EMR

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EMR and Second Opinions

September 16, 2010 in Healthcare IT | No comments

Electronic medical records have been touted as producing large gains in efficiency.  In fact, Kaiser Permanente has invested $3 billion in EMR.  One drawback of EMR, however, is that the value of second opinions may fall.  Instead of coming to a new physician with a clean slate or at the least seeking a fresh interpretation of a test, ‘second-opinion physicians’ in the same physician network will have access to the original physician’s diagnosis.  This may bias the doctor towards agreeing with the original interpretation of the patient’s condition.

To what degree do ‘second-opinion physicians’ currently have access to the diagnosis of the referring physician?  If they already have access to the original doctors notes or frequently call this physician to consult with them, the advent of EMR may not change the bias of the second-opinion physicians.  In fact, access to better information may improve the quality of second opinions.  On the other hand, if the increased amount of information available to the second physician changes their thought process, then they may be more likely to agree with the original physician.

Is this one of the cases where more information is actually a bad thing?

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Getting Electronic Medical Records Right

August 15, 2009 in Uncategorized | 2 comments

Currently, only 1.5% of U.S. hospitals have electronic records systems covering all their clinical units; an additional 7.6% have systems in at least one such hospital unit (Jha et al. 2009).  This low EMR usage rate is astounding, especially since the RAND Corporation found that using EMR could save up to $77 billion annually.  The Wilson Quarterly notes that the Obama administration has promised to invest $19 billion in order to institute electronic medical records in the U.S.  Problem solved?

Not so fast.  In a world where technology changes at warp speed will government-certified EMR systems soon become obsolete.  Will hospitals decide to go for the HDVD version of EMR when a “BlueRay” EMR will emerge victorious?  Instead, a paper by Mandl and Kohane use the Apple iPhone as a more flexible model for an EMR platform.  An EMR that would allow additional “apps” would allow for a more flexible EMR standard.  However, balancing this flexibility with patient privacy needs and a common EMR language for all hospitals and clinics remains a significant challenge.

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Will technology kill health care?

October 21, 2008 in Healthcare IT, Technology | No comments

Information technology has the possibility of greatly increasing the efficiency of health care.  EMRs can reduce the cost of accessing patient information.  New technologies can make medical devices more effective.  

But is there a cost to increased medical technology?  GigaOM wonders

“...will widespread diagnostics increase the burden on healthcare? Somewhere between 10 and 50 percent of autopsies reveal diseases other than the one that killed the patient. If consumers test themselves, then tell their doctors, the medical system could wind up treating 50 percent more diseases than it does today — even those that wouldn’t have killed the patient.”

Will treating diseases before they appear increase health care quality or just drive up costs?  On the future will reveal the answer.

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Is American Health Care Inefficient?

September 24, 2008 in HC Statistics, International Health Care Systems | 2 comments

Economists generally define efficiency in two manners: productive efficiency and allocative efficiency.  Productive efficiency means producing a good or service using fewest inputs.  A car company who produces a car that costs $20,000 to manufacture is less efficient than a company that can produce that same car (at the same quality) at a cost of $15,000.  Allocative efficiency is more subtle.  Are we producing the right amount of cars compared to trucks?  As gas prices rose, allocative efficiency compelled many car makers to shift to smaller passanger cars and hybrids compared to trucks.

Alan Garber and Jonathan Skinner (2008) apply the dual concepts of productive and allocative efficiency.  They ask: is the American health care system efficient?  The authors find that the American health care system is inefficient in both a productive and allocative sense.  The health care provided in other countries, however, is also inefficient, often for different reasons.

Productive Efficiency

Not providing low cost, high quality care or prescribing unnecessary treatment both decrease efficiency.  “There are sins of omission–one recent U.S. study suggested just half of recommended care is provided in a typical primary car visit (McGlynn et al. 2003)– as well as sins of commission–the spinal fusion surgery that provides marginal relief and more complications compared to conservative management (Rivero-Arias et al. 2005).”

Table 1 from the Garber and Skinner paper compares some key healthcare statistics between the U.S., Canada, France, Germany, the Netherlands, U.K., and Japan.  Any evaluation of a health care system must take into account the health of individuals before they are treated by medical providers.  Americans have the highest levels of obesity and diabetes and lowest levels of smoking in the world.  Further, rates of motor vehicles accidents and homicide are high compared to those in the rest of the developing world.  After taking these baseline population characteristics into account, is the production of American medical care efficient?

