Tuesday, June 24, 2008

June 24, 2008 - Far from Paperless

An editorial in today’s New York Times highlights a sleeper sort of problem with big implications for anyone who goes to see a doctor: American medicine’s stubborn refusal to embrace computer technology when it comes to medical records.

The numbers, from a recent survey conducted by researchers at Massachusetts General Hospital, are eye-opening: “a paltry 4 percent of the doctors had a ‘fully functional’ electronic records system that would allow them to view laboratory data, order prescriptions and help them make clinical decisions, while another 13 percent had more basic systems.”

“This,” the editorial continues, “is a startling contrast with other industrialized nations. A 2006 survey by the Commonwealth Fund found that nearly all doctors in the Netherlands and the vast majority in Australia, New Zealand and Britain were using electronic medical records. Denmark has a comprehensive health information exchange that allows doctors to see all medical care and testing provided to a patient. They can even see whether a patient has filled a prescription, which is information that most American doctors lack.”

When I read something like this, I think of the several-inches-thick manila file folder with my name on it at Dr. Lerner’s office. Everything else in that office is shiny and high-tech. Sophisticated machines analyze blood samples in seconds. Medications are stored in a smart refrigerator, to which nurses can gain access only by keying in a security code and a patient I.D. number. Even patient appointments are managed by a computer scheduling program.

But patient medical records? That otherwise high-tech office is still in the era of dog-eared, photocopied pieces of paper stuffed into bulging files.

This is in stark contrast to the Memorial Sloan-Kettering Cancer Center, where I go for my second opinions. Most of that hospital’s record-keeping is paperless. When I checked in for my first outpatient visit several years ago, there wasn’t even any insurance paperwork to sign: they had me sign with an electronic pen, on one of those machines they use in department stores for credit-card signatures.

There’s a huge cost to maintaining and archiving paper records. There’s also a significant potential for errors, especially when it comes to prescriptions. Jokes about doctors’ poor handwriting aside, there are computer programs that can flag medication interactions and simple scribal errors, as a back-up check on overworked doctors and pharmacists.

Why is it that American doctors have been so slow to embrace this technology, when they’re on the cutting edge of so many other innovations? The Times editorial writers have a theory: “The chief reasons American doctors cite for not moving into the electronic age is the high cost of buying and maintaining the equipment, the inability to find a system that met their needs and a concern that a system would quickly become obsolete. Other industrialized nations have moved faster because of strong national leadership in setting standards and helping to finance adoption”

To these reasons I would add another one: fear of litigation. With medical-malpractice lawyers potentially tracking their every move, doctors are fearful of letting go of every little piece of the paper trail.

It all boils down to the inefficiencies of America’s patchwork quilt of small, independent medical contractors, living in fear of predatory attorneys. Countries with a national health system have a powerful incentive for adopting record-keeping standards and developing computer systems (and backups) that work. They also typically have some limits in place when it comes to medical-malpractice lawsuits.

It’s the patients who pay the price of these inefficiencies, of course – both in financial terms, and in terms of human error.

Time for a change?


Bryce said...

Here in Canada suspect the paper versus no paper system varies.

if the physician is connected with a hospital as in using said hospital as a base site, it and often his own off-site office and patients therein are using electronic data systems. Ditto those physicians who are new to the profession; they've been brought up in the electronic methods. My cardiologist and my Lupus specialist both are fully electronic. In fact because of their connection, with me both can cross-share data about me.

However my own family physician still uses the tried and true paper method, along with the rolling
racks of numerous files. Like your own doctor Carl, my file is about about four inches thick. I don't think file folders were ever intended to wrap around "that" wad of paper!

The other think to keep in mind is how the system does or does not function. In the uSA lawsuits seem to be common for medical malpractice. And then too there is the private insurance angle.
In Canada there are supplementary insurance schemes to cover items above an beyond the supplied provincial systems (which are adequate IMO).
However in either case, records have to be available; if they are of an electronic form they usually at some point have to be in an readable non-electronic form.

Hence good ole paper!

Keep well...

Bryce Lee

Anonymous said...

"It’s the patients who pay the price of these inefficiencies, of course – both in financial terms, and in terms of human error."

I quoted your last sentence so that we may all think about it one more time.

The recent loss of a loved one, a real fighter, who battled AML for over two years and was just about to go for another when an infection -generated toxin affected her mental state (non-responsive). The victim was sent to the ICU where they chased a phantom stroke until it was too late to treat the infection. The patient died of acute intestinal hemorrhaging, and quite likely, toxic megacolon.

This unnecessary tragedy resulted from the medics in the ICU having two weaknesses: they were pursuing patient care with limited(a half page from a chart)data; and they appeared to have possessed limited abilities.

Policies must make it very clear that those who have such grave (no pun) responsibilities must be informed and adequately trained to discharge those responsibilities. It also must be clearly stated that the principle attending physician must not be discouraged from maintaining control of the patient's well being.

How long will it be --- I suspect it will be a long while after the cyber/mechanical elements of medical information systems are perfected --- until the current inter-disciplinary attitudes, prejudices and practices are recast. Until then the medical community cannot boast of a true state-of-the-art information system

In the meantime, I fear that the ancient, tragic and vexing truth will prevail: "They look, but they do not see."

Carl said...

Thanks for the further detail on the Canadian system, Bryce.

Carl said...

Thanks, anonymous correspondent, for the case you've shared with us - a sad commentary on what can happen with a paper-only system.

One of the leading advantages of a paperless system is that medical records can be available in many different settings. A patient's entire medical file, for example, could be recorded on a flash drive that a patient carries around on a key ring, like a medic-alert bracelet - or, better yet, could be available on a password-protected site on the internet.