Electronic Medical Records

Current State and Goals of CDSS

1. 
   Make the best knowledge available where and when it is needed. This consists of:
   
   1. 
      Standardizing knowledge, information and records formats to make it easier for developers to access and use such information.
      
   2. 
      Making this knowledge readily accessible and easy to incorporate into other systems and processes.
      
2. 
   Widespread adoption and use. Without widespread deployment of compatible systems, systems which are deployed will be somewhat limited in benefit due to their lack of access to complete patient records and limited inter-provider interaction. This requires:
   
   1. 
      Removal of legal, policy and financial barriers (for example concerning access to patient records, liability, and lack of financial incentives to adopt CDSS).
      
   2. 
      Improved ease of deployment and transparent integration of CDSS in clinical workflow systems.
      
   3. 
      Ensuring that CDS logic does not generate false warnings, alerts or directions which can lead to clinicians either ignoring or disabling the features. (In fact, one physician we interviewed commented that he ignores every pop-up warning he receives before he even reads it. He went on to say that in our litigious society, no-one, including the software developers, wants to take responsibility for missed alerts, and in so doing the designers overcompensate by providing an endless list of warnings.)
      
3. 
   Continuous improvement of knowledge and methods. This includes:
   
   1. 
      Continuously monitoring and learning from the lessons of existing deployments to get feedback about best practices.
      
   2. 
      Advancing medical knowledge by processing and mining the data that becomes available in electronic medical record systems and from the use of CDS systems.
      

1. 
   A triage nurse gathers standard information about an incoming patient, for example blood pressure, heart rate, symptoms, etc. Rather than filling out a paper form, the nurse enters this information into a computerized workflow system. In addition to being stored in the patient’s records, the system looks at the new information and the patient’s existing records and suggests additional questions or tests to the nurse.
   
2. 
   A physician enters his diagnosis into the system and fills out some electronic prescription requests. The system may flag unusual diagnosis-treatment combinations, dosage errors and dangerous drug allergies or drug-drug interactions between proposed and existing medications. Cheaper or more effective alternative treatments may also be recommended.
   
3. 
   Trends in misdiagnosis, dosage errors, over or under use of particular treatments etc. can easily be monitored by the system, and flagged to the physician and clinic management such that corrective action can be taken (for example, corrective training and review).
   
4. 
   A patient logs into a personalized health care portal provided by their insurer which allows them to manage prescriptions and appointments and view records. The system may suggest recommended screenings or tests based on age and/or medical history.
   

Policy Issues in Computerized Health Care

Demand for a Health Information Technology (HIT) Policy

In light of the potential benefits of ubiquitous health information technologies, many have called for a greater role for government and public policy in promoting their development and diffusion. Only within the last several years has the issue gained political traction. In 2004, President Bush called for the development of a national health information infrastructure. This infrastructure would include interoperable EMRs for most Americans by 2014. He established (by Executive Order 13335) a national health information technology coordinator (“health-IT czar”) position in the Department of Health and Human Services (HHS) to oversee its development and implementation, and appointed Dr. David Brailer to the post. Bush and his former HHS secretary Tommy Thompson have spoken out on the need to computerize health care, characterizing today's system as “twenty-first century medicine [held] together with nineteenth-century paperwork”³⁹. The Bush administration doubled funding for the effort in fiscal year (FY) 2005 and then made further increases in FY 2006, and it enjoys broad bipartisan backing.
If health information technologies have been in use for over three decades, why has there only now been a major policy push?

• 
  Recent high profile reports have exposed the prevalence of preventable fatal medical errors and the potential for HIT, including electronic records, computerized physician order entry and decision support systems, to reduce errors and improve the quality of care. In 2000, the Institute of Medicine (IOM) estimated that between 44,000 to 98,000 people die in the hospital each year as a result of medical errors such as prescribing errors, misinterpretation of orders, and diagnostic errors⁴⁰. Many of these could be prevented through HIT. A 2001 IOM report called for HIT as part of national efforts in quality improvement in patient care and disease management⁴¹. Studies⁴² have shown that efforts like the VA Veterans Health Information Systems and Technology Architecture (VistA) for HIT have resulted in a reduction in prescribing errors.
  
