Wednesday, January 27, 2010

Rage Against The Machine

I'm posting this for ClinkShrink at her request. She's in jail at the moment and they block Blogger. This is in honor of the Apple Tablet announcement today, and she's looking to pick a fight with Roy!

Rage Against The Machine

---by ClinkShrink.

With the pending announcement of the long-awaited Apple tablet, and on the heels of my new programming project (an
iPhone app), I'm thinking about health information systems. This blog post is a blatant attempt to yank Roy's chain, but I know he's smart enough to see right through it. Nevertheless, if he totally agrees with me I'm going to be quite disappointed.

The fact of the matter is, I'm a geek and I love technology but I really really dislike
health information systems. I've yet to meet one (other than stuff I've designed myself) that doesn't drive me screaming into banshee land.

I know all the supposed benefits of
healthcare information systems: they're supposed to improve care by allowing communication between providers, they're supposed to reduce healthcare costs by improving efficiency, they're supposed to contribute to medical knowledge by collecting aggregate data about diseases for research.

I also am concerned about the downside of health information systems: potential threats to information security, harmful uses of the data that's collected, breaches of confidentiality and loss of independent medical decision-making.

Fine. That's not why I've hated them. The reason I strongly dislike most systems I've used is because they make it harder to figure out what my patient really has.

Psychiatry is a descriptive art. You make a diagnosis through observation and description. You treat people through language and free communication. Information systems stifle all that. Instead of being able to document that the patient "believed he was the President so he hopped on a bus to Washington, camped out on Pennsylvania Avenue for three weeks, then climbed over the fence of the White House", I only get to check a little box that says "delusional". Now, that really loses something.

Even when the
computer programmers give me a textbox instead of a checkbox, I run out of room to document the treatment history of a really complicated patient. I could type for ten minutes about the stuff I want the next clinician to know, only to discover that my keystrokes have been brutally ignored and rejected by the $#@!J$#* healthcare interface.

I am a geek. I want my machines to obey me. Instead, I am forced to let the machine convert my prose into categories, to shave off the nuances and color and "flavor" of the people I treat, all because the system is designed by engineers rather than clinicians. I am peppered by little popup warnings about contraindications and medication interactions that only occur in one out of every 10,000 people. I have ignore these so regularly that I fear missing the one that might truly be dangerous.

Will the benefits of a
national health information system outweigh the risks? Better yet, will doctors be able to use them without wanting to smash a keyboard over somebody's head? Only time will tell.

So, that's my take on the 'con' side of the
national information system. I'll leave to Roy to be the 'pro'.



Sarebear said...

Great points! Hope you are keeping your spirits up, in jail!

Sunny CA said...

I sure would not want my psychiatrist to type in a whole lot of stuff about me! I don't feel privacy could be assured. In addition, I do not want to be simplified and categorized. Also, I think the temptation would be for the shrink to bring a laptop into the treatment room and to type while listening. Now THAT would cut down on care quality. On the flip side, I would like all my medical doctors to enter my data. I would like all my meds entered and tests entered and warning boxes to pop up if one prescribes something that conflicts with another. In physical medicine I don't mind having boxes checked about me for the most part.

Dinah said...

So in the clinic I'm in, medical notes in the EPR are text, not check boxes, they look like old-fashioned dictation.
What don't I like:
1) Often things are wrong. One doctor put that the patient is on restoril (I prescribe it: risperdal) another wrote that the patient takes 50mg of Zyprexa. Excuse me: 15mg. So you get a record of things the patient tells the doc that may be wrong. True of written documents as well, but not as easy to access.
2) Psych records aren't on it...they're on a different system and only the inpatient docs use this. But that system, with detailed psychiatric notes, is accessible to any doc in the hospital (oops, I haven't yet registered)-- their is no confidentiality and this is wrong.
3) Access to electronic medical records: anyone who can get in can access anyone in there, and there are rules about who you look at (your patients, your self, your children under age 10 == why can't I look at my own 14 year old's record?). If you GET CAUGHT looking at your neighbor or coworker's records, you get fired and it happens. But it's an after the fact, IF, and many of my neighbors and a few of my patients have access to these records, so I don't want mine in there.
4)Lack of control over what happens to them.
5) Does a patient have the right to hide information from a physician? Maybe that's it's own post.

