Use (or lack thereof) of Technology in Medicine

[digitlnoize]

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I am appalled by the current backwards state of technology in medicine. I'd like to discuss it. I thought this was the best forum for it (since the "medical technology" forum seems to be devoted to "what phone should I get", and I would like this thread to be more "problems and solutions" and how they impact patient care).

Problems I've seen so far:

1. All computers are running Windows XP or before.
2. Heavy reliance on Paper Charts
3. EMR's that are structured like paper charts, or worse.
4. Having to re-enter data every time. (i.e. there is not a universal place to keep a running list of patient allergies. Instead, they are entered anew at each visit).
5. Illegible Handwritting (by doctors, nurses, PT, ST, etc, etc, etc)
6. No communication between various medical technologies.

Solutions

1. Someone needs to make an EMR that actually works and makes sense. It should work at least as intuitively as the iPad "Mail" or "Twitter" app. At the worst, it should be as intuitive as Word 2007 (although that's still not good enough).

2. We need to throw all paper charts in the recycle bin. For real. Unfortunately, until #1 happens, people will continue to claim that paper charts are superior. This will also fix the handwritting issue.

3. Upgrade your stupid computers. Microsoft or Apple should give a discount to Health Organizations. Modern Medicine saved Steve Jobs' life, you'd think he could return the favor.

4. Make medical technology that's not stuck in 1975. Bluetooth or WiFi pulse-ox, BP, Thermometers, Scales. I'd like to point out that my Wii has a bluetooth scale that automatically updates and charts my weight. Why can't my doctor do the same.

Anyone else?

 

[The right Path]

Agreed. You know what is beyond silly? Our ED computer charting is not the same system as the rest of the hospital. So to look for information, you have to paw through a stack of cryptic paperwork. That's not a waste of time or anything. 👎

 

[docB]

This is a huge problem in medicine. I actually know a lot about this issue. I was the physician liaison for the implementation of an Emergency Department EMR back in 2006 that failed despite great expense and effort on the part of everyone involved. I'm now involved in the planned implementation of a new EMR for a 5 hospital system that will cover both the EDs and the rest of the hospitals. Note that as an Emergency Physician I do tend to look at hospitals as entities that are there to support their EDs first and do everything else secondarily. I'll try to tone it down for this discussion 😳.

Nationally a problem we have is that there is no standard system. Every local system in the country is somewhere on the continuum from have nothing, have invested nothing to have expensive systems in place and don't want to change. The ones that already have systems don't care that they're not able to communicate with anyone else. Any attempt at creating a national standard system will be incredibly corrupt with software companies, hospital systems, insurers, etc. lobbying like crazy for their own special interests.

Paper charting is fast and easy. It doesn't get more intuitive than that. But they are often illegible, get lost, are difficult to bill from, are difficult to pull later and are impossible to mine for data. We will have to abandon paper and soon. Every system out there is not as fast or easy as paper. The trick is finding the one that hurts your productivity the least.

There are two different kinds of EMRs out there. There are institutional systems, designed for an entire hospital, and departmental systems, designed for a specific area like the ED or the cath lab. Every institutional system has drawbacks for every individual department, ie. a system that works well for an inpatient medical floor won't work well in the ED or in outpatient surgery. So the institutional systems wind up with either massive amounts of feature creep that makes them unwieldy and more unstable or they are just poor for many niche applications. The departmental systems often work well for their area but then they can't be accessed by other departments.

Another huge problem for almost all EMRs (despite what the vendors try to tell you) is that there are always problems with interfaces between systems. For example the EMR will probably have trouble getting data from the lab system, the radiology system, etc. When they can get the systems to communicate it often destabilizes both systems. So you can either get your data in the EMR and have it crash frequently or you can have stable systems (as stable as they ever are which is still pretty bad) but you have to come out of the EMR to access the lab data in a different system and then transcribe it yourself back into the EMR (with the resultant errors that creates).

Many hospitals are still running Windows XP or Win 95 or DOS or whatever because Windows updates are notoriously bad. No one wanted to upgrade to Vista. Now they’re dealing with the issues of leapfrogging Vista to 7. And in doing this IT has to make sure that it’s all compatible with the legacy systems running all the various departments. This is no easy task.

