Obama Proposes Digital Health Records

An anonymous reader writes "'President-elect Barack Obama, as part of the effort to revive the economy, has proposed a massive effort to modernize health care by making all health records standardized and electronic.' The plan includes having all conventional records converted to digital within 5 years. Independent studies are fixing this cost somewhere in the range of $75 to $100 Billion, with most of the money going to paying and training technical staff to work on the conversion. Early government estimates are showing 212,000 jobs could be created by this plan."

stupid question but.....

If this can save so much money why isn't the health care industry already doing it? Are they really that stupid or are all the promises of big savings not likely to pan out?

Re:stupid question but.....

Good point, but the other question to ask would be who saves the money?

Having these records would make it easier to switch providers. Without them, more tests might need to be done since "we don't have the records". Switching providers isn't in the providers' interest. Charging for lots of tests is.

exatly

Having health records as a standard brings more transparency to the Health care industry, start with that and then soon people will want them standardized invoicing and billing etc. Obfustication seems to be a popular method to profit.

Re:exatly

ANSI 835 / 837 as mandated by HIPAA. I work with those things day in and day out. They (providers and insurers) do still find interesting ways to make me go "wtf" at least twice a week, though.

Re:exatly

I work in the same industry. Lots and lots of our carriers refuse to provide ANSI 835 documents though. Of all our carriers about 5% actually comply and supply 835's. ( I work in pharmacy ) btw, 835's are a mess anyway. We have to write parsers almost on a carrier by carrier basis because so much of the spec is optional everyone does it in their own way. I'm sure you know my pain.

Re:stupid question but.....

Having these records would make it easier to switch providers. Without them, more tests might need to be done since "we don't have the records". Switching providers isn't in the providers' interest. Charging for lots of tests is.

There is that possibility, but I'd be more inclined to believe inertia in record keeping is more to blame for them having different formats.

You know that all providers are going to need to pay out cash to get new software that obeys the rules and there will also have to be a data migration effort. And you also know who that cost will be passed on to. Hint: not the providers.

The question is: is it worth having health care customers pay for this? Will the investment be worth it? I think it might be, if it does help with the need to dispense with tests, retests, and other administrivia.

Re:stupid question but.....

Maybe the open source community should get off their butts and help to create client software and server software that will implement this standard, and provide it free to the medical community thus lowering the cost of entry into standardized medical records and systems.

This could be the best achievement of open source collaboration, and usher in a new era of open source projects that benefit mankind at the very basic level of existence.

Re:stupid question but.....

A standard isn't software; it's how to exchange information. That includes data formats, but also includes protocols and an awful lot of context. The standards work is a big job, and people have been working on it for years (see HL7 [hl7.org]). As eln points out below, it's boring as hell, but that doesn't make it unimportant. The industry has been in the process of moving from HL7 v.2 to v.3 for about a decade now.

If you want to get into the software part of the solution, have a look at the OHF Project [eclipse.org]. There are others, but that's a starting place.

I agree with tnk on the benign reason; the system as a whole will save money, but which individual players will save how much? Hospitals already spend very little on IT compared with other businesses, so spending a big whack that may end saving money for some insurance company isn't going to happen.

You want one big reason for doing this? If it can free up nurses from doing secretarial work chasing down documents in the mail and phoning around, it just might keep enough staff at the hospitals to serve the public. The U.S. department of health and human services prepared this report [hrsa.gov] on the subject. It's worth reading.

Re:stupid question but.....

There is that possibility, but I'd be more inclined to believe inertia in record keeping is more to blame for them having different formats.

There is that possibility, but with nearly a decade behind me in the health care industry, I'd be more inclined to believe it's the Not-Invented-Here syndrome.

Also, I'm very worried about a system like this from the user's point of view. If it breaks, the impact could be enormous. And breaking into a system becomes much more attractive when you can get everything in one place.
And who is to say that a future government won't use the data for nefarious purposes? If the data is there, the temptation might be high. Would you trust all the possible future governments to know who has had abortions in the past, was brought to the ER for drug pumping when 12 years old, who is lactose intolerant due to distant negroid ancestors, or who has and haven't had a bris?

There's also the problem that if a doctor enters something incorrect, imprecise or a red herring, it's going to stick there forever, and unless you demand to see your records, you may not even know about it. Speaking from experience, doctors are humans who will focus on the first interesting thing they see, and often have made up their mind based on your journal before even seeing you. Often they're right, but sometimes they're not, and when they're not, it tends to be the same patients who suffer over and over again, because the journals don't change -- they just get added to. (It could be that some doctor at one time entered 'fibromyalgia?' in a journal, and from that point on, every doctor who reads the journal will consciously or unconsciously think that any pain you report might be related to fibromyalgia. Whether or not you ever had it.)

I'm just surprised that privacy advocates aren't all up in arms about this dangerous proposal.

Re:stupid question but.....

Having these records would make it easier to switch providers

I don't know if I buy that. It's pretty easy to get your records now. You request them, sign a disclosure and receive them in a few days. Some providers will even copy them right there for you. Perhaps going electronic will eliminate the wait time to have your chart pulled and copied but perhaps it won't. Will there be legislation in place that requires them to give you copies faster? Or will the excuse just change from "we need to photocopy your chart" to "we need to get IT to open up your records for the new provider"?