Anonymous said...

Yes Clink, writing notes is an art.

I was taught that a mental status examination note should allow the reader to identify the patient when the patient walks down the hallway.

That being said, I now use a xeroxed template with a combination of check boxes and free text in order to decrease my writer's cramp and save paper.

Anonymous said...

I have recently encountered an amazing, comprehensive health management software program called bStable Advanced. This allows a patient to chart and manage mood, sleep, meds, appetite (with diet history), a number of symptoms, and create graphs of several variables at a time. There is also a journal.

One page summary reports and the graphs can be set up to be emailed to providers and family members. Reports can be printed to bring to appointments.

It is non-Web based so privacy is protected. It's also portable so can be brought in to office visits with any provider.

This is the website:

Mindful said...

I spent 5 weeks in a psych hospital not so long ago. Because I am writing about the experience, I requested a copy of my hospital records. After forking over $75 for processing and handling, I received all 73 pages. From a patient's perspective, my doc's notes and nursing staff notes made for fascinating reading. I was neither simplified, categorised or check boxed.

The Crazy Music Lady said...

webpage is back up and operational if you're looking for some Music Therapy blog!

Sarebear said...

There was a web page I wrote about a while back, either in comments here or on my blog, about helping track my meds.

Myself, I've had concerns about, say, the sister-in-law that I've had er, a "troubled" history with, well, her mother works at local hospital, and what if she decided to look me up on their computers, and then gossip about me with her daughter? Although from what daughter/sister-in-law says, they have a love/hate relationship, but anyway . . . .

Then, when I was up having my knee replaced, one night I was surprised when one RNA came up to me and paused, he was the new one after the shift changetd, and said, Wait, do you recognize me? I hadn't seen him for some years, but he recognized me right off . . . . he was my husband's cousin!! Now, all sorts of awkward thoughts ensued. First off, I'd called the nurse or nurse's aide in for help getting up going to the bathroom, and, well, I was like, well, as an RNA, he sees butts all the time. Of course, his cousin's wife's butt is a little more personal (not to get too graphic here, rofl!)

Anyway, I thought about it for a few as I was attempting to not show anything as well as thinking about the fact that he's a professional and seemed to be conducting himself as such, and I didn't want to insult his professional sensibilities. Eventually I decided well, he IS a professional and he DOES see rear ends all the time . . . as long as that's ALL he sees . . . that's where I drew, the, ahem, line.

Early on, on the first day, some of the female nurses saw more than that, as pads and mesh panties were struggled with.

Later, I did discuss my feeling with him, but said I had felt that he had given off a completely professional, but caring (as is appropriate for the field) demeanor, and that he had made me feel comfortable with his care of me, despite his being a relative, and so I had decided that I would try to set my worries to the side. I actually feel that, because I was family, that he may have gone a tad out of his way to take extra care of me, without going over the top or taking away from other patients to do so, if one could even say such a thing, because you want to make sure your family gets taken care of, so if you have even an extra half-second here or there . . . but I don't know. Perhaps he was a caring RNA with all his patients, which bodes well for him, as I heard him out in the hall that night later, saying he was studying, working towards becoming a full-fledged nurse.

I still remember when he was a kid, at my wedding. (Not that it had been THAT long since I'd seen him, lol!!!).

Anyway, later in the night I wondered, well, he's got access to the computer, he could look up anything he wanted . . . and that's when it occurred to me that one tiny embarrassing piece of info I had forgotten to include on the pre-registration info, so I sighed in relief (not pertinent in any way, or a potential problem medically for anything else although of course I'm not a doctor, I've had it long enough I know basically what the only long-term risk from it is, anyway).

But still, there was the niggling, could/would he look up info, and go home and discuss it with his wife, and would it make the "rounds" of the family, which tends to gossip . . . .

But then after seeing how he conducted himself and how good of care he was providing, I just had to think that he was too professional to do something like that.
all the more . . . . .

(continued next comment sorry for rambling)

Sarebear said...
This comment has been removed by the author.
Sarebear said...

