Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Sunday, March 22, 2015

Limits of Technology

The other day, I went to see a new physiatrist for my chronic back problems. She came highly recommended by my former physiatrist, who retired. I found her (the new one) to be lovely and helpful, as was her staff. No problem with the people.

The technology was concerning, though.

Some things they got right. The doctor typed on a computer while we talked, but she had the monitor and keyboard raised and next to the examining table, so that she wasn't constantly looking down or away. I didn't find that off-putting at all, surprisigly. And when I first registered, the receptionist asked for my email address. I declined, because I don't want to be spammed by the hospital she's affiliated with. The receptionist told me that it's for something called, "My Charts", where I can look up my results and summaries of my visits, and where I can easily communicate with my doctor. I still declined.

Later, the physiatrist encouraged me to sign up for My Charts. She didn't know I had refused. She obviously uses it regularly, so I decided to do it, and I sheepishly told the receptionist that the doctor had convinced me, and gave her my email.

What I didn't like about the technological aspect was the initial forms. Well, "forms". I was handed a tablet, and asked to fill out privacy and insurance forms that way.

Problem 1: The thing is a fomite. There are typical hospital-type signs in the office about properly wiping down all shared equipment with cleaning products, but you can't really do that with a tablet, and dude, this thing was not clean.

Problem 2: The user interface was crappy, but that's no surprise.

Problem 3: The software was less sophisticated than paper forms. When you're handed a paper HIPAA form, you can decline to sign it, and the doctor simply has to document that she made a good faith effort to give you the forms. Your lack of signature does not in any way prevent the sharing of information that HIPAA allows. In other words, your information can get tossed around publicly, whether you agree to it or not. If you don't believe me, see my post, What, Exactly, Is HIPAA?

The electronic version had no option for not signing. With paper forms, I generally refuse, because even if I have no say in what happens to my information, I don't have to jump on board that bandwagon by obsequiously signing. But I couldn't finish the electronic form without signing.

There were 4 different documents I had to sign. One said that if I didn't agree to the terms, I wouldn't be treated. At least I think that's what it said. The lack of clarity is another problem.

A second form was a standard, "I agree to share this info with my insurance," which I know I have to sign if I want coverage. And I was pleased that this doctor, who came so highly recommended, happened to be in my network. This is part of the upside of technology, which, if done well, can make it possible to manage a high volume practice that takes insurance but still makes money, and also treats patients well. And this practice, unlike my own, is high volume.

Another form gave me two final options. I could either agree to share all information with other providers, or I could refuse to share any information with other providers, including in an emergency. It specified that part. Then there was a line below the options that said if I didn't choose one or the other, it would be assumed that I wanted to share no information, except in an emergency. I thought, "Oh, good. I won't choose." Naturally, the software wouldn't let me do that. So I refused the sharing of any information, on the assumption that in an actual emergency, any intelligent doctor would just go ahead and get the necessary history.

There was one other form, and I can't remember what it did.

Like I said, paper forms would have made more sense. It was galling that there was a big sign in the office touting the use of these tablet forms, and how they would allow for better patient care.

I'm not comfortable having my health information readily available to pretty much everyone. In an article in yesterday's NY Times, Why Health Care Tech Is Still So Bad, Robert Wachter describes a lot of what I just did, but with the hope that today's tech is really version 1.0, and that it'll get better. He points out the flight industry wouldn't dream of using new software until it was tested extensively by pilots in simulation. Not so in health care. Go figure. And Apple interface, especially with iPhones and iPads, is a pleasure in large part because Steve Jobs was a tyrant who wouldn't market a product until it worked the way he wanted it to. Not so in health care. Maybe we need a Steve Jobs.

But the line that struck me from the Wachter piece was, "Big-data techniques will guide the treatment of individual patients, as well as the best ways to organize our systems of care. (Of course, we need to keep such data out of the hands of hackers, a problem that we have clearly not yet licked.)"

Personally, I'm far less concerned about hackers getting my health information than about insurance companies and the government getting my health information. Who else would hackers sell it to?


  1. I don't think that you have to sign up for My Chart to be spammed by whatever managed care company is mismanaging your health care. I think just the obligatory release to the insurance company so that they will pay claims is enough. At least that is all it took in my case to start getting mailings for asthma management from what I assume was a HIPAA "covered entity".

    I am also not optimistic about "Big Data" and all of its advantages. I would argue that all of the manipulations of HEDIS data and managing medicine on that has been suboptimal at best. What can possible be accomplished by by the manipulation of what is mostly administrative data? None of the IT or business geniuses seem to have recognized that and now we are supposed to trust them with all of the data?

    None of them has apparently figured out that with a big enough spread sheet you can prove just about anything? Or maybe I just have too much faith in mankind?

    1. Hard to maintain any faith under these conditions.

  2. I guess I'be given up on any hope of privacy -- for me personally -- for almost any reason. In terms of my health, I have lots of issues (via checklist) but I am actually pretty darn healthy for a 58 year old with multiple missing body parts. I run several times a week, I work full-time, I parent a teen-ager and generally do okay. My biggest issue with the EMR is how it has sucked the life force out of the work day. I HATE that I spend almost as much time charting as actually spend doing clinical practice. I do not see the point and I think whatever the point might have been ...has left the station. The Emperor has no clothes. Physicians will have to fight for control. But we seldom do -- we aren't hard wired that way.

    1. No, we're wired, or trained, to put our heads down and keep trudging along into the wind.

  3. I've come across an example of how big data will supposedly help, and I was not impressed. To Dr. Dawson's question ("None of them has apparently figured out that with a big enough spread sheet you can prove just about anything?"), I think what's scary is that they know precisely that with enough data one can prove anything, and the data will be used to support preconceived notions rather than break any new ground.

  4. I know that you're not a fan of EMRs, but there are situations where I think they're really essential if you don't want to waste a lot of time. And it is possible to limit who can see them to a subset of people. I worked in a state hospital where the lack of a decent one was such a barrier. What was particularly bad was that it was a hybrid--half on Meditech and half on paper.

    Treatment plans (what was on paper) were pretty much things that everyone on the unit needed to know about. That was on paper. VItals were all electronic. The treatment plans were also inaccessible to the patients who were supposed to sign them. The campus was kind of sprawling, and the Rehab Department was in another building, so they had no easy access to the plan when they were writing their monthly progress notes. (This was a note tracking how much progress the individual had made on their plan over the past month. Typical stay there was 3-9 months. Longer for those with complicated medical co-morbidities.)

    And finally, the nurses really struggled to read the hand-written orders.

    If the treaters are using a team model, it's challenging to work off of paper. It's also challenging when patients have dementia and can't really communicate what their previous provider did. This is really different from a solo practitioner treating legally competent patients.

    1. I'm not opposed to an EMR on principle. Even for private practice. But I think a bad EMR is worse than no EMR. My medical school's hospital started using an electronic charting and order system back in 1999. It was clunky and awful. I don't think there's anything better out there, even now. It would be great if a Steve Jobs type came up with a user-friendly system, where the user is the physician, and not the billing department. But then, there are all the requirements for what you need to put in a note, in order to bill properly and protect yourself legally, that have nothing to do with whichever note system you're using. Even handwritten notes that comply with those requirements don't tell you anything about what's going on with the patient.

  5. It galls me when an electronic form does not allow me to skip an inessential entry the way a paper form does. Often a question will not apply to me at all, or none of the available responses fit (as in your "sharing information" example), or the question is just too nosy and I don't feel like answering. On occasion I've simply stopped partway through, having made the instant decision that whatever my goal was isn't worth the frustration. One advantage of private practice is not having to face an EMR of that ilk in my own office.