Your point about Bluetooth and WiFi is well taken. But that is very expensive. No system can afford to upgrade everything at once and trying to do it piecemeal is difficult. In fact the technology for almost everything we all want is out there right now. It’s just expensive.

 

[The right Path]

True. Further, I had read an article which resulted in a near revelation for me. Software isn't chosen for the ease and convenience of those that use it. It is chosen for the ease an convenience of auditing it. Unfortunately, despite coucils, and task forces, and what not, those that use the equipment, really don't have much say in the shopping for it.

I would love, love, love small, wireless, monitoring equipment. It would be so much more comfortable and convenient for the patient, it would reduce microbes from hitching rides on wires and cords. But then, they would be more susceptible to loss and theft and would be way too expensive to justify. Maybe in the future.

 

[cpants]

There are solid EMR systems out there. The VA system, for example, has all the features you need without the ones you don't. It integrates pretty seamlessly with the PACS system and all of the departments use it by mandate (which is the way these things have to be). On top of that, it is cheaper to implement than most other systems out there.

Any hospital which allows different departments and clinics to use different EMR's is poorly managed. It's a waste of time and money, and probably endangers patients.

As far as updating Windows, there is good reason not to. The XP platform is finally stable and decently secure, which is more than I can say for Vista or 7. If you are going with a Windows system in a hospital, you have to stick with XP for now. Besides, XP has all the features a hospital application requires. Not only are Vista/7 less stable and secure, but to even run they would require massive hardware updates for most hospitals. Personally, I would rather see a Linux based system in the hospital. It's free, extremely secure, and reliable.

 

[DeLaughterDO]

There are solid EMR systems out there. The VA system, for example, has all the features you need without the ones you don't. It integrates pretty seamlessly with the PACS system and all of the departments use it by mandate (which is the way these things have to be). On top of that, it is cheaper to implement than most other systems out there.

Any hospital which allows different departments and clinics to use different EMR's is poorly managed. It's a waste of time and money, and probably endangers patients.

As far as updating Windows, there is good reason not to. The XP platform is finally stable and decently secure, which is more than I can say for Vista or 7. If you are going with a Windows system in a hospital, you have to stick with XP for now. Besides, XP has all the features a hospital application requires. Not only are Vista/7 less stable and secure, but to even run they would require massive hardware updates for most hospitals. Personally, I would rather see a Linux based system in the hospital. It's free, extremely secure, and reliable.

Agreed, or BSD would also work. Unfortunately, the vast majority of people in medicine are either computer illiterate (and can't use a Windows or *nix/BSD system) or are so dependent on Windows' crutches they refuse to use anything else and freak any time they see anything different. Also, it would require IT change and retraining (more money) and someone to write a good EMR for a *nix system. Right now, all the usable ones (so far as I am aware) are Windows based.

In a perfect world...

 

[cpants]

Agreed, or BSD would also work. Unfortunately, the vast majority of people in medicine are either computer illiterate (and can't use a Windows or *nix/BSD system) or are so dependent on Windows' crutches they refuse to use anything else and freak any time they see anything different. Also, it would require IT change and retraining (more money) and someone to write a good EMR for a *nix system. Right now, all the usable ones (so far as I am aware) are Windows based.

In a perfect world...

Yeah, unfortunately, most hospital IT decisions don't seem to be made with a common sense approach, and for all the frustration these systems cause us, there is little to do to remedy the problem. By the time we are using an inferior user-unfriendly system, the hospital has already invested millions in it.

It's a shame because the EMR is a tool for physicians. Good implementations truly do improve productivity and patient care. Unfortunately they are few and far between.

Imagine the outrage if the hospital decided we all need to start using inferior suture material or surgical instruments. But when they implement a system which lengthens our day and contributes to medical errors, we all just shake our heads and sigh helplessly.

 

[The right Path]

Yeah, unfortunately, most hospital IT decisions don't seem to be made with a common sense approach, and for all the frustration these systems cause us, there is little to do to remedy the problem. By the time we are using an inferior user-unfriendly system, the hospital has already invested millions in it.

