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Tilting at Windmills

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April 2, 2007
By: Kevin Drum

INNOVATION....In an op-ed about the VA system today, Betsy McCaughey talks about a new technology called computer physician order entry (CPOE) that cuts down on physician errors:

With CPOE, a doctor enters the prescription at a computer terminal instead of scribbling it on a pad. The computer identifies incorrect doses or a medication that conflicts with other meds the patient is taking. If the computer sounds an alarm, the physician has to override it. In Australia, Britain, New Zealand and much of Western Europe, hospitals have adopted CPOE, but most U.S. hospitals have resisted. An exception is the VA, which has installed CPOE nationwide.

Question for the free market crowd: if you oppose national healthcare because you think it will reduce the pace of medical innovation, how do you explain this? Why is it that the VA and the national healthcare systems in Europe have all adopted this plainly useful innovation but American hospitals mostly haven't?

Kevin Drum 1:51 PM Permalink | Trackbacks | Comments (74)

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Comments

It is simply a truism, Kevin. Guvment bad.

Faith-based truthiness.

Posted by: Gore/Edwards 08 on April 2, 2007 at 2:00 PM | PERMALINK

Because the free market is a myth perpetrated by conservatives, rather like the myth of the Iraq-al Queda connection.

Posted by: anonymous on April 2, 2007 at 2:00 PM | PERMALINK

Because Kevin, its cheaper to pay off and fight malpractice claims that come some from doctors own wallets than it is to have to pay for this expensive capital equipment that you can't over use and charge for like a CAT scan.

Posted by: Rob on April 2, 2007 at 2:02 PM | PERMALINK

CPOE doesn't make any money. It just saves lives.

Literally, this is the problem with it.

Unbelievable.

Posted by: anonymous on April 2, 2007 at 2:04 PM | PERMALINK

If you want it, demand that your hospital adopt it. For the free market to work, you have to make your desires known. The most likely scenario is that it doesn't actually save any lives, or has so many bugs that it's counterproductive. Preventing one malpractice suit would make the machine pay for itself, so the logical conclusion is that it doesn't save any lives.

Posted by: Seabiscuit on April 2, 2007 at 2:07 PM | PERMALINK

THIS is supposed to be innovation???

My mother and stepfather have a small computer software company (3 people) that has had a program that does this for hospitals for AT LEAST 15 years. They market it (and other software packages) to small hospitals as a way to save money.

I see no logical reason why every hospital wouldn't do this.

Posted by: guachi on April 2, 2007 at 2:07 PM | PERMALINK

Question for the free market crowd: if you oppose national healthcare because you think it will reduce the pace of medical innovation, how do you explain this?

The first comment nailed it, Kevin. C'mon -- haven't years of comments by the likes of tbrosz, Yancey Ward, Will Allen and the rest of the faith-based libertarian crowd convinced you that they simply aren't receptive to data (i.e., history, economics, current events, etc.) that conficts with their beliefs?

Posted by: Gregory on April 2, 2007 at 2:08 PM | PERMALINK

The simple (and sad) truth is that most physicians are resistant to change. The VA is a centralized system, so physicians there have no choice but to adopt any changes enforced from the governing body. In the private world, physician intransigence is a lot more effective at preventing change. I don't think there is a more sinister reason; I could be wrong, though. I'm pretty sure that a computer based entry system would also cut down on malpractive suits (less errors mean less bad outcomes), and I believe in 5-7 years most private hospitals would have incorporated such a system.

Posted by: MD_blog_reader on April 2, 2007 at 2:08 PM | PERMALINK

How dare you question the absolute perfection of the completely unregulated free market! Don't you know that even one little interference in pure laissez-faire capitalism will lead to Nazi tanks rolling across Europe? Don't you know that that is what Bin Laden wants? Why do you hate America?

Posted by: American Squawk on April 2, 2007 at 2:12 PM | PERMALINK

Well, there's a lot more to be said.

The simple fact is that all of these fancy automated systems make a lot more work for the initiating doctor that the present paper system does.

The government can mandate that its physicians spend their time doing data entry rather than see patients. It's not so easy for for cash-starved hospitals to mandate that their physicians spend their time unproductively.

So the real downstream benefits are lost.

Posted by: Gary on April 2, 2007 at 2:15 PM | PERMALINK

How are doctors supposed to innovate without the power to write faulty prescriptions?

Posted by: dj moonbat on April 2, 2007 at 2:17 PM | PERMALINK

The only investment health care providers make willingly is one that brings in revenue, for instance, MRI machines -- yes!! -- computerized prescribing and health records -- No!!! Any any facility that adopts such a system risks losing revenue to other facilities that spend all their cash on revenue enhancements instead of patient safety.

