4 ms·

I was on the back-end of a large electronic health records implementation. I'm not actually sure better care resulted, and the security was that dystopian type,

I was on the back-end of a large electronic health records implementation. I'm not actually sure better care resulted, and the security was that dystopian type, ridiculous and insecure at the same time (we had to downgrade some systems to connect). At least in this mental health practice, you charted on paper / locally to the providers systems. We had a billing team (in old model) that only uploaded key patient info (MRN / DOB / Service date / time / billing code) to a billing system. This was done using billing slips that went to someone trained on it (who could handle all the weird hassles around eligibility etc etc). Provider would actually talk to patients etc etc. The notes were pretty focused afterwards. And yes - pretty secure - it was actually hard to just browse around - providers locked up their notes in their office, and their office was locked (we had a three lock rule -> front door with alarm (metal gate), office locked, file drawer locked. What people don't tell you is with the electronic health record, they also required that all these required elements be "charted" - on EVERY visit. So in new system pretty soon charts become a pages of boilerplate per visit - copy and paste stuff. It was not useful anymore to do a case history from this chart. So we made the admin folks happy, but what a trash experience - the EHR folks are selling bills of goods and the admin folks implementing and the compliance folks mandating endless boilerplate and macro entries to get anything approved are wasting all our time and money. I got out, never felt better - the people were great, the ordered from on high decade old java app through a double VPN that worked 50% of the time with no user experience thinking - a nightmare. And in this new system, every sysadmin could basically snoop on anyone (all in the name of patient coordination) as could lots of others who just ended up with the extra permissions because the system was so locked down we all basically had to be superusers. To run billing reports you needed access to every record - so they had to give you these ridiculous permission levels. And to avoid QC issues billing staff are reading all the chart notes to make sure all the required boilerplate is in them. Such BS. This system was integrated with a lot of providers, so you could also see everything related to that person everywhere (all the office / admin / billing staff at literally every provider included). While a bit helpful if you had a billing issue (same unit type billed at an unapproved frequency) all the benefits focused on that type stuff (admin ease) and privacy was zero across that backend system.

monkeydreams 6y ago
> I was on the back-end of a large electronic health records implementation. My organisation has done many EHR/EMR, PAS and EMPI implementations using systems from third party vendors (i.e. I don't have any dog in the which-system-is-best fight). With modern systems (i.e. applications developed during and after the HIPAA act) we have seen significant reductions in error rates relating to drug interactions and dosing. > What people don't tell you is with the electronic health record, they also required that all these required elements be "charted" - on EVERY visit. So in new system pretty soon charts become a pages of boilerplate per visit - copy and paste stuff. It was not useful anymore to do a case history from this chart. I did not know we were meant to keep this a secret. Yes, it is important that you record every encounter with "boilerplate" code. There are funding impacts (as case complexity rises with these lifestyle and prior history codes). If a patient presents with a cough and blood in the sputum, it is important to know that they were once a smoker. If a patient presents with a broken leg and they have a history of diabetes, their treatment will be considerably more difficult and expensive. > And in this new system, every sysadmin could basically snoop on anyone (all in the name of patient coordination) as could lots of others who just ended up with the extra permissions because the system was so locked down we all basically had to be superusers. I have worked on these systems as well. I find more recent systems to be far better better at accountability with regards to patient record access tracking. It has been a long evolutionary path, however.
- temp667 6y ago
  Mental health I think is at least somewhat different. I'm surprised this hasn't been studied at least a little. A fortune in implementation costs (system I was stuck with was 10 years ago now - absolute trash / hell). The patient wants time with their clinician. So in a 20-30 minute visit either the clinician has to be busy charting away (we called them progress notes) or you get actual patient time and more summarized to the point notes. Why can't charts include decision useful info. For example, if a patient has 5 objectives in their plan, why make EVERY 20 minute encounter go over all these objectives yadda yadda - is it unfair to expect the clincian will be working on these issues during their visit. Now every progress note has to have. We discussed patients success and potential tools to help them improve in their ability to control X, including various strategies and evidence tested techniques shown to demonstrate good results in this area. We discussed patients success and potential tools to help them improve in their ability to control Y, including various strategies and evidence tested techniques shown to demonstrate good results in this area. This was govt delivered / managed care BTW - so in reality, the EHR made clear that they gave to craps about patients or outcomes and just wanted to check boxes, so everything was both insanely detailed and offered no decision usefulness. The tell is that most of these systems have been total top down forced (from national level). That's a good good sign there is not much natural desire for them. In other fields you get bottom up adoption of tools - a proof in the pudding point of evidence that folks find value in them (beyond the admins).

monkeydreams 6y ago

> I was on the back-end of a large electronic health records implementation. My organisation has done many EHR/EMR, PAS and EMPI implementations using systems from third party vendors (i.e. I don't have any dog in the which-system-is-best fight). With modern systems (i.e. applications developed during and after the HIPAA act) we have seen significant reductions in error rates relating to drug interactions and dosing. > What people don't tell you is with the electronic health record, they also required that all these required elements be "charted" - on EVERY visit. So in new system pretty soon charts become a pages of boilerplate per visit - copy and paste stuff. It was not useful anymore to do a case history from this chart. I did not know we were meant to keep this a secret. Yes, it is important that you record every encounter with "boilerplate" code. There are funding impacts (as case complexity rises with these lifestyle and prior history codes). If a patient presents with a cough and blood in the sputum, it is important to know that they were once a smoker. If a patient presents with a broken leg and they have a history of diabetes, their treatment will be considerably more difficult and expensive. > And in this new system, every sysadmin could basically snoop on anyone (all in the name of patient coordination) as could lots of others who just ended up with the extra permissions because the system was so locked down we all basically had to be superusers. I have worked on these systems as well. I find more recent systems to be far better better at accountability with regards to patient record access tracking. It has been a long evolutionary path, however.

temp667 6y ago
Mental health I think is at least somewhat different. I'm surprised this hasn't been studied at least a little. A fortune in implementation costs (system I was stuck with was 10 years ago now - absolute trash / hell). The patient wants time with their clinician. So in a 20-30 minute visit either the clinician has to be busy charting away (we called them progress notes) or you get actual patient time and more summarized to the point notes. Why can't charts include decision useful info. For example, if a patient has 5 objectives in their plan, why make EVERY 20 minute encounter go over all these objectives yadda yadda - is it unfair to expect the clincian will be working on these issues during their visit. Now every progress note has to have. We discussed patients success and potential tools to help them improve in their ability to control X, including various strategies and evidence tested techniques shown to demonstrate good results in this area. We discussed patients success and potential tools to help them improve in their ability to control Y, including various strategies and evidence tested techniques shown to demonstrate good results in this area. This was govt delivered / managed care BTW - so in reality, the EHR made clear that they gave to craps about patients or outcomes and just wanted to check boxes, so everything was both insanely detailed and offered no decision usefulness. The tell is that most of these systems have been total top down forced (from national level). That's a good good sign there is not much natural desire for them. In other fields you get bottom up adoption of tools - a proof in the pudding point of evidence that folks find value in them (beyond the admins).