• 
  HIT has a potential role in helping to contain escalating health care costs. National health care spending grew to $1.96 trillion in 2004, with government spending accounting for $888 billion (or 45 percent)⁴³. The estimated cost savings from complete implementation of EMR is in the billions, and the financial costs of preventable errors have been estimated at $17 billion per yearError: Reference source not found. A 2005 RAND Corporation study commissioned by the HIT industry put the figure at $500 billion in savings in direct costs over the next 15 yearsError: Reference source not found.
  
• 
  Finally, there is empirical evidence of substantial labor productivity gains in other business sectors in the 1990s that have not yet been seen in health care⁴⁴.
  

The convergence of these facts has brought the long ignored issue of a national health information infrastructure to the fore.

A Broken Record?

Commentators in medicine and computer science have lamented the slow spread of health information systems (HIS) almost since their introduction. Public policy is often cited as a critical factor. In 1974, computer scientist Anthony Wasserman commented, “The development of information systems in health care has proceeded more slowly than expected ten years ago”. He posed questions about privacy, information security and legal liability arising from the use of decision support systems and patient monitoring technologies.⁴⁵ Dr. Donald Lindberg, a pathologist and medical computing expert who became Director of the National Library of Medicine (NLM) of the National Institutes of Health (NIH), remarks in the introduction to his interestingly titled 1977 book The Growth of Medical Information Systems in the United States:

“The United States health care system has become subject to increasing public criticism. At the same time, computing systems are ever more ubiquitous and successfully used in nonhealth fields to increase management capability and labor productivity. It is natural to wonder why health system management has not also benefited from dosing with the remedy of computer systems. It is this overriding question which makes this case of interest. Why has medicine not been able to use computer systems to solve its information processing problems?”⁴⁶

Lindberg’s question remains today, as do some of the policy questions surrounding the adoption of widespread interoperable HITs that he raised. These include both standards (such as terminology, record format, content, etc.) and the issue of Medicare reimbursement of HIT-related activitiesError: Reference source not found.
The following sections highlight the government’s role in promoting medical computing, beginning with a brief overview of government sponsorship of research that started in the 1950s. The federal government has fed the HIT research pipeline and invested in agency systems, most notably the VA’s Veterans Health Information Systems and Technology Architecture, whose recent experience has shown the value of widespread use of EMRs. While extra funding, federal coordination, and goal setting by the current administration is seen as an important policy shift even within the medical computing community⁴⁷, there are enduring factors that may continue to slow the adoption of HITs. At the end of this section we highlight the most important factors, namely 1) problems of collective action, 2) network externalities and standard-setting, 3) economic organization of the health care industry, and 4) concerns about privacy and security.

