Paperless Health Care? A Hospital’s Long Journey

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    proud tatty

    I saw this on a news site. I thought it would be an interesting conversation to have in the Coffee Room.

    This is the eerily paperless hospital of the future, what the “electronic medical record” that President Barack Obama insists will transform what health care looks like.

    No chart full of doctors’ scribbles hanging on the bed. No hauling around envelopes full of X-rays. No discharge with a prescription slip. Even the classic ER patient list has changed from the white-board of TV-drama fame to a giant computer screen.

    By the best count, only 1.5 percent of the nation’s roughly 6,000 hospitals use a comprehensive electronic record.

    “Sometimes before I even see the ER patient, the X-ray is in here and finished and read,” said Dr. Jonathan Bickel, the ER attending physician who whipped out his laptop to check on Riley’s overnight stay. Not too long ago, “I had to take mom’s word for it.”

    Look, he pointed: An outpatient lung specialist tested Riley for cystic fibrosis just before his mother brought the 6-month-old to the emergency room. The specialist’s detailed exam notes hit the ER computer in hours, not the days it takes to transcribe into a paper chart. Cystic fibrosis didn’t cause his wheezing; quick, test for something else.

    Still, Children’s evolution isn’t finished.

    ‘Whoa, I’m back in the 1970s’

    Money, and doctors’ resistance: A study in the New England Journal of Medicine this spring named hospitals’ top two reasons for not going digital.

    “When you walk into a hospital, you’re like, ‘Whoa, I’m back in the 1970s,'” said lead researcher Dr. Ashish Jha of the Harvard School of Public Health. Younger patients growing up with the speed of e-mail and now Twitter “are shocked.”

    It’s not just the equipment’s price tag. Administrators find the cash to buy new MRI machines or build new hospital wings, said Dr. David Blumenthal, the Obama administration’s new health IT director.

    Studies show electronic medical records, or EMRs, can greatly improve the quality of patient care and reduce errors. Children’s has seen medication errors drop 45 percent since it started automating in 2002. But hospitals won’t necessarily recoup their investment, because a patient who goes home sooner means lost revenue.

    “Our health care system has not valued quality and efficiency,” said Blumenthal.

    So Congress added a stick to the carrot of the stimulus money: Health providers that aren’t digital enough by 2015 will start losing Medicare dollars. Blumenthal told The Associated Press he’s seeing a sudden surge in interest.

    Digital journey

    Children’s moved from a decades-old building to a new hospital in May, a final step in its digital journey. One wing is inpatient, the other houses offices for specialists’ outpatient care, all linked by the “eRecord.”

    Some 4,000 computers line the halls. Nurses swipe patients’ wristbands with bar-code scanners to see when it’s time for medication, and then match the bar-coded dose to the prescription.

    And the giant patient database lets health IT chief Dr. James Levin spot practices that need improving. He found too many doctors ordering specially filtered blood transfusions, at $30 extra a bag, when medical guidelines say few patients truly need them.

    Building an EMR doesn’t just mean buying software and flipping a switch. It physically changes how doctors and nurses work, a disruption that Harvard’s Jha sees as key to even tech-savvy doctors’ resistance.

    Children’s first step: Install electronic prescribing. In October 2002, verbal or paper orders for medications, lab tests, X-rays, IVs ended hospital-wide. Medication errors immediately started dropping.

    But ICU doctors reported a surprise, a temporary jump in deaths among just those patients transferred in from other hospitals. Those handoffs are a perilous time, and the doctors examined 75 deaths over 18 months to conclude in the journal Pediatrics that the death rate doubled in the five months after the computer switch. They blamed changes to their well-organized routine: Patients weren’t registered en route, delaying medication orders; clicking through unfamiliar software took longer; wireless computers weren’t always at the bedside.

    Changes were made, but Levin said the real lesson: Get doctors to help customize their piece of the EMR upfront. That’s who was tapped when it was time to cut paper charts.

    “The way physicians think is different” from off-the-shelf EMR software, said ICU specialist Dr. Shekhar Venkataraman, who found himself a convert to the resulting custom digital dashboard. “It is elegant.”