That is the state of affairs: unless it is required for accreditation or certification, health care providers do not adopt health care technology "merely" for the benefit of patients. Try to imagine a hospital refusing to pay for laundry and housekeeping services. The standard setters have to make it clear that CPOE is not a voluntary standard.

Posted by: Barbara on April 2, 2007 at 2:19 PM | PERMALINK

Could it be that whereas the computer record of a prescription is unambiguous, the typical doctor's chickenscratches allow for some wiggle room ("It says 100 milligrams." "No, I wrote 10 milligrams. It's the pharmacist's fault for misreading my handwriting."

Posted by: Matt on April 2, 2007 at 2:19 PM | PERMALINK

In fact, systems like this are coming to hospitals and clinics around the country in steadily increasing numbers. In part it's because declines in reimbursement have forced people to look at cost savings in all areas. This is one of the good consequences. Cutting back money-losing but essential services, reducing time spent per patient, finding ways not to serve the underserved -- those are among the bad consequences.

Posted by: Sid Schwab on April 2, 2007 at 2:26 PM | PERMALINK

I spent two years trying to get UCI to adopt something like this back in the 1990s. They are definitely not free market. As it happens I do support single payer although I have grave reservations about politicians running anything as important as healthcare. As it happens, the VA has done a very good job in a number of areas, chiefly geriatrics, until the Iraq War came along. Their studies of frail elderly were the basis for another program I tried to get UCI to support with no luck.

The UC hospital system risk management guy told me they could fund an EMR system out of savings from med-mal suits alone. Their medical records system at UCI was so bad that medical and family medicine residents kept their own personal patient records. They could never get the medical center records for clinic visits. When they finished their training, they took the records with them or threw them away. If there was a subsequent suit, it could not be defended for lack of any records.An EMR would mean that records were always available.

That ignores the benefits of decision-support systems embedded in the order writing module. For example, UCI had an order writing software system (just not records) and the surgery department only wrote 17% of orders on it. The rest was verbal and later copied down by nurses or clerks. This is really inefficient but surgery practice involves little time sitting at a desk or computer. Some hospitals have gone to mobile carts with laptops and wireless networks, a huge improvement not available in 1995. Routine orders would be a huge benefit of such a program. They could be personalized for each doctor and would allow all the drug interactions and dosage calculation to be automatic.

Why isn't this done now ? Mostly inertia and a myth that quality is expensive. It has nothing to do with free market or politics. You won't find many Republicans or free marketers in a university medical center but they turned it all down flat. Many of the UCI scandals came later.

Posted by: Mike K on April 2, 2007 at 2:29 PM | PERMALINK

You're falling down on the job, Kev -- you forgot to link to this piece by Phillip Longman on the VA system and the VistA CPRS application.

Posted by: WatchfulBabbler on April 2, 2007 at 2:34 PM | PERMALINK

CPOE takes a lot more time to use than paper actually. There are several articules measuring increase in physician time (up to 50% additional time).

Posted by: Jor on April 2, 2007 at 2:38 PM | PERMALINK

Many hospitals have attempted and will continue to attempt to implement CPOE, but it is very, very difficult particularly in a hospital that is not "closed panel" like the VA or Mayo Clinic.

There is really no cynicism at work here. Few hospital administrators would argue that such an innovation would not save dollars by cutting down on waste and liability and reducing length of stay. It is just complex, difficult and very expensive.

Posted by: jasr on April 2, 2007 at 2:42 PM | PERMALINK

"If you want it, demand that your hospital adopt it."

Oh yes, because hospitals are so responsive to patient demands. What am I going to do, drag my IV cart out with me and drive to another hospital?

It's not like buying burgers, you know.

Not to mention that free market healthcare means that it's not MY hospital but my insurer's hospital. If I try to gripe through my insurer, all they will say is "Tough. Take our insurance or do your own appendectomy."

Do libertarians just have no understanding of how healthcare actually functions (or doesn't?) The patient has almost NO power. None. We're just widgets on an assembly line in this system.

Posted by: emjaybee on April 2, 2007 at 2:44 PM | PERMALINK

I know this is heresy, and it pains me to say, but the Administration has been supportive of implementing EMR throughout the U.S. healthcare system. Their reasons are perhaps arguable, but they have been at least open to the idea.

I think that this is actually something most healthare systems in the U.S. are interested in implementing. But they are signficant obstacles, not the least of which are the inherent difficulties of implementing a large, complex system such as an EMR, and making it talk to your current systems, breaking down barriers among users that are culturally oriented to the papers system, etc. There is a genral belief, as far as I can tell, that it will improve patient care, and save money. If this seems like the usual claims that the latest software solution is both a floor wax and a desert topping, I think the VA experiment has helped mitigate that fear.

