Frankly I think it is a symptom of our deliberately fragmented ‘for profit’ system, which is not really functioning that well. Keep filling the forms properly though. “in network”, “out of network”… That is it from me on this topic, and yes, I think it is contentious and political not technical as such.
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Which we need here. This is mostly a product of our broken ‘for profit’ system and not a technical problem at all. Wait till you see the billing stations and the 17% + of costs that go into that, compared to the 2% for those overheads on Medicare. Most of the costs are not due to the Insurance companies either in fairness contrary to what a lot of folk think: they have the thankless task of trying to implement the chaos.
The problem with email and fax is the same, no encryption. If someone wishes too, they can easily wiretap a fax line and receive all the information. So neither option is good for sensitive information. The advantage of email however is that encryption can be added on top. There is no way to encrypt a fax, it is forever insecure.
It’s hard for those of us living here to comprehend too. A lot of time the issues are not just the computer systems but the processes and workflows the office uses. We moved to a new city during the pandemic and needed new medical providers. We found a dentist that runs an incredibly efficient office. As a systems guy, it’s always nice to see.
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This has been a fascinating discussion. It’s too bad that our US government officials are not required to read it. It might lead to a few of them understanding the myriad issues that plague our healthcare deliver system today.
One point that has not yet been made concerns the use of Electronic Health Record systems (EHR). There is a common misconception that the primary function for an EHR is to contain, organize, and potentially share medical information used in patient care.
In practice, the primary role for EHRs is actually to support medical billing. EHRs are not, from a practical standpoint, positioned to support recording and understanding medical information.
As @rkaplan has pointed out, one method by which payors (Medicare, commercial health insurance providers) determine “level of service,” that all important index that governs the amount paid for what is known as an E&M or Evaluation and Management service, is based on a the amount and type of information included in a medical note. The net effect: I am paid more for itemizing the answers to a dozens of questions unrelated to the purpose of a given patient visit than for spending more time discussing the actual reason I am seeing a patient. (There is a way around that called “time based billing”, which requires documentation of specific time spent using prescribed verbiage). EHRs are designed around the idea of capturing this kind of activity, around making the capture and review of medical information efficient.
Interoperability remains a pie-in-the-sky goal. One dominant EHR in the US touts its ability to integrate records from multiple institutions, but in practice the data that one can obtain from outside sources is limited, incomplete, and in the end the claimed interoperability is a sham. This despite billions spend by the US government to support “interoperability.”
The fact is that our EHR system is poorly thought out, expensive (many others have already pointed this out) to implement and sustain, and not designed to meet the needs of patients or health care workers. There is a mess of legal requirements and restrictions that hamper the growth of this area.
Interesting, btw, I agree that the VAMC’s self-developed EHR system is excellent when it comes to sharing data among VA hospital, providers and facilities, but horrible when data is exported. I read not that long ago that the VA was planning to transition to a commercially available EHR, which makes me wonder…why?
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Even in the UK where we have a national health service, the actual implementation varies significantly between regional/hospital ‘trusts’ which are semi self governing bodies.
I have worked with the NHS ambulance service in three different trusts all of whom have collected, recorded and distributed their patient data in completely different, incompatible ways.
In my most recent trust we have an ‘advanced’ tablet that will collect the patient data directly from our monitoring equipment, record clinical observations as actionable, queryable database values that the programme can interact with quite intelligently (flagging medication allergies, highlighting suggested tests based on inputs, suggesting referral pathways etc) as well as allowing us to input subjective data via text.
However, all this information is printed out on a4 paper on arrival at hospital or is exported as a humongous multi-page unfriendly PDF which is attached to the EHR and seemingly never viewed or analysed again. This negates most of the value that the electronic system has over just writing it out by hand to be scanned, which was the traditional way and the thing these multi-million pound programmes were brought in to improve.
Interesting - since you do not have the billing issues which encourage checkboxes in USA, do you have more of an opportunity to chart pertinent details in narrative format rather than being pushed to chart irrelevant boilerplate in checkbox form?
As one person said to me only yesterday while compiling a complicated list of something or other vaguely related to something a patient complained about. “Problem is it is all about profit and nothing else”. People in Government do understand quite well but “Death Panels” you know: not the ones that resulted in one Million Covid Deaths due to public health and Government failures though I assume, the fictional ones used to incite panic about ‘single payer’.