There's also privacy issues that need to be addressed. I know people will scream 'HIPAA' at the top of their lungs but have you actually read your insurance contract lately? Yeah, law enforcement/civil parties can't generally subpoena your Doctor to get at your medical records -- but they can and do subpoena insurance companies for billing records, which tell them much the same things. Why that's allowed is beyond me but it is.

24%

Almost a quarter of every dollar we spend on health care is used by administrative expenses. In Taiwan where they have digitalized medical records their overhead is only 2%. There is plenty of examples around the world to why electronic records are better economically. Also there is the benefit of less mistakes since cross referencing medications and such can be done electronically for drug interactions etc. Frontline had an excellent episode were they looked at the health care systems of several other modern democratic countries. A must watch for anybody who cares about the health care debate. http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/ [pbs.org]

Re:24%

I don't think that the reason for reduced overhead should be entirely attributed to digitalized medical records. You also have to remember that one of the main problems that medical companies don't do this already is liability problems created by HIPPA. Likewise, insurance is a nightmare to work with. These will both continue to be true whether or not records are digitalized.

One problem few people think about with regards to health care is that the U.S. is such a diverse society, you have a lot of different types of needs. In countries with a monoculture, it is much easier to have low overhead and have a one-size-fits-all way of doing things. Also, in other countries, privacy is not so much of an issue. Here, for some reason beyond my understanding, medical records have become almost the equivalent of classified documents in terms of how they are protected. This has probably cost us much more money than whether or not the records are digital.

I think it is _possible_ we could save money with digitization, but not the amount suggested by this post. On the other hand, based on previous experience with medical IT, I think it's possible it could actually lose money in the long run, especially if "being digital" becomes more important than actually solving the communication problem.

Re:stupid question but.....

Standardization is one of those things that's good for everyone, but that would not be cost-effective for one player to attempt. When a bigger player (which in this case has to be the government) moves in and lays out standards for everyone to follow, everyone benefits.

You should be asking not why the industry isn't doing it, but why the government didn't step in a long time ago, to do this and a lot more. Many doctors -- people who have invested more time in training and education than almost any other group in our society -- are spending half of their work hours on paperwork and arguing with insurance companies. The level of inefficiency and waste in American medicine borders on criminal, and it translates not just to massive deficits for taxpayers, but second-rate health care for citizens.

Re:stupid question but.....

Interoperability is where the government steps in, for better or worse -- only the most ideological libertarian would deny that such a role exists.

I'm not a libertarian and I've never denied that Government has some roles. I'm just really skeptical about UHC. Here are just some of my concerns (off the top my head):

1) What evidence do we have that it will actually make health care more affordable? When has Government ever been able to do anything cheaply or efficiently?
2) Will Government in health care be used as yet another excuse to expand the nanny state? Will alcohol be taxed higher because it's bad for me? McDonalds? Doritos? Will all of this enforced by my employer similar to the way the so-called War on Drugs is enforced? Stop smoking or lose your job? Lose weight or lose your job?
3) What reason do we have to believe that our new Government overlords will be anymore benevolent than our existing insurance company overlords? I don't see how arguing with a Government bureaucrat over treatment is any preferable to arguing with a private sector bureaucrat. Who would you rather deal with: DMV or your auto-insurance company?
4) Will there be a way for me to opt-out if I don't see the benefits in having my health record instantly accessible from anywhere in the United States?
5) Will Government involvement in health care be used as an excuse to further erode the doctor-patient privilege? Go read the laws around credit reporting sometime -- the Government wrote in nice little exceptions for itself for all of the privacy laws related to credit reports. Will it do the same thing for medical records?

Just are just off the top of my head. I'd have to say that #2 is probably my biggest concern. I'm sick of the nanny state and the war on vice. And I see no signs that it's going to get any better. In fact [nydailynews.com] I see the exact opposite......

Re:stupid question but.....

"why isn't the health care industry already doing it"
Because it'll cost a fortune, and be a nightmare to implement. (Look at the mess the UK is making of their health computer system, with loads of interest groups, all pulling in different directions, pushing up the costs).

"Early government estimates are showing 212,000 jobs could be created by this plan."
Yeah, and how many paper pushers etc.., will it put out of work? ... While it will create jobs, it will also wipe out existing jobs. Political drones just want it to sound like its creating jobs. Plus even if its adding more jobs overall, then surely its going to end up costing more money in total to keep funding the system?

Re:stupid question but.....

Note the part where this will "create 212,000 jobs". It's not supposed to save money, it's supposed to spend it -- and the sugar daddy footing the bill is you.

Regulatory boondoggles. Girls singing to ABBA albums. It's like 1979 all over again.

Re:stupid question but.....

The idea is sound, but very difficult to properly implement. You'd think with all the benefits, healthcare providors would be clamoring to make the switch (some already have), but there are a lot of hidden problems associated with digital records.

