Godzilla vs. Megalon

The electronic medical record (EMR) has delivered on some on its promise to put patient information at the fingertips of the practicing clinician. Before the EMR, I’d wistfully read about airplane mechanics who carried a tablet that served as a gateway to everything there was to know about the plane they were working on, as well as provided a simple platform for documenting the problems they found, the ones they fixed, and further steps that needed to be taken. Healthcare industry information systems have always been well behind those of other information-intensive business sectors, like aviation, banking, and hospitality. I’d longingly observe how every worker at a McDonald’s was connected to every other worker and to the machines they used to make meals, via a well-designed digital network that maximized efficiency, leaving front line workers free to smile and say, unhurriedly, “You want fries with that?”The data it takes to get ahold of customer throughput at a McDonald’s restaurant pales in comparison to what there is to know about the human body. Even Boeing’s 737 MAX, with its 367,000 parts, is way simpler than the most humble of the creatures that god made. The 737 MAX was grounded last March after a couple of crashes, ultimately attributed to bad management decisions that inhibited the flow of good information among engineers and pilots.There are so many more types of data that apply to medical practice than can be found in a standard airplane schematic or operating manual: lab test numbers; radiology images; physical exam findings and lots and lots of prose in the form of histories and consultant reports. Plus, every individual is unique. In other words, medical information is dauntingly complex.In spite of these challenges, EMRs have accomplished some things. Once a record is available in electronic form it is retrievable by anybody who is connected to the internet, which is just about everybody, just about everywhere (so long as, hopefully, they have the right credentials and permissions). This has been a huge boon. Whether in the exam room with the patient or on the beach in Mexico, a connected clinician can give advice or make a decision based on real data, not on just on imperfect memory.Trouble is, recording a patient interaction in the EMR generally takes a lot more time than it used to take to dictate an encounter note. Study after study has found that doctors now spend more than half of their work hours doing things besides being with patients. A large share of that non-patient time is devoted to the EMR, which has bled work over onto after hours and weekends. Fortunately or unfortunately, one can work on an electronic medical record from anywhere.[caption id="attachment_584" align="alignright" width="230"]

what scares me in telemedicine

Click to read my last article, "What Scares Me."[/caption]My last blog, "What Scares Me," is about what the EMR leaves out, which is the story. Clinicians spend their documentation time clicking boxes on problem templates rather than recording answers to open-ended questions like, “What’s bothering you?”Data are essential to medical care. The more complete and usable the data, the better the care. “Usable” is italicized because, if data are not well organized and well presented, they are pretty useless. That’s often the situation when one requests medical records from another institution. In olden days they’d send you a thick stack of photocopied pages, a fair share of which were filled with illegible handwriting. Now you get, electronically or as hard copy, a printout “summary” of the patient’s EMR. Faxes and Nike nets (CD-ROMS carried from sender to receiver) are also employed more often than they ought to be this far into the electronic age. Everything is legible in an EMR because it’s all in a print font. But it’s really not organized. It is not unusual to find in a so-called record summary about 1 part of usable information hiding amidst 99 parts of useless crap.Why is that? Because there are not agreed-upon standards for data interchange among medical records from different vendors and from different institutions. Data from each is dumped uncooked on the poor requester who is unfortunate enough to come from an institution that uses a different record system. Efficiency be damned. And why is that? Because information is power and money. Holders of patient information are not very interested in improving the efficiency of their rivals.Of course, this is an intolerable state of affairs. Everybody who cares for a patient ought to have the best quality, most pertinent, best-organized information possible. When they make decisions, healthcare organizations pay lip service to having patients’ best interests at heart. No matter what, though, in the competitive medical marketplace, money must be the first consideration of all those well-meaning people who run medical institutions and who sell electronic medical records. On a good day, what the finance people have ascertained will pay overlaps with what’s in patients’ best interest. On a really good day, that decision will even make sense in terms of what the community needs. Those are the good days.

medical data holders quote

In February 2019, the US Department of Health and Human Services proposed rules and standards for medical data sharing. The uproar over the government’s proposal has gotten louder with each passing week. In the name of doing what’s best for the patient, many of the heavy hitters in healthcare have pulled out the stops in their opposition to the proposed regulations, not incidentally, preserving their own slices of the healthcare pie. Epic Systems, the largest purveyor of the EMR, with $2.9 billion in revenue in 2018, is leading a very public charge against the rules, mostly out of concern, they say, for patient privacy. Out in front is Tommy Thompson, ex-head of HHS and ex-governor of Wisconsin. Epic is located in Verona, Wisconsin. Some 60 health systems sided with Epic this month in a letter to Alex Azar, DHSS secretary.Meanwhile, Apple, Alphabet, and Microsoft, who make a ton of money lubricating the flow of information, have come out in support of the data-sharing rules. So have Humana and Walgreens.In the realm of standards for medical data sharing, it’s come down to a battle of behemoths, as in the 1973 classic Japanese movie, Godzilla vs. Megalon. The difference between reality and the world of the movie is that, as far as I know, neither Godzilla nor Megalon claimed their fight was over concern for anybody else’s best interests.

March 1, 2020
 in the
Digital Healing
Written by
Marc Ringel, MD

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