    It’s also a work in progress. On the next floor, 7-year-old Nicholas Swinehart had multiple organ transplants and now is recovering from an infection. It takes repeated swipes before the bar-code reader OKs his medication.

    “This takes longer, we never used to scan,” said nurse Lindsay O’Toole.

    Officials are working on better scanners. “We have to make it work-friendly or they just don’t want to do it,” said hospital president Christopher Gessner.

    Systems not compatible

    People always ask, what if the power goes out? There are back-ups for the back-up generators, and for the servers. That’s the easier side of going digital.

    The big hurdle: Most of today’s EMRs can’t be read by the computers at another doctor’s office or hospital across town.

    Children’s aimed for a community approach, with the eRecord available at all 20 University of Pittsburgh-affiliated hospitals. More than 100 primary-care doctors in western Pennsylvania are adopting it.

    But just three miles down the road, Dr. Kristin Hannibal illustrates the hitch. Her 60-pediatrician practice is affiliated with Children’s but only partly digital. She logs in to check on hospitalized patients, but must scan her own patient checkup information into the eRecord. And her practice next year is buying a competing company’s software, one it deemed better suited for outpatient use. The systems don’t read each other.

    “We are far better off than we were even five years ago when there was no … access,” Hannibal said. “It’s just we have another big step to make.”

    But Riley Matthews’ mother, Kenya, sees the change with every visit. She hauled chest X-rays from doctor to doctor when her oldest child, now 9, was diagnosed with asthma.

    “We had to wait on records” just to make appointments, she said. Riley’s ailment isn’t solved yet, but the electronic system is “making our specialist appointments easier.”

    Copyright 2009 The Associated Press.


    But hospitals won’t necessarily recoup their investment, because a patient who goes home sooner means lost revenue.

    This is what is sad about the healthcare system in the states. The fact that it is more about business than about curing the ill.


    Mod39 – unfortunately, health care costs money. And many people don’t pay their bills. Insurance companies only give them $x amount of dollars per procedure. Someone has to come up with the difference. If you use up all your money in the first 3 months of the year, you have 9 months where you cannot cure anyone.

    Everyone always makes it out like the “big bad hospitals and doctors” only care about money and not patients. Someone has to be logical about how to run the system.


    39, I suspect that point is true universally, amongst the goyim.


    Read the article. The writer leads one to believe that one of the main reasons why hospitals do not want to switch is due to the fact that it will make them more efficient and people will stay in the hospital less.

    I agree with you, but something is wrong when the hospitals forgo efficiency and the quick release of patients in order to get more money.


    Welcome back josephf


    Thank you 39.


    Thank you 39.


    Tovim hashnaim min haechad.

    You are very welcome x2


    Mod39, I did read that. But understand that sometimes being slightly less efficient might help save others because more revenue is coming in. Its not always just to squeeze the last dollar out…


    Equipment issue. 🙂


    SJS: But yet this would be able to cut overhead, and possibly save in other areas like malpractice lawsuits.

    Studies show electronic medical records, or EMRs, can greatly improve the quality of patient care and reduce errors. Children’s has seen medication errors drop 45 percent since it started automating in 2002.

    Who would you suggest pay for this? Insurance companies? Taxpayers? Private Donors?

    Do you think the change is necessary?

    josephf: It wont be held against you


    Thank you (x1).


    Mod, I love the change. I’m all for paperless systems (although they do have their faults also). I was just pointing out that its not just a “doctors are heartless” kind of thing.

    Who should pay for it? That is tough question. We don’t have universal healthcare and for the moment I am glad. After all, how are they going to fund healthcare? More money out of my paycheck. I can’t afford that. Should the rich have to always support the poor? I don’t think that is fair either.

    There is no good answer, even though the politicians want to make it about that.



    As with many other items (Eco 101), the government must pay for items that are for the good of all, but each person is unwilling to pay as they will not recoup their costs.