It's a good idea, for many of the reasons enumerated above, but there are real obstacles to actual implementation that need to be understood.

Posted by: Hebisner on April 2, 2007 at 2:44 PM | PERMALINK

Seabisquit: For the free market to work, you have to make your desires known.

Most hilarious item posted yet.

Posted by: anonymous on April 2, 2007 at 2:46 PM | PERMALINK
CPOE takes a lot more time to use than paper actually. There are several articules measuring increase in physician time (up to 50% additional time). Posted by: Jor on April 2, 2007 at 2:38 PM

Taking longer to do things is not a valid objection.

Time spent to do things right is time well spent.

Posted by: Dr. Morpheus on April 2, 2007 at 2:46 PM | PERMALINK

Jor is correct; CPOE often does take more of the physician's time, especially in the case of older physicians who came of age before computing. But this is not a reason not to deploy it. There is time saved for the system, and some of the extra time is taken up by built in error checking and inevitable extra steps required by evidence-based medicine.

Posted by: jasr on April 2, 2007 at 2:49 PM | PERMALINK

mhr: Cuba's system works great!

Bush's system works great!

Just ask the soldiers at Walter Reed!

Posted by: anonymous on April 2, 2007 at 2:50 PM | PERMALINK

Betsy McCaughey--wasn't it as Betsy McCaughey Ross that she wrote that article for TNR a decade ago that did its own little part in scuttling a national health initiative?
An article fallacious and dishonest?
Maybe I'm the Jew who still won't buy a Volkswagen, but I'll believe it when someone else writes about it. A little infamy might elevate the discourse.

Posted by: Steve Paradis on April 2, 2007 at 2:51 PM | PERMALINK

Jor: CPOE takes a lot more time to use than paper actually. There are several [studies] measuring increase in physician time (up to 50% additional time).

Did the studies take into account physician time spent defending lawsuits and correcting errors, including treatment by a second physician necessitated by the mistake of the first physician?

How about the extra time spent by those trying to read the hand-writing of the physician?

Posted by: anonymous on April 2, 2007 at 2:53 PM | PERMALINK

I know this is heresy, and it pains me to say, but the Administration has been supportive of implementing EMR throughout the U.S. healthcare system. Their reasons are perhaps arguable, but they have been at least open to the idea.

The administration has been as supportive of EMR as they have been of switch grass ethanol and balancing the federal budget. That is to say they mention it from time to time in glowing terms, and do nothing substantive to advance it.

EMR requires stringent data formatting standards, and their imposition on industry, so that a complete blood count performed on a Roche medical device and reported to a Cerner EMR looks exactly like a PTT performed on a Hitachi and reported to a McKesson EMR. Only one really effective standard exists currently, and that is the self-adopted DICOM standard for radiologic images.

But if it can't fit into a state of the union speech, the Bush administration isn't really interested in it.

Posted by: jasr on April 2, 2007 at 2:56 PM | PERMALINK

A ah um a ii a um I don't recall.

Posted by: john john on April 2, 2007 at 3:02 PM | PERMALINK

Does not the doc have to orde his little RX scratch pad with his name and Hospital on the header,And then keep it locked up.Each time he has to scribble on his pad he has to get it from his locked drawer,and then return it to a locked location.And the cost of these little note pads,Well one could go on and on.

Posted by: john john on April 2, 2007 at 3:07 PM | PERMALINK

In part, it's because in America, 'physician' is spelled E - G - O.

Posted by: phramptom on April 2, 2007 at 3:07 PM | PERMALINK

Actually, the free market does everything it's supposed to do, except that there is no competition to speak of, no customer choice to speak of, no incentive for the medical care system to listen to their patients, no desire for the medical care system to spend money on anything that doesn't produce revenues and the hospital systems have become inbred unionized nameless faceless bureaucracies which just don't work for us.

OTOH, the doctors and nurses very often are great. They do care and want the system to work.

Go figure.

There are a couple of possible solutions: one is to use government to regulate them into using life-saving, money-saving, public-serving information, knowledge, technologies and the like; two is to do more than regulate -- take it over completely. Which do you think the people making money off the system would prefer?

Maybe they just need to be pushed to the thing they really want, but hate spending money on. Maybe for something like this they'd just like a little sugar to sweeten the deal. Who knows. Is there a dialogue between the medical industry and government or do the lobbyists just present a laundry list of things they want?

Posted by: MarkH on April 2, 2007 at 3:11 PM | PERMALINK

"time of physician" is a bogus objection. I've been told that nearly 1/3 of prescriptions are unreadable or cannot be filled as written, necessitating a call to the physician to clarify. I can't believe that those calls don't take more of a physician's time than inputting an electronic prescription.

