Wednesday, December 22, 2010

Health IT and the Carob Tree

At a certain point in time, somewhere in America, someone stated that people should all have lifetime, complete medical records. Sounds reasonable and I presume nobody ever asked, “Why?” As time goes by and health care services in America are approaching an unsustainable 18% GDP, the mythical lifetime record is quickly becoming panacea to the obvious problem health care has become. Americans accustomed to thinking about their health care as “the best in the world” are now being instructed that American health care is fraught with errors, needless deaths, unsafe treatments, uninformed physicians, unsanitary hospitals and basically stuck in the stone age of technology. And all this while sucking inordinate amounts of cash from simple-minded folks who have “no skin in the game” and thus completely oblivious to being robbed, bankrupted, maimed and killed by greedy health care providers and industry financiers. Don’t know about anybody else, but I am positively terrified... mortified... petrified... stupefied... by this.

Enter the aforementioned lifetime health record, a.k.a. “EHR for every American by 2014”.  EHR in this context denotes collections of information or data, not a software product. Instead of overstuffed manila folders and oversized yellow envelopes, each one of us will have a complete electronic dossier, stored somewhere TBD later, chock full of every lab result and imaging study we ever had, all blood pressure, weight, height, temperature, etc. ever taken, all pre-op, post-op, consultation and progress notes ever written, all diagnoses and medications, all cuts and bruises, all chief complaints and histories and all treatment plans that we followed and even those that we did not. When our EHR is ready for use, doctors will be making fewer errors, order fewer unnecessary tests, make more informed decisions, prescribe safer treatments and charge less money for more thorough work. Well, maybe the last one is a bit of a stretch….

Problem #1: Do we really need a comprehensive lifetime health record? Here and there, particularly for small children with chronic conditions, such record will be clinically meaningful. For the vast majority of Americans, a lifetime EHR may be a cute thing to have but not really a necessity. One may need records for recent years if managing chronic disease or battling a potentially fatal diagnosis, but for everybody else, including the exotic case of someone ending up in the ER unconscious, buck naked and all alone, the most you will need is a brief summary of vital information. So if we don’t need our pre-school growth charts and we don’t need an itemized litany of every URI we ever had, every story we told our doctor and every “RRR, normal S1, S2 and without murmur, gallop, or rub” ever recorded, what is it that we do need? I guess a reasonably healthy 40-year-old could derive some joy from perusing his comprehensive lifetime record – “Look honey, that awful cold I had in the winter of 87’ when we went skiing for the first time was really pneumonia. No wonder I broke my leg the next day… It’s all here. Isn’t this great?”  When the same 40-year-old goes to see his new family doc the next day for persistent “heartburn”, his 87’ adventure would be largely irrelevant, and if he ends up unconscious and naked at the ED that night, they may be interested in his recent “heartburn”, but still have no use for information on his hapless skiing vacation 23 years ago.

As Dr. David Kibbe aptly observed, what we, or our health care providers need, very much depends on the context. Defining a relevant superset of information should of course be left to practicing physicians, but if I had to define such superset, I would go with immunizations, problem list and medications (current, with option to view historical), allergies, a couple of years of lab results and imaging studies (longer for certain studies), standard major medical and family histories and for chronic or serious conditions, the last few physician notes. Interestingly enough, these data elements are already being captured in structured and codified manner by most currently available technologies. If money were no object, I don’t see a downside to cataloging and retaining every tiny piece of information, provided that it can be contextually filtered for different circumstances. But judging by the billions of dollars being spent on HIT, money is a very big object indeed and either way, those who care for unconscious, naked people presenting at the ED in the middle of the night, should not be expected to peruse lifetime records.

Problem #2: How do we get access to either comprehensive or contextually appropriate information? As we all know, our “fragmented” health care system is nothing but a collection of data “silos” maintained mainly on paper under lock and key by greedy providers, no doubt purposely so in order to maintain a competitive advantage in a brutal health care market where an overabundance of physicians are fiercely competing for an ever dwindling number of patients . Or maybe not…. Perhaps traffic of clinical information has been severely hampered by that one antiquated oath physicians still take which commands doctors to keep patient information downright secret. Either way, since in most instances people are treated by multiple providers, medical information must be shared between providers and certainly must be available to patients electronically (faxing, copying and phone calls are so uncool). Unfortunately, we don’t have a national healthcare system where all providers are employed by one entity, conform to one set of policies, use one technology platform and clinical data is easily shared. We do, however, have a few “look alike” entities such as Kaiser and the VA. Why not do away with the remaining “fragments” and consolidate our health care in a handful (a single one would be too Socialist) of fully integrated systems? It would certainly simplify things for HIT grand-designers and programmers.

The financial system, our beacon of informatics wisdom, has resolved this pesky problem long ago, as evident in the world-spanning network of ATMs, where card carrying customers with unique identifiers can exchange several bytes of information with their remote financial institution. For those desiring comprehensive financial records, there is Yodlee and Mint, which will aggregate all your financial accounts in one cloud based dashboard free of charge (any takers?). Strangely enough this hallmark interoperability accomplishment did not require federal funding, government committees or a compulsory “universal financial language” (arithmetic seldom does). One can never be certain, but it is possible that financial IT experts were less obsessed with fostering/stifling innovation and more concerned with providing pragmatic solutions to real problems without requiring that banks change the way “financial services are delivered” or that smaller banks cease to exist in order to simplify software programming.

