Electronic Medical Records and Impatient Patients

I read a blog post by Andy Kessler today, who has written a book called The End of Medicine, which I have admittedly not read as of yet. The post alleges that the medical industry has created a complete boondoggle of finances, and if we were to employ electronic medical records and their efficiencies, physicians would suffer and therefore, the emphasis and resistance to EMR is merely doctors protecting their own. (Or that’s how I read it.) While the Oliver Stone conspiracy theory plays well to an audience who has increasingly less and less trust in authority, it’s not even close to the facts of the matter. Let’s start out with a few basic facts:

- While many medical technologies like ultrasounds are slowly being digitized, there is no standard language or interface that makes this information easily accessible in a secure form. For example, an ultrasound machine does not automatically save all images onto a SD card and you can’t upload the images easily to Flickr. Add to this that small distortions can be indicative of disease and change a diagnosis, and you have a problem- not only that of having to retool and replace thousands of very expensive diagnostic equipment in every medical practice and hospital across the country, but how do we ensure that these images maintain fidelity when they are transferred between a doctor, a hospital, or over the net? Let’s not even alk about the fact that different EMR’s on the market do not as of yet interface smoothly with one another, let alone the labs- there are not, as of yet, any web-like standards for medical EHR.

-Part of the problem caused by EMR is that the data needs to be measured the same between doctors and institutions. The quality of the data- not just your hemoglobin, but measurements of say, fundal height, are not nearly as standard as one may assume. Data fidelity is as much an issue as is accuracy. Without more investment in standardization of data collection, sharing data between providers and institutions causes more problems than it solves.

-Paper records are sometimes better at flagging problems and inconsistencies than EMR. Some physicians I know were recently discussing a case where the blood tests of a woman showed conflicting Rh factors between what was in her office chart and what was in the hospital’s chart, which was an EMR. It was a problem tracked down to an error in the lab- but the problem was almost overlooked because there’s no way to put a big yellow post-it note, yet, on most EMR’s to make sure, without a doubt, the physician notes this sort of minor, but critical discrepancy. We need to make sure EMR’s are not just a sea of numbers, but that there’s some reasonable attention-getting mechanism so inconsistencies are readily apparent.

-Kessler talks about the problems that could be solved if all the data were gathered in one place. This is very true. But between HIPPA laws to protect patient privacy and the use iof their data in any sort of medical research, and the thorny issue of who would own, maintain, and allow access to this data, let alone pay for its creation, this is not an easy problem to tackle. A physician I know well just went to ask for some of the stimulus money to help start a data storehouse to solve some of these problems in respect to pregnant women. If the NIH and government own the data, there may be more equal access to it, than say, if a private healthcare company or drug company owns it, and creates an access and monopoly issue- can they cut off access to their competitors? How much money would a project need to buy access to the data? Who pays for the accumulation and submission of the data? How does it get stored? How are redundancies built in so the data is backed up and resilient from both unauthorized access and failure in the event of an emergency?  How do you make sure smaller, poorer hospitals have enough data infrastructure to interface with larger, referral centers, especially in times of emergency?

Healthcare is fragmented more so than our financial services and banking ever have been.  Individual practitioners are like individual small businesses- asking them to create and adopt an EMR for all their patients is like trying to make sure that Target and Kmart communicate to one another regarding your buying preferences, and then provide that data to your favorite pizza joint and dentist.  We’d like our cardiologist and internist to have the same system, but if they do not have hospital based practices, this is highly unlikely at this point in time.

I appreciate the frustration that Mr. Kessler and others feel with the slow transition from paper to pixels in medicine, but the issues are WAY more complicated and nuanced than he lets on.  This is not a conspiracy like the JFK assassination, nor is it a plot for doctors to secure their position as high earners. Most docs I know and I am married to one, would love for the data to be easier to centralize and maintain.  But look at how data fidelity errors could cost people their lives- small errors propagating poor decisions in a diagnostic tree- and look at how fast incorrect data can spread- like the rumors of celebrity death on Twitter- and ask yourself if you want fast, or you want accurate when it comes to your health care.