Posted by: Barbara on April 2, 2007 at 3:13 PM | PERMALINK

EMR order modules can be designed to take less time. For example, the standard orders that most physicians write are identical by the time they are in practice a few years. The orders can also be set up as default sets that can be approved or modified. Intermountain Health Systems is an innovator in this and published results of ICU adoption of decision supported embedded orders 10 years ago. The big advantage is time. And avoiding errors. All you have to do is take your ACLS recert test to see how stereotyped orders are getting. Everything is algorithms in acute care. Computers love algorithms. All you have to do is adapt to the physician's preferences. If he or she goes to multiple hospitals, a declining pattern, he or she can carry a card with their preferences and load them into the EMR at each place.

One area that has held up EMR and it hasn't come from the Bush people, is concern about confidentiality and the Big Bad Insurance Company knowing all that stuff about you, as if they don't know now.

Posted by: Mike K on April 2, 2007 at 3:16 PM | PERMALINK

Why don't you doctors and medical workers shut up and sit down? What do you know about how to run a medical system? Let us handle it from Washington. We're lawyers, and we know things.

Posted by: dnc on April 2, 2007 at 3:23 PM | PERMALINK

Shitbiscuit:"If you want it, demand that your hospital adopt it. For the free market to work, you have to make your desires known. The most likely scenario is that it doesn't actually save any lives, or has so many bugs that it's counterproductive. Preventing one malpractice suit would make the machine pay for itself, so the logical conclusion is that it doesn't save any lives."

Yes because they have been so receptive of all the other public demands.Remember personal responsibility is ONLY for the poor not for doctors with stock in insurance companies.

Posted by: vbrans on April 2, 2007 at 3:34 PM | PERMALINK

Is this the same Betsy McCaughey who trashed Bill Clinton's health care efforts, landing her a brief Lt. Governorship under George Pataki? If so, don't belive a word she says.

Posted by: MaxGowan on April 2, 2007 at 3:43 PM | PERMALINK

I don't know if Kaiser has this particular program, but I really appreciate their computerized records. I don't have to tell each new doctor about my medical history or meds. I go to the OB-Gyn and she asks how my neck is doing from when I went to the physical therapist.

As a contrast, my mom went in for neck surgery recently, and I accompanied her to some preparatory appointments. She had to bring in every med and vitamin and supplement she ever takes (probably 20 items), in a bag, and the surgeon's PA went through each one with her. Not so bad.

But then we went over to the hospital to go through their prep procedure. They had her write down each med/vitamin/supplement, how much, how often, etc. on a form. Then, a pharmacist working for the hospital came and sat down with us and went through the whole bag of stuff with my mom and entered in to *her* form. So three times, in one day. I am *very* skeptical that computerized records take more time.

Posted by: EmmaAnne on April 2, 2007 at 3:46 PM | PERMALINK

Further proof of the value of socialized, government-run medical systems. In the past six months, I finally converted my 18 months in hell 40 years ago into becoming a client of the Veteran's Administration. It's the best medical treatment I've ever gotten, and that includes the way Kaiser Permanente worked 30 years ago when I worked for the State of California. I can personally attest to the value of the CPOE system, because I recently went in to get some treatment for what my "nonspecific flu-like virus" had turned into (a mild case of pneumonia, which was at least treatable with antibiotics). With the way antibiotics have to be used nowadays due to the prophylactic use of drugs on the animals the rest of you eat, which has resulted in drug-resistant bacteria, there are dangers of "adverse drug reactions" in combination with other drugs a patient is taking (in my case, drugs for prostate treatment). When the doctor put in the first antibiotic prescription, the computer kicked it out because of known interactions with my other drugs bringing the probability of an adverse reaction into the "danger zone." So I was prescribed another antibiotic.

That sure as hell beats Republican medicine every time.

Posted by: TCinLA on April 2, 2007 at 3:53 PM | PERMALINK

In the free market all decisions about implementing new technology are boiled down to a simple equation, if the savings from the new technology and/or additional revenues brougth in are less than the cost of implementing the new technology, the new technology does not get implemented. In health care actuaries can predict quite accurately what the dollar and cents cost of a human life is, so the argument that implementing this or any system will save lives still has to overcome the argument that the law suits involved in those deaths will cost more than the system before the market will pay attention.

Does CPOE save lives?

Medication errors and adverse drug events (ADEs) are common, costly, and clinically important problems. Two inpatient studies, one in adults and one in pediatrics, have found that about half of medication errors occur at the stage of drug ordering, although direct observation studies have indicated that many errors also occur at the administration stage. The principal types of medication errors, apart from missing a dose, include incorrect medication dose, frequency, or route. ADEs are injuries that result from the use of a drug. Systems-based analysis of medication errors and ADEs suggest that changes in the medication ordering system, including the introduction of computerized physician order entry (CPOE) with clinical decision support systems (CDSSs), may reduce medication-related errors.

