

Electronic medical records don’t save money - jessaustin
http://blogs.law.harvard.edu/philg/2013/01/11/electronic-medical-records-dont-save-money/

======
famousactress
Let's not conflate the theoretical (and very achievable) advantages, with the
shit being peddled to date. The current state of available systems is really
abysmal, and I'm sure it's true that using any of most of the systems on the
market won't save you money.

 _"Fundamentally there is not as much value to be obtained by having the
ability to do a structured query into multiple patients’ data. Nor is there
much value in being able to do a structured query into a single patient’s
data."_

I supremely disagree with this point, _especially_ the first bit.
Specifically, the author is comparing the labor of him looking for information
he's thought to look for in one or more patient's records via computer or
paper, and finding them similar. That's the sign of a completely failed
system. Most EMR systems are built to act like the file cabinets they replace,
which is a shame. Meanwhile, my mint.com account sends me emails when I'm
charged an ATM fee and facebook knows way too much about my current interest
in purchasing a juicer.

I believe the unrealized benefits of automated predictive, proactive, and
historical analysis of patient health data is _enormous_. The author is
excused for disagreeing with me though, because presumably billions of dollars
at this point have been poured into building software that rivals late
nineties Visual Basic POS systems in quality and effectiveness. There's so
much untapped potential here it's unreal. It's just such a shame that the
Health IT industry has eroded the patience of caregivers over the last decade,
especially ones who were eager to explore the possibilities early on.

[Full disclosure: I build electronic medical record systems for a living -
<http://www.quora.com/What-product-is-ElationEMR-building>]

~~~
mcphilip
I worked on a browser based full fledged EMR (i.e. Charting, Billing,
Scheduling, etc). Besides being an enormously complicated software system in
general, there were many factors related to consumers' usability of the
product in a real time interaction with patients.

For instance, we built IMHO beautiful note taking app where doctors could free
text in notes taken from patient consultation. The beauty of the system is it
had a large natural language parsing backend that would help highlight parts
of the notes that could be codified in a system such as ICD9 or SNOMED. There
was even a rich templatimg system allowing doctors to pull up a note template
for something like chest pain and then the system would prompt the doctor to
fill in the relevant codifiable sections.

It demoed great to physicians interested in an EMR, but in practice, doctors
did not like the extra effort required to record a real time interaction in a
codifiable way. I'm not sure what's to blame: EMR usability or hospital
staff's lack of time and training to document patient care in a standardized
format.

Like Google said, Health care is hard...

~~~
dazzawazza
I know a few doctors in the UK and they don't understand two things:

\- they are a reasonably efficient expert system

\- large scale data mining can find patterns of behaviour and disease that are
impossible to find any other way.

Point one can partly be explained by the fact that as a society we rightly
respect doctors and as humans over the years they take it to heart that they
really are quite special. They also rightly diagnose hundreds of common
illnesses a week which boosts their ego.

Point two is a common problem for people outside of the tech world. Doctors
are used to small studies growing to large studies about a specific illness.
They do use meta studies and use large scale statistics to medicate (everyone
over 60 gets cholesterol medication etc) but that is the exception. They don't
understand that an abstract statistical analysis of patient records could
deliver gold.

So when asked to codify patients notes (something they have to do in the NHS
using a ridiculous DOS based app, with over the top word templates for paper
forms) they resent it. They don't feel the advantage of this. When the system
controls their flow they feel like they are robots and that this gets in the
way of their treatment of the patient.

It pains me to have to explain to them that they are, for the vast majority of
patient interactions, meat robots. For 99% of their interactions they are
slower and less accurate than an expert system (although of course the doctors
I know have a more pleasing interface than a robot).

They can't see that if the burden of the 99% was lifted they could genuinely
help their patients by having more time. Instead they insist awareness
campaigns are the way to go: "If less people came in to the surgery with a
cold we could DOUBLE the time they spent with patients"

