Gear Grinding 9: I Need a Wine!

[leswp1]

The downfall of any EHR is the data, and any time we move from one system to another - in any industry - data is lost. In healthcare, the data is "owned" by the operational groups/management and not by IT. We - IT folks - inform the operational folks of this constantly, and in the case of system migrations, what those same ops folks need to do. And they almost never dedicate sufficient resources to it.

Data migration is hard and important, so people simply don't do it. Especially when they can simply blame this nebulous "IT" thing to patients.


And you know what? It's still a thousand times better than paper.


edit: that said, it's super super frustrating when you're on the short end of the stick.

Data that needs to be mined is transferable. If it doesn't fit into a little box then many times free text is the only way to document. Free text does not migrate.
This was simple demographic info that didn't migrate.
In the last few months have seen a couple of large studies showing there is no benefit to efficiency, patient outcomes, shown from using EMR vs paper or other non-EMR systems. Anyone who has used a good system pre-EMR has no surprise for this. People who have no experience before EMR have no idea how much more efficient it was to document.

It was in my medical journal stuff. Of course I can't find it now when I went looking for the link. SYnopsis- There was no statistical improvement using EMR and in some cases older systems were more efficient and less prone to error. They looked at pt outcomes, efficiency, timeliness and ability to find information (I think those were the parameters but I can't remember)

EMR inefficiency, ability for info to be entered in places where it could be missed, ability to create and perpetuate errors by copy/paste/ repopulate, the loss or 'corruption' of data as it was migrated from system to system were some of the things they noted. They also noted the EMR was initially created to be able to mine data for insurance companies and the structure remains focused on data mining so no matter how inefficient, confining in ways to convey information, it will not change.

The commentary after the article was fascinating. Those of us who learned to practice real medicine (not driven by insurance) and wrote/dictated notes rich with details about the patient were on one side. Those trained to consider insurance parameters and EMR templated notes on the other. Eye eye opening to see how much knowledge has been lost and how patients were viewed more as objects when you just click a button. Some of the stories people told about how really important stuff was missed -there was no place for it in the chart or it was in there and not accessible unless you looked really hard for it.

It isn't IT fault. There is no way in heaven I am going to be able to click a little box to tell the story about someone's suicidal ideation, family issues, past trauma, weird sign or symptom and get more than the category across. Every time I saw a patient with only EMR records I had to basically start again to get the real story.

Still hunting for the link.

 

[Swansong]

I hope you take this as half tongue-in-cheek as I intend, but that just screams "I don't like change" to me.

Being able to swiftly intersect different systems has revolutionized healthcare delivery. Video conferencing, and the integration of it directly into EHRs, will be one of the enormous positives to come out of Covid. Patient portals and release of clinical data has converted healthcare from an opaque system where people have ... ahem ... varying levels of trust in their providers to a system where patients can actually own their own health. Not to mention things like e-prescribing and its ability to reduce doctor shopping and pill milling. You may not like the Cologuard test vs. a colonoscopy (I don't mean you specifically, Les, I mean the general "you"), but I've now built two interfaces with them to drastically cut back on manual work when ordering and getting results for these tests, and the actual instances of CRC screening use has jumped specifically at both institutions I've set it up in.

Plus, now that we have a lot of healthcare data, we're able to do observational studies across vast populations of patients and further help with clinical decision making. This part is only in its infancy.


I'm with you that healthcare-by-insurance-mandate is bad, very very bad, but things like PAMA - that require the consultation of approved (by cardiologists) decision-making tools when ordering high-tech imagining - have helped reduce costs and reduced wait times at imaging centers (and cut back on BS profiteering from companies like Shields).

 

[MissThundercat]

Roommates have been taking more than they give, but have the audacity to call me selfish. But since they've refused to listen to my concerns, I applied elsewhere and was approved to move in on October 13th.

 

[leswp1]

I hope you take this as half tongue-in-cheek as I intend, but that just screams "I don't like change" to me.