Table 1 also show that the U.S. has low levels of EMR usage and high administrative cost.  Elderly influenza vaccination, however, is fairly high compared to other developed nations.

An interesting survey by the McKinsey Global Institute looks at the cost and outcomes for 3 procedures (gallstone disease, breast cancer and lung cancer) in Germany, the U.K. and the U.S.

“In each case the United Kingdom was more parsimonious in its use of resources for the management of each condition.  However, Germany, not the U.S., use the most resources in the three conditions in which it was included.

In the treatment of lung cancer, patients in the U.S. experienced better outcomes than those in Germany and far better than for patients in the United Kingdom.  For breast cancer, outcomes were slightly better in the U.S. while for gallstone removal, the United Kingdom had worse outcomes than the U.S. or Germany.  Germany in turn had slightly better outcomes than the U.S. but much greater resource use.”

Allocative Efficiency

Allocative Efficiency determines whether health care spending is at the correct level.  Should we increase health care spending or instead spend those resources on education, roads or R&D?

Table 1 shows some statistics to quantify the allocative efficiency of the U.S.  Physicians per capita in the U.S. is in line with that of other nations, but this does not reveal the U.S. preference towards utilizing more specialist physicians than generalists.  Hospital beds per person is fairly low in the U.S., but this statistic hides the fact that the U.S. uses more outpatient facilities and that hospital care in the U.S. is more resource intensive than is the case in other countries.  Surgery wait times in the U.S. are fairly low, but many 20% of Americans receive unnecessary medical care.  Further, the American reduction of preventable deaths was the lowest of any country in Table 1.

While the U.S. does have a famously high MRI rate of 26.5/million, Japan loves the MRI machine the most.  The Japanese MRI rate is 40.1/million.  “The cost structure of …[high-tech] treatment seems ideally suited to rapid diffusion in the U.S.: high fixed cost of installation, low marginal cost of operation, and reimbursement rates based on average rather than marginal cost.”

Conclusion

The Garber and Skinner paper provides a nice overview of the American health care system compared to those of other countries.  While the paper works mostly in generalization and country-level statistics, it does provide a nice framework for thinking about health care reform.  The American health care system is certainly inefficient, but so are the health care systems in other countries.  How inefficiency manifests itself depends on the health care system adopted by the country.  In the U.S., inefficiency is mostly due to the fact that “the U.S. typically does not consider effectiveness relative to its costs or to the costs of alternative treatments.”  Further, because of the fee-for-service compensation system, American patients have high quality care available to them, but at a high cost.  Further, fee-for-service compensation induces providers to recommended unnecessary or less cost-effective care to patients.

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An EMR that protects your privacy?

March 3, 2008 in Healthcare IT | Permalink

Electronic medical records (EMR) hold the promise of vastly improving the quality of medical care received in the U.S. today. One of the major issues with EMR is privacy however. Patients generally want their doctors to know as much about their health as possible in order to make the best possible medical diagnoses and treatment decisions.

Yet who should you trust with your EMR? Physician groups are generally too small to efficiently implement EMR. Further, if you switch doctors, most patients want their EMR to follow them. What if the health insurers are put in charge of the EMR? This may make the most sense, but some health insurers can use the EMR to learn more about the health of their enrollees. While this seems like a good thing, when a certain enrollee gets sicker, they may decide either to increase their premiums or to try to drop their coverage. A clear conflict of interest exists here.

What about a third party EMR vendor? Google and Microsoft both are offering EMR services. But do you really want one of these enormous corporations selling your most personal medical information to other companies?

One solution to this problem is Keyose.com. Created by Dr. Julio Bonis, Keyose is a completely anonymous EMR service. Here’s how it works:

  1. Users sign up and enter their personal health information.
  2. A username code is generated along with a public and private password. The public password is printed on an ID card that doctors can use to access medical information. The private password enables users to update their medical information. Further, Keyose allows patients to use their private password to enter confidential medical information that people with the public password (e.g.: physicians) will not be able to view. This allows patients to manage their own health care information.
  3. You do not enter personal data (e.g.: not your name or an e-mail) when you sign up in Keyose. Thus, you will not receive any marketing materials. Even if a hacker breaks into the system, they will not be able to match your medical information to your name or email.
  4. Finally, it is free to sign up.

As you know, there is nothing in life that is free. How does Keyose plan to fund this project? According to their “Help” section:

In the future we could include information about sponsors (including private health insurance companies, pharmaceutical or biomedical industries) mainly intended for doctors who access the personal health records. We could also charge for premium services (for instance translating the personal health record for international patients or providing contextual information about a patient’s diseases).