------
lostlogin
This person has clearly never worked in a stressful trauma unit. I have
actually tried the google docs and drop box think in an outpatient clinic, and
it is terrible. People accidentally delete things (sure you can get them back
but the non-it person at the coal face wasn't able to). Records get written
over and multiple people try to edit the document at the same time and
conflict with each other. People forget their logins and then ask you for help
working out their password (quote: shall we just ring them?). People accident
sign the wrong email address up and distribute access to the wrong person.
Privacy? Forget it. Data is stored offsite. Dunno where. Who is accessing the
data. Unsure. Does it auto logout? Depends. Piecemeal electronic record
systems are bad, but consumer focused solutions are far worse. The trauma unit
isn't interested in population cholesterol or stuff like that. They want
platelet levels now. X-rays now, CT Report, before now. Google and dropbox
weren't made for this, and don't work on a day to day basis. I've tried. Edit:
typos. This subject makes me frothy mouthed as the commentator has valid
concerns, terrible suggestions. Try it and see.

~~~
jessaustin
I appreciate your experience (and it's good to learn that using these tools in
the outpatient clinic didn't violate any regulations) but I don't think Phil
is really suggesting Google Drive specifically here. He's suggesting instead
that medical records should be more like a blank page (document) that
physicians can fill in than e.g. a FoxPro app (dbms). Personally I think the
"ideal" would fall somewhere in between. Physicians should probably be allowed
to keep records however they like, but lives would be saved by the structure
of a well-implemented [what a caveat!] digital checklist system.

~~~
lostlogin
One of the killer problems we have is that a huge local hospital (servicing
probably several hundred thousand in population) won't give us any real access
to their RIS and PACS, despite us doing lots of scanning for them. We have to
get previous imaging and notes delivered on CD and DVD which is probably the
worst type of digital info transfer possible. Even if we did have access it
would likely take the IT team a few weeks to cobble together something that
worked for us end users, but that would be an amazing improvement. We just
finished a spell using google drive - oh wow it was terrible. I live in New
Zealand btw.

------
joeyo
From the RAND report [1]:

"Some exceptions prove this rule. One of most successful health IT systems in
use today is the Department of Veterans Affairs’ Veterans Health Information
Systems and Technology Architecture, which actively engaged clinicians in its
development process.25 Health IT is widely credited with helping transform the
Department of Veterans Affairs into one of our nation’s highest-performing
health care systems.26–28"

Something like 8 million people are managed by the VA records system [2].
Perhaps a solution would be to expand this existing system, with a
demonstrated track-record, to the broader population.

1\. <http://content.healthaffairs.org/content/32/1/63.abstract>

2\. <http://en.wikipedia.org/wiki/VistA>

~~~
sjg007
It would be but big companies (like IBM) lobbied against it.

------
jpdoctor
> _But where is the value to the patient? Does it help to have Patient A’s
> cholesterol information in the same database table when treating Patient B?
> No._

This is incorrect. Phil might have experience from the DB side, but apparently
not sufficent experience from the patient side.

One example where it has major value for the patient: While contemplating a
heart valve replacement at age 71, a recent patient had many conflating
factors (diabetes etc). What is the previous history of people with the same
conflating factors surviving? How about surviving but only with a ventilator?

Only after considering the DB of about 100K entries did the patient decide on
the valve replacement. (I'm happy to report she came through with flying
colors.)

~~~
carbocation
If you care to disclose, are you at Vanderbilt? I ask because this is one of
the few places (known to me) to have such a large, query-able database and I
am curious to learn about others.

~~~
jpdoctor
The location was Yale-New Haven.

To be clear: It wasn't me running queries, I was hearing about this second
hand.

~~~
carbocation
Thanks! What's hilarious is that I was literally there today and they didn't
mention this extraordinary capability during the entire 8 hours I was there.
Talk about missed opportunities!

~~~
jpdoctor
This was one of the links from the discussion:
<http://riskcalc.sts.org/STSWebRiskCalc273/de.aspx>

The tl;dr = Society of Thoracic Surgeons reduced a dataset and built a
website. For people dealing with some pretty heavy heart issues, it's a damn
useful item.

~~~
carbocation
We definitely used that site clinically (STS risk score) when I was rotating
through the CVSICU at JHH. I don't usually barf out whatever I'm thinking, but
I figured some people on HN would also be interested to know that this is
actively used.

------
ChuckMcM
I missed the part where they said how the savings were expected to be realized
and weren't. I got that a complex system might cost $1000 per patient, but
that isn't even one month's "health care" fee for a family of four, much less
the cost of healthcare for the patient over the 5, 10, maybe 30 years they are
visiting the doctor. I also missed the point where creating new structured
documents out of existing structured documents was harder to do than
constructing structured documents out of unstructured documents. And I missed
the part where the quality of care in terms of unnecessary tests or procedures
was compared at hospitals with such systems and those without. Other than that
it seemed pretty reasonable, and that Bill Gates was commenting was
interesting.

~~~
jessaustin
Most families spend less than $1000/month on medical care, on average. Even
for those that spend that much, presumably much of that pays physicians and
nurses and buys drugs, rather than paying for IT. It would be difficult to
sell e.g. Ford Motor Company on the idea that since people pay $25k for the
average car, they should be happy to spend about $25k/customer on IT. The
other things you "missed" seem oddly beside the point.