History of Government Involvement in Medical Computing

Not surprisingly, government labs were early users and innovators in medical computing. Government purchases of large mainframe computers in the 1950s enabled the development of early applications of medical computing, then called “bioengineering.” The first use of computers for use in health is credited to Robert Ledley, a dentist at the National Bureau of Standards, who used them in dental projects⁴⁸. He would go on to invent the full-body CT scan in 1974. Ledley and Lee Lusted, a NIH radiologist, published a series of articles, including an influential piece in Science in 1959 about their early work in CDSS using computers and patient information data to conduct Bayesian diagnosis and decision making.
As in other areas of science and technology after World War II, the federal government became the primary funder of medical research. Medical informatics gained a foothold in 1960 as a legitimate field for basic research with the establishment of the NIH Advisory Committee on Computers in Research, first headed by LustedError: Reference source not found. This opened up the field to extramural funding. The first academic treatments of the subject came in the mid-1960s as did the “oft-repeated policy recommendations for fostering medical computer use”.⁴⁹
Several of the early advances in medical information systems were sponsored by government research. Massachusetts General Hospital’s MUMPS programming language was supported by a 1966 NIH grantError: Reference source not found. The NLM also became involved as a major supporter of medical informatics. In the early 1960s they digitized the Index Medicus which would eventually become the Medline database. Beginning in the early 1970s and continuing today, the NLM has helped to build capacity in universities by funding extramural grants and training programs in medical informaticsError: Reference source not found.
In the late 1960s and 70s, the establishment of Medicare and Medicaid and the rising costs of health care led to a new emphasis in medical computing beyond strictly research purposes, that of systems that emphasized the ability to reduce costs and improve communication in the delivery system. In particular, the need to process vast numbers of Medicare claims for reimbursement created incentives for hospitals to develop systems for medical billing, perhaps at the expense of patient care applicationsError: Reference source not found.
Hospital information systems (HIS)⁵⁰ developed in this era combined patient records with financial systems for fee-for-service billing. The National Center for Health Services Research (NCHSR), which was the precursor to the Agency for the Healthcare Research and Quality (AHRQ)⁵¹, funded both the Technicon system, developed in 1965 with Lockheed and then commercialized, and the open source MUMPS-based COSTAR (1968). Both of these systems were successfully transferred to hundreds of other sites⁵². In the mid 1960sError: Reference source not found, NCHSR funded systems that combined patient records and decision support, such as the LDS Hospital's HELP system and the University of Vermont’s PROMIS. Many of these systems were models for systems that would be developed in the 1970s and 1980s. Early work in decision support and expert systems in medical computing also received government support during this period, notably MYCIN which was funded initially by the NIH and later by the Defense Advanced Research Projects Agency, the US Navy Office of Naval Research, and the National Science Foundation⁵³.
The failure of Medicare reform and other efforts by the federal government to constrain costs lead to a “rationalization” of the health care system. This included critiques of the cost effectiveness of computing applications in medicine, such as overspending on CT scanningError: Reference source not found. This period marked a further shift of the use of computers in medicine away from patient care and towards cost reduction, business management, and administrationError: Reference source not found. Some experts in this era, such as Kaiser-Permanente founder Sidney GarfieldError: Reference source not found, emphasized the ability of computers to make medicine more effective and humane. They could make “a whole new kind of medicine possible”. These ideas have come full circle in today’s policy debate.
Rising out of this early work in medical computing, much of which was government sponsored, medical informatics established itself in the 1980s as a discipline concerned with all applications of computing to biomedicine and health. The American Informatics Association, founded in 1990, has served in a leadership role and has been active in U.S. policyError: Reference source not found.
Another notable outgrowth is the development of VistA, the VA Medical System’s scalable information system that runs the largest health system in the U.S. It has over 4.2 million patients and over 1000 care sites in its network. VistA is a MUMPS-based system first introduced in 1996, but its origins date back to 1974 with the VA’s predecessor, the Decentralized Hospital Computer Program (DHCP). The system is credited with demonstrated productivity and performance increases in the VA system, in addition to reduced errors. Since 1996, while health care costs per capita in the U.S. have shot up 60 percent to $6300, the VA has maintained at $5000 over the same period, ostensibly due to the introduction of the system⁵⁴. Under the Freedom of Information Act, the federal government has released the source code for VistA. The several available open source versions of VistA, such as WorldVistA, present low cost options for small practices.
At the macro level, most of the prototyping for the National Health Information Network is being conducted in the private sector. Experts doubt whether private practices will be able to utilize the VistA system, however, “at a minimum, design decisions that make such systems successful in terms of functionality, workflow support, decision-support protocols, and data definitions would be useful input into the national standard setting process”⁵⁵. Perhaps the most fundamental importance of the VistA system is that it makes a strong “v-c” case for a national HIT network.
Through basic research and continued and direct development of systems such as VistA, the federal government and has played an integral role in fostering the development of health informatics tools that can and have been applied in other care settings. While private sector software developers will have a critical role to play in commercializing EMR systems, ongoing barriers to interoperable EMRs remain that may require policy action. Four major sets of issues are summarized below:

