On 12/7/2010 12:04 AM, Tim McNamara wrote:
In ,
Peter wrote:

http://www.nejm.org/doi/pdf/10.1056/NEJMsa0900592

"Results On the basis of responses from 63.1% of hospitals surveyed,
only 1.5% of U.S. hospitals have a comprehensive electronic-records
system (i.e., present in all clinical units), and an additional 7.6%
have a basic system (i.e., present in at least one clinical unit).
Computerized provider-order entry for medications has been
implemented in only 17% of hospitals. Larger hospitals, those located
in urban areas, and teaching hospitals were more likely to have
electronic-records systems. Respondents cited capital requirements
and high maintenance costs as the primary barriers to implementation,
although hospitals with electronic-records systems were less likely
to cite these barriers than hospitals without such systems."

This seems orthogonal to the discussion.

I don't think so. There is a very low adoption rate of integrated EMR
systems in the US. The barriers most commonly cited are initial cost and
projected operating cost, not inaccuracy, security or productivity
declines. Those who have implemented have a more positive outlook than
those who have not.


http://www.ncbi.nlm.nih.gov/pubmed/12773650

"CONCLUSIONS: The quality of care in the VA health care system
substantially improved after the implementation of a systemwide
reengineering and, during the period from 1997 through 2000, was
significantly better than that in the Medicare fee-for-service
program. These data suggest that the quality-improvement initiatives
adopted by the VA in the mid-1990s were effective."

http://www.ncbi.nlm.nih.gov/pubmed/1...t&holding=f100
0,f1000m ,isrctn

"Since 1995, the Veterans Health Administration (VHA) has had an
ongoing process of systems improvement that has led to dramatic
improvement in the quality of care delivered. A major component of
the redesign of the VHA has been the creation of a fully developed
enterprise-wide Electronic Health Record (EHR). VHA's Health
Information Technology was developed in a collaborative fashion
between local clinical champions and central software engineers.
Successful national EHR implementation was achieved by 1999, since
when the VHA has been able to increase its productivity by nearly 6
per cent per year."

The data to date suggests that EMR implementation in the US is pretty
minimal, and where it has been extensively implemented (e.g. VA), it
has significantly improved care and lowered costs.

Unfortunately for interpreting the data there has been a spectrum of
initiatives of which an EMR is only one part, as your own examples
indicate. As a result it is difficult if not impossible to determine
which interventions resulted in the improvements in quality of care.
Could EMRs contribute to improved quality of care? Possibly. I just
haven't seen it happen yet.

The VA apparently has, or so they claim. They're hardly a small system,
and they have a long track record with technology.

More arrogance, since you are assuming that computerization =
better health care. When health care is done unerringly by
computers, that might work out to be true.

It seems to be true according to at least some major studies. The
list of benefits is long. Your objections seem to be centered on
efficiency, but there is evidence that has been substantially
improved, also. If efficiency was actually lowered, it would be
rather unique across the very wide range of computer assisted
activities.

That's nice to hear. I haven't seen it; what I see is a lot of
providers sitting behind computers typing and clicking instead of taking
care of patients. I hear almost zero accolades for EMRs and a wealth of
compiaints. My perspective on it is that health care providers don't
treat computers, they treat people.

Yes, and productivity and accuracy are keys to providing better
treatment at lower costs.


I think that's a given. The only thing that appears to be
controversial is the gains in efficiency and cost/benefit. I would
expect that vets are at least as concerned about costs and efficiency
as human medics.

I think you are drawing unwarranted conclusions about the benefits of
EMRs and overlooking the problems. This may be the result of
perspective- you're a computer programmer and not a health care provider.

I am only citing reports in the public domain.

Why not design computers to capitalize on the characteristics and
economics of a highly sophisticated, well-developed pre-existing
documentation system?

To fully take advantage of the benefits of computerization data must
be standardized and encoded.

And has been so for a long time, long predating computers.

Not to the extent that is needed for effective use of computers,
including data exchange between systems. There have been fairly recent
initiatives, as you might expect, in the medical data standards area,
there's clearly the need.

This allows both easy data exchange between systems and automated
data processing. Those two benefits are enormous.

Except they don't exist. Data exchange between different EMRs is
cumbersome at best, if even possible.

Hence the need for further standardizations.

As medical facilities, by necessity, become more distributed and
specialized, the need to coordinate and share becomes proportionally
greater.

The trend, locally at least, is towards a more comprehensive range of
services on one campus rather that wider distribution and
specialization. There are good business and customer service reasons
for this as well as pressure from payers to make more services more
conveniently available for their insureds. Small distributed
independent practices are going away through attrition, affiliation and
mergers.

Consolidation seems to be a natural phenomenon in virtually every
industry -- economies of scale, etc. In my case, while my specialists,
hospitals (explicitly plural), primary care and diagnostic labs are all
part of the same system, they occupy geographically separate facilities.
This is Boston, a major medical hub, so I think it is pretty standard.
It's a real benefit to have all records available to all players. It
would be even better if my complete medical records were available to
other systems should I travel.