Some in Government, which is us, or supposed to be, are fully aware of the issues but frankly our hands are tied by a combination of factors and those with power. However this will take this excellent thread and site into partisan politics, or rather third party politics.
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Yes indeed even a NHS can be undermined and messed with for decades and show problems. Hold your breath while privatization by stealth takes hold and American companies are invited in to make ‘improvements’. Really I ain’t jokin’. CF the Post Office.
I can only speak for the ambulance service and ED. (The strains on GP practices here are immense and quite different) but yes, and this is particularly useful in our calls which are really social, welfare or mental health issues (which by far outweigh our trauma calls, actual medical emergencies etc).
The trusts are beholden to targets; usually timings, treatment bundles etc and there are endless checkboxes for these. However as long as the key performance indicators for a patient are recorded (every ?stroke must have a glucose and temperature value recorded etc, every chest pain receives x,y,z) there is no penalty for also including an in-depth psychosocial history if you notice issues that should be referred to social care, community nursing, general practice etc.
Sometimes we may have to spend 3-4 hours on scene with a patient organising referrals and follow ups with the goal being that no-one is transported to ED who really doesn’t need to go. Better for the patients and less strain on the system. Our call volume is so high that it would be easier for the organisation to just scoop and run and thus clear more calls and so occasionally a manager will complain your on-scene times are too long, but there are no real consequences.
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Beautifully said! I work in a dental office and we are not computerized. My bosses perspective is “if it’s hacked I am responsible”. I have encountered a “non-patient “ attempting to access our internet from our parking lot. Imagine his surprise when I told him there wasn’t an internet service and to vacate the property or I would call the police!
As with most areas of life, there is more than one way to do things. We go back and forth looking for solutions. National or private health service? Profit-motive or social welfare? Centralize or de-centralize? Pursue a political or technologic solution? Or perhaps a return to simpler life?
In the extreme, follow a charismatic leader on the promise of improvement or even communal utopia? And sometimes the decision is taken out of our hands when a strong man thinks that he can order the world to his liking and tries to impose his will dictatorially.
Life is messier than I would like it. 
Lest anyone think that this discussion must be politicized, in Canada we have (more or less) universal, publicly funded health care, and I do not have the ability to access any of my health information online. The system is nationally funded but provincially managed. My province is further divided into health authorities, none of which are required to use the same EMR. Also, doctors (in my province, not sure about elsewhere) are independent contractors each of whom is responsible for their own record keeping. With respect to medical record interoperability, it’s a mess here too 
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Thank you for sharing that information. It is extremely valuable to me.
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The vast majority of the time, the purchase decision-makers are not the users. This is not uncommon in corporate environments, but it greatly holds back innovation and evolution of software.
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HIPPA is a major problem in so many areas of medicine, but one is the ability to have a real marketplace of software to store medical records. The costs and complications of HIPPA compliance exclude small-scale players.
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A standard to define the fields etc. of medical records was never embraced. There were some attempts, but the consumers never had or created the power to force this issue. Interestingly, in the sub-area of medical imaging, the DICOM format standard for diagnostic imaging managed to take hold. But for years, the big players in medical imaging fought this because they wanted to create lock-in with their own proprietary formats. To the everlasting credit of the American College of Radiology, they led a fight to have one standard that vendors had to coalesce around. So now there is more competition in the field of presenting medical images; the software just has to implement the DICOM standard.
It is a little reminiscent of the domination of Word/Excel where for many years a propriety format dominated and thwarted competition. Currently, proprietary formats dominate and support the effective monopolies of a couple vendors in the medical field.
HIPPA and proprietary formats and the depowering of the actual users of the software combine to make the evolution of medical record software extremely slow when compared to many other areas in the computer world where innovation is extremely fast and improvements appear regularly.
IMO, it is a tragedy that the government did not enforce a “standard” of the medical record in terms of how the data is defined, etc.
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They really haven’t been more ‘homogeneous’ that the United States, including my old country, which is possibly going to fragment over the next period and has the NHS. In other words some very non homogenous countries have a fairly good national health system. You did say ‘some’ European countries, I don’t know which ones you meant.
The US also manages to have a coherent and unified military over its whole area and well beyond, so size is irrelevant in principle.