~~~
ChuckMcM
Your right of course, it was more rant than argument.

The paper claims that $1000 per patient is extortionate as compared against
the 'free' cost of existing web based tools. However it never supports that
claim except through that single comparison. Thus, I am not persuaded that
$1000 per patient is extortionate.

Lets take that cost as legitimate. The structured system exists for the life
time of the patients who use the hospital, so understanding that cost requires
understanding how the cost of that system is recouped over the lifetime of the
patient. Picking three cohorts, a 5 year patient, a 10 year patient, and a 25
year patient, they would have lifetime costs of $16/month, $8/month, and
$3.33/month to recoup a $1000 cost to both enter them into the system and pay
for the system (these costs weren't split out in the article).

One of the arguments for electronic records is a reduction in unneeded tests.
So for example when Bob comes in for a physical do you order a cholesterol
test or not? If the previous test is still valid, you don't, but if you miss
the previous test in the record? The doctor re-orders the test "to be sure."
which occurs because insurance companies can find you partially negligent if a
test was available and you didn't order it but should have.

In order to quantify the 'value' of electronic records, either structured or
un-structured, you really have to compare the patient costs for hospitals with
such systems and those without. And any thorough treatment of that question
would also cover the ingress process of a new patient coming from a hospital
with a function structured electronic record capability and one without.

I can see why its hard to see that this was what I was saying in my original
comment.

~~~
jessaustin
Thanks for the explanation! I accept that healthcare is different than other
industries, but even the lowest IT cost/month you cite seems exorbitant for a
customer you're not billing on a regular basis (and many people can go decades
without entering hospital). IT is a cost center, and this is just too much
cost.

~~~
ChuckMcM
True things are different in different places. But in the US most healthcare
is part of an employment package and as an employer I'm paying every month to
our healthcare provider whether or not my folks actually get any services.

------
darkarmani
This is a classic argument from ignorance:

"Fundamentally there is not as much value to be obtained by having the ability
to do a structured query into multiple patients’ data. Nor is there much value
in being able to do a structured query into a single patient’s data."

ie: I can't imagine anyway to do these queries that derives value, so
fundamentally there is no value.

I'm far removed from the healthcare industry, but I'm absolutely positive
there are correlations hidden in those files. How would you ever spot
commonalities between similar patients' histories without structured records?

~~~
bcoates
The question isn't how many correlations are in the files but how many of them
are real. Medical records aren't a random sample and have no controls.

------
armored_mammal
I agree the systems in use seem horrible and expense from a cost, engineering,
and IT perspective, but I'm also a big fan of my doc being able to see my
records in digestible format, IE graphs showing a series of test results over
time and such, rather than just 20 pages of paper to eyeball in a hurry and
hopefully spot a trend. Or the old situation where you'd inevitably be asked
about a test or other visit and they'd have to get results and such faxed over
to look at later basically wasting the whole visit. "Oh, sorry, we haven't
received the x-rays/blood work/random other diagnostic, referral, or test
yet..."

Now most times they just bring it up on their computer and are like "oh, I saw
you had X done 2 weeks ago, no sense in doing it again..."

But that's possible because all my providers are using the same system.

------
ef4
As somebody who's trying to build a startup in this space, I'm not surprised.

The root problem I see is that emphasizing "records" is completely backward.
Making health records electronic is about 5% of the real work.

The real value is all in building systems for effective collaboration and
operational excellence. Records are almost a byproduct.

My pilot customers have measurable money savings. And my product isn't even a
"full-fledged electronic health record", because that's rather beside the
point for my customers. Their problem isn't fundamentally about records, it's
about coordination between pharmacists, nurses, health aides, and
administrators.

~~~
betterunix
You know what would really be great, and would almost certainly save money? If
prescriptions could be done electronically. I am amazed by what it is like to
get a prescription medicine, especially Schedule II -- the doctor types a lot
into a computer, then puts special paper into a printer, prints it, hands it
to me (and now we will just assume I cannot figure out how to copy it), then I
walk to the pharmacy and what happens? They look at the paper, type more
things, and then I get to wait 15 minutes for the medicine to be dispensed.