Being able to swiftly intersect different systems has revolutionized healthcare delivery. Video conferencing, and the integration of it directly into EHRs, will be one of the enormous positives to come out of Covid. Patient portals and release of clinical data has converted healthcare from an opaque system where people have ... ahem ... varying levels of trust in their providers to a system where patients can actually own their own health. Not to mention things like e-prescribing and its ability to reduce doctor shopping and pill milling. You may not like the Cologuard test vs. a colonoscopy (I don't mean you specifically, Les, I mean the general "you"), but I've now built two interfaces with them to drastically cut back on manual work when ordering and getting results for these tests, and the actual instances of CRC screening use has jumped specifically at both institutions I've set it up in.

Plus, now that we have a lot of healthcare data, we're able to do observational studies across vast populations of patients and further help with clinical decision making. This part is only in its infancy.


I'm with you that healthcare-by-insurance-mandate is bad, very very bad, but things like PAMA - that require the consultation of approved (by cardiologists) decision-making tools when ordering high-tech imagining - have helped reduce costs and reduced wait times at imaging centers (and cut back on BS profiteering from companies like Shields).

I don't think it is the change aspect. It is the failure of the system to do the job is is supposedly taking over. If the systems actually worked then great. If they intersect successfully then great.

My experience so far has been they do not or if they do it is rare. I am stuck with the abomination that is "Circle Health" They are a monopoly that has forced out all other choices locally. They spew nonsense about how everything is integrated and being in one system is great. They need a larger shovel to heave the BS. I cannot tell you a time I walked into a Provider and they had accurate information from my Specialists or from a referral. I correct/update information and it reverts to previous info so I needed to correct it again. It is pretty obvious when I need to give a synopsis of what has happened in the last yr and it is all news to them.

When I use the Portal to submit info prior to my visit, it doesn't capture. They manually correct it when I show up and tell me it almost never updates properly when people do it online.

That is not "I don't like change". That is "I have seen a system that worked so don't tell me I shouldn't expect the same functional level and detail of the new system". I know to ask to bring up the changes, make sure the information is correct. A lot of people assume the info is accurate. Decisions are made based on incomplete or incorrect info.

Are there some aspects that can be good? yup. They also have gaping holes where info gets lost and where people foolishly believe all info is available.

Example- my Aunt is changing her PCP within a hospital system. Initial visit they review her information. Much of it is incomplete, out of date or incorrect. The worst was her Immunization record- that should be straight forward. They reviewed immunizations on the Mass site and the hospital site. She is not up to date and they recommend 2 different imms. I remember her getting them so I ask they hold off until I can get info. They give me a list of what they can find. I walk upstairs to her old PCP and get a copy of the imms they have on record. Review and find she has had THREE of each of the missing vaxes. She should only have had 2. If I didn't do the homework she would have had FIVE.

The concept is grand. If we were like most developed countries and had seamless healthcare system with compiled records then it could be grand.
We don't. We have a sucky medical system, sucky communication and millions of little islands where people are reinventing the wheel with things that don't interconnect and or mesh. And most of it is driven by what data needs to be mined, not by the details that make each patient different [climbs off soap box]

 

[Swansong]

I will say that Circle Health is a competitor to my company, but I also agree that their for-profit model is not good. They also use a hodgepodge of disparate EHRs, instead of one big one, and that's a major problem. It's not a huge surprise to me that they don't interact between them. I no longer work on the interfaces (current role is to manage patient portals, mobile apps, our partner provider access and telehealth), but I know my now-big company is planning on investing rather substantially in getting all owned-entities onto one instance of Epic. Private practices won't be on it but will use an affiliation system where their own private EHR has a direct connection to our main system, so your example won't happen.


Regarding the immunizations, that's just lazy on their part. There are two ways to get state immunization data - auto-pull (which we do and for god's sake there's no excuse not to) and manual pull. It sounds like the auto-pull doesn't happen (inexcusable, in my opinion) and either the provider doesn't know how to manually pull or they have not set it up to do so (also inexcusable).


But to me, this all comes down to a crappy, for-profit system not wanting to do what's right and what's necessary. EHRs - modern EHRs - can do all of this and more. Those that don't do it have chosen not to.

