Preparing for surgery tomorrow

[This is what I wrote in an e-mail, but I'm just leaving it here in case you're researching what to do.]

My head explodes when I think what we pay for these EMR!! How many billions ($27 billion in 2009) and there wasn’t a shred of evidence from any studies it would help health care.

 

We just had a call from the hospital (9 a.m. Tuesday) from a clerk checking all the details for surgery tomorrow. We have to call between 2-4 p.m. today to find the hour of the surgery on Wednesday. The hospital still didn’t have any of the test results from his complete physical on Aug. 16—different doctor, 2 miles down the road. Carrier pigeon could have done it better. And as I think I mentioned before, his internist never received the results of the scans 3 weeks before his physical. Also the hospital had him listed as 5’11”, high blood pressure and cataract surgery. None of that is true. I’m wondering what other Bruce’s medical records got folded into his. He’s about 5’8”, no problem with blood pressure ever, and his eyes are fine. Always, always, have another person checking. The lobbyists for IT made a bundle on this, but at our expense. 

 

Rant over. I’m going to vacuum to blow off steam.

 

http://www.prnewswire.com/news-releases/report-electronic-medical-records-market-nears-25-billion-300066515.html

 

http://www.hitechanswers.net/about/about-arra/

 

As a bonus, here’s what I wrote about this problem 7 years ago:

 

I stopped by to pick up a prescription at my doctor’s office because the “electronic transfer” of information between that office and the pharmacy I used hadn’t been able to manage the job in 3.5 days, and I was out (old methods of fax and phone aren't used anymore). Normally, I would have just told the receptionist what I needed, and my file (paper) would have been retrieved (human). No. I waited about 10 minutes as she struggled getting the right screens up, then worked from screen to screen, asking me questions I didn’t know, like date of my last appointment and address of the pharmacy. A line was forming behind me. When she finally found it, she said there was no record from the pharmacy requesting permission for a refill, but the doctor would decide.

That night we got a call from the doctor’s office that “it was ready,” i.e. the prescription script. My husband went to pick it up and waited about 15 minutes in line as the receptionist struggled with the screens of 2 or 3 people ahead of him. Fortunately, it was in a paper envelope with my name hand written on the outside. We can only hope and pray that the national “network” that Obama is forcing thousands of small offices to buy into (causing many to close their doors), doesn’t work any worse than what you’ve all experienced at the local level as your doctor or clinic transitions.

Free at last--from pain--guest blogger

A former colleague of mine comments on my comments on Dr. Blumenthal's 2 part series on HITECH which appeared in December in the New England Journal of Medicine. I was concerned about a number of issues, including the rush to push it through and the shaky privacy issues, but here's an alternate view of how advances in digitized health records mandated by PPACA could benefit the patient. She is now pain free after surgery and it has given her back her life, but some of her experiences in getting there were extremely unpleasant.

I thought this was an excellent article evaluating the benefits and challenges of bringing one part of American health care into the 21st century. I recommend we all read the full Blumenthal article. It's short and accessible. I took away something very different from it. It left me hopeful that things might change for the better.

Although we all rightly are concerned with the privacy of our health care data, as the article mentions, paper data is not secure either. But online data does present more challenges because no system is un-hackable. However, that's not a good excuse to stay in the 19th century forever.

My doctor's office automated their records and system a few years ago, making him an early adopter. There was slow down in the first 6 weeks, they told me, but then it got VERY efficient. When I go in now, it is faster, he knows exactly which tests are due and he prints out any prescriptions right from his laptop or faxes it directly to the pharmacy. He spends time talking to me, not flipping through paper files looking for previous test results, which are all on his laptop. I love it. He does too. After the initial few weeks of learning the new system, everyone in his office is fluent in it and very efficient.

None of these systems are developed from scratch in each doctor's office. They are turnkey systems with training provided. So the analogy of creating LCS from scratch isn't comparable.

Here's my example of why I think a state-of-the-art health care information system is desirable. Before my second hip surgery, I was in a wheelchair and in excruciating pain. I realized I couldn't keep working unless I got "real" painkillers. So I was referred to an OSU-affiliated pain clinic.

The biggest fear that pain clinics have is that patients will game the system, get painkillers from multiple doctors and sell them on the black market. This does happen. But I didn't realize that this fear made some pain clinics abuse their patients.