Ask why doctors make a decent salary- could it be 8 years of advanced education, plus residencies of an additional four or more years, plus the responsibility for the health, well being and very lives of their patients- and ask yourself if you would take on that responsibility for minimum wage.  Not me.  We want doctors to still be magic, yet be as concerned with customer care and treat us like family, yet we want them to do it as cheaply as possible.

My secret concern is that our third party payor system insulates most money issues from coming between a doctor and patient- a doctor can assume he will be paid for his work without running a credit check on you first like other businesses.  But then again, the office, insurance and the hospital are in charge of the billing and negotiating payment, and he may sincerely not know if the meds he is prescribing or the sutures he is using are more expensive than alternative options- they use what is the standard of care, or what the hospital stocks in the OR.  A doctor himself may have very little idea what his patient pays, and while that makes for inefficiencies and possible overuse of more expensive treatments, we have traditionally taken on these costs to prevent ability to pay from determining which tests a doctor may use, and somehow using less sophisticated and cheaper tools for patients of one economic class over another.  Money is important, to be sure, but we all want chemo when we need it, regardless of our ability to pay out of pocket. We already know people forgo treatment of illness and injury if they can’t pay for it, often making their condition worse and more catastrophic.

I don’t think we really want doctors spending all their time constructing a consumer reports of medical equipment, looking for the cheapest stuff available- we want them to use reliable equipment at a reasonable cost, to do their jobs well.  If we add the burden onto docs to be full time cost containment vehicles, what will we be losing as a result?

The health care problems in this Country are thorny at all levels.  I just think all of those who think the answers are as easy as putting your med records into a word file or in the cloud don’t know enough about medicine to appreciate some of the more difficult issues out there.  It’s only by having doctors and geeks in the same room that we’ll be able to solve these problems globally.  That, and making sure we have some data standardization that all ancillary medical equipment businesses would be willing to adopt, so the infrastructure works well.  Until then, we have a mess of puzzle pieces that don’t easily fit together.

Tags: andy kessler, decisions, economic pressure, electronic medical records, EMR, health care, health insurance, healthcare IT, medicine, third party payor

Health Care, Under Cover

Disclosure- I am married to a physician who is in an academic medicine practice.

I sit on the nexus between two worlds- that of the normal, every day patient, and that of someone who practices medicine every day. It’s often an odd place to be, especially in these days of debate over health care reform. It’s so very clear that medicine has to start keeping up better with the changing ways of communication. Yet, it is hamstrung by a world where health information can be used as leverage against someone for their employment, where disclosure of information and security are at a premium, and where litigation and taking things out of context abound.

A friend of ours said to me the other day that the best piece of advice they ever got was that “You have to be treating patients, not practicing medicine.”  In a nutshell, that means patient-centered care should always be the rule, and the institution of medicine needs to make sure the rules, regulations, procedures, and even science do not lose sight of what’s most important here- making people well, or keeping them from getting sick in the first place.

That said, the markers doctors use to judge the quality of care and those used by patients could not be more different.

As in any business, the people inside the field know who they can trust. If a doctor needs to see one himself, they ask other doctors for their advice if they don’t know someone in that specialty themselves, or ask their nursing staff what they think of the doctor in question. Just like a secretary knowing more about her boss than any customer ever will, the same goes for nurses and doctors.

Doctors, especially in academic medical centers, know how current and up to date the practitioners are in the area. (Or better yet, ask a nurse, since they work more closely with a doctor than most other doctors do.)

They know who is Board Certified in their sub specialty, and who is not, as well as those who had trouble passing their Boards. (This means the Doctor passed some lengthy exams requiring them to pass a written exam as well as an oral exam before a group of doctors, examining the patient cases they treated during training, questioning what decisions they made and why, good and bad.)

While there are plenty of caring physicians who haven’t been able to pass their Boards, many of the more prestigious hospitals don’t allow those doctors to practice there because they aren’t certified. If you are in a rural area, or have a small community hospital, there’s a pretty good chance not every doctor practicing there will be Board Certified in their sub specialty, in contrast to hsopitals in larger, more competitive markets.

As the wife of a physician, I know the back room gossip of who’s good, who’s okay and who is starting to lose some of their sharpest surgical skills. It may not be something we talk about in public, but everyone knows who is not always on their “A” Game at work, and medicine is no different from any other job in that respect. I know I’d rather be treated by someone who has a good combination of clinical skills, surgical skills when needed and who is doing some research or otherwise engaged in teaching or the latest treatments.

