Medical Records

[Nords]

Just hope that your betamax doctor can talk to the VHS doctor. Or your Blu-ray doctor can talk to your HD DVD doc.

 

[deserat]

"Regardless of the governments attempt to automate the industry and the billions of dollars spent so far (we spent over $50 million on one project) the lack of enforceable standards limits the usefulness of a interoperable EMR. Until a nationally accepted standard is established and adopted there is little hope that the medical community will be able to provide more than episodic treatments."

Standard what? Application, network, data semantics, physical connectors, images? All of that? I think the network stuff is fairly done; physical connectors - depends on if you are willing ot replace a ventilator because is doesn't have a USB connection; data semantics - LOINC, SNOMED or IEEE 11073? Application - EPIC or others - some work better for certain specialties or outpatient situations than others - if you have a real-time application (anesthesia charting0, you might not want a episodic approach being used as your application design feature; images - DICOM works for most, however, is you could embed the mark-up of other aspects of the clinician use of the image and report, that would be better - not all systems will accept that, so you might end up with a separate repository for the images and the report; think about the size of the storage needed to ensure all of this is available for all of the patients....

As for the Sweden comment - well, it depends, Sweden doesn't necessarily have all of their personal health record or remote monitoring information being captured in their EHR. Also, one of my bugaboos about that type of comment is a misunderstanding of how scalability can break a system that works for a fairly small population versus a much larger one. If you compared Europe to the USA, then I'd bite. And yet, Europe still doesn't have a working interoperable patient summary nor pharmacological summary that works across borders - EPSOS is a political desire, not a reality yet. In fact, Europe is even more of a patchwork in terms of what they have from country to country than what we have in our states in the USA. I did a presentation at AAMI this year about just that subject.

 

[Alan]

.... Here in NY, they still give me paper prescription. I haven't used a paper prescription in decade (in Sweden.) All it takes is govt. willingness to streamline the system.

I worked in Louisiana until I retired to Texas in 2010. The doctors there were all electronic when it came to prescriptions (Rx's). When the Doc prescribed something he asked which pharmacy I used, typed a few things on his hand-held PDA and the prescription was ready to pick up when I arrived there.

Once I knew I was going to be on the meds for a long time, I asked the Doc to switch it to 90 day supplies and send the Rx to our mail order company, FlexScripts. Again, a few clicks on his PDA and it was done.

I moved to Texas, went to see the Doc to get a refill. I gave my details 2 weeks ahead of time so the records could be sent over, but when I went for the appointment, they weren't there so I had a full exam and when he gave me the Rx, not only was it paper, but they wouldn't fax it to FlexScripts, I had to do that myself.

No idea what it will take to drag all the medical system into the 20th century. (yes, I know we are in the 21st century now)

 

[Cato]

deserat;1103024 [/COLOR]
Standard what? Application, network, data semantics, physical connectors, images? All of that? I think the network stuff is fairly done; physical connectors - depends on if you are willing ot replace a ventilator because is doesn't have a USB connection; data semantics - LOINC, SNOMED or IEEE 11073? Application - EPIC or others - some work better for certain specialties or outpatient situations than others - if you have a real-time application (anesthesia charting0,
I'm not sure why anybody would want all individual ventilator data or anesthetic charting stored on the patient's EMR for 7 years - surely this is overkill ? Who would need or even read this stuff 3 years down the line ?
you might not want a episodic approach being used as your application design feature; images - DICOM works for most, however, is you could embed the mark-up of other aspects of the clinician use of the image and report, that would be better - not all systems will accept that, so you might end up with a separate repository for the images and the report; think about the size of the storage needed to ensure all of this is available for all of the patients....
It is my understanding that memory has become significantly cheaper and surely if Google and Amazon can do it, every individual state can do it as well, provided they go with a single vendor/supplier and concentrate on the kind of stuff that are really important such as medication, test results, operative reports, hospital discharge summaries, consultation reports and emergency room visits and their reports. As for compatibility, is'nt that what standards for manufacturers are for? Dicom compatibility on diagnostic imaging seems to have been adopted by all manufacturers of imaging equipment and whilst there are still issues from one manufacturer to the next - all new imaging equipment is digital in format already.
As for the Sweden comment - well, it depends, Sweden doesn't necessarily have all of their personal health record or remote monitoring information being captured in their EHR. Also, one of my bugaboos about that type of comment is a misunderstanding of how scalability can break a system that works for a fairly small population versus a much larger one. If you compared Europe to the USA, then I'd bite. And yet, Europe still doesn't have a working interoperable patient summary nor pharmacological summary that works across borders - EPSOS is a political desire, not a reality yet. In fact, Europe is even more of a patchwork in terms of what they have from country to country than what we have in our states in the USA. I did a presentation at AAMI this year about just that subject.