The waiting room was NOT filled with 20-somethings in black leather strung out on illegal drugs. It was filled with about 30 moaning elderly middle-class men and women, some in wheelchairs, some with canes or walkers, most were accompanied by worried relatives. One women was in such pain, she passed out during the wait. The office staff wouldn't help her. She said: "They do that to get sympathy so we'll give them drugs."

Her husband, who was almost shouting, had to be calmed down by other patients and we all demanded someone come out and help her into the bathroom to put cold water on her face, since not of us was strong enough to help her out of her wheelchair. They begrudgingly helped this "potential" drug abuser.

When it was my turn to be seen, the questions the doctor asked had to do with whether I was being seen by another doctor and if I was getting drugs from them too. If it had been said for my benefit to make sure I didn't overdose on a combination of things, it would have been appropriate. But it wasn't. It was an interrogation that implied I was a drug addict trying to cheat the system. I had never been treated so nastily by a doctor and I was really surprised. But pain clinics act this way because there is NO WAY TO CHECK RECORDS TO SEE IF OTHER DOCTORS are also handing out prescriptions. Finally, the doctor said he'd give me a prescription, if I passed the drug test, which was required of everyone.

So I went to the drug testing clinic he mandated. I had to be there in 20 minutes (or it was invalid), so I wouldn't have time to get a "clean" sample elsewhere. If you've never had a drug test (some states want all welfare recipients to pay for one themselves, before they can sign up for benefits), it isn't as easy as you might think.

A same-sex attendant accompanies you into a bathroom and watches you. You pee in a cup while someone watches your hands to make sure you don't substitute another sample. It was not handicap-friendly. The commode was on a platform in a small room with nothing I could hold on to easily. Because of my hips, it was excruciatingly painful. It was humiliating. I thought of the women in their 70s and 80s in the waiting room of the clinic who had to do this. It made me angry at our backward system.

The clinic said the test was a nominal cost, like $30. (Just like states say the charge will be nominal for welfare recipients, who must pay for the drug test themselves.) Turns out it was $250. I refused to pay that much and after weeks of arguing over paperwork, the price was changed.

Had there been a centralized health information system in place, this entire traumatic episode would not have been necessary. The pain clinic could have pulled up my x-rays, seen the bone-on-bone hips, seen I had no other prescriptions, and prescribed an appropriate painkiller. Instead, they were ruled by fear and lack of information. The prescription they gave me was inadequate; the surgeon said he didn't know how I managed the pain with only what the clinic prescribed me.

I, and all those suffering people, would have gotten better, cheaper, less humiliating care. The people who REALLY are gaming the system might be caught faster and punished. The insurance companies and we might have saved a small amount of time and money, but multiplied by millions of people resulted in huge savings, if there had been an investment by the government to create a unified medical information infrastructure.

I'm afraid of abuse of medical information. But that won't keep me from wanting to have a modern medical information system to allow better care, better tracing of public health concerns (like food poisonings from unknown sources), better tracking of outcomes using different types of procedures, and brings us closer to the care provided by other industrialized nations.

Do you know where you should move if you are a Type 1 diabetic? FRANCE. Because they have proven the slower speed of their dialysis treatment provides better patient outcomes and longer life. U.S. hospitals don't have a system to track outcomes, unless they do a special (costly) research study, because we don't have any medical information infrastructure. So we do what the insurance companies will pay for, which is the faster version, which results in more deaths for US diabetics than in other industrialized countries overall.

I went to my doctor years ago with what could have been either food poisoning (after eating at a new restaurant) or a flu bug. I asked him if other people in the area were coming in with similar symptoms, in case it was food poisoning. His answer: we don't have any way of knowing. They would have gone to different doctors and no information is shared. How's that for public health? We have to wait for multiple people to die to find out if there is a public health issue in an area, because deaths are reported.

I know I'm not going to convince anyone who, like the clinic doctor, is guided primarily by fear of abuse. But I believe shared medical information is vital to us as a country and as individuals. Everything can be abused. That clinic was so afraid of abuse that they were abusing people in a different way, by treating everyone as a criminal. They provided expensive, inadequate care. They had no way to track the outcome of the treatments they prescribed or even if their patients lived or died.

The only follow-up I ever received from the pain clinic was a post card a few years later saying they moved to a new address. We deserve better health care than this.