We certainly have a bias towards academic research hospitals for that reason. Even when you might be seen by a resident, the chances are you are getting better and more consistent care than in some of the other practices around. This means I often sit next to medicare patients while waiting in the office, since these doctors treat anyone regardless of their insurance status. Being in the office of a doctor who treats the wealthiest and most prestigious people in the community is far less important to me than being treated by the doctor who knows the most.

I worry that being a lawyer and a doctor’s wife gives me a very skewed picture of what quality of care looks like. I know when I show up at the office or even in the Emergency Room with a kid with a broken arm, we get some favors, some “professional courtesy”, like not having to wait as long before being seen.  (It’s one of the few perks that helps compensate for the huge number of hours each week my husband spends at the hospital and on call.)

But at the heart of it, quality of care to physicians is based first and foremost on the science, who is best trained and who keeps up with the latest advances.  From a patient’s perspective, we often don’t have the all the knowledge necessary to make the best health care decisions.  We don’t ask if our doctors are board-certified.  We don’t know if they are practicing rountinely within the standard of care.  Most likely we’ve chosen them because they take our insurance, they aren’t too far from home or work, or we like them personally.  We judge a lot of the quality of health care by how we are treated emotionally- Do I like the receptionist and the nurses?  Is the lobby and waiting area nice?

None of that has anything to do, however, with the quality of our care, but it has everything to do with our perception of being cared for.

One of the things we’re going to have to sort out in health care reform is how much of the reform needs to be based on allowing doctors more time to really see their patients and get to know them- one on one care that takes time, and is not an assembly line.  If we want an efficient system, the first thing that gets factored out is the more personal attention- just like “making schools more efficient” has meant factoring out smaller classrooms and things like art for the sake of cramming as much knowledge as possible into the heads of outr kids in each school day.

But in both cases, the efficiency has detracted from the perception of quality, andwe have factored out the “quality of life” factor which is so essential both to great education and great healtcare.  These are not services that can be effectively mechanized like an assembly line- the human touch does really matter, and we have to accept that quality and efficiency are not always going to be 100% compatible metrics where humans are concerned.

Tags: health care, medicine

What is Quality Health Care?

Disclosure- I am married to a practicing physician.

As we enter the great debate of what is quality health care, I worry that most patients don’t know.

From a patient’s perspective, we tend to look at the poshness of the office, how long we had to wait, the doctor’s staff, and the personality of the doctor, before we evaluate anything else.  we might look at his/her credentials- wheere they went to school and did their residency, for example- but few patients know if their doctor is Board Certified in their subspecialty, or even know what this means.

I think the Associations that certify doctors as ready to practice in their subspecialty do a lousy job of making this certification mean anything to patients and consumers.  Being Board Certified is very important to doctors, as being “BC/BE ” (board certified, board eligible) is required to practice and have admitting privileges at most of the best hospitals around the Country.  But as for patients- do you know where your doctor went to school?  Doe sit matter?  Where did they graduate in their class?  Did they win any awards?  What kind of contnuing medical education do they do?  Do they do any cutting edge research?  Does it matter to you at all?

I saw a big flap in the news this morning about doctors seeking to get their patients to agree not to post anything negative about them online.  The article states in part:

“Consumers and patients are hungry for good information” about doctors, but Internet reviews provide just the opposite, contends Dr. Jeffrey Segal, a North Carolina neurosurgeon who has made a business of helping doctors monitor and prevent online criticism.

Some sites “are little more than tabloid journalism without much interest in constructively improving practices,” and their sniping comments can unfairly ruin a doctor’s reputation, Segal said.

What this says to me is that doctors are under tremendous financial pressure, and are having problems being good doctors and good business men at the same time.  The pressure to make enough to keep a practice open, to have it adequately staffed and to see enough patients and do enough procedures to make it all work financially is almost ludicrous.  It means doctors are often treating disease and not patients, and are not allowed the time to spend with patients and make sure they know that they care.  Medicine is supposed to be the caring profession, yet we are trying to make sure everything is profitable, which means time is not a luxury anymore.

