Forbidden Topics In Health Care–Part One

The official line on health care, which pervades not only the mainstream, but also much of the alternative media is this: The most important thing is that we all receive the best care, and that someone else pays for it. Which brings us to our first forbidden topic…

1. What IS the “best care”?

While what constitutes the best of anything is largely subjective, most of us agree, at least in generic terms, that certain things are better than others. Moreover, limited by our budget, we usually have the opportunity to make such choices–unencumbered by third parties. No doubt, plenty of misinformation circulates regarding whatever we are interested in obtaining, but based on some due diligence, we believe that we can make informed decisions.

With health care, however, there are serious impediments to making a purely informed decision. For one thing, health care is an extremely technical field–arguably the most technical field that the average consumer will ever encounter. Many conditions are the purview of specialists or sub-specialists, and the so-called state of the art seems to be constantly changing–based on the endless avalanche of research papers. Notably, any meaningful critical review of these papers is sorely lacking.

Currently, the consensus on “best care” is a potpourri of an engaging bedside manner; the use of high-tech diagnostics, whether required or not; the dispensing of a potent drug, ideally a new and proprietary version of an old standby; and, of course, a very small co-pay. The quality of the outcome of such care is usually not considered.

Might I suggest that a better definition of “best care” would be a potpourri of superior outcome; prudent use of diagnostics, pharmaceuticals, and invasive procedures; and true cost-effectiveness–no matter who pays the tab.

Our second forbidden topic combines the hot-button issues of electronic health records (EHRs) and patient privacy, as exemplified by the HIPAA Privacy Rule…

2. The false promise of EHRs

Unashamedly touted and heavily subsidized, as well as being an important component of the Affordable Care Act (Obamacare), EHRs have been presented as the greatest thing since sliced bread, with virtually no downside. At present, before full-scale implementation of the ACA, the EHR market is already worth more than $20 billion annually, with robust growth predicted. So, if your name happens to be Epic Systems, McKesson, Cerner, Allscripts, or Siemens, the rosy description is spot on.

In my judgment, though, the truth is far closer to this observation from Leora I. Horwitz MD, MHS, of Yale Med School: “I would never go back to paper charts–clearly electronic records are better. But while they’re good, they’re so far from great it’s astonishing.” Bear in mind that Horwitz’ experience with EHRs exists within the vast resources of Yale, not exactly a typical setting.

While there is nothing wrong per se with the transition to EHRs, there are dozens, nay hundreds, of issues in health care reform that should have taken precedence. Unfortunately, it is abundantly clear that the rush to EHRs has much more to do with regulatory control, than it does with improving patient outcomes. Entire treatment modalities can now easily disappear, since they will simply not exist on software pull-down menus. Not to mention “helpful hints” that do appear for providers, so that revenues can be maximized. In fact, in many institutions, failure to abide by these hints can bring disciplinary action.

Scot M. Silverstein, MD, medical informatics guru at Drexel University, has long been an advocate of vigilance in the adoption of EHRs. Quite tragically, his worst fears were realized in 2011, when one of his 84-year-old mother’s medications–Sotalol (used to control rapid heartbeats and abnormal heart rhythms)–inexplicably disappeared from her EHR during a hospital stay. Complications ensued and she subsequently died. Not surprisingly, he blames her death on EHR problems. “If paper records had been in place, unless someone had been using disappearing ink, this would not have happened.”

Insider blogs are rife with other EHR horror stories. Perhaps, the cash incentives for early adoption of EHRs produced some unintended consequences.

Finally, there is no argument that EHRs are easier to steal and hack on a wholesale basis than old-fashioned paper records. Some unauthorized individual photocopying or poring over manila folders would be far more conspicuous than an invisible digital hacker. As to HIPAA, the most notorious breaches of EHRs have been by people who were authorized to access them. Ask Kim Kardashian, whose records at Cedars-Sinai were abused during her recent maternity admission. Despite Cedars’ reference to its “high standard for security,” it was revealed that relatively low-level hospital employees, as well as a volunteer were readily able to gain access.

