reason for the physician record is for physician use. Therefore you have to appeal to his needs and his fears, not to the government or the insurer or even to your own preferences.… Read more »

BobbyG
Guest
BobbyG

“the primary reason for the physician record is for physician use” ___ “primary” perhaps, but not “exclusive.” What do you imply by “primary”? 51%? 95%? e.g., in the much maligned “meaningful use” program, when assisting with workflow adjustments, we have always taken pains to point out, for example, that 11 of the 15 core measures involve data capture that don’t require physician EHR interaction at all. With respect to those measures that DO need provider interaction, we try to make it seamlessly part of normal workflow — albeit, with uneven success, to be fair (e.g., eClinicalWorks: FIVE different workflows for… Read more »

Al
Guest
Al

BobbyG, did you ever think of why it has been called the physician record? Do you realize the courts recognize the physician record as the physician’s work product and therefore the physician has the right of primary ownership? Have you looked historically at physician notes and records? If not, I think you should do so. Do your own manipulation of data on your own dime and your own time or prove to me that you will aid me in my task so that I will use your service. Years ago the pen and paper manufacturers hawked their wares as well… Read more »

BobbyG
Guest
BobbyG

@Al says: July 22, 2013 at 4:01 pm “BobbyG, did you ever think of why it has been called the physician record? Do you realize the courts recognize the physician record as the physician’s work product and therefore the physician has the right of primary ownership? Have you looked historically at physician notes and records? If not, I think you should do so.” __ I’m really not that interested in this “history.” That’s a forensic thing more than a clinical one. States increasingly also recognize the data comprising the “physician record” as the property of the patient (I have the… Read more »

Al
Guest
Al

BobbyG: “I’m really not that interested in this “history.” ” That sounds about right. You are so ultra focused on what you want and what you think your abilities are that you have developed tunnel vision. I look at you as an accessory much like I look at the MRI or any other piece of equipment available for me to use. I have no problem with my work product being shared with my patient or others that I or my patient feel add to his care, but I do have a problem sharing it with you or anyone else especially… Read more »

Bobby G
Guest
Bobby G

“Do you even know what it is, as it goes to Health IT? ” If you are asking me if I know about health IT or computers the answer is yes. I also understand how IT interacts with my patients and my treatments and above all I know how to practice medicine. That is one thing you lack. The second thing you lack is understanding how I think and what I need to do my job properly. When IT accomplishes that I will say job well done, but right now you are overreaching so I consider you dangerous. __ You… Read more »

Al
Guest
Al

You are right. I don’t know what your views are. I only know what I read here on the blog and nothing you say here has changed my views.

BobbyG
Guest
BobbyG

“distressing how you react to criticism.”
__

Being called a “shill” or a “HIE vendor” or an “amateur” who doesn’t show the proper humility is gonna get pushback every time. Those are not criticisms of my ideas. Sorry.

BobbyG
Guest
BobbyG

@Al says:
July 22, 2013 at 7:49 pm
You are right. I don’t know what your views are. I only know what I read here on the blog and nothing you say here has changed my views.
__

Fine. End of debate. The feeling is mutual. I won’t trouble you again. Good luck to you.

Al
Guest
Al

One of the good things about health IT and the logging of all information on a computer is that one always knows where all the nurses are.

Boris Katz
Guest

I agree that there is nothing meanigful for patients and doctors within the MU requirements – only for the bureaucracy. But my post above was not about MU but rather about medical software concepts (EMR/EHR) which are not all about MU.

Mighty Casey
Guest

I’m (maybe) going to take this in another direction by observing that the current status of EMR tech does exactly what it was designed to do: make getting paid easier. What’s called medical-record tech is really medical-billing tech, since all those lovely ICD-9/soon-to-be-ICD-10 codes have little to do with dx/tx, and everything to do with GETTING REIMBURSED FOR CARE. Cherchez l’argent, tout le temps. EMR tech will, over time, shift into actual meaningful use. However, it will take herculean effort on the part of both clinicians AND patients to get to that useful point. The time between here and there… Read more »

BobbyG
Guest
BobbyG

Good comment.

Mighty Casey
Guest

Thank you!

BobbyG
Guest
BobbyG

I have long argued CHANGE.THE.PAYMENT.PARADIGM.

The totemic 15 minute office visit has everything to do with keeping the doors open, and much, much less to do with providing quality care.