Patients know this.  Doctors always seem busy and hurried, and no one likes to feel that they aren’t being heard or listened to.  And in medicine, really hearing and listening to a patient’s complaints may be an important part of the care and diagnosis.

Yet posting a note that you don’t like your doctor’s personality, or his waiting room smells, or his magazines were lousy may or may not help you or anyone else.  You would think a doctor might be responsive to these Consumer Report reviews if he wants to stay in business and be popular, but most doctors I know are less concerned with being popular than they are getting through the day, doing a good job, and making all the finances work at home and on the job.

In fact, some of the best care is delivered in academic medical centers, which see all patients in clinics, regardless of their insurance coverage.  The less than posh waiting rooms and outdated magazines may not make you feel like the Queen of Sheba, but you may still be getting the best medical care available from some of the best doctors around.  Likewise, the most posh offices may be charging you more to keep up those appearances, but in fact, the care delievered may be no better, or even worse than that in less posh surroundings.

I think the public does not have a good idea what constitutes quality health care, and I think we can all fall for the shiny and posh exteriors as proxies for good care, when the exact opposite might be true.  After all, we go to the doctor for a reason, not to window shop (unless you are a hypochondriac.)  We judge the care by the few things we have to judge, and don’t always spend a lot of time evaluating the things that DO matter- how many cases does the doctor do?  What is their experience?  Do they regularly attend Continuing Medical Education classes?  Do they teach others?  Do they do research?  How do their peers evaluate them?  How does their staff feel about them?  Would they send their relatives to see this Doctor?  Would they recommend them to a friend?

Likewise, even doctors are struggling with quality of care issues.  When you are treating patients, there are so many variables- how does this patient respond to the medicine?  Did they call if they weren’t getting better?  Is my staff treating them well?  Is the patient compliant with their care?  Are they telling me the truth?  I may know the latest treatment, but is this patient in need of that, or would some lesser, and perhaps cheaper treatment be better and more cost effective?  Is quality of care always outcome determinative?  Sometimes people get bad  results- they scar more than others, they have complicated anatomy- things that may not be anyone’s fault, but medicine is not a factory where all outcomes are uniform and guaranteed successful.

I agree with these doctors that online rating systems for doctors are probably not good markers for quality of care.  But in the absence of medicine taking a stand in this area- in making things like board certification mean something to the consumer/patient, patients will naturally start taking matters into their own hands.

One last note-We went to a medical insurance system in this Country to try to get doctors out of the “money” part of the business and into the “care” business.  Instead of making all doctors small businessmen  having to worry about collections and business on top of medicine, the insurance system was supposed to act like a guarantee that doctors would be paid, so they gave you the care you needed without worrying about the money.  This had many unintended consequences, including Doctors practicing defensive medicine (leave no test undone- after all, it’s paid for by someone else) and not having to be conscious of  costs or cost containment until very recently.  It also created a whole layer of administrative costs associated with administering insurance, both at the practice,hospital, testing and insurance company end of things, adding to headaches for everyone involved.  (It sure created jobs, though!)

So what constitutes quality fo care for you?  What makes a doctor good? Bad?  how can we make patient feedback meaningful to physicians, but also relevant?  How do we construct a system that doesn’t serve as a way to assasinate a doctor’s reputation, argulably his most important asset, yet have a level of transparency and accoutnability that’s meaningful?

What do you think?

Tags: medicine, quality of care

Are Social Networks for Everyone?

A friend of mine asked what I thought about lawyers using social media tools for communication and networking.  I wrote a long email back, and it became clear there was a blog post brewing, so here it is- my thoughts on the use of social media for professions, specifically law and medicine.

Lawyers And Doctors – Special Considerations

Lawyers have a duty of privacy and privilege.  So we can’t just let it all hang out there, so to speak.  We have  an aspect of confidentiality in our business relationships with clients.  So we have to be careful, because many communications, especially when they are written or recorded, may become “discoverable”- that is, subject to a court ordered disclosure for the purposes of a lawsuit.  This may make some kinds of social networks more difficult online for lawyers in particular.  While a non-recorded skype call or video chat would not be discoverable, since there is no recording, if you send an email, record a conversation or chat, that may indeed become a record or business record subject to discovery rules under certain scenarios.