 

[leswp1]

I will say that Circle Health is a competitor to my company, but I also agree that their for-profit model is not good. They also use a hodgepodge of disparate EHRs, instead of one big one, and that's a major problem. It's not a huge surprise to me that they don't interact between them. I no longer work on the interfaces (current role is to manage patient portals, mobile apps, our partner provider access and telehealth), but I know my now-big company is planning on investing rather substantially in getting all owned-entities onto one instance of Epic. Private practices won't be on it but will use an affiliation system where their own private EHR has a direct connection to our main system, so your example won't happen.


Regarding the immunizations, that's just lazy on their part. There are two ways to get state immunization data - auto-pull (which we do and for god's sake there's no excuse not to) and manual pull. It sounds like the auto-pull doesn't happen (inexcusable, in my opinion) and either the provider doesn't know how to manually pull or they have not set it up to do so (also inexcusable).


But to me, this all comes down to a crappy, for-profit system not wanting to do what's right and what's necessary. EHRs - modern EHRs - can do all of this and more. Those that don't do it have chosen not to.

They manually pulled. It is because the old imms didn't migrate to the new system and the State system does not talk to their system. If you go to France they have one system. You swipe your card and all your information is in one place. That is efficient. My Auntie has 8 Specialists who all practice independently with no consistent, reliable communication method.

Been saying since they first mandated switch- the systems are not good enough to do the job. The insurance cos like it. They can mine data, claim things didn't happen because it wasn't coded or entered right. It is not structured to meet the needs of the Providers. Also, really scary to us older folks- the people entering the system now have all learned to practice and respond in direct relation to what the EMR requires or what insurance says they have to do. This results in care being compartmentalized instead of thinking in a decision tree with a holistic approach. Its like going to Burger King Drive thru. everyone is their own island

 

[Swansong]

The issue on immunizations is that we have 50 states and 50 different sets of laws and thus, 50 different registries. That has nothing to do with insurance or EHRs. I'd love to have one central "master chart", but so long as the US is special and loves freedom and liberty (please read the dripping sarcasm here), it's on individual healthcare companies to configure their EHRs - that are all 100% capable of doing everything you say they should do - to do so.*

My company mostly does, or at least we plan to by 2025/2026 when we're done consolidating. Circle Health... ahem. Does not.


But to reiterate. Modern EHRs - Epic, Athena, ECW, even older ones like Meditech or Cerner, and even niche ones like Varian and Aria, can do literally everything you're saying they cannot do. If an individual instance of them does not do some function, it's because the organization chose not to.




*In fact, Epic has a "Care Everywhere" network that allows most data to transfer between implementations, and they have a growing connectivity network called "Happy Together" (Epic loves these idiot mnemonics) where we map individual note types and tests and whatnot to a central database, and once that Care Everywhere link has been established, it just pulls all that in natively. Meaning if you go see a Lahey PCP but your cardiologist works for Brigham, on two different Epic installs, they can link charts and all your data flows back and forth seamlessly. When I transferred PCPs from a UMASS-based provider to an independent provider who uses the Mount Auburn system, I gave approval, my new PCP clicked 3 buttons and all my years of UMASS data was in the MAH system.

 

[leswp1]

The issue on immunizations is that we have 50 states and 50 different sets of laws and thus, 50 different registries. That has nothing to do with insurance or EHRs. I'd love to have one central "master chart", but so long as the US is special and loves freedom and liberty (please read the dripping sarcasm here), it's on individual healthcare companies to configure their EHRs - that are all 100% capable of doing everything you say they should do - to do so.*

My company mostly does, or at least we plan to by 2025/2026 when we're done consolidating. Circle Health... ahem. Does not.


But to reiterate. Modern EHRs - Epic, Athena, ECW, even older ones like Meditech or Cerner, and even niche ones like Varian and Aria, can do literally everything you're saying they cannot do. If an individual instance of them does not do some function, it's because the organization chose not to.