It's a shame because the EMR is a tool for physicians. Good implementations truly do improve productivity and patient care. Unfortunately they are few and far between.

Imagine the outrage if the hospital decided we all need to start using inferior suture material or surgical instruments. But when they implement a system which lengthens our day and contributes to medical errors, we all just shake our heads and sigh helplessly.

Fer sure. Ya know, though, there is an emerging niche in medicine called informatics that deals with exactly these issues. Definitely not my cup of tea, but I could totally see others really excelling and making great contributions (not to mention lucrative 😎). So the present is rather frustrating, but I see hope for the future.

 

[digitlnoize]

Good stuff! I understand the cost obstacles, but I don't understand why the costs are so high.

Does every single station in the hospital need it's on PC? Does it have to run full fledged windows? 1 PC could easily handle all the charting duties of an entire floor without breaking a sweat. Why run a full OS, when all you need to do is chart? It seems wasteful, silly, and very expensive. Have 1 central server (preferably in a closet somewhere, to keep the heat down) and some satellite devices (iPads or whatever you want).

 

[DeLaughterDO]

Good stuff! I understand the cost obstacles, but I don't understand why the costs are so high.

Does every single station in the hospital need it's on PC? Does it have to run full fledged windows? 1 PC could easily handle all the charting duties of an entire floor without breaking a sweat. Why run a full OS, when all you need to do is chart? It seems wasteful, silly, and very expensive. Have 1 central server (preferably in a closet somewhere, to keep the heat down) and some satellite devices (iPads or whatever you want).

I can't answer why the costs are so high, but it seems that anything marketed to the government or to healthcare is at least 1000 times what one would expect the market value to be. Maybe because they know soon we are going to be forced to buy it, so they are jacking up the prices now?

You are absolutely correct about not needing every station to run a full version of an operating system, regardless of which one.

Server/dumb clients (a dumb client is a computer, or client, that is essentially a modified computer with a hard drive with instructions only to connect to the server for further boot instructions) would be ideal, but there would still need to be a significant number of clients. Say 2 physicians and a nurse wanted to chart at the same time, or a critical patient needed orders and someone was charting on the one client for a unit - efficiency is improved by performing tasks in parallel vs in series.

The problem with the server/dumb client model is money. While in the long run, they would likely be cheaper (upkeep/upgrade is essentially only for the server as the clients can generally be pretty old/barebones computers), scaling a hospital-wide operation with adequate server power and bandwidth would be a nightmare, IMO. Likely, every floor or small group of units would require a server, which would then have to be able to talk to the central server, etc.

Another problem would be software: someone would have to write software that can work on a dumb terminal. To my knowledge, this has not been done yet.

Maybe I'm wrong. It has definitely been awhile since my big tech-nerd days, but unless servers now can handle significantly more load, the scalability would be questionable.

Your other question about iPads, etc, is something that is being actively looked into for EMR use. One of the EMR companies has a software package for the iPad that can talk with their EMR, but I've not heard any reviews about how well it works (if at all). I'd rather see an open source option for this as well, rather than tying everyone to the closed Apple ecosystem.

A guy can dream, right?

 

[digitlnoize]

I can't answer why the costs are so high, but it seems that anything marketed to the government or to healthcare is at least 1000 times what one would expect the market value to be. Maybe because they know soon we are going to be forced to buy it, so they are jacking up the prices now?

You are absolutely correct about not needing every station to run a full version of an operating system, regardless of which one.

Server/dumb clients (a dumb client is a computer, or client, that is essentially a modified computer with a hard drive with instructions only to connect to the server for further boot instructions) would be ideal, but there would still need to be a significant number of clients. Say 2 physicians and a nurse wanted to chart at the same time, or a critical patient needed orders and someone was charting on the one client for a unit - efficiency is improved by performing tasks in parallel vs in series.