Doctors, on the other hand, have duties of patient privacy.  While it is less likely that all the communication back and forth will lead to a law suit, what would happen if someone relies on your advice over twitter, for example, and ends up having serious medical consequences as a result?  Were you engaging in treatment over the internet?  Were you practicing medicine in another jurisdiction without a license?  What are the privacy issues about talking about someone’s condition online?  These are things to at least consider.

Communication & Business Generation

Lawyers tend to communicate with others for two purposes- one is client or potential client communication, and the other is work based- referral, negotiation, etc. I might want to get to know other attorneys online so when, as happened last week,  someone I know through a social network needed a lawyer in another State, I had someone I already had a relationship with to refer the case.   So work can be generated for attorneys through sites like twitter, but it is secondary to the majority of the content contributed and gleaned from that particular network, on most days.

Other social networks would seem better suited for certain types of contact.   MySpace, for example, strikes me as a site you might choose for trying to generate business (somewhat like ambulance chasing) rather than make professional connections; Facebook is not bad, but there’s not too much to really do there that’s sticky and interesting- if there were some forums to discuss issues openly, it might be more useful, but as it stands, it’s basically a placeholder for me.

Linked-in is the professional site, and where I might start to search for referral out to other attorneys, but it’s not where I would go necessarily to develop a client base. Find an expert witness, yes; find new clients and make rain, no.

For medicine, on line generation for business and patients is tricky.  Medicine is largely a local service, and delivered in person, so you are casting an international net with these social networks who may not ever be able to benefit from your services.  Most of the social networks like Twitter, Facebook, MySpace and the like are better ways to communicate than to solicit services.  It is probably a great way to find other doctors and commiserate rather than generate business.

Likewise, Law is like politics- it’s largely a local concern.  Communities are best built locally – only the big class action cases should consider using facebook or myspace…… I think there’s lots of room for lawyers to talk to each other anonymously through a site comparable to what medical residents use to share war stories- ScutMonkey.com.  This kind of group support network can spawn new ideas, help you look at a problem differently, and blow off steam as well.  However, like everywhere else, you have to be really careful, because the whole world can listen in on your conversations, and Google picks up names, so it becomes searchable as well.

Education

There are very successful sites like Web MD that dispense information to patients, so patient education can be done effectively over the net.  Find Law is a similar site for law information.  Lawyers could consider doing more client communication  and education through web based tools like newletters, PDF forms and the like.  All of this can help clients and patients feel more valued and a part of the on going practice than they might otherwise through phone calls and meetings .

So- Use ‘em or No?

I think there’s lots of ways for lawyers and doctors to develop trust and relationships through things like twitter, which may become useful down the line, but it also pays to exercise caution using these tools.

But all of that aside, I think lawyers and doctors could be more open with each other. By talking they can learn and build relationships that could build referrals and business, by enhancing their trust relationships.  So many people are very naive about the law, contracts and the like, and building trust by just answering small questions on twitter or other social groups could generate tons of business- a client wants to know the person they are paying to handle their sensitive legal matters is trustworthy and they feel like they know them- it’s personal stuff to talk to someone about real estate, finances, estate plans, legal trouble, etc.

Similarly, being married to a doctor,  I prefer to feel the same sort of social bond with my doctors that  I like to feel with my lawyer(s) and legal friends- I want a more collegial relationship and a less paternal one.  We just have to separate out cooperation and competition, which is often hard in the legal profession, especially.

Professionals still need all the benefits provided by social networking, but this mode of communication poses risks as well.  If there could be some kind of insulated safe harbor of communication, it might actually allow people to be more open with each other, and there might be more movement in making law and medicine more human and transparent professions.

The days of pure reverence for these professions have passed, and it may be time to consider making the information more available.  After all, if you are confident in your abilities to practice your profession, it is unlikely telling someone how to do a hysterectomy will make their ability to do it themselves any easier.  Likewise, showing someone a contract won’t make it any easier for them to draft it themselves, consider all the possible pitfalls, and extricate themselves from disaster later on.

We still need expert prectioners in every field, because despite the DIY culture, we all simply don’t have the time, bandwidth, education or experience to do it all ourselves all the time.  Let’s just make the determination of quality easier to measure- that seems to be in everyone’s best interest.

Tags: education, law, medicine, social networking