• 
  The Collective Action Problem. The principal strength of the U.S. health care system in promoting competition between providers, which has contributed to innovation in cutting edge treatments and diagnostics and greater consumer choice for patients, has also created a patchwork of public/private care providers, payers, and insurers. Given this competition, individual providers have little incentive to share systems or patient information across providers especially given the high fixed costs of implementing EMR systemsError: Reference source not found. However, recent exemptions offered by the Center for Medicare and Medicaid Services (CMS) to the Stark anti-kickback regulation, which prevents cross-subsidization of HIT, have spurred some hospitals to begin purchasing information technology systems for their off-site doctors⁵⁶.
  
• 
  The “New Economy” Problems: Network Externalities and Standards. Just as with the Internet, network externalities are at play in the EMR story. The value of the health information network, where different actors (hospitals, physicians, pharmacists, insurers, government, etc.) in the system can communicate directly, increases as more people join. Similarly, as in the Betamax/VHS case, private markets may not converge on universally accepted standards, terminology, record formats, record interfaces, and network exchanged platforms, which will cause fence sitting on EMRs to continue. The role of the national health information technology coordinator and standards organizations such as Health Level Seven (HL7) will be crucial; however, these issues will take years to unravel.
  
• 
  Making Economic Sense. In the fee-for-service system, care that is unnecessary or redundant generates revenue for the provider. Additionally, doctors and hospitals would only receive a small fraction of HIT’s potential economic benefits. An estimated 90 percent would go to insurers and purchasers of care, including the federal government, in the form of lower premiums and enhanced worker productivity⁵⁷.
  
• 
  Security and Privacy Issues and the Health Insurance Portability and Accountability Act (HIPAA). There are widespread concerns about protecting and securing patients’ protected health information (PHI) in a national health information network, especially one that is based on the Internet. However, the 1996 HIPAA provisions have set into motion the regulatory mechanisms for vendors and providers to supply secure private data exchange within a national EMR system. While HIPAA rules are still in flux with respect to EMR, the framework and many of the safeguards to facilitate such a system are already in place⁵⁸.
  

Given the policy momentum along with the current mood in the administration and Congress, there is an impetus for the government to take action to address many of these issues and to hasten the adoption of EMR systems. If history is any indication, the complex incentives and technology and policy choices involved in creating a robust national health information infrastructure portend a steep uphill battle.

Unexpected Consequences of the Computerization of Health Care

While it is hard to disagree that computerizing health care is the direction we should be headed in, as we have shown there are obstacles and deterrents to the introduction of computerized health care systems. These include privacy issues, the cost of installing a new system and training the users, altering people’s habits, lack of interoperability and fear of lawsuits against hospitals that share data. There are also some less obvious consequences that bear consideration.