And how often do these ADEs cause serious harm?

It is estimated that over 770,000 people are injured or die in hospitals from ADEs annually. The few hospitals that have studied incidence rates of ADEs have documented rates ranging from 2 to 7 per 100 admissions. A precise national estimate is difficult to calculate due to the variety of criteria and definitions used by researchers. One study of preventable inpatient ADEs in adults demonstrated that 56% occurred at the stage of ordering,...

So long as bean counters are the ones responsible for making the decision, there will be no innovation without clear proof that it will be "cost effective" and human life is just another dollars and cents part of that calculation.

Posted by: majun on April 2, 2007 at 3:56 PM | PERMALINK

Most people oppose national health care only because the idea comes from Liberals.

They'll rationalize any excuse they can to argue against it.

When you boil down all the fallacies and bs, you find that there is no substantive Free Market argument in favor of our current Health Care System.

It's just another excuse to bash Liberals.

Posted by: American Squawk on April 2, 2007 at 3:56 PM | PERMALINK

My guess would be that the early CPOE systems weren't much good, just like the early automobiles weren't much good, etc. And everyone was a better driver of horses than of horseless carriages. It takes a while to figure out how to handle problems with radical new systems(like setting up the physician-specific defaults one commenter mentioned) particularly when you're probably dealing with people who've never figured out VCR's. They have to retire or get convinced by peer pressure that the system really works, really isn't that hard, etc. Twenty years later you look up and find that most people can't drive a team of horses but can drive a car.

Posted by: Bill Harshaw on April 2, 2007 at 4:02 PM | PERMALINK

As long as health care is not treasured as a valuable national resource, but rather treated as an expendable commodity, we're going to see these types of issues recur repeatedly.

In 21st century America, it's becoming painfully obvious that there are certain necessities of modern life which are so important to the collective security, health and welfare of the American people that the means of generation, distribution and delivery need to be collectively held in common by the people, and not be subject to privatization and the economically subjective whims of the "marketplace".

Health care is one. Education, communications, electrical power and water are others.

And I might also argue that in certain select locales like Hawaii where the supply of land is obviously limited, housing and real estate might also be placed in that category -- but that's another discussion for another day.

Posted by: Comrade Donald from the People's Republic of Hawaii on April 2, 2007 at 4:03 PM | PERMALINK

The clinic system I go to (Healthpartners in MN) has adopted this - every exam room etc. has a pc that the nurse/doctor log into. The entire chart is electronic, and accessible from any clinic. When they write a prescription, they look it up in the database (which automatically checks for drug interactions against everything else in your chart and checks that the dosing is within guidelines) and the computer faxes the prescription to the pharmacy. It's a great system.

I did a case on this in an MBA class a couple weeks ago - these systems do save lives and money, especially if paired with automated dispensors that prevent mistakes in filling the prescription at the hospital.

Posted by: Hillary on April 2, 2007 at 4:08 PM | PERMALINK

I saw this on Beyond Tomorrow a couple years back. ...It's a Science newmagazine from Austrailia.

...That airs in the US a year after it airs everywhere else.

Posted by: Crissa on April 2, 2007 at 4:25 PM | PERMALINK

My guess: they're very short sighted.

Why?

Because in the takeover atmosphere and the atmosphere of CEOs who only stay a couple years, upgrading infrastructure doesn't pay.

Even if the company will long-term save many millions.

This is actually a problem of our electoral system, too. Long-range planning is discouraged by a system with a presidential second election coming only 4 years after the first, and only 8 years total for the president and no possibility of his taking credit for anything that happens 20 years down the line.

Posted by: catherineD on April 2, 2007 at 4:39 PM | PERMALINK

EmmaAnne: I don't know if Kaiser has this particular program...

Kaiser is writing its own software and is having trouble. After two years, it still has lots of bugs, and they recently fired the guy in charge of implementation. This type of software is hard to make work.

I recently visited a Kaiser urgent care, and the doctor I saw there knew from the computer about one medication I take but not the other, which I've been taking for about 4 years.

Posted by: anandine on April 2, 2007 at 4:43 PM | PERMALINK

A lot of the opposition might be generational, with many senior doctors & older administrators being less than computer literate. That has certainly been at the heart of objections to Computerized Physician Order Entry's adoption & eventual full implementation here in Australia. The often very powerful older doctors & administrators within the hospital system were very resistant to the change & found, once it was implemented it took them a lot longer. Younger doctors, administrators & the older staff who were computer literate found the system easy to learn, easier to apply & a valuable adjunct in preventing mis-dosing & overlooking a patients contra-indications.