Problem #3: Should we plant a carob tree? Legend has it that carob trees require 70 years to reach maturity and bear fruit (more like 7 really), thus planting a carob tree is a selfless act to benefit posterity. There is a remarkable disconnect between the voice of physicians who treat twenty, thirty patients every day, one patient at a time, and physicians in the academia and those in “leadership” roles who routinely converse about population health, bio-surveillance and clinical research. Doctors who make a living by touching patients today, not tomorrow and not after Meaningful Use Stage 5 has been achieved, usually find that an EHR has very little to contribute to the quality of care they deliver to the one patient in front of them. Health IT is promising them a paperless future, devoid of software and hardware both, where every metadata tagged digital piece of information about their patient is “a click of a button” away. Health care delivery will become well informed, efficient and flawless to the point that the patient may not even need to be “seen” in order to be treated. Magically frightening? No; just futuristic technology which may come to fruition in, say, 70 years. Perhaps EHRs are our carob trees.

Moral: If you insist on planting nothing but carob trees, you will starve to death and there will be no one left to enjoy the fruits of the carob tree.


  1. Health care isn't a new issue, so why do you think no private sector solution, like those you mentioned in the area of finance, have emerged to simplify personal health records?
    We have WebMD and other self-diagnoses/advice sites, but nothing like a Mint for health. Wouldn't it make sense (and a good amount of money) for someone to put together a platform not unlike online banking for health, where reminders can be set up (texts to take meds, go to the doctor), online scheduling can occur between compatible doctor/home-use platforms, patient journals can be kept, etc?

    And why does this have to take such a long time to do? The technology is already there. And there should be incentive for SOMEONE (more likely A LOT of people) to collect all of this data on people for use in medical studies.

    In short, what's stopping the market from streamlining medical information? Are incentives misaligned? Does current government regulation guide funds to less efficient products? Is the private sector itself broken?
    Everybody's got a price, including "greedy" providers.

  2. First, most medical records in this country are on paper. Unlike financial data, which is mostly numeric, medical records have been historically a narrative, thus significantly harder to digitize.

    Yes, there is a potential for someone(s) to make a boatload of money by creating a Mint for health care, and this is why there is such a great push to coherently digitize medical records.

    Yes, incentives are misaligned. In order for data to exist in an electronic format, which is a prerequisite to a Mint style solution, someone must input it into the computer. The individual(s) who need to do the data entry (i.e. clinicians) have very little to gain from their efforts. Data entry is not reimbursable and, from a physician point of view, it reduces productivity, which has a negative impact on the bottom line.
    Furthermore, there are no definitive studies showing improvement to patient care when current EHR tools are used.

    The financial benefits of EHR will accrue in the future and will accrue to those who pay for health care, not to those who provide health care services. The immediate financial investment on the other hand, has to be made by service providers. Government is proposing to help some, but the incentives cover only a small fraction of projected costs.

    Yes, everybody has a price, but so far the "reserve" hasn't been met.

  3. Provocative essay Margalit. Hopefully the EHR carob tree will be mature in 7 years and not 70. I think you might have mentioned that there is still little evidenced based medicine to 'encourage' with CDS and that places like Intermountain Health use EHR as part of the EBM discovery and distribution process. And finally, referring to decreases in productivity when that productivity includes less than ideal care and a lot of unnecessary care is counterproductive. Thanks for pointing out that the common comparison to financial services (ATMs) is a really unfair. Health care will never be as simple as arithmetic.

  4. Thanks Dr. Vaughn.
    Funny you mention productivity. I often wondered what exactly does that mean. My mental picture has always been of a frazzled pcp rushing through weary patients who have spent a long time in a crowded waiting room already. EHRs are poorly equipped to solve this particular problem.
    The "other" productivity could indeed stand some "losses" and hopefully EHRs will be able to help a little when they become a lot more than a data collection tool.
    7 years sounds right....

  5. I'd like to add in response to the comment by Elad Gross that I think there's a different mentality when it comes to health care. Financial records have traditionally been a person's perogative to keep, both in the days before people trusted modern banks to safely hold their money (see Margalit's other excellent post comparing finance and HC) and even now in the days of electronic banking. People view their finances as their responsibility to keep up with. Wheras in health care, the record keeping has traditionally been the doctor's responsibility. People just don't think about them in the same way, and it will take time for that kind of mental paradigm to change.

  6. Hi Margalit,
    Very thoughtful post. I find you one of the most interesting bloggers out there. Sometimes in the medium of the written word it's not always obvious where irony is intended, but I think I have it figured out in your Carob tree analogy. I'd like to link to your blog from my "Harmonious Health IT" blog where I just wrote some recent thoughts on a related matter.

    The "superset" (actually I think you meant "subset") lies behind the clinical summary concept started with CCR then CCD and currently enthroned in MU. While I don't disagree with the items you mentioned in the general case, how much will clinicians want to rely upon this least common denominator, vs. wanting more intelligence based on their context, sort of "personalized medicine" with personalization here applying to the combination of patient, provider, and encounter. I realize that the perfect shouldn't be the enemy of the good, and don't want to imply a 70-year carob tree though.



  7. Hi David, thank you for the kind words and by all means feel free to link this, or anything you else you like.

    I did mean superset, with the intent of sharing less not more depending on the context. That said, I can see how advances in genetics, for example, could lead to a need to expand the superset. I can also see how eventually, advances in computational technologies may make expanding the superset to include every piece of data, and distilling contextually relevant information on the fly, almost trivial (that's the 70 years program :-)).

    I find it both interesting and telling that the Netherlands, which are considered to be very advanced in this field, are actually creating special summaries to be shared through the national hub. They do not share the full record as is. I like the Dutch approach. I also like the CCR/CCD/CDA and HL7 in general, which seems to be globally accepted, and I don't know why we need to reinvent the wheel....

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