Now, what if instead, my doctor would type in the information, and then either
(a) prints a QR code that I can just bring to the pharmacy or (b) asks if I
will be using the same pharmacy as last time, and has the prescription sent
their automatically, so it is waiting for me when I arrive? Let each doctor's
office create a prescription record in some database, and let each pharmacy
update that database when the prescription is filled -- why rely on copy-
evident paper, when we can rely on computers instead? We could even connect
this to an EMR system, so that doctors not only know what a patient was
prescribed, but whether or not the prescription was actually filled (when I
was last prescribed an opiate painkiller, I never filled the prescription; yet
my followup appointment involved the receptionist printing a sheet that showed
the prescription, with no indication one way or the other if I had bothered
with it).

I understand that regulations and so forth and probably the doom of these
ideas. Still, it would be nice to get something a little better than the
ludicrous anachronism we have today.

~~~
leonth
What you describe here has been happening in Singapore public sector for quite
some time. Most patients in a hospital will fill their prescriptions in the
hospital pharmacy anyway to enjoy subsidies.

Some patients still prefer to have some kind of paper with them, so the doctor
will actually print out the prescription but the pharmacy will still process
it from the system anyway. When the pharmacy is not busy, we will also pre-
process pending (and short) prescriptions from the system and the patient
would not need to wait that long for the medicines. It's also a boon for the
pharmacy operations because they can smooth out workload throughout the day by
pre-processing prescriptions before the peak hours.

------
DanBC
What health care records really need is a set of RFC-like standards documents.
These documents would define the information that a health record must have;
or how interrogations of the database should behave. You make sure you include
a requirement for the data to be transportable. Once those documents have been
done you allow the market to create the software and hospitals (etc) to buy
the software.

The UK had a ridiculous mostly failed system that cost £12 billion for a
population of about 60 million people. A lot of that is from the UK
traditional terrible huge it project implementation, but also from a top-down
approach by people who didn't really know what they were doing.

> Let’s consider what an unstructured electronic health record would look like
> and cost. You’d create a directory in Google Drive or Dropbox and give
> doctors and hospitals access to this directory. Physicians could type into a
> shared Google Doc with other physicians or upload scanned output from tests,
> etc. It would be paperless, organized, and electronic, but not very
> structured.

With medical records you need to know who has accessed them (when and why);
who has changed them (and if they had the permissions level to make changes
(eg, receptionist can change appointments, doctors can change prescribed meds,
nurse can add test results); who has the notes now (and lock the notes for
single person only); all of this needs cryptographic signing. (Because people
die when doctors make mistakes, and doctors do make mistakes.)

"Chuck it on dropbox" is a bafflingly bad idea.

~~~
drivingmenuts
You mean standards like:

[http://en.wikipedia.org/wiki/Electronic_medical_record#Techn...](http://en.wikipedia.org/wiki/Electronic_medical_record#Technical_standards)

those?

Or do you mean yet another standard that supposedly solves all the problems,
ala The 15th Standard?