Depersonalization

The depersonalization of health care was the biggest complaint of Gale Thompson MD, an anesthesiologist at Virginia Mason Medical Center in Seattle who has been practicing since the early 1960s. He believes that computers have only gotten in the way of efficient patient care by diverting the physician’s attention away from the patient. Instead of monitoring clinical signs such as pupils and skin color, physicians now concentrate on a computer monitor with “blings and bleeps and charts and graphs”. He also stated that today’s providers have lost the art of clinical assessment due to the advent of computerized monitoring. Steven Angelo, a physician in Connecticut, echoes these sentiments in an editorial he wrote in the Journal of the American Medical Association about the day when his hospital’s computer system crashed. At first, the physicians were at a loss as to how to assess a patient’s condition. Then, they slowly started migrating to their patients’ bedsides to monitor them directly, evidently a practice that is no longer a natural reflex for some physicians. Angelo states of the period when the computers were down: “…for a brief moment, I saw what true patient care could be like, without technology’s oftentimes distracting presence”.⁵⁹
That is not the only way in which medical care has been depersonalized by computers. Today it is common for doctors to enter notes into a computer as the patient describes his symptoms. In some examination rooms, the computer is even positioned in such a way that the doctor has his back to the patient as he types. Not only is this type of interaction more impersonal, it has also been reported that some patients are less likely to give a full and accurate description of what they are feeling in such an objectified environment.⁶⁰
Electronic communications such as email and instant messaging have reduced face-to-face interactions between people in the world in general. In his blog, author Steven Johnson states: “…we’ve embraced technologies that help us block out the people we share physical space with”.⁶¹ The hospital setting is no different. Gale Thompson stated that medicine used to be about people working together to take care of patients. Today, instead of impromptu meetings in the hallway to discuss a patient’s care, for example, doctors and nurses often exchange notes and place orders via email and computerized order entry systems.
Perhaps the situation is not as dire as it may at first seem, however. In at least one hospital, the Miami Children’s Hospital, the introduction of an electronic record system and the use of handheld devices has helped to re-personalize the doctor-patient relationship. Doctors and nurses there are using camera attachments on their handheld devices to take digital photographs of their young patients, which then get sent up to the patient’s chart; now there is a face to associate with each record. According to the article, “The images have restored a little of the humanity that the factory-inspired paper records diminished”.⁶²

Outsourcing

The growth of the Internet and the availability of high speed network access have enabled medical images to be sent halfway around the world in a matter of seconds. This means that radiology work such as the analysis of X-rays, M.R.I.’s and CT scans⁶³ can be sent to places like India, where radiologists make far less money and thus cost less. This trend of “teleradiology”, which started in about 2003, is appealing not only for the cost reduction, but also because when an emergency case arises at midnight in America, it is daytime in India. The interpreted results can be received back by the originating hospital in less than 30 minutes in some cases.⁶⁴ Before computer networks made this possible, a groggy radiologist might have been woken from her sleep to analyze the image, or else the scan and its interpretation would have had to wait until morning.
Other forms of “telemedicine” are appearing as well, such as surgeons operating robotic surgery machines from a remote location. While in some cases such a choice might be made in order to have the expertise of a specialist operate without the patient having to travel a great distance, in other cases it might just be a matter of cost savings.
The outsourcing of medicine has caused some radiologists to worry about job security, and an adviser to President Bush suggested that fewer medical students would specialize in radiology.Error: Reference source not found There has also been concern about the quality of patient care given that the overseas radiologists may not have the same qualifications as those in the U.S.

Medication Errors

While electronic medical records and computerized order entry systems are touted for their ability to reduce the occurrence of medical errors, they are not foolproof. Daniel Warren MD, an anesthesiologist at Virginia Mason Medical Center in Seattle, commented that "there is a problem with relying on computers to reduce errors in the sense that computers still rely on human input. And the human input is the continued source of error, even in a "perfect" computer system".
In addition, computerized systems may also introduce new opportunities for doctors and nurses to make errors. One study showed that a computer system could actually increase the risk of medication errors due to factors such as having to scroll through 20 screens of information to find all of a patient’s medications.⁶⁵ Another study showed that a computer for physicians failed to warn of many adverse drug effects⁶⁶, an advertised feature of information technology pharmacy systems that some doctors and nurses may be depending on. In addition, computerized systems can make it easy to drag and drop a medication onto the wrong chart, or to confuse the charts of two people with very similar names.
In the end, it has not been shown that these risk factors outweigh the benefits of the electronic systems, and it is only through iterative development that these systems can improve. As Dr. Herbert Pardes put it in a letter to the editor of the New York Times, “[medicine] also unfortunately experiences mistakes on the way to innovation. When we identify the mistakes and push to correct them, then advances occur.”⁶⁷

Faulty Information on the World Wide Web

A 2002 article stated that more than 50 million adults in the U.S. use the World Wide Web as a source of medical information. A well-informed patient is better equipped to maintain good health and to recognize serious problems when they occur. However, much of the health-related content available on the Internet is “inaccurate and even potentially life-threatening”.⁶⁸ This can mean, for example, that a person could make a self-diagnosis based on faulty information and decide not to visit the doctor. In some cases, misleading numbers inaccurately communicate the risk of a disease.Error: Reference source not found The solution to this problem is to implement quality standards for publicized health information.

