Just saying.

As for single payer: "Make me do it." That's the ticket.

I've been in IT in a big-city hospital for 20 years.

Two words: Please, Mary.

But it's a new year, so I'm going to spin on the potentially positive aspects:

* I hope (heh heh) federal initiatives will supersede the ability which insurers currently enjoy of mandating the use by health care facilities of particular systems and vendors.

* I hope (heh heh) that minimal federal standards get introduced which will once and for all put out of business the snake-oil salesmen who try to make their proprietary image and data formats a de-facto standard at the expense of productivity in the healthcare workplace.

* I hope (heh heh) that any technology which includes a core of patented "intellectual property" gets a special "unfavored nation" status, and is officially declared at the Federal level to be full of cooties.

* I hope (heh heh) that healthcare facilities big and small, some of whom do not have the necessary expertise and experience in picking out and implementing systems and holding vendors' feet to the fire, can get some technical assistance and training so that they can pull themselves up by their bootstraps, so to speak, and not be unduly influenced by actors with a lot of sway but no real talent to speak of.

Of course, none of this will happen. Here's what will happen:

* Our New President will still confuse health insurance with health care delivery, so insurers will get all the labor-saving they've dreamed of, no matter how many more FTEs the hospitals and practices have to pay for to keep it going. Think of the hours currently spent on hold to get pre-certs. Now think of congress getting told that a fabulous new system/standard will eliminate that, and then imagine every hospital getting a $2,500 voucher to help pay for implementation.

* Vendors. The wonderful "private sector" will be the go-to guy for answers. The fact that the current Healthcare IT situation - lack of interoperability among the problems - is entirely a "private sector" failure won't matter. cf. Give banks more money.

Just my $.02

Did I mention that vendors SUUUUUUUCK?

After all, Obama can hire McKinsey to straighten all this out, right?

Who is in charge of safeguarding our information when someone is asking for additional information whether it's a doctor, an insurer, or police? Will the strictest laws regarding privacy still be upheld or will that go by the wayside since all (federal, state, local) will have easier access to the records?

CD sez:

Color me totally unimpressed. Discussing it with some people, I'm told that doing so will "reduce costs" by cutting down on fraud and redundancy, thus making insurance more affordable. Anyone want to take the bet, that 5 years from now, barring real reform of the insurance industry, costs won't have gone down?

Some processes cannot be tightened up by buying a new Medical Records system.

You still have to take your temperatures, stick your needles, prep and transport your patients, break a sternum, what have you, etc.

There are savings and outcomes improvements to be enjoyed by a hospital/practice with a good EMR (Electronic Medical Record), but the savings mostly come in the form of being able to treat and discharge a patient faster: one less room-day in the length of stay is one crude measurement. And once the LOS for condition X goes down by a day across the industry, you'll just see the capitation fee paid to the hospital shrink by the unfettered insurers, too.

They can't lose. They never do.

And in terms of savings and safety, the real investment needs to come in actual, you know, medical research (remember that?), and in developing genuinely new technology (not just faster filing systems) and more non-invasive techniques. Of course, insurers no like daring new techniques.

And anyway, it's not the "cost" of health care that's killing me, it's the complete lack, and inability to get insurance if I do pay out of pocket for care and am diagnosed with some condition.

With capitation now the standard practice in place, not just for a type of treatment or surgery, but for how primary care physicians (PCPs) get paid in HMOs and Medicare Advantage plans for taking on N patients as PCP clients, the cost of health care is killing you because it is in fact limiting your access, via the insurance leeches.

For years now, the insurers have been simply paying less and less for the same services, and expecting the free market of health care to develop efficiencies - somewhere, somehow - to continue making a profit from it. But, as the new efficiencies and standards develop, and it's, say, two fewer days in a bed for a bypass than it was five years ago, the insurers simply suck the savings up - it's not like a windfall is left in the hand of health care providers.

You can only pull efficiencies out of your ass for so long - reducing the length of stay or switching your stent vendor. Eventually, the providers in this system have to start cherrypicking less sick patient populations which aren't going to actually use up the check they get for admitting you. It's sick and immoral but as Michael Moore showed you, it's EXACTLY how the insurers behave - it's their goddamnned business plan.