Mighty Casey
Guest

Why I registered the hashtag #howmuchisthat with Symplur, and have been pressing cost/price transparency for … ever. Patients can be massive change agents, if only we wake up and start asking that question: how much IS that?

Boris Katz
Guest

You may be right in most of the cases but certainly not in all because my software (and despite the fact that I do not try to sell it to anybody – just share the idea) is not only about “getting reimbursed” but rather about automation of the workflow – clinical in the first place, but everything else as well. And taking everything else equal it improves the quality of care because the more time is left for a doctor to spend on talking and examining the patient, test results and other clinical information – the better it is. Of… Read more »

Whatsen Williams
Guest
Whatsen Williams

The progress note is a misnomer. Call it the bill. Meaningful use requirements do not improve outcomes or reduce costs, but the gig of doing them nets $ millions for the hospital that beats on the doctors to abide ( or suffer the consequences).

BobbyG
Guest
BobbyG

A longer assessment timeline is required to determine whether any of this MU stuff will bear clinical or financial fruits (and I am rather dubious on the latter).

Al
Guest
Al

Mighty Casey: “given that it’s likely that close to 100K patients die every year due to medical error, ”

Firstly correct your data for the year we are in. Secondly, do you know the difference between malpractice and preventable deaths? A little extra morphine to a patient with metastatic cancer to the bone might kill him several hours earlier than letting him stay in pain and not trying to alleviate it. That death may have been preventable, but it was the appropriate thing to do.

You should check out your slogans before using them.

Mighty Casey
Guest

I didn’t name a year, because there is no hard data attached to any year. There’s only the extrapolated data from sources like “To Err Is Human” [1999, IoM, http://www.nap.edu/openbook.php?record_id=9728%5D; ‘Epidemiology of Medical Error” [2000, BMJ, based on IoM report, http://www.bmj.com/content/320/7237/774?view=long&pmid=10720365%5D; the 2005 followup “5 Years After … What Have We Learned?” [2005, JAMA, their site’s squiffy right now but article is linked inside this one, http://www.commonwealthfund.org/Publications/In-the-Literature/2005/May/Five-Years-After–To-Err-Is-Human—What-Have-We-Learned.aspx%5D; the most recent, and best, assessment in recent memory is “The Toll of Preventable Errors: How Many Dead Patients” [2012, Health Affairs, http://healthaffairs.org/blog/2012/03/09/the-toll-of-preventable-errors-how-many-dead-patients/%5D. I don’t know why you bring up giving extra morphine… Read more »

Al
Guest
Al

Casey, Maybe you should learn a bit more about the IOM report and what it means. You should also quit with the secondary and tertiary sources that don’t know any more than you do. You should also learn the terms that were used and what they mean. You were sloganeering based upon insufficient information. I will quote from a senior researcher with the Harvard group ” “I have cautioned against drawing conclusions about the numbers of deaths in these studies. The reliability of identifying errors is methodologically suspect.In both studies (New York and Utah/Colorado) we agreed among ourselves about whether… Read more »

pmanner
Guest
pmanner

“To Err Is Human,” used studies of errors during hospitalization in New York State in 1984, and in Colorado and Utah in 1992. The results of these studies were then extrapolated to the entire nation, which is where the 100,000/year number comes from.

In essence, the data is 30 years out of date.

Mighty Casey
Guest

But where IS the hard data? Were are the aggregated M&M stats? That’s the issue, AFAIC.

pmanner
Guest
pmanner

The short answer is that we have no idea. Standards of reporting are different, metrics are different, and there is no good evidence that EMRs are responsible one way or the other. http://www.ahrq.gov/research/findings/nhqrdr/nhqr08/Chap3.html The only data I see that is possibly relevant is “Deaths per 1,000 discharges with complications potentially resulting from care (failure to rescue)”, which went from 160 events to 120 during the period of 1994 to 2005. Which was before the big push for EHRs. (These are hospitalizations complicated by pneumonia, thromboembolic event, sepsis, acute renal failure, gastrointestinal bleeding or acute ulcer, shock, or cardiac arrest. Many… Read more »

BobbyG
Guest
BobbyG

sleuth says:
July 21, 2013 at 4:03 am
Bobby G seems to be s shill for the vendors; or a vendor himself, desperate to maintain the facade that HIT needs no regulation for safety, efficacy, and usability.
__

That is completely stupid. A Clue awaits you at my REC blog:

Google “REC blog”

I’m the 1st result.

Search on “FDA”.