And, if this weren’t bad enough, the Kardashian incident was only one of at least 12 more that occurred within a seven-day period last month. All this at one of the most prestigious medical centers in the country. Not exactly a confidence builder, is it?

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17 responses to “Forbidden Topics In Health Care–Part One

  1. I’ve been glad to see the medical profession being dragged kicking and screaming into the 20th century by computerization of health records. I thought it would improve efficiency. However, the sales pitch for Obamacare that this would be some great innovation was laughable. I’m amazed that they are still pushing the myth, but not amazed that it was used to buy out the software companies.

    • The problem is that these were designed in a rushed and haphhazard fashion, not accounting for real world conditions (including hospitals where wired connection is impossible and a wireless connection intermittent using a web-style interface that clear the page when it loses connection). Then, the interfaces are designed for management and accounting, not line nurses. The multitude of questions required for entering data makes even filling prescriptions difficult at times.

      Two of my nurse relatives took early retirement because they felt that they were treating the computer chart instead of the patient.

      And my father could list you the problems with the childrne’s

      • Sorry about the last sentence. My father could tell you the exact problems with Children’s EMR just from listening to my mother complain. It’s a classic example of a user interface designed by someone with no clue how the user actually uses the system.

        • @ben–

          The entire law was written by people who seem to know absolutely nothing about how health care is delivered in the real world.

          • Howdy Mike and Ben
            The health care law was written by the same kind of people who are trying to manage energy policy. They figure that if you can run the power grid on pixie dust and unicorn doots, you can probably use them to deliver health care too.

  2. Richard T. Fowler

    Thank you, Michael.

    The clear purpose of mandatory EHR is to take additional control over patients’ lives from the hands of their health care providers and move it to the government-controlled care managers. This is textbook Communism, and too many who should know better are failing to see what’s going on. By being divided, a people are more easily conquered.

    I’m sure that many have already been killed by EHR “disappearance”, and this trend is just getting started. If people who’ve never even seen the patient and are neither a doctor, a nurse, nor a health technician, are now allowed to enter and delete or modify patient health records, without any complaint being raised, then any pretense that science is being practiced within medical care settings has been utterly abandoned.


  3. On the first topic: optimal care at everyone else’s expense is a pipe dream. Health care is an economic activity; the people and goods involved have to be paid for. And it’s essentially a private good: my appendectomy would matter to my family and me, like my car does, but it’s not a benefit to my neighbor.
    There is a key problem with health care, though. Some forms of health care, and those the most costly, are absolutely required when they’re required. If you do have appendicitis, you will suffer greatly and may well die without surgery. If you’re in a serious accident, your survival or your functionality will depend on prompt care. You won’t have time to figure out the financing or shop around for price comparisons.
    This is very different from buying an older car or using other transportation, from choosing a smaller home or a used TV set form a pawnshop.
    And people are social animals who worry about the suffering of others as well as our own suffering or our family members. That’s the dilemma we keep slamming into with health care.
    Prudent people with some means will use healthcare insurance to cover the ugly bills. Many people will chip in to provide financial help for those who are poor and need care they can’t pay for or provide for.
    As for routine things like contraception or allergy care, perhaps we should leave those as out of pocket expenses. That would put serious downward pressure on the costs of routine items.
    It’s a dilemma because we care about the poor or those who failed to make good provision, yet we also have other priorities. Making this government business is a terrible idea, though.
    EHRs: within certain limits, they can be great. I’ve done some work related to them. But they are not the great efficiency tool that will cut costs dramatically because record-keeping isn’t the big driver of health costs.

  4. “there is no argument that EHRs are easier to steal and hack on a wholesale basis than old-fashioned paper records”

    And who most likely to steal?


  5. It is habit number one for those of us that use computers to back up our work. Evidently EHRs do not provide for this. Since it is my health and my life at stake, why should I not have a back up copy myself? And have access to my parents’ EHR to consult with their doctor’s during an emergency? I have a gut feeling this data will be most valuable to the bureaucrats on the IPAB to justify ObamaCare letting us die.