But hey, at least it's not socialized medicine.

Our health care system sux, whether you are in it or outside. All this clamoring to get universal health care ignores the fact that as currently delivered simply being in our health care system is the third leading cause of death in America.

This from Wikipedia, which I normally eschew but this article was apparently written by someone who knows the issue (and/or I embrace because it contains conclusions that conform closely to my own POV, wev) and I don't have time to track down all the data independently:

In the United State alone, recorded deaths per year (2000):

12,000—unnecessary surgery
7,000—medication errors in hospitals
20,000—other errors in hospitals
80,000—infections in hospitals
106,000—non-error, negative effects of drugs

Based on these figures, 225,000 deaths per year constitutes the third leading cause of death in the United States, after deaths from heart disease and cancer. Also, there is a wide margin between these numbers of deaths and the next leading cause of death (cerebrovascular disease).

This totals 225,000 deaths per year from iatrogenic causes. In interpreting these numbers, note the following:

most data were derived from studies in hospitalized patients.

the estimates are for deaths only and do not include negative effects that are associated with disability or discomfort. [IIRC, that total is between 1.5 and 1.8 million serious injuries]

the estimates of death due to error are lower than those in the IOM report. If higher estimates are used, the deaths due to iatrogenic causes would range from 230,000 to 284,000.

Most of these untoward events could be prevented by better record keeping and improved systems of reconciliation and confirmation. Electronic systems while not foolproof demand sufficient clarity in instruction and allow levels of redundancy powerful enough to clean up most of the problems.

Additionally, the ability of researchers to parse these databases would open entirely new vistas on the efficacy of care and more rapidly pinpoint ineffective, damaging or promising therapeutic modalities. Currently it takes decades to properly assess new interventions; with a national database we could know if a new procedure or drug is beneficial or not within just a couple of years, as well as be able for the first time to do retrospective analyses of existing methodologies. This would represent a huge advance in health care, far beyond what we can achieve by bringing the uninsured into a deeply flawed system. (see this post and discussion thread also)

Finally, and this is I admit the somewhat hopey part, I predict that once established this database will certainly be breached and individual health status including pre-existing conditions will become known. I can think of nothing more powerful as an incentive to treat healthcare as a right than the certain knowledge that huge swaths of people, the vast majority, will be excludable from private insurers due to pre-existing conditions. Amassing this database and making it available will crush the private insurance business and mandate collective government-run universal single-payer coverage as the only viable option.

aren't most errors not because of records but because of human error -- and humans incorrectly recording things?

how will 3rd-party and/or overseas people -- not in those offices and hospitals -- know if what they're "computerizing" is correct or not to begin with?

Electronic medical records as a means to save money has always been silly to me. It will save some money sure, but it won't in any way "solve" the problem. Hillary and Obama's plans both had this included but Hillary's was still about half as much per person as Obama's plan. That in itself speaks to the limits of e records alone.

As much as it pains me to agree with BIO (*fluttering eyelids*), they are right about the benefits of e records. While Tony is also correct about marginal gains and security concerns from insurer based attempts, a national system will make many of those concerns moot.

Understanding the problems with misdiagnoses and problems associated with monitoring drug interactions is worth looking into. The immense computing power we now have means you can have an undergrad write a few lines of code to anylyze scores of different potential correlations otherwise inaccessible with a universally accepted pool of data rather than tiny samples from scattered locales which may have regional biases. All that data makes this scientist salivate. Of course there need to be protocols in place for safety, but would people be as concerned about their medical history if they didn't have to worry about insurance companies?

Not Quite Fail-Safe --

... But a new study of a computerized physician order entry (CPOE) system manufactured by Eclipsys Corp. of Boca Raton, Fla., and used between 1997 and 2004 at the Hospital of the University of Pennsylvania, identified 22 types of persistent errors such systems are supposed to prevent. ...