*In fact, Epic has a "Care Everywhere" network that allows most data to transfer between implementations, and they have a growing connectivity network called "Happy Together" (Epic loves these idiot mnemonics) where we map individual note types and tests and whatnot to a central database, and once that Care Everywhere link has been established, it just pulls all that in natively. Meaning if you go see a Lahey PCP but your cardiologist works for Brigham, on two different Epic installs, they can link charts and all your data flows back and forth seamlessly. When I transferred PCPs from a UMASS-based provider to an independent provider who uses the Mount Auburn system, I gave approval, my new PCP clicked 3 buttons and all my years of UMASS data was in the MAH system.

Yes. Yes. Yes. and this is why we have horrid healthcare. https://yourlocalepidemiologist.sub...&r=wnmow&utm_source=substack&utm_medium=email
She is a great person to follow re info. Very clear about just how much we suck with links to sources.

Hot under the collar right now about all of this. Dealing with multiple old people, all of whom are audio-visual aides for just how embarrassingly bad our system is- even with my knowledge base and advocacy. The number of errors, lack of communication, misinformation, roadblocks to care- telephone trees, hr long waits on hold, "that's not my job! So and so should be managing X" is overwhelming. Trying to deal with correcting info whole trying to explain to disbelieving olds (of course they have the right information!!!) I can't even....

 

[Slap Shot]

A Philly cop won't even have to go to trial for killing a driver that was sitting in his car.

 

[Swansong]

Yes. Yes. Yes. and this is why we have horrid healthcare. https://yourlocalepidemiologist.sub...&r=wnmow&utm_source=substack&utm_medium=email
She is a great person to follow re info. Very clear about just how much we suck with links to sources.

Hot under the collar right now about all of this. Dealing with multiple old people, all of whom are audio-visual aides for just how embarrassingly bad our system is- even with my knowledge base and advocacy. The number of errors, lack of communication, misinformation, roadblocks to care- telephone trees, hr long waits on hold, "that's not my job! So and so should be managing X" is overwhelming. Trying to deal with correcting info whole trying to explain to disbelieving olds (of course they have the right information!!!) I can't even....

Beyond all of our back and forth here, I sympathize very much with you on this. I'm sorry you - and everyone else for that matter - have to deal with this. I admit, I was vocally opposed to any concept of single payer or nationalized system... until I started working in healthcare. It shouldn't have taken that, but whatever, it did. I'm a slow learner

If you decide you and your family need a change and want to come to the other big company that isn't MGB (we're not for profit and have a 4-letter acronym), let me know and I may be able to assist. Changing doctors and a known network is incredibly difficult, but all the same, the invite stands.

 

[leswp1]

Beyond all of our back and forth here, I sympathize very much with you on this. I'm sorry you - and everyone else for that matter - have to deal with this. I admit, I was vocally opposed to any concept of single payer or nationalized system... until I started working in healthcare. It shouldn't have taken that, but whatever, it did. I'm a slow learner

If you decide you and your family need a change and want to come to the other big company that isn't MGB (we're not for profit and have a 4-letter acronym), let me know and I may be able to assist. Changing doctors and a known network is incredibly difficult, but all the same, the invite stands.

Thanks. Appreciate it.

I think we are probably on the same page as far as what we think should be happening in the systems. There is enough chatter in the journals and medical sites that something is going to have to break soon. The mass exodus is applying even more pressure. Maybe some day it will force change that will improve care.

 

[dxmnkd316]

A Philly cop won't even have to go to trial for killing a driver that was sitting in his car.

Two events forever cemented the fact that cops are allowed to outright murder people, on camera, and we just don't give a fuck. Worse, they get medals in a lot of these cases and we hold them up as patriots.

the first was the Boston marathon bomber who hid in a boat while the cops unloaded hundreds of rounds into it. Not one femtosecond were they in danger. They found him hiding and tried to execute him. He'll get what he deserves but those cops should have all been put on trial for attempted murder.

the second was the cop killer in Texas. He was black so we all just forgot about the fact that the PD literally drove a robot up to him with an explosive and killed him in a parking garage. That still weighs heavily on me. It really formed my opinion of how and when the state should be able to take a life.

Obviously there are several other examples, but most (not all) have some mitigating circumstances where fuckups were made earlier that resulted in death. But very rarely is it actual first degree murder or attempted murder on tape.