(continued from prev. comment sorry for rambling)

Then again, you never know. It DID, however, make me glad that he was a guy, in this sense. I'd worry more about the gossip aspect and temptation if he was a woman, and perhaps that's a stereotype, but he really did seem to enjoy and take pride in how well he did his job, so I hope it ended there.

Now, if he went home and told his wife, and perhaps later his mother, my husband's aunt, that hey guess who I took care of the hospital, and that she had xyz surgery, . . . . that I'd not be too upset by. I mean, that's pretty basic.

I don't know if that basic info would violate his patient/privacy thing, possibly it would, but as long as that was as far as it went . . . (course, once it was told to his mother, the rest of the extended family would soon know, within a week or two, that "guess who's wife just had xyz surgery?") . . . . said cousin wouldn't have meant it in the gossipy way that it would have potentially ended up making it round the family, in that scenario, he would have genuinely been like, wow, I haven't seen cousin and/or his wife in a long time, and can't believe that lo and behold, there she was on my shift, to take care of, recovering from a total knee replacement surgery.

But then, you don't know how my husband's extended family can be, when they get a bit of information . . . . lol! Not that this one is harmful, unless they start asking RNA cousin about possible awkard aspects of his shift with me lol.

See? Things can get complicated.

I believe at one point the nurse, on the same shift, that my cousin reports to, later that night, had finally realized some of the potential awkward aspects that could arise (possibly took some time because he works with the guy alot, and as I say, my cousin worked in a caring, professional manner, so was possibly hard to take a different perspective of the situation) asked me if it was going to be too awkward, and would I like a different RNA, but by this point, I'd already thought through and felt through my own issues, and he'd already seen my backside, so . . . and I figured, what's one more behind, anyway. Although I also thought, will hubby have a problem with his male cousin seeing my butt? That was another consideration I had, too.

He did not, especially when I described how professional yet caring his cousin was. And that there was a line past which some nurses and RNA's had gone on the first day that said cousin would not be allowed on this second day, all of which my husband thought was good and appropriate boundaries on my part. As well as, well, he does see a zillion bums a day, not that I have a thing for showing mine off. . . by the time I hobbled to the bathroom with help, that ended up being about the last thing I was thinking about, except for the fact that he WAS family, and male family at that. But if family can't help you in that situation, who can?

Sorry to go on and on. It was just a REALLY different wrinkle to the health care info and uh, even more personal, uh, access, visually, anyway, when it comes to the cousin, and then there was the sister-in-law's mother thing that sometimes I wonder about, when it involves a certain facility that I go to, that said sister-in-law KNOWS that I go to and has never bothered to call me up to ask how I'm doing, which makes me wonder

(deleted and reposted to cover up and inadvertently used name)

moviedoc said...

We had those checkbox-fillintheblanks forms on paper years before we even had computers. As for patient control over what goes in the chart: You can't have your cake and eat it, too. If the patient has a right to sue the doc for malpractice, the doc has a right to keep records which will be shared with the court to defend herself.

I have used a tablet PC for 7 years. Unlike the ipad it is a computer, I can write on it, and it can recognize my handwriting (sometimes when I can't!), but I dictate my records with Dragon -- no checkboxes.

Midwife with a Knife said...

We use Epic where I'm working, and I have to say, it's fantastic. Sometimes the IT people put some of the orders and diagnoses in not-completely intuitive spots, but that's usually overcome with a simple call to pharmacy, a "MD to RN Communication" order, or a general "pregnancy concerns" diagnosis. I love it. I love that I can check the hematology note on my patient with an incidentally diagnosed factor VII deficiency from home (because in the real world consults tend to be done either right before or right after office hours). I love that I can followup on labs from home. I love that I can enter orders from home and look at fetal monitoring from home. My only EMR type problem is that the nurses document some of the vitals in QS (the monitoring system) and others in EPIC (the system for everything else).

As an aside, I was totally disappointed by the iPad. I was hoping for something more than a giant iPhone.

Midwife with a Knife said...

Oh, forgot, while I can do checkbox documenting if I want, I can also write as long a note as I want. I could put War and Peace in the progress note section if
I wanted to.