At Penn these electronic drug orders, which are sent directly to the hospital pharmacy, are reviewed by clinical pharmacists who check for harmful interactions and catch mistakes, Koppel said.

"We are so enamored of the technology that we are not making it responsive to the way people work," said Ross Koppel, a medical sociologist and lead author of a study, published in the March 9 issue of the Journal of the American Medical Association. Koppel said the errors his team uncovered by interviewing and shadowing 261 doctors were "stunningly frequent." Because Koppel's team did not measure errors before CPOE was installed, it is not known how often they occurred under the paper system. ...

Some errors his team reported were the result of design flaws that could have been easily corrected, Koppel said, while others reflected a fundamental mismatch between the functions they were supposed to perform and the way doctors actually work. ...

Although the system has been replaced, some of the newer versions Koppel has examined "still have many of the same faults," he said. "They are better, but they make other stupid mistakes." ...

the failure rate for large IT projects in health care is about 75 percent.

"Behind the cheers and the high hopes that dominate conference proceedings, vendor information and large parts of the scientific literature," they wrote, "the reality is that systems that are in use in multiple locations, that have satisfied users and that effectively and efficiently contribute to the quality and safety of care are few and far between."

Clinical pharmacists won't be going over America's archival medical records -- nor will any kind of medical professionals, unlike this study--and i'm willing to bet all the money in the world that there won't be professionals on-scene everywhere at every doctor's office and hospital and clinic, etc, doublechecking entries while they're actually providing care either.

Bush was pushing this for years too -- it wasn't to help save lives then either. It was to save money.

As I understand it, VA (which is not Walter Reed) has an excellent system.

Amberglow is, in my view, 100% correct to worry about the quality of the data, and bringiton is 100% correct to argue that the problem is soluble.

Whether we'll be able to solve it is an open question. VA seems good -- under correction from experts -- but then that's socialized medicine, just only for veterans.

I can well imagine a situation where a privatized data conversion effort -- led, possibly, by McKinsey, snicker -- turned out to be a clusterfuck that ate up billions and killed a bunch of people. Exactly the result Obama would compromise himself into.

We already have data harvesting in several specialties, and all the pie-in-they-sky ingredients people believe will emerge from a National Health Database are already there - standardized databases, standardized thresholds - as well as a free-market incentive for accuracy in the form of surgeons eager to track every last risk factor and drug history in his or her population.

Up until recently, harvest participation was voluntary, but in some specialties right now, including implantable devices, CMS (Medicare) absolutely mandates data harvest participation. This usually means an FTE or two, to say nothing of licensing and/or support of the products necessary to comply.

It certainly addresses quality of care at a site and practice across the industry, but a cost saver? On what planet? Just leave out entirely the question of who saves bucks - it's not saving anything. It's pure expense, and usually just adds to the workload of the QA people.

And BIO's wiki-numbers about deaths? Complete non-sequitur to anything Obama has thus far talked about (which admittedly ain't much). How exactly do you get from a National medical Database to eliminating drug errors, infections, or unnecessary surgery in house?

And just out of curiosity, what does your Wikipedia expert mean by "unnecessary" surgery? Surgery performed on wrong patients and/or limbs? Surgery performed as a result of a bad diagnosis? Surgery performed which only after the fact and in retrospect shows no statistical advantage on certain populations (e.g., stents on cardiac patients versus medication, 5 years post-op)?

I'm all for technology that makes insurance companies work faster and better, but then, I'd also like to see things like a hard time limit on the time it takes to get a pre-cert from an insurer:

Pre-cert in 2 minutes or your specialist visit is FREE!!

Physicians debate computerizing medical records --

... the U.S. Department of Health and Human Services' Stark Exemption program, which subsidizes up to 85 percent of the cost of electronic record software for hospitals and insurers, said Joe Schneider, a pediatrician in Baylor's network who also chairs the TMA's Health Information Technology Initiative.

Only 17 percent of physicians in the TMA survey reported that the cost of their electronic record system was subsidized by a hospital, government agency or other sponsor.

