Many Hospitals Resist Computerized Patient Care

NY Times ^ | April 6, 2004 | MILT FREUDENHEIM

[neverdem]

Chicken scratch penmanship causing fatal prescription errors is not the only issue. While making docs look like lazy Luddites and the hospitals like cheapskates, the article ignores the fact that many docs can't type other than hunt and peck, the software is less than perfect, and the confidentiality of patients' medical history is potentially compromised once it is online.

Patients may even be less inclined to reveal important parts of their medical history. Drugs that are only indicated for only one particular diagnosis automatically reveal that diagnosis, e.g. AZT, therefore AIDS.

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[neverdem]

PING

[Born Conservative]

I work for a fairly large health system in the Northeast, and we implemented an EMR (electronic medical record) about 3 years ago. Everyone bitched about having to change, but now we would find it much worse to go back to the old way-handwritten notes. Our employer is very strict about confidentiality and does enforce it; if you have no business in a particular patient's record and you are found to have looked at it, then "don't let the door hit you on the a$$ on the way out". Since our system spans 20+ counties, a doctor 100 miles away can have instant access to his/her patient's visit notes from the specialist's office. Radiology films are online and provide instant access for the doctor to view MRI/MRA's, CT scans, and x-rays. While the learning curve is higher for some than others, and the cost of implementation is high, it definitely has it's advantages; I wouldn't want to go back to the dark ages of charting by hand.

BC (RN)

[neverdem]

What kind of terminal do the docs use for making their progress notes? Are results the results from radiology, CBC, Chemistry, etc. accessed from that same terminal?

[q_an_a]

you must be in the medical field to defend 90,000 deaths as a problem of the patients not the doctors. I was a medic in both hospitals and small dispenceries. doctors have been getting a free pass for 30 years and nurses can't find their way to a computer in many hospitals.

I've worked with companies that can put lots of help in the hands (pda) of doctor and nurse and yet they resist, like teachers resist. it is not because they are under paid.

[FierceDraka]

Oh, I'm with you there!

I do tech support for a large East Coast hospital system, and I see it first hand.

The doctors are certainly not Luddites, but most of them really have no comprehension of information technology.

I mean, here we have docs bringing their own computers in to work, which is fine. BUT - many of them are bringing in Apple Macintoshes, and expect them to interface flawlessly on a Windows network. No can do. (Honestly, I think that the docs' predilication for Macs comes from the "snob factor" implied by the higher cost of an Apple machine, but that's another topic)

Also, I've seen the chaos that comes from rolling out a new system and springing it on unsuspecting users, who are often mystified by the simple concept of double-clicking on an icon to make an application run.

To add a little more vinegar to the milk, many of these systems are hodge-podges of old and new systems. Old, command-line Unix-based systems are forced to work with newer Windows, Novell, and web-based platforms, causing never-ending headaches with compatability and interface issues.

But in the hospitals that have built their systems all at once, these problems are alleviated since everything runs on a single Windows 2000/NT platform.

From any of my IT brothers and sisters out there, can I get an "Amen"?

[FierceDraka]

LOL You and I might know some of the same people.

[neverdem]

you must be in the medical field to defend 90,000 deaths as a problem of the patients not the doctors.

I'm doing no such thing. I'm merely criticizing the false hope of completely computerizing all medical records.

BTW, that number of 90,000 iatrogenic deaths is tossed about like it's the Gospel truth. It's not. The following citation is from doing a search at "PubMed" of "mortality, iatrogenic" using the following limits: review articles, English language and human studies type. It's citation # 49.

Eff Clin Pract. 2000 Nov-Dec;3(6):277-83. Related Articles, Links

How many deaths are due to medical error? Getting the number right.

Sox Jr HC, Woloshin S.

Dartmouth Medical School, Hanover, NH, USA. harold.c.sox@dartmouth.edu

CONTEXT: The Institute of Medicine (IOM) report on medical errors created an intense public response by stating that between 44,000 and 98,000 hospitalized Americans die each year as a result of preventable medical errors. OBJECTIVE: To determine how well the IOM committee documented its estimates and how valid they were. METHODS: We reviewed the studies cited in the IOM committee's report and related published articles. RESULTS: The two studies cited by the IOM committee substantiate its statement that adverse events occur in 2.9% to 3.7% of hospital admissions. Supporting data for the assertion that about half of these adverse events are preventable are less clear. In fact, the original studies cited did not define preventable adverse events, and the reliability of subjective judgments about preventability was not formally assessed. The committee's estimate of the number of preventable deaths due to medical errors is least substantiated. The methods used to estimate the upper bound of the estimate (98,000 preventable deaths) were highly subjective, and their reliability and reproducibility are unknown, as are the methods used to estimate the lower bound (44,000 deaths). CONCLUSION: Using the published literature, we could not confirm the Institute of Medicine's reported number of deaths due to medical errors. Due to the potential impact of this number on policy, it is unfortunate that the IOM's estimate is not well substantiated.