Virtually all commercial activities undergo continuous transformation
via technological innovation. That's what drives productivity, and
has for millennia. That medicine is somehow immune to this is naive.

That's not what I've been saying. What I am pointing out is that IME
the computerization of medical records has not been helpful to health
care providers being able to get their primary job done: providing
health care to patients. I'm not sure why you seem to think I am
somehow lying to you about my observations and experiences.

I am not accusing you of lying. I am responding to your charges of
inevitable inefficiency in EMR systems. My argument is that computer
systems are primarily driven by efficiency benefits (productivity).
Those gains have been reported in actual implementations such as the VA.

Medicine, in the US, via a number of mechanisms, is pretty much a
cartel.

Bull****. But you have to stop mixing things up to be able to
understand that.

HMO's and pharmaceuticals aside, there's the AMA, called by some "the
strongest union in the country". But the hospital/clinic/practice
segment is becoming rapacious in its own right:

http://www.newyorker.com/reporting/2...urrentPage=all


Among other things, it has done a poor job of improving productivity
and quality via technology.

Bull**** verging on delusional. Technology advances more rapidly in
health care than most other fields. The technology of EMRs- as they
exist now- hold providers back (again noting that I have never worked
with EPIC, which is the most commonly used hospital EMR around here, so
I can't comment on that one. It might be fine).

Technology has been applied in instrumentation, not (widely) in computer
records, medical decision support and quality measurement. Even in
instrumentation, the US is not a world leader, despite our leading costs.


Are EMRs all bad? No; few things are all bad. EMRs help the bean
counters, to be sure. They make inventorying medications, timing
procedures, billing, etc. easier (they also make it easier to propagate
mistakes: I found a hospital bill for my wife to have been inflated by
30% (yes, that's right) by computer-facilitated data errors. *Always*
get an itemized bill and read it line by line; in this case three
services were entered multiple times which were only provided once).
There is indication that computer technology can reduce medications
errors, which is a good thing.

As a group, it's a foot dragger, anecdotes aside, the overall numbers
tell an unambiguous, and damning, story. It's not all about HMO's and
pharmaceutical companies.

Most of it actually is.

Consider the Mayo clinic.

See Arizona organ transplants. It's the future.

I've missed out on this story.

http://www.tampabay.com/opinion/colu...-again/1138473

There is the matter of degree. Health care is principally involved
with serious physical and mental issues, other industries only
peripherally, hence the difference of degree in regulation.

There is a matter of degree. Thank you for realizing that nuance,
which was not evident in your earlier writings.

It's not a "nuance", it's the very core of the matter.

"A matter of degree" is nuance, pretty much the definition of nuance.
You still overlook the point that health care is not unique, by any
means, in it's ability to help or ruin your life; more people are harmed
every year by industries other than health care.

Again, I cite the Hippocratic oath. It's been obvious for millennia.


Even Medicare and Medicaid, with their low overheads, will break the
bank if efficiencies aren't achieved. The way forward is to improve
productivity in the same manner with which it has been improved in
virtually all other segments of both the service and product
economies -- with technology, mainly with computers.

Medicare is already 98% efficient, spending only 2% of its revenue on
overhead and 98% on paying for care. The delusion that you can avoid
breaking the bank solely through computerization is a pipe dream.

If the VA gets 6% cost savings per year via using computer technology
(as they've claimed), which is not unusual across many industries, then
it's no pipe dream.

Wringing out the overhead costs -- if there's ever the political will
-- is only a one-time event. Once overhead is reasonably low, it's
the actual productivity of the providers that becomes the only issue.

That's naive.

No, take your example of Medicare. With only 2% overhead, there's no fat
there left to trim. Further reductions in costs come from efficiency --
maximizing the outcome (benefit) per treatment (cost). That requires
coordinated exchange of accurate information between all involved and
close tracking of treatment and outcomes. You can't do that without
computers.

Productivity that extends to both treatment and prevention in a
coordinated way.

And that's radically incomplete. This is a lot more complex than you
appear to realize.

Yes, and the tool to manage complexity is the computer, not paper.

A kinder, gentler, more responsive, and less mistake-prone medical
system is all very nice. What is really needed is a much less
expensive system.

Pretty much not going to happen. The best that can happen is containing
the increases in costs over time. Even just looking at the demographic
reasons for increasing health care costs over the next 50 years shows an
insoluble problem in cost reduction. Unless you plan to massacre 50% of
the baby boomers as they hit 65.

You make the Malthusian argument, which is the default case -- unless we
rescue ourselves with technology. One major type of relevant technology
is the use of computers to manage the administration of medical care.
That includes aspects of communications, statistical analysis and
decision support, among others. The medical industry is not unique in
needing to do more with fewer human resources.


A system that can both heal and prevent at much greater efficiencies.
The US medical system is still pretty much in the past century
despite the fancy gadgets.

You're running your head into the wrong wall there. Health care is, of
necessity, a personal service of generally multiple providers per
patient (doctors, nurses, etc.).

Yes, and the number of different types of providers and the required
coordination keeps increasing -- that is a problem of complexity --
something computers are very good at, humans, not so much.