CPOEs adoption by doctors outside the hospital system also helps prevent patients "doctor shopping" (ie. going from one doctor to another for multiple prescriptions of, mainly addictive, pharmaceuticals.) Last but not least it helps to eliminate misdosing patients who are unconscious, forgetful, inaccurate or dishonest when asked about allergies & drugs they are taking already, with associated contraindications. It's a great system, seems to work really well (my doctors are all young-ish) & while taking no longer than the antique hand-written model, provides an excellent fail-safe & oversight function for all-too-human clinicians.


Posted by: DanJoaquinOz on April 2, 2007 at 5:04 PM | PERMALINK

This is actually a problem of our electoral system, too. Long-range planning is discouraged by a system with a presidential second election coming only 4 years after the first, and only 8 years total for the president and no possibility of his taking credit for anything that happens 20 years down the line.

And yet the Clinton administration undertook the overhaul of the VA system, and delivered a much improved product to the veterans. Could it be that it was just...the right thing to do?

Posted by: jasr on April 2, 2007 at 5:07 PM | PERMALINK

Thanks for this thread, Kevin.

As I am currently on eight different medications from the VA system, it is great information, indeed.

Now, if only Senator Larry Craig, the Repug from Idaho, doesn't screw with it or underfund it's functions.

Posted by: thethirdPaul on April 2, 2007 at 5:11 PM | PERMALINK

"...hospital systems have become inbred unionized nameless faceless bureaucracies..."

Oh no! Not UNIONS!

I'm pretty sure it's not the presence of unions (I was under the impression that most healthcare workers weren't unionized, except maybe some techs or service staff) that has been responsible for our healthcare problems. Considering that many errors are caused by healthcare workers being on the 11th hour of their second 12-hour shift...I'd guess more unions might actually help a lot.

Posted by: emjaybee on April 2, 2007 at 5:30 PM | PERMALINK

I think these are used more by pharmacists then physicians. It should be used more at the physician level since a pharmacist doesn't always know what other medications a patient is taking.

Posted by: John Gillnitz on April 2, 2007 at 5:54 PM | PERMALINK

The article about the VA system last year in the Washington Monthly gave an anecdote about a nurse who hated the system. While the writer watched, she scanned the patient's wrist bar code, her own, and the medication bottle and cursed the whole time because it didn't work. The stupid system wouldn't let her give the patient the medicine. After several tries and many curses, she read the label again and discovered she had been about to administer a fatal medicine. She liked it better after that.

Posted by: anandine on April 2, 2007 at 6:20 PM | PERMALINK

My doctor has switched to some kind of automated, computerized prescription entry. And my employer has mandated that long-term meds be obtained through a scrip-by-mail service. Previously, my doctor had to write a new paper prescription and mail it in to them. Now she enters it on the computer and transmits it electronically. The time saved is like snail mail vs. e-mail. If there's also error checking, and there probably is but I haven't inquired, then it's a godsend for people with multiple physicians prescribing for them.

Posted by: Daddy Love on April 2, 2007 at 6:23 PM | PERMALINK

re: last paragraph of the op ed -- Walter Reed is not a VA facility, right?

Posted by: David on April 2, 2007 at 6:31 PM | PERMALINK

I talked this afternoon with somebody who is very, very involved with the VA's VistA system. He tells me that the people who say that CPOE requires the physician to spend a little more time than writing an old fashioned order are correct. The ordering physician does spend a little more time. I am told that the initial physician is the only one who spends more time. Downstream, every step of the way, from radiology, to pharmacy, to consulting physicians, to billing (yes, the VA does collect from third party insurance if possible), to medical records, to....you name it, the VA has determined that CPOE saves time and money every step of the way. Those are dollar savings that don't begin to take into account the improved quality of care and dramatic reduction of medical errors which is really the VA's primary goal.

Posted by: Ron Byers on April 2, 2007 at 6:32 PM | PERMALINK

Why, aren't physicians actually "Gods" in white coats? That's the impression I've always gotten when around them...

Not all of them, but definitely most.

Posted by: Ranger Jay on April 2, 2007 at 6:38 PM | PERMALINK

David >"...Walter Reed is not a VA facility, right?"

You are correct, it is an Army facility.

For those of you that really want to look into the non-use of computerized medical systems & the mess that can result might want to read about the DoD and their lack of actual top notch support for our troops.

Talk about E-G-O...