I get the sense that it is a more a political than a technical problem.

I'm surprised that you haven't mentioned the biggest problem with EMR - Privacy issues - I suspect that portability is important from one state to another is important, but privacy concerns seem to trump all other issues.

 

[rescueme]

I retired from the IT field, after 40+ years. Not to impress anybody, but just to show I have a background in what I'm about to say.

Anybody who says that you can't "combine systems" due to different formats, and show a common view are full of dung.

As long as you have a "matrix" to convert to a common standard (assuming a country/world wide government standard) there is no reason that current dispersed systems cannot be used.

To suggest anything else is just foolish, IMHO.

To those providers who have a "system", it can be provided in a manner world-wide.

To those providers who are using "pen and ink", please get with the program...

 

[toofrugalformycat]

I get the sense that it is a more a political than a technical problem.

I'm surprised that you haven't mentioned the biggest problem with EMR - Privacy issues - I suspect that portability is important from one state to another is important, but privacy concerns seem to trump all other issues.

For all of us who have ever been forced to apply for private health insurance, privacy is not an issue. We have absolutely no privacy. None.
I left a good primary care doctor because her staff would not retrieve my (paper) records when I went in for a problem. The reason - I had not been in for a couple of years. They were in storage and it was too hard to find them.
This is after I phoned ahead and verified they would be available.
Electronic is the only way to go, IMHO. However, I do want a paper copy to take home with me.

 

[GregLee]

I'm not sure why anybody would want all individual ventilator data or anesthetic charting stored on the patient's EMR for 7 years - surely this is overkill ? Who would need or even read this stuff 3 years down the line ?
...
It is my understanding that memory has become significantly cheaper ...

If memory storage is cheap, why not keep all medical data forever? That way, you don't have to decide what to discard.

 

[Katsmeow]

I've had mixed result. My primary physician has come a long way in the last couple of years. Physicians and nurse practioners work on laptops and have all the records in electronic form (well I assume it is all the records...He has looked up stuff from a few years ago, not sure how far it goes back). Prescriptions are mostly done electronically. On the other hand, I keep trying to tell them my old home phone number is no more but they still keep calling it (yes, they say it is deleted every time but it comes back)

I recently needed to take some mammogram and ultrasound results to another physician to look at (no problem as it turned out). I was given large films to take. On the other hand when I had a gall bladder ultrasound a couple of years ago at the same hospital they gave me the records on CD.

I've thought about requesting a copy of my records from various physicians but never got around to it. I've gotten copies of specific test results at time but not all the records. For those who get all the records, how does that work? Do you just get a copy of test results or do you get a copy of the written notes? Also do they charge for it? If so, how much? What do you do if it is a physician you still go to? Do you update it at each visit or what?

When I think about all the physicians I've seen in, say, the past 10 years it is a daunting task to get copies of everything. If I added in hospital visits it is even more so. Still I might do it. My knee is bothering me and some years ago I had major knee surgery. The surgeon has since retired (I know I got a letter about who would have the records but can't find it but sure I could track it down since he was in a big practice). Anyway, at one time I had a copy of some letters from him about what was wrong and what he was doing but I've lost all that (I do actually still have the video of the actual surgery although it is a VHS tape). Anyway, I was thinking it would have been helpful to have the records.

 

[East Texas]

It seems to be a common practice for doctors to ask for social security number and driver's license number on their new patient forms. What I don't get is why people feel the obligation to provide that information without a care in the world if it's really needed and how the information will be stored and safeguarded.