Unnecessary Procedures

“It’s very, very, very hard to control a technology.” These are the words of Dr. Hlatky of Stanford University, referring to the overuse of multidetector CT scans of the heart.⁶⁹ While this scanning technique, developed in 2004, takes only seconds, produces detailed images of the heart and arteries, and can be used in place of painful angiograms, its very ease of application has led to much debate in the medical community. It is technologies like this that can cause doctors to apply them to people who do not need them, for example scanning people who do not need to be scanned. Sometimes these unnecessary scans uncover "problems" that do not need to be fixed, leading to undue worry for the patient, or worse yet, unnecessary procedures. Every medical procedure carries risk and if there is no demonstrated benefit, that risk cannot be justified.

Care Expectations and Information Overload

Electronic access to years of case histories and patient data can put everything a physician needs to know at his fingertips as he works through a case. One of our interviewees, Dr. Daniel Warren, reported that while it is beneficial to have all that data, patients expect their care to be based on all of it. In reality that can be an insurmountable task given that the physician would need to weed through all the information and pull out only that which is applicable to his specific case.

Centralization of Health Care

The development of technically advanced medical instruments for diagnosis and treatment has “centralized” health care by creating a wider gap between wealthy urban medical centers that can afford the machines and less wealthy rural clinics that cannot. This means that some patients may now have to travel greater distances for a procedure than they did in the past.

Other Consequences

There are various other less serious but nevertheless interesting consequences of the continuing computerization of medicine. In the emergency department of a New York hospital, doctors pointed out that the arrival of their computer system had brought some peace and quiet to the place. Whereas before the department was “positively cacophonous” with announcements, now they hardly use the intercom.⁷⁰ In the same department, a system called LastWord that tracks patients in emergency care makes it easy to see how many patients each nurse is caring for. This feature has led to some disgruntlement and complaints from nurses who believe that the workload distribution is unfair.⁷⁰

Summary

Computers have been used in medicine since about the 1950s. We showed a timeline of historical events in computerized medicine as well as the broad spectrum of medical applications where computers are used today. We discussed two of these applications, electronic records and decision support systems, in detail, listing their advantages and disadvantages. There are many incentives for clinics and hospitals to computerize various processes and techniques: to increase quality, reduce errors, reduce costs, provide greater accountability, and increase efficiency. However, the associated policy issues are enormous and government will have to step in with funding and other measures if medicine is to move convincingly into the computer age. We ended with a discussion of some of the hidden consequences of computerized health care systems.

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68 Risk A, Petersen C. Health Information on the Internet. J Am Med Assoc 2002:287(20);2713-2715.

69 Kolata G. Heart Scanner Stirs New Hope and a Debate. The New York Times November 17, 2004.

70 Schiesel S. In the E.R., Learning to Love the PC. The New York Times October 21, 2004.

⁷¹ Freudenheim M, Pear R. Health Hazard: Computers Spilling Your History. The New York Times December 3, 2006.

Directory: courses -> csep590a -> 06au -> projects
courses -> Ieor 4600 Mixed-Integer Rounding Inequalities
courses -> San José State University Social Science/Psychology Psych 175, Management Psychology, Section 1, Spring 2014
courses -> Kennan's Telegram (Excerpt)
courses -> The university of british columbia
courses -> A hurricane track density function and empirical orthogonal function approach to predicting seasonal hurricane activity in the Atlantic Basin Elinor Keith April 17, 2007 Abstract
courses -> Cover page need figure & title by Proposed Table of Contents
courses -> Objectives
courses -> Dr. Jeff Masters' WunderBlog
projects -> The Past and Present of Supercomputing by David Mortenson and Luis Cabrera-Cordon Introduction

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