Publication Types: Review Review, Tutorial

PMID: 11151524 [PubMed - indexed for MEDLINE]

[q_an_a]

if you have some nice facts, what would be interesting is to read "out of the crisis" by w. Edward Deming from 1986 and see how he treats doctors and their ability to learn from their mistakes. Deming argues that they don't and that is why our tread exists today, they have made no progress in transformation in 15 years.

it is possible that the 90,000 mistakes can be found in scripts that are poorly written.

I would venture to say that the legal weasels have a place in our society in part because of some of the mistakes we are talking about. Computers may not solve all problems, but they help alot especially when you consider that medicine is really car repairs done in a cleaner environment.

Everyone that thinks that doctors have to do everything, they do in medicine, has not been in a field hospital or a remote military site where medics do plenty. Doctors have an inflated view of their contribution to health care.

[neverdem]

I've worked with companies that can put lots of help in the hands (pda) of doctor and nurse and yet they resist, like teachers resist. it is not because they are under paid.

For many primary care docs working 55 - 60 hours per week, not counting time on call, making 100K - 150K per year before taxes, is not like they're overpaid. With the ever increasing hassles of administrative requirements from the government and insurance companies, many can't wait to retire.

[Born Conservative]

What kind of terminal do the docs use for making their progress notes? Are results the results from radiology, CBC, Chemistry, etc. accessed from that same terminal?

We use regular PC's; each exam room has a PC, and the nurses' stations have several PC's also (I work in a large clinic). We use a specific program (EpicCare: http://www.epicsystems.com/), and from that you can chart, view radiology images, view all test results, view med lists, write rx's, place orders, etc. We haven't gone to PDA's yet, but there are enough terminals available, that I really don't think an investment in PDA's would be worth it. It's much easier to use a terminal, IMO.

Also, each person using the EMR has "phrase files" and "smart sets", which are phrases or groups of phrases that you can use to "blow in" to your documentation. For example, a doc may set up a smart set for a child's 18 month exam. It allows the doc to choose from different words/phrases when charting the physical exam, or to type in something that isn't one of the choices. It will also place orders which are standard for that visit (for example, specific vaccines), and when the doc is done charting, he/she goes in to the order page and "accepts" the orders, types in his/her password to verbally "sign" them, and then prints out a billing sheet that includes everything that was done. In addition, the patient is given a printed summary of the visit, including vital signs, medications, and orders that were placed.

There are also many ways to view data; for example, one can pull up all of the CBC's done in the last year, and it will show them side by side to allow for comparison. It will also graph weights, blood pressures, growth curves,etc. Right now, our medical center/hospital will implement an in patient model that will tie in to the outpatient EMR that we are currently using.

[q_an_a]

if you are telling me that primary care doctors make only 150K per year then you and I can go in the bridge selling business.

a salary survey shows that primary doctors with 3 years in practice have an average 146,000 but after 3 years that number goes off the chart. Doctors with 3 years in a specialty earns over 200k with the hign end pushing 400K. Pretty good money for a mechanic.

[neverdem]

Thanks for your reply. It sounds great for an outpatient setting. I was thinking more along the lines of inpatient. It sounds good in theory, and it should reduce a certain amount of redundancy. But there are enough situations where you're left in a bind because you're a slave to the software or the number of available terminals at the nurses station, that I can see older docs especially, easily getting frustrated.

[Taliesan]

Another health care article written by an observer.

1. There are not 90,000 deaths a year from medical errors.

2. Computerizing the record will not prevent most errors.

3. Computerizing the record will not compromise patient privacy.

4. The key element in making an EMR work is NOT a PDA (the screen is too small) but the Tablet PC. The implementation of EMR is taking off now because the tablets are lighter, cheaper, and faster.

5. Doctors are notoriously resistant to change, but there are some good reasons for that, not the least of which is that one of the chief preventatives of medical errors is ROUTINE.