 

[JOHNNIE36]

I just had a few minutes to review this thread and couldn't get into the detail and every word spoken (sorry, written), but I get the basis of the post. I was just at my doctor's office last Thursday and this thread triggered a thought. Both of my doctor's offices have these giant rolling bookcases with thousands of files. I asked to get a prescription the doctor had written for me and to check the prior dosage. I couldn't believe the process they had to go through to find my file. Not the prescription. They had that ready. They had to roll these stacks of files around to get to "me". I'm wondering, "what would you do if there is a major fire"? Is there a backup system? Is everything on a disc somewhere? Then you think of other things. When I visit the doctor he always has this history "on paper". Why doesn't he just pull up my history on the computer? I do think we might be behind the times when it comes to records, history, files, documentation.

 

[Brat]

Complaining to the software representative is futile and somewhat dangerous - it's like telling a new mother her baby is ugly

Oh ya. My nephew is a software engineer for MS, I gave him an earful a few years back about a Windows product. That is when I learned that a softwear engineer who makes mistakes is almost discharge proof, s/he is the only one who knows where the bugs reside.

 

[travelover]

Slightly off topic, but I'm curious as to the effect of merging all your medical files on your insurability with respect to pre-existing conditions , especially if the Affordable Care Act doesn't get implemented.

I can just see insurance companies looking back to see if you ever had a pimple on your butt before they cover some new malady.

 

[Rustward]

Maybe this is resistance to change. Or maybe it is just a business decision by the doctor.

So the doctor (who must foot the bill for this activity) will ask what's in it for me?

I can see an office switching to electronic records for new records going forward, but entering older records is going to require some manual data entry, and at best, some custom code for conversion. And it won't be cheap -- but as was mentioned in an earlier post it is certainly possible.

So, yes, I can understand a mandate at some point in the future to require a standardized data format that would work with any vendor's product, and make the data portable and interchangeable. Hey, that is how the internet works. Standardization is, for example, what allows a Cisco router to exchange routing tables with a Juniper router, and allows a little Lynksys consumer wifi access point to communicate with any other vendor's wifi product.

Entering older data into this is not going to be popular. I have been involved in some large scale data conversions (but nothing anywhere close to all the medical records in the US) and it is just not an easy task when the data comes from disparate sources. It also presents opportunities to introduce errors and omissions into a set of data, and there is a cost involved with that. Been there and done that -- on both sides.

 

[Rustward]

Too late to edit my previous post, but does anybody have any security / privacy concerns about electronic records?

. . . and some people freak out when their credit card number gets stolen . . .

 

[TromboneAl]

I don't worry too much about the privacy of my medical records. If someone steals my CC number, I'll have to go through a major hassle, and might lose use of my card when on a trip. If someone finds out that my shoulder was sore a few years ago, then, what?

Yes, I could think of some examples (being denied employment because you have headaches in your history), but personally, I'm not too concerned about it.

 

[braumeister]

You mean security concerns like this?

SAN FRANCISCO (AP) -- Until recently, medical files belonging to nearly 300,000 Californians sat unsecured on the Internet for the entire world to see.

There were insurance forms, Social Security numbers and doctors' notes. Among the files were summaries that spelled out, in painstaking detail, a trucker's crushed fingers, a maintenance worker's broken ribs and one man's bout with sexual dysfunction.

At a time of mounting computer hacking threats, the incident offers an alarming glimpse at privacy risks as the nation moves steadily into an era in which every American's sensitive medical information will be digitized.

News from The Associated Press

 

[M Paquette]

You mean security concerns like this?



News from The Associated Press

Heh. A collection agency. I think we all know how very concerned they are with privacy. (One of my retirement hobbies. I collect autographs from agency owners. On checks. Some deadbeat put my phone number on a form, and I get all his calls. I follow the law and document everything, they don't. Hilarity ensues...)

Southern California Medical-Legal Consultants, which represents doctors and hospitals seeking payment from patients receiving workers' compensation, put the records on a website that it believed only employees could use, owner Joel Hecht says.
The personal data was discovered by Aaron Titus, a researcher with Identity Finder who then alerted Hecht's firm and The Associated Press. He found it through Internet searches, a common tactic for finding private information posted on unsecured sites.
The data were "available to anyone in the world with half a brain and access to Google," Titus says.
Titus says Hecht's company failed to use two basic techniques that could have protected the data - requiring a password and instructing search engines not to index the pages. He called the breach "likely a case of felony stupidity."