<http://xkcd.com/927/>

~~~
DanBC
Your point is weaker when the link you provide starts

> _Though there are few standards for modern day EMR systems as a whole_

------
chrismealy
They do for VA hospitals, and improve care:

[http://www.washingtonmonthly.com/features/2005/0501.longman....](http://www.washingtonmonthly.com/features/2005/0501.longman.html)

------
tom_b
Much of the EMR system I deal with was built primarily to address billing
rather than patient care. The structured data (ICD-9 codes, service dates,
etc) exists for that. The crufty part of the system is related to patient test
results and other information (pathology reports related to tissue
evaluations, etc).

So, the data that is tangential to patient treatment is highly queryable, the
data related to patient status is mostly free text. Worse yet, the free text
does not follow much of a "standard" entry form - whoever entered the text
followed, at best, a departmental standard, at worst, just some quick thoughts
randomly sprayed into text.

But even that terribly inefficient and crufty free text is highly useful to
staff (MDs, nurses, etc) when reviewing patient treatment during, say, tumor
board meetings discussing specific cancer treatments and patient status.

What might be really nice would be to divorce the two functions - separate
billing/scheduling from other information. For the patient treatment/status
data, there is some fine line in the data model with having some structured
data, plus (probably) some flexible key/value annotation system.

One killer issue is that given any software tool, medical staff is smart
enough to bend it to do what they want, rather than what it was designed for,
if that makes sense.

------
jessaustin
I fear that as the practice of medicine is increasingly centralized and
depersonalized, such quaint questions as "what would be cost-effective?" and
"what would be good for the patient?" will be made increasingly irrelevant.
The rest of the software industry should carefully consider this case before
emulating the "lobbyists as salespeople" model.

------
jack-r-abbit
The author wrote this in the comments in response to a reader's comment about
the value of structured data: _But reflect that a U.S. doctor might earn
$600,000 per year, the nurse’s salary might be $120,000 per year, and the same
task could be accomplished by a worker in India or Cambodia, starting from the
unstructured data, at a cost of $2 per hour._

Let's assume I didn't already think this guy was way off the mark... that
comment right there makes me think he's just an arrogant twat. Never mind the
huge privacy nightmare of having some "$2/hr worker in Cambodia" sifting
through our medical records on Google Drive.

------
qwerta
Suggestion to use Google Docs for medical records published on Harvard.edu?
Ehm...

------
mchahn
I don't care what it costs or whether it saves money or not. I just want to be
able to walk into a medical office and not fill out all the damn forms over
and over again.

------
rwmj
Also: Electronic medical records are far easier to steal than paper records.
By steal I mean invisibly copy, en-masse, remotely.

~~~
n09n
They are far harder to steal on a small scale, though.

~~~
rwmj
Are they? Keylogging software is widely available.

~~~
n09n
It's still not as available as grabbing a piece of paper when nobody is
watching.

------
chrismarlow9
It only saves trees, time, data loss, and death by decimal. But hey, we
haven't found a solution to the problem in 10 years, so we should probably
just quit trying.

I think fear of change in dinosaurs is stopping this. Respected doctor = lots
of school + lots of practice = old age.

------
rikacomet
Well, the particular systems that have been proposed might not be that cost
effective, but it doesn't mean, that to pursue for a cheaper more effective
electronic record is wrong. Putting things in google drive might be quite safe
in most ways, but it would still effect patient privacy in long run, mainly
because each year millions of accounts are unlawfully accessed due to guessed
or phished passwords. Doctors included, as at the end of the day they are
still humans.

~~~
lostlogin
Just to add to that, I'd estimate that patient records are accessed far less
by doctors than by allies health staff, booking clerks, receptionists and such
like. Te actual time in front of a doctor is small compared to the amount of
time everyone else accesses records. The system for booking in one CT where I
work would have probably 5 people see the record, one being a doctor.

~~~
rikacomet
indeed, but most of them are from medical field or allied fields, people who
have gone through tons of records, and don't really care to snoop anymore even
if they unprofessionally did in the past. But putting it on the internet, even
if its in the corner, strict no-no. But I wouldn't mind to say this that the
person who wrote that article didn't actually do that bad, because its of
course natural to perfectly identify a mistake yet not being able to perfectly
suggest a alternative. So yeah, he got a point somewhere.

~~~
lostlogin
Sorry, rereading what I wrote (argh, typos), perhaps I've been a bit unclear.
I don't mean to imply that any of the record viewing is unprofessional
(although I know this does occur). The 5 people viewing with only one being
the doctor is professional and appropriate. One person books the scan, another
greets them and enters their details into the RIS, another scans them, another
sees them off, takes payment (or confirms who is paying) another reports the
scan, another types the findings, and then someone distributes the findings
once authorized by the reporting doctor. Sometimes these roles are filled by
the same person (eg typist greets patient, takes payment and types the
report), but the point is, there are many steps to the service and appropriate
use of the patient record requires many people to have access to it.

------
anactofgod
Electronic medical records don't save money... yet.

Mr Greenspun left of the trailing "yet" from the title.

------
gte910h
They don't save money...YET. Give it 10 years.

------
Crake
"Electronic medical records don’t save money"

If you implement it retardedly, of course they won't. It's just what they were
doing before (different formats and methods making it impossible for the hand
to know the leg is doing, in terms of communication between multiple or even
within a single organization) except with the added layer of electronic
technology that means even the people within a single institution won't know
how the hell to use it.

10000x this for a profession centering around doctors, since so many of them
believe the world of knowledge hasn't changed since when they graduated
medical school back in 19xx. :/ They are unaccustomed to accumulating new
methodologies as a result of recent advancements.