"...It is in the religion of ignorance that tyranny begins..." - Benjamin Franklin

Posted by: daCascadian on April 2, 2007 at 7:13 PM | PERMALINK

I am a (first year) doctor at a large academic hospital. I saw a lot of hospitals on my interview trail last year, and it is only the rare large hospitals that are not strongly moving towards computer medical records and ordering. The doctors who are lagging behind are the ones who own private clinics and the small hospitals. There is a good recognition to the medical errors prevented, although our POE system is deathly slow also.

Unfortunately, at my hospital, our computer system is piecemeal with a bunch different programs needed (1 for ordering, 1 for old notes, 1 for radiology, 1 for appointments). Each individual piece is slow and all together it is barely workable. The hospital has already sunk untold millions into it and it will never all end up as one system.

I have had the priviledge of working at the largest VA in Houston. The VISTA system there is truly a wonderful program, with everything at your fingertips. I have heard that the program, being in the domain of the US Government, is essentially free to all who want to implement it. You would think every hospital would jump at the chance. Unfortunately, it is a Windows front-end to the old CPRS system that is still the backbone of it. And CPRS runs (to my knowledge) exclusively on VAX mainframes. So essentially, it is a pretty front-end to a system that has been around since the early 80s. I'm not even clear if you can still get the hardware, let alone implement it...

Posted by: Ed on April 2, 2007 at 7:27 PM | PERMALINK

You got it all wrong, Kevin. CPOE is anti-competitive.

CPOE prevents doctors from making mistakes, thereby ensuring that incompetent doctors not be identified and ferreted out of the system via competition.

See, you just have to learn how to think like a market cultist.

Posted by: Disputo on April 2, 2007 at 7:37 PM | PERMALINK

Because -- I hate to say it -- and despite intense propaganda to the contrary, there isn't ENOUGH medical malpractice liability to make hospitals and doctors search for the best way to avoid these mistakes. If the liability system doesn't make people pay sufficiently for their mistakes, then the cheapest solution is to keep making them.

Posted by: RiMac on April 2, 2007 at 7:39 PM | PERMALINK

There are VAX emulators out there, so HW shouldn't be a constraint.

Posted by: Disputo on April 2, 2007 at 7:40 PM | PERMALINK

I'm in New Zealand, and my doctor has been using this for ages. Unfortunately, she's not exactly what you'd call tech-savvy, and my last visit time was doubled because she had to print out each medication on a separate script, instead of listing them all on one script. I had to refrain from jumping on the computer and teaching her how to do it!

Still and all, very effective system -- and just self-evident.

Posted by: plum on April 2, 2007 at 8:28 PM | PERMALINK

i believe that this system was implemented at cedars-sinai, columbia presbyterian, and a few others. it worked very well.

but the doctors killed it. as far as they were concerned it made them function as clerk-typists, a role their highnesses thought way beneath them.

so, we're back to the system where the lower orders of hospital staff are responsible for records, face sheets, orders, etc.

Posted by: albertchampion on April 2, 2007 at 8:31 PM | PERMALINK

It's obviously easier to mandate universal standards or tools in a monolithic system, than it is in a robust, disparate free market. Your example certainly proves that this is true.

The problem of course is that our current healthcare system is not a true free market. Free markets cannot exist when there is opacity and an utter lack of pricing or performance data.

A more appropriate comparison might be the US Postal Service versus FedEx. Which organization do you think is better run, provides superior customer service, and is a faster adopter of technology. Why?

Posted by: HealthMarket on April 2, 2007 at 9:50 PM | PERMALINK

It's hard to believe that there's any opposition whatsoever to Electronic Medical Record and CPOE. As more and more medical entities make the switch, even physicians admit that it lowers their chance of making an error that could result in a fatality. (So I'm surprised that docs at cedars-sinai et al were able to kill it.

The results of testing on these programs are absolutely compelling, if you're into the evidence-based medicine thing. And as a patient, if you've ever switched from an EMR system to a paper-chart system, you'd feel extremely motivated about going back to EMR--it's very scary when you go to urgent care for something, only to discover that your chart, with its list of medications you take, is all the way across town at the place where you had your last appointment. It really is night and day.

Posted by: erica on April 2, 2007 at 9:56 PM | PERMALINK

Btw, I'm disappointed that we haven't seen widespread use of expert systems to assist doctors in diagnosis, much less use of DBs to automatically check for prescription accuracy and drug interactions.

My father was recently diagnosed with a rare autoimmune disorder, but it took him several doctors before he found one who could diagnose him (read: had ever heard of the disease). With a diagnostic expert system, the first doctor should have been able to diagnose him and send him directly to the specialist which he eventually wound up with.

Posted by: Disputo on April 2, 2007 at 10:17 PM | PERMALINK

Ed >"...Unfortunately, it is a Windows front-end to the old CPRS system that is still the backbone of it. And CPRS runs (to my knowledge) exclusively on VAX mainframes..."

