January 18, 2011
Electronic Patient Records Offer Little Benefit?
A meta-analysis finds little evidence for the improved outcomes from using electronic medical records and other information systems in medicine.
Despite the wide endorsement of and support for eHealth technologies, such as electronic patient records and e-prescribing, the scientific basis of its benefits—which are repeatedly made and often uncritically accepted—remains to be firmly established.
Furthermore, even for the eHealth technologies that have proven to be successful, there is little evidence to show that such tools would continue to be successful beyond the contexts in which they were originally developed. These are the key findings of a study by Aziz Sheikh (University of Edinburgh, Edinburgh, Scotland) and colleagues, and published in this week's PLoS Medicine.
In the study, the authors systematically reviewed the published systematic review literature on eHealth technologies and evaluated the impact of these technologies on the quality and safety of health care delivery. The 53 reviews (out of 108), that the authors selected according to their criteria and critically reviewed, provided the main evidence base for assessing the impact of eHealth technologies in three categories: 1) storing, managing, and transmission of data, such as electronic patient records; 2) clinical decision support, such as e-prescribing; and 3) facilitating care from a distance, such as telehealthcare devices.
The authors found that the evidence base in support of eHealth technologies was weak and inconsistent and, importantly, that there is insubstantial evidence to support the cost-effectiveness of these technologies. They also found some evidence that introducing these new technologies may sometimes generate new risks, such as prescribing practitioners becoming over-reliant on clinical decision support for e-prescribing or overestimate its functionality, resulting in decreased practitioner performance.
Quite a few new technologies offer only small initial benefits and substantial costs. But later their benefits soar and their costs drop. I expect the same will happen with electronic medical records. Computer software that does diagnosis holds considerable promise because as it becomes more capable it should produce more accurate diagnoses on average as compared to humans.
One big long term benefit from electronic medical records will come from the ability to feed test results in to diagnostics expert systems. The more health and medical tests information that is captured electronically the more of it that can be fed into diagnostics applications.
You and the researchers seem to miss the point. Patient records automation is not really about improving medical care per se. It is directed much more toward generating economic efficiencies by automating record keeping and payment systems. It all about the "book-keeping". Any improvements to patient care are a unexpected bonus.
You are correct that incorporating doctor intelligence and experience into patient-decision tree iterative expert diagnostic systems holds potential but these would be dedicated sub-systems without much relation to prior general patient record keeping systems. Do you understand how expert systems are created and operate, Randall ? They do NOT operate via generalized data gestalt but rather follow predefined binary decision pathways and the predefinition reflects the incorporation of the experts knowledge into deciding how the tree path flows.
Yup, electronic records are all about cost saving (and probably increasing profit at least in the USA) and nothing at all to do with patient benefit. In practice they raise costs because of the cost of implementing such systems which always go vastly over budget, because they always seem to turn out to be more complex than people seem to realise - goodness knows why since anyone who has done any kind of analysis of health record systems knows that they are probably one of the most difficult things to organise. Just sorting out the "need to know" permissions paths for the data is a complete nightmare - the basic problem is the lack of flexibility in computer systems, human systems at least have some ability to be bent in emergencies,
Remember, when you see the words "expert system" substitute the words "large complicated C program" and read the text again and see if it still the same thing. Expert systems aren't in general (yes there are some successes but they tend to be very specialised)
I think you all have it wrong!
Electronic medical records are all about government control of health care. How can the government force or coerce doctors into obeying the government's guidelines, i.e. rationing care based on government quotas and rules, if they can't monitor what each individual doctor is doing? Electronic medical records not only makes it possible for them to do this, it makes it possible for them to analyze and compare doctor utilization of health care resources in ways not previously possible. What about the HIPAA privacy laws you may ask? Read the statutes! While HIPAA made it more cumbersome and risky for doctors to release your medical information to people (including people you would typically want it released to for your own convenience) it also gave the government new powers to pry into your medical records and to force doctors and hospitals into supplying the government with these records if and when the government wished. Indeed, the real reason HIPPA was implemented was NOT to protect patient confidentiality, but rather to enable the government to demand access to this data.
As far as cost saving, electronic records COULD potentially reduce costs for some providers - if the government didn't mandate their use. When the government mandated electronic records, the sellers of these systems immediately increased their prices. When the government promised doctors a financial reward or "kickback" for incorporating these systems, the sellers increased their prices further to grab most of this government money. If these systems are really money savers, providers will be happy to incorporate them without government mandates.
As far as improving patient care, don't count on it. What we can get out of these systems is only as good as what we feed into them and when bad data gets into a computer, it's assumed to be correct. After all, it's a computer, it can't be wrong. The best thing that can be done to improve patient care is for doctors to spend more time listening to and examining patients.
On the application side, I've noticed a bandwidth problem between the examination room and the hospital, the patient can see the screen (Dr's don't like that), and miserable screen resolution in the examination room. Seems young people decide "Wow, look at all that space! Just think of all the junk we can put in there!", and the use frames. My Doctor is pushing 70.
There's also a serious potential for cross contamination on that keyboard.
All this can be addressed, but good execution is not to be found yet.
I was impressed many years ago by the utility of having a personal, portable complete medical record by that great Patrick Swayze movie, "Roadhouse". Patrick's character, as a freelance bouncer, called in to quiet down troubled honky-tonk bars, had over the years received quite the collection of contusions and lacerations. When he went to a doctor in a new town for the first time and she asked for his medical history, he pulled out a THICK manila folder of all his medical record and dropped it with a thunk on the table.
Every time you move or change doctors you are relying on your faulty memory of "what was that antibiotic I had the bad reaction to back in '87?"
I want a Flash drive with a personal copy of my records AND web database that you can give access to medical providers when they need it. Your medical history needs to be attached and accessible to you. Not in little folders spread out between dozens of hospitals, doctors offices and clinics.
For portability, I am going to be trying out the 911 Medical ID Card.
It seems to be reasonably cheap and easy to use, and should be a good
entry point for further medical information management.