This is certainly an eye-opener, however, if patients can be abused in such a manner with face to face, 21st century care, I can hardly see EHR improving on that!

How we got HITECH folded into the Stimulus Bill

Abstract from New England Journal of Medicine, Dec. 15, 2011, "Wiring the Health System--Origins and Provisions of a new federal Program, pt. 1, David Blumental, MD

In February 2009, the U.S. government launched an unprecedented effort to reengineer the way the country collects, stores, and uses health information. This effort was embodied in the Health Information Technology for Economic and Clinical Health (HITECH) Act, which was part of a much larger piece of legislation, the so-called stimulus bill. The purpose of the stimulus bill, also known as the American Recovery and Reinvestment Act of 2009 (ARRA), was to stimulate the economy and prevent one of the worst economic recessions in modern history from becoming a full-fledged depression. Congress and the Obama administration took advantage of the crisis to enact programs that might spur short-term economic growth as well as promote scientific and technical advances with potential long-term benefits for the American people. In the health field, one such program involved a commitment to digitizing the U.S. health information system. The HITECH Act set aside up to $29 billion over 10 years to support the adoption and “meaningful use” of electronic health records (EHRs) (i.e., use intended to improve health and health care) and other types of health information technology.

According to the article, which goes on for pages and has voluminous footnotes, there were only TWO arguments in favor of this program:

1) the conviction (i.e., no facts, no data, no research) that information technology could improve health and health care
2) a need for the government to remedy the perceived but unproven problems inhibiting the spread of health information technology

Looking further for statistics on why this was needed, I found in Blumenthal's puff piece a number of additional arguments for HITECH based on nothing more than intuition, lack of statistics, and a hunger of government officials for more or more.

3) it was “intuitive.” How’s that for hard evidence?
4) the lack of what they wanted--only 17% of physicians and 12% of hospitals had fully functioning electronic health records. (Wow! what a bonanza for the IT industry and its lobbyists!)
5) We already had the most expensive system without IT, and Europe had health IT, so if we heaped this cost on top of that, we could have a “fundamental technological breakthrough.”
6) It would be a benefit to “policy makers” (that means DC law makers) and
7) the “implied” need could improve care if information were shared, and paper records are difficult to share.
8) There was some empirical evidence from the Veterans Administration System and the Kaiser Permanent Health Plan (a tiny puddle in the overall sea of health records) for treating chronic illnesses.
9) The National Institutes of Health (a government agency) wanted it.

Just as the reasons HITECH was necessary to rush through in the stimulus bill in 2009 (to help the economy) were as fragile as a butterfly's wings and its movement of air, so the reasons not to do it were much more substantial.

1) economic--no reward for improved efficiency in medicine--except to patients and insurers--which in government talk means the markets have failed.
2) logistical and technical--it is so complex, that obviously the government needs to step in to help overcome this barrier.
3) the ability to do this is "underdeveloped," so therefore this huge challenge requires something even more huge--the federal government
4) privacy and security of records--no solution is even offered for this one except noting the health record industry is not currently regulated, so you know where they're going with that one.
Wiring the Health System — Origins and Provisions of a New Federal Program
Clever terms only a doctor on the government payroll (Blumenthal was national coordinator) could use:

• "meaningful use" of electronic health records
  
• meaningful use was a new idea with no precedent in law, policy, or the health care literature
  
• multiple major new regulations with far-reaching impact with a short deadline
  
• new programs had to be created from whole cloth (his exact words, folks!)
  
• targeted public investments
  
• encourage millions of health professionals and institutions to adopt and use
  
• justified intervention
  
• create the need for government remedies
  
• intuitive rationale
  
• experts agreed
  
• policy makers need
  
• bunches of vague statistics about quality, doctors, sharing information
  making available $27 billion
  
• federal government is correcting market failures
  
• EHR can create huge databases for local, national and international research
  
• If left to their own choices/devices providers would "never use them efficiently"
  
• Congress incentivized, with secretary of HHS allowed to define "meaningful use"
  create an opportunity
  
• the gov't dept charged with all the regulations for HITECH had never drafted a regulation or run a technical assistance or training program and had only 35 employees, so obviously the first job creation of ARRA was to add government staff!

This is only pt. 1, and I think Blumenthal has no idea he has made this sound like the Katzenjammer Kids on Parade. I can hardly wait for pt. 2.