 

[TromboneAl]

I'm switching doctors, and transferring the records has taken almost two weeks. The two offices are about 3 miles apart. An outsourced company comes from three hours away, copies the records, then goes back and snail-mails them from their office. A week since mailing, and they still haven't arrived.

 

[Koolau]

It seems to be a common practice for doctors to ask for social security number and driver's license number on their new patient forms. What I don't get is why people feel the obligation to provide that information without a care in the world if it's really needed and how the information will be stored and safeguarded.

When I recently switched doctors I got into this with them BIG TIME. They stated that they would not take me as a patient without SSN and copy of DL. I didn't think that was legal, so I pushed back, talking with several administrators. Got the same answer. Went to SS and got this answer. No one can require you to give them your SSN without a government need for it. However, they CAN deny you service if you refuse. So, basically, you are screwed. I threatened my new doc(s') business if they misused or otherwise let my SSN info out. They nodded and took my number. First piece of paper I received from them (a form to hand to the doc for my first exam) had the SSN right there on the form. $%&82#$&^%^%$ SOBs. I scratched out the number and continue to do so each time, but sheeeshh! My doc (nurse) doesn't need to see my SSN (they don't ever comment on my mark out). And if the billing dept. does happen to need it, they have it in their computer. Why do they put it on every piece of paper about me that they print? That's a standing invitation for ID theft. Think of all the folks who roam through a doc's office who could take a videophone pic of your document as it sits in the "in box" at the nurse's counter.

So every piece of paper my doc has about me has the two items needed for ID theft. SS and DOB. Really smart. 11 years of med school and residency to come up with THAT for a system. Yeah, I know, the doc's didn't do it, some computer geek did. But still, you would think the docs would want to protect themselves from such a likely source of liability (forget medical malpractice - how about ID theft?)

End of rant - for now.

 

[TromboneAl]

No one can require you to give them your SSN without a government need for it. However, they CAN deny you service if you refuse.

Typical meaningless rule. I guess "cannot require" means they can't point a gun at you.

 

[GrayHare]

I suspect they are merely using SSN to uniquely identify patients. Unless there's a government need, and provided it is not for fraudulent purposes, AFAIK it is legal to tell them an invented SSN.

 

[TromboneAl]

AFAIK it is legal to tell them an invented SSN.

Interesting idea. They require a SSN but not the correct SSN. Of course unless you have a fake one that you've used from the beginning, you are probably going to run into trouble.

I have a fake birthdate that I use to avoid identity theft.

Using 123-45-6789 is probably not a good idea.

 

[Brat]

ya, because another patient has already claimed it..

My medicare # is my ssn so it is out there with my insurance # and gosh knows what else.

Today the office of every physician I see makes a copy of my ID (driver's licence), health insurance card and medicare card. I think this may be the way health care providers prevent the uninsured from assuming the identity of someone with insurance and to prevent mixing health care records where two people are using the same identity with the same health care provider.

About 10 years ago a physician submitted a bill to Medicare for my mother who was in a nursing home in Portland. The physician is in Honolulu, where Mother lived for many years. I knew that there was another woman in our community with my mother's name and Honolulu is a popular place for retirees from Portland. I called Medicare and told them that I suspect that my mother and another lady with the same name used the same physician, the billing office mixed them up. A few weeks later medicare called me back, told me that my guess was correct, and thanked me on behalf of Medicare and the physician's office.

 

[REWahoo]

My medicare # is my ssn so it is out there with my insurance # and gosh knows what else.

Yep. Everyone concerned about giving your SS# to medical providers needs to come to grips with this inevitability. "Resistance is futile"...

 

[Koolau]

Yep. Everyone concerned about giving your SS# to medical providers needs to come to grips with this inevitability. "Resistance is futile"...

Yup, just got my card (not good for a few more weeks yet). SSN right there, big as life. The SOBs even had the gall to suggest I not carry it with me - except when I would be visiting my doc (ID theft and all). Now, I don't know about anyone else, but I always suspect there is some finite chance that leaving my house to enter Honolulu traffic gives me a half decent chance of needing to see a doc that day - and I may not be in any shape to go home and get my card. What's a guy to do??