The problem with the server/dumb client model is money. While in the long run, they would likely be cheaper (upkeep/upgrade is essentially only for the server as the clients can generally be pretty old/barebones computers), scaling a hospital-wide operation with adequate server power and bandwidth would be a nightmare, IMO. Likely, every floor or small group of units would require a server, which would then have to be able to talk to the central server, etc.

Another problem would be software: someone would have to write software that can work on a dumb terminal. To my knowledge, this has not been done yet.

Maybe I'm wrong. It has definitely been awhile since my big tech-nerd days, but unless servers now can handle significantly more load, the scalability would be questionable.

Your other question about iPads, etc, is something that is being actively looked into for EMR use. One of the EMR companies has a software package for the iPad that can talk with their EMR, but I've not heard any reviews about how well it works (if at all). I'd rather see an open source option for this as well, rather than tying everyone to the closed Apple ecosystem.

A guy can dream, right?

I have a sub-500 dollar PC at home running a movie server to my house. It can stream 1080p movies to 2 iPads and 3 TVs simultaneously without breaking a sweat. I haven't tried more than that. EMRs are 99% text. A cheap PC server should be able to run a few hundred simultaneous instances of a charting/orders routine without a problem.

The money they'd save in air conditioning costs alone would pay for the system. At least down here in Florida.

I've looked at some of the currently available iPad software. They're mostly crap. It's times like this I wish I knew how to code.

 

[janV88]

I have a sub-500 dollar PC at home running a movie server to my house. It can stream 1080p movies to 2 iPads and 3 TVs simultaneously without breaking a sweat. I haven't tried more than that. EMRs are 99% text. A cheap PC server should be able to run a few hundred simultaneous instances of a charting/orders routine without a problem.

The money they'd save in air conditioning costs alone would pay for the system. At least down here in Florida.

I've looked at some of the currently available iPad software. They're mostly crap. It's times like this I wish I knew how to code.

Sounds like you have the idea and the knowledge to possibly "fix" this problem. Why don't you run with it and see where it goes. Who knows...you might be the one to bring medicine to the computer age!

 

[cpants]

Ipads, or anything Apple really, are highly unlikely to happen in a hospital. It costs too much. For the cost of one Ipad they can buy 2 full fledged PC's. Plus Ipads are likely to walk pretty quickly.

Tablets seem cool b/c they are high tech, but they are, again, very expensive, and they don't really add much functionality. Most of your charting tasks will be accomplished more easily and quickly with a simple keyboard and mouse interface than a touchscreen.

A simple linux distribution can run on very cheap hardware, and you cut out the huge cost of those Windows licenses. There are many great GUI's out there which are free and extremely easy to use. People fear Linux, but if you ever sit down and use a Linux machine for five minutes, you will realize that it basically requires no learning.

 

[Hernandez]

1. All computers are running Windows XP or before.
2. Heavy reliance on Paper Charts
3. EMR's that are structured like paper charts, or worse.
4. Having to re-enter data every time. (i.e. there is not a universal place to keep a running list of patient allergies. Instead, they are entered anew at each visit).
5. Illegible Handwritting (by doctors, nurses, PT, ST, etc, etc, etc)
6. No communication between various medical technologies.

1) why is this bad? As long as the os is stable and maintained with up to date virus protection what's wrong with xp?
2) nothing wrong with this. As even by your own admission there aren't many decent emr choices
3) how else would you suggest structuring it?
4) a well done paperchart and all of the emh I've used do maintain a running record
5) Ive used one of the big name emh at a large instituion and while it is legible it turns out to that you get 4 pages of useless but readBle Copy & pasted crap on each progress note/h&p/etc
6) won't disagree with this.

Solutions

1. Someone needs to make an EMR that actually works and makes sense. It should work at least as intuitively as the iPad "Mail" or "Twitter" app. At the worst, it should be as intuitive as Word 2007 (although that's still not good enough).

2. We need to throw all paper charts in the recycle bin. For real. Unfortunately, until #1 happens, people will continue to claim that paper charts are superior. This will also fix the handwritting issue.

3. Upgrade your stupid computers. Microsoft or Apple should give a discount to Health Organizations. Modern Medicine saved Steve Jobs' life, you'd think he could return the favor.