    Pres. Obama got this one right. Lower payments to those who will not invest in care. If only there would be lower payments for bad treatment…

    anon for this

    The problem is that hospitals, like any other business (and yes, even if they are non-profit, they are still businesses) must justify their capital expenditures. Would you expect a bank or other business to invest millions in a business improvement that would not yield any extra revenue? The economic downturn is affecting hospitals too, because more patients are paying late/ not paying & their investments are tanking. Hospitals here are laying off employees (doctors, support staff, administrators) & closing entire departments. In this financial climate a new EMR system is not a simple proposition, especially considering the time required to learn & customize the system & the inevitable loss of efficiency (and, according to the article, lives) during that time.

    proud tatty

    gavra, I agree with you 100%


    Weighing the pros and cons, I think the pros definitely win. Unless like anon, that particular medical facility is low on funds.

    For the doctors that have a hard time figuring out the program, give them a few trainings and all should be fine. You CAN teach an old dog new tricks.

    Regarding scanning the patients unique ID code, I think there should be a number as well that can be manually typed in to expedite services faster.

    It is so much more efficient when the records are just there, they dont get missplaced as fast and you do back-ups periodically so you’re really safe. Also, with written records, there is always a chance of someone editing the records without anyone else knowing. With EMR’s, it is not that simple to edit a record. I believe you need to be authorized to do that.

    So the only con there really is, is the funding. I think the facility should pay for it, not the patients!

    anon for this

    mepal, you say that the facility should pay to implement EMR. The costs of implementing EMR–equipment, training, staff, etc–run into the millions. Efficiency of doctors/ support staff will obviously decrease during the training/ learning/ software customization period, and patient care will suffer. Nearly every hospital will need to cut something out of their budget to pay for this. Most hospitals will choose to cut their least profitable or money-losing departments. This may include eliminating ER beds, cutting nursing staff, or laying off entire departments (one hospital near here eliminated all pediatric subspecialties, from cardiac to orthopedic).


    Come on, I think you’re taking it to an extreme. Doctors can rotate when training. Oh, and a lot of places are in the process of changing to EMR’s right now and everything’s turning out just fine so far.

    anon for this

    mepal, I think EMR is probably a good idea. Ideally it can make treatment more efficient, especially when sharing records. Making the most of EMR will require compatible software systems, but the article noted that institutions prefer to customize the software for their own needs, so standardization will be an issue. However, EMR probably won’t save as much money as some of its backers hope.

    Which part of my post is “taking it to an extreme”? Most of the doctors learning EMR aren’t learning it as part of their residency/ fellowship, they are already working as attendings & hospitalists & learning EMR while seeing their regular patient load. The same is true for the nurses & support staff who are learning it. The downsizing I mentioned above is happening in hospitals across the country even without EMR. EMR is inevitable & will probably ultimately improve patient care but it’s naive to imagine that the implementation won’t cost money or hurt patient care. The $10 million to fund it has to come from somewhere. And the article cites a Pediatrics study that attributes an increased rate of patient deaths to EMR transition.


    ames: murder?

    anon for this

    ames, do you mean that an evildoer could, say, order an insulin overdose & put someone into a diabetic coma? EMR systems are probably set up so that only certain individuals can authorize medication. Any hackers attempting to order meds would have to be working inside the hospital & have the doctor’s login info. And usually the nurses administering the meds would notice that the dose wasn’t right, just as they would if the doctor made a mistake in a written or verbal order.


    Ames, in order to access the doctor’s abilities on the system, they would need to either mimick the doctors username and password OR work around it. Neither is easy.

    anon for this

    SJS, that’s true. One way to make hacking much tougher would be to use biometric identification instead of usernames & passwords. While a hacker might be able to find a user id & password it would be tougher to copy a fingerprint.

    The theoretical hacker would in any case need to have a good medical background. He would need to falsify the record in a way that would point to using a medication/ treatment that would be immediately fatal to the patient, so the medical staff could not correct the mistake. But the change would also have to be one that would not arouse suspicion, since usually when confronted with an anomalous result the doctor would order further testing.


    Hacking is not that difficult; it is merely a skill set that most people do not have. But skills can be bought.


    Ames, I agree that the benefits outweigh the risks. In fact, there are a lot of risks with the current paper system as well (misreadings etc). Its the transition period that is really scary.


    Well, now they know that there is a possibility of such an attack in the future as well, they’ll take the appropriate action to be prepared for such an eventuality.

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