I'm a healthcare technician in the USAF, where the DoD has already implemented a system called AHLTA. When a patient presents for a doctor's visit, all the screening, labs, tests, orders, prescriptions, and physician's notes are entered into the system, where they can be referred to easily for future visits. No need to store thousands of paper records, or train records techs to pull them and locate the appropriate exams.

Problems we experience: Privacy. It's difficult to ascertain just what records which type of doctor should be seeing, so right now we basically have a system where any variety of doctor or technician can see any variety of a particular patient's records (except Mental Health and STD visits, which are accessible only by password by default). This situation makes some patients rather uncomfortable.

Data load. That's a lot of records. And it requires a lot of trained technicians to keep track of it. And it requires frequent audits to ensure the information is current, and has not been illegally accessed. And the system has to communicate and exchange information with several other (often outdated) systems.

Server outages. When we have one, the clinic is virtually paralyzed. We can't refer to the patient's paper record for reliable case history, because the system was implemented five years ago. There won't be any recent records to refer to.

Good Old Boys. The transition has been difficult chiefly because, let's face it: doctors just don't wanna have to go to all the trouble of learning a whole new computer system. It's easier for them to scribble some notes on a sheet of paper, and stick it away in a paper record and be done with it.

There are clear advantages, but it just seems like we're not quite far enough along to handle such a system for just DoD personnel, let alone every single man, woman, and child in the US. A five-year plan is just not feasible from where I'm standing.

Other issues

I work for a healthcare organization that was one of the first to switch to an EMR. You make a lot of good points, and I'd like to follow up.

In terms of privacy, we audit all access to our medical records and have a team of auditors who monitor access. I've been responsible for writing exception reports and such. It's far easier to tell who's accessing your medical records than paper copies laying around.

Data load is a big deal. We have our main EMR and multiple data repositories where we can do reporting and other non-operational work. Lots of people support all that infrastructure. On the plus side, that infrastructure lets us do things that saves money and lives.

Server outages have been pretty bad, but we have assorted downtime procedures and downtime systems. An example is a downtime database located in the various medical record office that are constantly updated with patient allergies.

Our staff has gotten quite used to working with an EMR, but there are still cultural issues. For example, what a physician writes in a medical record may be visible to the patient. They have concerns about speaking plainly (e.g. describing a patient as alcoholic). At the same time, patients have a right to know how they're being treated.

My biggest worry about the new plan to convert paper records is that there are so many EMR systems. Will they pick one of the existing vendors? Build a new one? The ideal for the patient is to have a single nation-wide EMR that they can take wherever they go. This has a huge impact on existing EMR vendors and installs, though, so I doubt people will take that approach.

stepping stones to universal health care

Getting all of the records into a standardized format is a stepping stone to universal health care. By biting it off in pieces, he's going to be able to make the apparent cost of the transition lower because much of the expensive work will have already been done by initiatives like this.

A Better Idea...

How about doing this for my 401K? My current one through my employer is impossible to manage, and the insecurity around the thing is downright scary. My rollover IRA through Fidelity is ok, though.

On that note, how about making it so that I can choose whoever I want to put my pre-tax money into vs. whatever firm my employer wants me to use?

On healthcare, stop allowing the 'insurance' companies to be in charge, for one. Let me see any doctor I want, and they cover me. Enough with the in network, out of network bullshit. Don't cover routine stuff, but do cover surgeries, long-term care, therapy, etc. I don't use my car insurance for oil changes </bad car analogy>

That estimate seems really high

$100billion? There are millions of patient records, but they do not reside in millions of databases. Let's be generous and say there are thousands of databases. But most of those databases are already manned by DBAs. Some of them may not be up to the task, but most can convert their tables to the specified format if you tell them what that is.

So it seems the task is coming up with a standard format and enforcing it. Security is another question, but again it seems a matter of mandating healthcare providers adhere to a specified standard. But hospitals and insurance companies are quite used to such bureaucracy, so it's difficult to understand where they're pulling this $100billion figure from.

Saying they'd need to hire an entire new class of DBAs and techs to make it happen is silly, since they already exist.

Odds are the figure was thrown against the wall by companies hoping to win a fat contract, and counting on the knowledge that politicians have no sense of what it takes to get the job done. I hope Obama's CIO has the knowledge and grit to tell them to take a hike.

Doublespeak time!

In case most of you had forgotten, Obama is basically copying John McCain who specifically mentioned doing this in the debates. Of course at the time McCain did it Slashdot thought it was an evil intrusion of privacy. But now that Obama wants to do the exact same thing it's an enlightened 21st century idea that only some Luddite old guy like McCain could ever oppose.

Good luck, didn't work in UK

We have a similar "project" or rather it should be characterised as a "permanently stalled horror story." There are only 70 million or so people in the UK so nobody understood why the initial budget was in the billions. Now it's in the tens of billions and no end in sight. Google NHS IT if you really want to spoil your day.

Create 212,000 jobs?

So what they're saying is that this system will require 212,000 more people to operate than the current one. I have to ask then, why they're going to develop a new system that's more inefficient than the current one? Shouldn't a new system like this actually eliminate jobs?

Re:Format

While your post is intended to be a dig at Microsoft, HIPAA may actually require a form of DRM.