  6. Every article you read or medical show you watch emphasizes that you must advise doctors what other drugs or supplements you are taking. If they can screw up the records of Scot M. Silverstein’s mother, there is little hope for the rest of us.
    I assume he was able to force some type of investigation to trace how it happened and the result is that the records “inexplicably disappeared”.
    This should be on the front page of every paper and/or the lead story of every newscast–every single day.

  7. HIPAA simply states, “We promise not to give your records to anyone, unless we want to.” The patient has NO control over their own medical records. The legislation is boilerplate to protect the medical community and has nothing to protect patient privacy.

    The Feds have the authority to get any medical information they want on any, and every, patient. In addition, they demand unique identifiers so the information is not confidential but can be traced directly back to each individual patient. But they Promise they will meet all federal privacy obligations and only use the identifiers for computer sorting purposes. So far their track record is terrible and a private company would have been sued millions of dollars for the same track record.

    Electronic records are like electronic books, electronic notebooks and electronic spreadsheets – they aren’t as capable as pen and paper, they aren’t as flexible, and they aren’t as easy to use. A paper file must be handled to ‘steal’ it but an electronic file can go viral in seconds, so much for security. Little boxes and note places aren’t as easy to use as simply writing in a margin of a paper.

    One thing I learned long ago is it is you get better information when you give a blank paper to an individual and ask them to write down everything they see. The alternative is to give them a list of what they might see and ask them to check off everything on the list they see. People will answer the questions you ask (and doctors fill in the blanks) but the records will be better if you don’t necessarily have those little boxes to check off.

    Medical care will never be perfect. We have pharmacists double check a patient’s prescription lineup. We have nurses double check the care status. Even so we are human and the benefits of the human brain are also checked by ego, blindness, greed and stupidity. Electronic records may be nice but they are no panacea.

  8. And who is to say that hospitals and doctors are 100% responsible for your health? Take a paper record of your medications and conditions with you. Keep a paper record of what you are there for, your doctor(s)’s name, procedures done, times medications taken, etc. Ask nurses and doctors to wash their hands before they touch you. Demand to know what the medication is that they are giving you. And finally, speak up when something seems wrong. You want better healthcare? Fine. Be part of the solution instead of being a helpless waif hoping someone else doesn’t destroy your life.

    I have had numerous run-ins with the medical profession and I’ve found that they are people who make mistakes all the time. That’s why nobody in my family goes to a hospital without a family member there. I’ve seen doctors forget to wash their hands in an oncology clinic. I’ve seen doctors give so much pain medication that it nearly stopped the patient from breathing. I’ve seen nurses forget to provide medication or not bring the right medication. I’ve seen patients completely forgotten in an E.R. department. I’ve seen doctors forget to warn patients about dangerous drug interactions.

    You want better healthcare? Make it happen. As the USA continues toward socialized medicine these problems will increase. We need to fix the system, but in the meantime we need to protect ourselves and our loved ones from the system.

  9. Does O-Care block individuals’ suing the federal government for damages, malpractice, and malfeasance due to errors in, deletion of, and “inexplicable” disappearance of EHR data?

  10. JT you are spot on. People must learn about their own health conditions. It would not be a bad idea if schools taught children something about how the human body works and how using good food that our forebears used and clean water helps for starters. But if you get sick you must take your own responsibility. Get well-trained health professionals, and family or friend back-up to keep an eye on things. This is most important. “Well-trained professionals” means nutritionists, nurses, masseurs, naturopathic consultants and anyone else certified in a genuine profession – not just the doctors that use only drugs and surgery etc.

  11. MT Geoff is absolutely correct when he points out that many forms of health care are absolutely necessary which separates essentially prevents free market principles as such from applying to health care. More importantly is that physicians do not keep track of their results over time so there is no track record of performances for comparison! Those few and documanted times when such results were tabulated resulted in reductions in cost and near miraculous improvements in outcomes!

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