As Disputo has already mentioned there are hardware emulators available so that really isn`t a reason NOT to adopt this system. There are also enough methods to do clustering etc w/any old set of computers that load is not a factor when folks are knowledgeable. And MSWindows doesn`t have to be run on crappy hardware shoveled out the door of some sweatshop "over there".

All in all there are no existing significant computer related reasons NOT to try this system which, as you mentioned, is available to all under the open source model of software licensing.

As a last item I will just note that this all seems to me to be a very ripe area for some smart IT people to get in and make this system Web 2.0 savvy. Seriously big bucks await.

"The pessimist complains about the wind; the optimist thinks it will change; the realist adjusts the sails." - William Arthur Ward

Posted by: daCascadian on April 2, 2007 at 10:24 PM | PERMALINK

A well programmed computer has tremendous advantages over a mere mortal doctor in diagnosis too. Para-medicals trained to accurately assess and describe symptoms armed with such a computer would be more than sufficient for initial diagnosis, cheaper too.

Posted by: Michael7843853 G-O in 08! on April 2, 2007 at 10:25 PM | PERMALINK

Disputo >"...With a diagnostic expert system, the first doctor should have been able to diagnose him and send him directly to the specialist which he eventually wound up with."

This was seriously looked into early in the 1980s but was dropped partly due to fearmongering about law suits from those evil ambulance chasing lawyers. Note the time frame and I think you will understand what was going on "behind the curtain". PROMIS also was a big deal back then (shadows of "Big Brother").

"...It is in the religion of ignorance that tyranny begins..." - Benjamin Franklin

Posted by: daCascadian on April 2, 2007 at 10:33 PM | PERMALINK

Before I went to medical school I was a software engineer. The company I worked for built military training systems which computerized a lot of functions that had previously been done with clipboards and pencils. Introducing a system like that -- even to non-Godlike military and retired military/civilian trainers -- was a nightmare. Admittedly this was back in the bad old days before there was a PC in every home, but it was still hard to get people to transition from their comfortable habits.

Since I can type and interact easily with computers, I was always an early adopter of hospital technology. I've used a bunch of them and with the exception the VA, they suck. I was at UCI 1997-2000 and I actually used the OE system the whole time as well as getting myself clerk priveleges so that I could do OE on the LBVA's pre-VistA system (hey Bill K, do I know you?) I've used assorted commercial out-patient systems (EMR or "near"-EMR) since that time. I don't currently see in-patients, but the last two hospitals I worked at had scrolling monochrome menus running under emulators. Unfortunately, EMR and CPOE is massively expensive to purchase, interoperatbility is a huge issue, the users are fearful of it, and the administrators have seen early-adopters getting burned. However my current employer is about to go fully EMR as is my previous employer.

Anybody know someone who wants to hire an experienced systems engineer/physician in southern California?

Posted by: J Bean on April 2, 2007 at 10:51 PM | PERMALINK

The Northwestern Hospital in MInneapolis had a great system for use in rural clinics where the only provider was a PA. They were screening patients for cardiac cath, especially angiograms. Some of it was driven by Medicare complaints about patients sent to the city for angios who did not need them. It was a fuzzy logic system and that was 10 years ago. After my experiences at UCI I gave up for a few years but am about to plunge back in as a consultant. We'll see how much motivation has changed in the interval.

Posted by: Mike K on April 2, 2007 at 10:55 PM | PERMALINK

To have allowed doctor-scribbled prescriptions the last few decades, with all the deaths and other troubles caused by errors, is criminal.

Posted by: Neil B. on April 2, 2007 at 10:55 PM | PERMALINK

Texas Tech's El Paso medical school is the first medical school to implement VistA. I understand that the family practice clinic went live in January and is doing fine.

From what I have read Texas Tech chose VistA because they didn't want to be tied to a proprietary system.

Posted by: Ron Byers on April 2, 2007 at 11:58 PM | PERMALINK

The simple fact is that all of these fancy automated systems make a lot more work for the initiating doctor that the present paper system does.

Bullshit.

I suppose they don't use ATMs, book flights online, scan their own groceries, or use e-bay either.

This is the argument that lazy people use when they don't want to change their work habits. Sure, it will be difficult at first, but if the interfaces, systems and networks are designed correctly, it won't take them 90 seconds even if they are totally inept.

Do you think the techs that have to run the ultrasound machine would have problems entering data into a simple form?

If a UPS delivery person can be paperless, then a physician can too. This is simply a failure to invest short term to save long term costs.

Posted by: Paper Fascists Must Die on April 3, 2007 at 12:01 AM | PERMALINK




 

 

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