4. Make medical technology that's not stuck in 1975. Bluetooth or WiFi pulse-ox, BP, Thermometers, Scales. I'd like to point out that my Wii has a bluetooth scale that automatically updates and charts my weight. Why can't my doctor do the same.

Anyone else?

 

[docB]

One reason costs are so high is the liability involved. If an EMR makes an error the liability for the hospital or the vendor is huge. It also has to be much more (or at least the vendors claim it is) reliable than typical systems. If the system at a hair salon crashes hairdos might be delayed. If an EMR crashes badness can ensue.

The reliability issue also effects the ability of a system to use less expensive terminals. Most of the systems I have seen do use a fully capable networked PC because they want it to be able to keep functioning for a least a while if the network goes down.

The issue of using small peripherals like iPads, tablets, etc. is complicated by loss, theft and breakage. I can tell you that my hospital system is nver going to buy any of those things for its nurses. The post portable they'll go is COWs (computers on wheels) which are lap tops bolted to these cart things. Otherwise they'll get lost and/or stolen.

 

[hithere3387]

One reason costs are so high is the liability involved. If an EMR makes an error the liability for the hospital or the vendor is huge. It also has to be much more (or at least the vendors claim it is) reliable than typical systems. If the system at a hair salon crashes hairdos might be delayed. If an EMR crashes badness can ensue.

The reliability issue also effects the ability of a system to use less expensive terminals. Most of the systems I have seen do use a fully capable networked PC because they want it to be able to keep functioning for a least a while if the network goes down.

The issue of using small peripherals like iPads, tablets, etc. is complicated by loss, theft and breakage. I can tell you that my hospital system is nver going to buy any of those things for its nurses. The post portable they'll go is COWs (computers on wheels) which are lap tops bolted to these cart things. Otherwise they'll get lost and/or stolen.

This is off topic, but at the ER where I sometimes shadow, when the residents are doing rounds they "moo" when someone with a COW needs to pass. Cracks me up. Then again, I'm terribly immature.

 

[Hernandez]

This is off topic, but at the ER where I sometimes shadow, when the residents are doing rounds they "moo" when someone with a COW needs to pass. Cracks me up. Then again, I'm terribly immature.

our admin is demanding they are called wows ( workstation on wheels) so that it isn't offensive. 🙄

 

[deleted116380]

Ipads, or anything Apple really, are highly unlikely to happen in a hospital. It costs too much. For the cost of one Ipad they can buy 2 full fledged PC's. Plus Ipads are likely to walk pretty quickly.

Tablets seem cool b/c they are high tech, but they are, again, very expensive, and they don't really add much functionality. Most of your charting tasks will be accomplished more easily and quickly with a simple keyboard and mouse interface than a touchscreen.

A simple linux distribution can run on very cheap hardware, and you cut out the huge cost of those Windows licenses. There are many great GUI's out there which are free and extremely easy to use. People fear Linux, but if you ever sit down and use a Linux machine for five minutes, you will realize that it basically requires no learning.

I heard USF Health here in Tampa is going to buy 1,600 iPads for their physicians. What a waste of money. 🙁 There's also rumor the med school will require us to buy a smart phone for 3rd year...my guess is that it will have to be an iPhone to run some kind of app made for that. I certainly will not be buying that.

I always like the KISS method when it comes to stuff. All the upgrades to Vista, 7, etc, don't make any sense. There is no need for a full OS to be on those computers in the hospital...just run what you need and keep it at that. It shouldn't cost too much for a large hospital system (i.e. USF Health) to get some people to write code for exactly what they need.

My brother is a computer programmer, my dad is a hardware electrical engineer, and I'm a med student. Maybe the three of us should work together to make something happen, lol! Won't happen because the big companies will end up using their inside connections to secure an over-priced bid for crappy software. 🙁

 

[docB]

As many here, including me, have pointed out there are a lot of good reasons hospitals avoid updating their Windows. But sooner or later you have to do it. Microsoft eventually stops supporting their old versions and XP without security updates would be horrifically unsecured rather than just ridiculously unsecured.