6. The relatively slow pace of adoption of computerized records in healthcare is NOT due to physician habits,but due to the simple fact that technology has yet to solve the legal and information technology problems. The subject of the record, the patient, moves around at will, and the information that comprises the record comes from multiple incompatible sources and in incompatible formats and crosses legal and institutional boundaries.

Etcetera, etcetera.

[q_an_a]

slow adoption would not be allowed with cars at a dealership, but it is allowed by doctors. kids in medical school today are in a cake walk compared to 20-30 years ago.

while a PDA is small it is about the same size as a script pad and doctors have no problem with them. the tablet is a great idea, but it too is short on software. but that is a red herring.

doctors don't resist change any more than guys at US Steel. At the steel companies they went bankrupt due to competition. Doctors have keep med schools small to keep out competition. if the medicare, insurance companies and state associations got pressed by the public, change or don't get paid, the change would happen over night. the public is held hostage by doctors and if they where really all that good how come so many of their doctor owned hospitals get bailed out every year? /rant off.

[Born Conservative]

You are right about some of the docs being resistant to the change to an EMR (not necessarily all of them are the "older" docs). From what I have seen, it's just like anything else; people do not handle the THOUGHT of change very well, but once they do change something, they oftentimes can't imagine going back to the old way.

[hunter112]

The key element in making an EMR work is NOT a PDA (the screen is too small) but the Tablet PC. The implementation of EMR is taking off now because the tablets are lighter, cheaper, and faster.

You beat me to it. Not only are the Tablet PCs becoming more durable, reliable, etc, but the systems to deal with the data they generate are rapidly improving. When data being input on a tablet by a physician in an examining room (or patient's bedside) can be wirelessly transmitted by encrypted means to a central server, it can be used immediately by pharmacists, billing people, nursing and dietary staff, etc.

The crushing burden of paperwork will REQUIRE the computerization of patient information. I went to a Microsoft seminar last month, and saw a film on their InfoPath product, used in a medical situation. It wowed me, all we were waiting for was the hardware to get to the point where it could handle the pressing needs of medicine. Just like speech recognition, handwriting recognition takes an enormous amount of processor and memory capacity, the computer billing systems that have been used by hospitals for decades simply had no way to handle it.

The problem with the use of computers is when you try to get people to change the way they do things, if you can come up with a system that relies on the way that people have already been doing things, you'll have way more success implementing it.

[neverdem]

Please take a look here.

Those annual salaries appear to be based on the assumption of a 40 hour week, fat chance of that unless you're working for the gov't.

The income and hourly average can vary wildly from being a solo practioner with your own practice, being a member of a group practice, or working as a salaried professional for a fixed yearly amount, the number of hours that you work don't matter.

You can see the source of those figures at the bottom. Would you care to provide the source of your numbers?

BTW, those estimated mortality numbers were not solely attributed to physicians, but also included nursing and pharmacy errors, hospital acquired infections, allergic and adverse drug reactions in patients already very sick, etc., IIRC.

Here's the whole article from that previous abstract.

Here's another abstract on the issue of preventable deaths:

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1: Hosp Case Manag. 2000 Oct;8(10):suppl 3-4, 146.

Related Articles,

University study identifies problems with IOM report.

[No authors listed]

The Institute of Medicine's (IOM) report on medical errors is faulty because it does not include a control group and all the patients studied were 'very sick' according to researchers at Indiana University. "What the figures suggest is that people don't die [without an adverse event]," says Clement J. McDonald, MD, director of the Regenstrief Institute and Distinguished Professor of Medicine at Indiana University School of Medicine in Indianapolis. McDonald is referring to the study released by the IOM of the National Academies in November that states 'preventable adverse events are a leading cause of death' and 'at least 44,000 and perhaps as many as 98,000 Americans die in hospitals each year as a result of medical errors.

PMID: 11143166 [PubMed - indexed for MEDLINE]

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Apr 6 2004 10:25:18

Left clicking on "related articles" will give you an idea of how controversial those numbers are. It is not simply a matter of prescription errors.

I'm too old to change my career now, but I couldn't recommend to a young person these days.

If you had an unfortunate experience with a physician in the past, do you think it's fair to take it out on the whole profession?

Pretty good money for a mechanic.

If you think being a physician is just like a mechanic, then you obviously don't know about what you write. I'll let you have the last word.

[Chad Fairbanks]

Are results the results from radiology, CBC, Chemistry, etc. accessed from that same terminal?

You can do it from Windows, with a DICOM Viewer...