Chauvin was the first time I think that I put a tally on the other side. Maybe, maybe we can fix it. Someday.

Anyways, those two have always stuck with me for some reason. Really shitty awful people who should have been locked away for a very, very, very long time.

 

[FadeToBlack&Gold]

The sooner I can roll off this DoD work, the better. I generally dislike being formally addressed by strangers as "Sir" or "Mr." and it seems to be the norm here even among the civvies.

 

[Handyman]

Two events forever cemented the fact that cops are allowed to outright murder people, on camera, and we just don't give a ****. Worse, they get medals in a lot of these cases and we hold them up as patriots.

the first was the Boston marathon bomber who hid in a boat while the cops unloaded hundreds of rounds into it. Not one femtosecond were they in danger. They found him hiding and tried to execute him. He'll get what he deserves but those cops should have all been put on trial for attempted murder.

the second was the cop killer in Texas. He was black so we all just forgot about the fact that the PD literally drove a robot up to him with an explosive and killed him in a parking garage. That still weighs heavily on me. It really formed my opinion of how and when the state should be able to take a life.

Obviously there are several other examples, but most (not all) have some mitigating circumstances where ****ups were made earlier that resulted in death. But very rarely is it actual first degree murder or attempted murder on tape.

Chauvin was the first time I think that I put a tally on the other side. Maybe, maybe we can fix it. Someday.

Anyways, those two have always stuck with me for some reason. Really ****ty awful people who should have been locked away for a very, very, very long time.

Chauvin only got nailed because he was caught on camera and the quality was good enough you could see look on his face and hear/see how not in danger he was and how bad Floyd was suffering. If a young lady isn't there to get that footage or if it was grainy or out of focus there are no protests and George Floyd is just another uppity Negro who threatened cops and should have never resisted. It was dumb luck...especially since his fellow officers were trying to stop the taping.

 

[dxmnkd316]

Chauvin only got nailed because he was caught on camera and the quality was good enough you could see look on his face and hear/see how not in danger he was and how bad Floyd was suffering. If a young lady isn't there to get that footage or if it was grainy or out of focus there are no protests and George Floyd is just another uppity Negro who threatened cops and should have never resisted. It was dumb luck...especially since his fellow officers were trying to stop the taping.

I don't disagree. But 10 years ago I'm not sure he's convicted.

 

[Handyman]

I don't disagree. But 10 years ago I'm not sure he's convicted.

If it happened tomorrow he wouldn't be convicted. It was a lucky number of coincidences not the least of which was the world going bat[bleep] crazy. But cops are doing this stuff every day and nothing is being done to stop them so I think Chauvin is still the exception.

 

[dxmnkd316]

If it happened tomorrow he wouldn't be convicted. It was a lucky number of coincidences not the least of which was the world going bat[bleep] crazy. But cops are doing this stuff every day and nothing is being done to stop them so I think Chauvin is still the exception.

You're probably right. I'm still leaving it as a notch in the win column.

 

[Kepler]

Cops have been doing this to blacks since the invention of cops. Blacks have been telling whites about it for that long. Whites never believed them. Then cell phones happened.

Stop making conservatives your cops, soldiers, or priests. Abuse and murder are inevitable when conservatives have any power. They are cowards overcompensating for the futility of their lives.

 

[FadeToBlack&Gold]

Cops have been doing this to blacks since the invention of cops. Blacks have been telling whites about it for that long. Whites never believed them. Then cell phones happened.

Stop making conservatives your cops, soldiers, or priests. Abuse and murder are inevitable when conservatives have any power. They are cowards overcompensating for the futility of their lives.

When some whites started to believe them, we created dozens upon dozens of TV procedurals and Dirty Harry movies to shove the "all copz R heeros!" narrative down suburban America's throat. Even Cowboy Cop is always depicted sympathetically - his methods may constitute police brutality, but dammit he gets results and if the stupid chief would just cut him some slack, a lot more bad guys would be off the streets!

 

[dxmnkd316]

As much as I love The Shield, it wasn't healthy for the country.