 

[digitlnoize]

As many here, including me, have pointed out there are a lot of good reasons hospitals avoid updating their Windows. But sooner or later you have to do it. Microsoft eventually stops supporting their old versions and XP without security updates would be horrifically unsecured rather than just ridiculously unsecured.

I understand why they don't update. I don't understand why they're using Windows in the first place. There's just no need for a full OS for the tasks they need to perform. It's a huge waste of money and time, with the IT headaches.

 

[docB]

I understand why they don't update. I don't understand why they're using Windows in the first place. There's just no need for a full OS for the tasks they need to perform. It's a huge waste of money and time, with the IT headaches.

Well, another reason they run a complete OS on our workstations is that each terminal has to be able to run many programs. We have our proprietary records/lab system (OPUS), PACS, the admitting system (SMS), the incident reporting system, the patient tracking system and then the intranet to access all the various educational and reference materials there. And that doesn't even include the systems for which we have dedicated terminals such as our EMS tracking system and our prescription writing/discharge instruction system.

There is no stand alone system that can absorb all of those functions at this time.

 

[digitlnoize]

There is no stand alone system that can absorb all of those functions at this time.

And that is exactly my point.

 

[keepworking10]

I work three different EMR software programs every day at work. They all three suck! For instance, there is no place to list a PMH and a CMH. All of the EMRs I use place it all together. There is no way to make a note for a doctor to check to see if the abstracted data is correct.

Don't even get me started with how horriblay contradicting so many charts are....one document will say the patient smokes, another will say they never smoked, and another will say thei quite smoking 30 years ago. It pisses me off.

Unless you spend all day abstracting clinical data, you have no idea how bad so many paper charts are contradictory with their information.

 

[cpants]

I work three different EMR software programs every day at work. They all three suck! For instance, there is no place to list a PMH and a CMH. All of the EMRs I use place it all together. There is no way to make a note for a doctor to check to see if the abstracted data is correct.

Don't even get me started with how horriblay contradicting so many charts are....one document will say the patient smokes, another will say they never smoked, and another will say thei quite smoking 30 years ago. It pisses me off.

Unless you spend all day abstracting clinical data, you have no idea how bad so many paper charts are contradictory with their information.

Well that's a problem with records in general, not paper charts. Never trust a history you didn't take yourself.

 

[digitlnoize]

Well that's a problem with records in general, not paper charts. Never trust a history you didn't take yourself.

But these things shouldn't have to be asked every time. What about AMS with no family to tell you the hx? We should have a reliable, consistent source of information.

 

[cpants]

But these things shouldn't have to be asked every time. What about AMS with no family to tell you the hx? We should have a reliable, consistent source of information.

I get it, but that error is person error not technology error. You can find that kind of discrepant information in both paper and digital charts

 

[Hernandez]

I get it, but that error is person error not technology error. You can find that kind of discrepant information in both paper and digital charts

Especially when they leave the copy and paste option intact.

 

[The right Path]

Also patients tell different providers different things. Especially when it comes to asking about drug, alcohol, cigarette use.

 

[tk2med]

As a former systems engineer and network admin I left a job coding and building servers for a living to going back to school to become a physician. Now, starting internship in a week I can't count the number of times I have been asked to write some code to do something because the EMR's can't do it.

There is a large amount of money to be made in Health Care if your code doesn't talk to the other systems in the hospital b/c then every department must by that vendor's specific suite if they want to interface. Therefore there are a few large companies making tons of money for subpar programming.

CPRS-the VA system, is the best I have seen so far in training. The best thing the government has ever made, which isn't saying a whole lot but shows how bad the private sector is in this field.

Support contracts for the proprietary systems are astronomically expensive as well, another reason to keep your systems complicated and mysterious to support in house.

NO sharing of data outside of system from hospital to hospital. This is my favorite thing I have seen. Someone says, "we have a great paperless system". High risk patient get's referred from hospital across town. What happens? We get 100 pages of faxed records printed from their EMR. AWESOME.

I have a deep interest in informatics and am glad to see all of the discussion. You are all spot on with your observations, and a lot of great improvements can be made.