The US also has a nationwide cartel of pharmacies, 99% belong to three companies. Medicare alone is larger than the health care systems of many countries.
I wrote a longer post on this but it, was for some reason it was flagged as inappropriate: there was no reason for that other than somebody disagreed with it, it was not heavily focused on the IT side so I won’t make an issue out of it: I did raise a point about ‘homogenous’ and what it normally means which I won’t repeat in case that was the issue. I would appreciate though if this one is left alone even if you don’t agree with it.
Many technical issues are solvable regarding IT, which, as Lars said, happened in Europe and as I said before is independent really of whether a system is ‘socialized’, depending on what one means by that. Our system is heavily socialized, I can’t amplify that here as it seems opaque to many Americans who don’t see the need to deeply understand it.
There are issues with the NHS and other systems, most are strategic and/or politcal in my experience, deliberate underfunding and lack of resources and so on included. Frankly there is no big deal very often with filling a few checkboxes. Many researchers and doctors like to start from scratch or have a few direct prior indicators from patients.
You made useful, simple and correct points Lars and know enough really. Problem is that in the US decades of lobbying and expensive PR have made many Americans quite irrational about Healthcare, “keep Government hands off my Medicare” is one famous poster at a rally.
One of the hosts of this site, Ian, has done great work for a place called ST JUDES, which I support 100%, look it up. Kudos to him. St Judes is a free at the point of delivery children’s hospital. One of the best too. As with the Miner’s Co-op health care which served as a template for the NHS in Wales and the UK, that hospital should serve as a model for a US health system. But… well, ‘death panels’ and this is the land of the free…
I lived in both Europe and now the US, nobody ever has detailed ‘enough’ knowledge of a country or a system which takes up 20% of the economy and frankly the failures of the US system don’t lie with either expertise or IT but with other factors. All of us have to farm out expertise, especially medics themselves. Medical records are not, in fact, that complicated: that isn’t where the science ‘is’ as it were.
Problems don’t lie with having to fill in a few checkboxes really but it is an interesting technical problem and really probably more appropriate to this site, you can’t disentangle the issues really though I find. I really hope this reply doesn’t get flagged like another one here I posted which had nothing wrong with it.
Not it isn’t it is designed, or rather allowed, for a plethora of reasons, to create profits and is run and controlled by the Insurance Industry, who don’t actually, themselves have a high rate of profit, very low actually. The recent pandemic showed the principle it works on. Huge public investment, including R&D and yet private control of patents and resources and the profits pretty much with no question. The role of Government is mixed and contradictory, depending on the level of ‘capture’ in my view and internal partisan opposition to any kind of real solutions. The problem really isn’t ‘red tape’ for example or frankly technical IT issues: or to talk for myself, technical medical solutions, many of which are actually quite straightforward once you have solved the deeper scientific questions. nRNA vaccines are a perfect example.
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Fascinating discussion. A few thoughts:
- The patient on boarding experience varies dramatically based on how digitalized the practice. Within the same city you have providers who run an all digital practice and others who are all paper for cost or tradition reasons. Mostly cost of transitioning and integrating a new system drives hesitation to adopt a new system. Consider that if a practice started in 1970 and maintained a paper system all of their records would have to be digitalized and that’s a huge additional cost on top of buying into whatever EHR they decide to use. Government incentives make this easier to stomach but the balance sheet varies.
- Completely agree that relying on patient memory is unreliable but it’s the best we can do without outside access. Patients have often logged into their digital portal on their phones and shown me outside results or notes that way while we are waiting for the paperwork to process which is a nice (if clunky) solution.
- Re: fractured health systems, it’s much worse than you may realize. Not only is each health system separate from others but each EHR manufacturer is highly incentivized to be incompatible with the others. Software interoperability has to be bought into by all the stakeholders before it can be implemented. My practice has enrolled in a system called CareEverywhere as part of our Epic license but this is still limited as everyone is not on board.
- I’m glad the EU citizens in the chat are proud of their system! I will say that every system has problems and many of my good friends trained in England and Germany before moving to the US and those national systems are about as abysmal on the docs’ end as ours so from that side of things they’re not that different! I think the analogy made with the Veteran’s Administration is very apt: within that system record retrieval for patient care or research is trivial but interfacing with other systems digitally is impossible so analog methods must be used.
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Thank you for sharing your experience!