There are drawbacks to this patient-based EMR. Patients do not use the same jargon as physicians and, thus, much important information could be lost in translation between the physician and the patient. Also, the information is uploaded by the patient, and not physicians, nurses, or trained staff.

I tried out Keyose myself. It was pretty basic and could have used more pre-defined fields (currently there is only DOB, gender, blood type, allergies, and personal and family history). Specific fields detailing whether or not you have certain allergies, or whether you have received certain vaccines would be helpful. Also, I could view the confidential information section even when I logged in using the public password.

Nevertheless, Keyose does seem like an step in the right direction.

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Google Health

February 21, 2008 in Current Events, Healthcare IT | Permalink

Google is everywhere. CNN reports that Google is venturing into health records biz.

“Google Inc. will begin storing the medical records of a few thousand people as it tests a long-awaited health service that’s likely to raise more concerns about the volume of sensitive information entrusted to the Internet search leader.

The pilot project to be announced Thursday will involve 1,500 to 10,000 patients at the Cleveland Clinic who volunteered to an electronic transfer of their personal health records so they can be retrieved through Google’s new service, which won’t be open to the general public…

The third-party services are troublesome because they aren’t covered by the Health Insurance Portability and Accountability Act, or HIPAA, said Pam Dixon, executive director of the World Privacy Forum, which just issued a cautionary report on the topic.

Passed in 1996, HIPAA established strict standards that classify medical information as a privileged communication between a doctor and patient. Among other things, the law requires a doctor to notify a patient when subpoenaed for a medical record.

That means a patient who agrees to transfer medical records to an external health service run by Google or Microsoft could be unwittingly making it easier for the government or some other legal adversary to obtain the information, Dixon said.”

The New York Times blog BITS also has a post about Google Health as well.

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EMR: Promise and Problems

December 19, 2007 in Healthcare IT | 3 comments

Implementing electronic medical records (EMR) have been elevated to a top priority by healthcare policymakers. Using EMR, medical providers may be able to improve quality and better detect adverse events.

One way to improve quality with EMR is chart abstraction. After a physician-patient encounter, the doctor can review the medical chart to see if he or she prescribed the correct treatments or advice to the patient. This quality improvement methodology is certainly feasible without EMR, but is made much easier and inexpensive when patient records are held electronically. A paper by Luck et al. (2000) claims that chart abstraction may not capture all quality measures. In fact, chart abstraction typically underestimates the quality of care provided. This is likely due to the fact that physicians do not write down every minute detail of the visit and thus quality may be underestimated. Another issue is recording bias. “Busier practitioners may do more than they write down or good recorders may not be careful history takers (or physical examiners).” Plus, one must realize that a patients medical record serves multiple purposes. It is not only a medical document, but a legal record and a source of billing information. These facts may compromise the integrity of the EMR (e.g.: DRG creep).

A paper by Bates et al. (JAMIA 2003) claims that chart review or chart abstraction is overall a good technique, but may be too expensive for routine use and may fail to detect may adverse events. The Bates paper reviews a number of studies looking at electronic tools such as “event monitoring” and “natural language processing” which can help to detect problems before they occur.

EMR are only useful if physicians actually use them. A study by Miller and Sim (Health Affairs 2004) find that “the path to quality improvement and financial benefits lies in getting the greatest number of physicians to use the EMR (and not paper) for as many of their daily activities as possible. The key obstacle in this path to quality is the extra time it takes physicians to learn to use the EMR effectively for their daily tasks.” EMRs are only useful if all relevant data are included in the EMR. If most information is documented, but a physician records a patient’s allergies in the paper, but not electronic chart, there could be serious adverse medical affects. The Miller and Sim paper also proposes some solutions of how to best implement EMR.

Another unforeseen side-effect of using EMR that physicians will spend more time typing and gazing at a computer screen and less time interacting with the patient. A study by Margalit et al. (2006) finds that in Israel, “physicians spent close to one-quarter of visit time gazing at the computer screen.” The computer may enhance record keeping, but it also may diminish dialogue.

Finally, whenever EMR are implemented, they must be integrated in to the current systems in use. The new EMR must be integrated with the technology currently in use and well as the social system in place. One must also take into account the technical and physical infrastructure in place. For instance, Harrison, Koppel and Bar-Lev (JAMIA 2007) document that implementing computerized physician order entry at one children’s hospital “reduced beside nurse-physician interaction about critically ill infants. Nurses had fewer opportunities to provide feedback that sometimes led to beneficial medication changes.

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