"A hospital may come along and say, 'We can give you this great deal on Vendor X,' but if Vendor X goes out of business or doesn't respond well to my needs, I'm stuck," Dr. Schneider said, explaining why some doctors shy away from the subsidized programs.

Secrecy prevails

Doctors are also reluctant to sign on because it is difficult for them to gauge whether they are getting a good deal. Because of all the pricing secrecy demanded by vendors, doctors have no way of knowing how much it generally costs to maintain an electronic system, said Pamela McNutt, senior vice president and chief information officer of Dallas-based Methodist Health System. Ten percent of physicians in the TMA survey reported that actual costs exceeded the vendor estimate by more than 50 percent.

"The big cost overruns on the electronic health records are beginning to become an industry scandal," said John Hummel, chief technology officer of health care at Perot Systems. Before joining Perot Systems in January, Mr. Hummel installed electronic medical records throughout California's prison system. ...

... work faster and better, because their business model is denying people care.

I don't want to improve them, I want to abolish them (as, Tony, I think you do).

Meanwhile, the technical challenges are huge. Even standardizing names and addresses is hard. Standardizing medical data (and past histories...) is orders of magnitude harder. Not saying it can't be done, but it could be tried and fail, too. Is the task more complex than, say, rebuilding the Air Traffic Control system? Or more complex than computerizing FBI criminal records? I'd say yes, and both of those IT projects are famous Clusterfucks that cost many billions.

So, why on earth make computerized medical records your first priority? If your priority is the health of people, I'd say it's low on the list.** How about we worry about people who don't even have records because they're not in the system? Now, if your priority is the health of the insurance companies, and possibly the health of IT companies, then it's high on the list.

And there you have it.

NOTE ** Subject to correction on Bringiton's WikiPedia numbers, for which I'd be interested in seeing the primary sources.

UPDATE Also, the interchange problem is caused by lack of interoperability in the private sector, since that's how they're incentivized. The only answer is a government mandate on data interoperabilty. So why not go the whole way to single payer?

President Bush on Wednesday evening renewed his call for the use of better technology in hospitals and in doctor's offices for storing and sharing medical records.

Using the high visibility of his State of the Union address, Bush said he will ask Congress to enact sweeping health care reforms, including "improved information technology to prevent medical error and needless costs."

Also in his speech, Bush asked Congress to approve politically controversial legislation such as tax code simplification and Social Security reform, and he vowed his budget for the 2006 fiscal year will include funding for "leading-edge technology," including clean coal, ethanol and hydrogen-fueled cars.

Wednesday night was not the first time that Bush has talked about electronic medical records. ...

Obama's now calling for the same thing -- and also "tax code simplification" (which means tax cuts) and SS reform too.

So, why on earth make computerized medical records your first priority? If your priority is the health of people, I'd say it's low on the list.

At an individual facility or practice, a successful EMR (Electronic Medical Record) is worth its weight in gold. It improves patient care and satisfaction. It improves physician satisfaction.

Here at Big City Hospital, we have a woefully cumbersome EMR, from a vendor without a great reputation, but when it works as it is supposed to - it's a thing of beauty, and it's hard to count the ways: docs aren't trudging down to Medical Records in the basement to pick up and sign off on charts. Charts don't get lost. Up on the floors, handwritten case notes and final reports from all the patient's encounters are no more than a terminal away.

I'm just not so sure that all of this necessarily scales to the entire country or to what end.

Speaking for myself, I also think I'd rather just have an old case report, signed and finalized by the old physician, faxed over to my new physician, than rely on data abstracted and entered by some low-level untrained clerk. If it takes me a month or two to get a bloody specialist appointment, why exactly am I so worried that it takes half a day to get my hands on an old MRI??

If you feel differently, then I guess get your SSN tattooed on your ass or
something.

(NB: This is not a flip attitude at anybody - I just realized it looks that way...)

... Obama said in an economic address on Thursday that he was committed to ensuring all U.S. medical records are computerized within five years, a move he said would "cut waste, eliminate red tape and reduce the need to repeat expensive medical tests." ...

these are his reasons for it.