What are really the problems with EHRs

There are a lot of complaints about EHRs (2016). Too much useless typing, too many clicks to get what you want, records are not really available. scanned documents are a pain, release forms take forever.

The intended benefits of an EHR are obvious. Data gathered about a patient should be available to everybody who needs to see it, quickly and seamlessly, just like all the other rocket science apps that track our dating.

I see two major problems: data sharing, and user experience.

• Data sharing - electronic health records was never a community service. When a doc or medical situation of a small team needed an IT solution, it was solved only for that particular team or doc. Nothing was intended to be shared. This creates the data silos. It would be a perfect metaphor except real silos can exchange grain so easily just by trucking it over. There is also the other turn of phrase, standards, of which there are, comically, many. There's no universal heath record, or even univesal health patient identifier.
• User Experience, both data entry and retrieval. The pencil used to be the universal recording medium. It was infinitely creative, hobbled a bit by legibility. Typing is so ... easy... that you're expected to do it constantly, but you can't draw. For retrieval, the current EHRs have at best the most rudimentary search. The EHR for a single patient reads like an electronic phone book: if you know what you're looking for you can find it, but it doesn't tell you what the town is like. Everyone complains that you get a lot of data but you just don't get what is happening to the patient.

It's annoying to hear complaints with out solutions. For once I feel I have some.

• Data sharing - the world is going to have to spend some time and money making a universal health record, just like a utility. It's not difficult to do, it just takes some desire and money
• UX - there's a lot of deeply -thought out UX design that could happen. But really just a quick modification to the 'facesheet': add a 3 line text box for a few notes about current status. A lot more could be done but that would change things radically.

These problems are not rocket science. Technologically they are simple. Maybe labor is involved but not much thought.

Weird pronunciations in medicine

- pathology - obviously pronounced puh-thology (in IPA /pə 'θɑ lə dʒij/) But all I ever hear when docs say it is path-ology (IPA /'pæθ 'ɑ lə dʒij/), the first syllable not unstressed sounding like 'path'. Since everything in life must have a reason, I wonder what it is. Is it an attempt to differentiate it from something that sounds similar? Do they just want to emphasize it somehow?

- patent - obviously pronounced pa-tent (in IPA /'pæ tent/). Like patent attorney, patent leather shoes, patently false. But docs use it to refer to, say, a vessel or duct or that is not collapsed, that is full of liquid or air keeping it mostly cylindrical-ish, never mushed or squeezed down (blocked or occluded or limp). And when they do so, they say pay-tent (IPA /'pej tent/)

There are others. Doctors are weird.

Where is the universal electronic health record?

It's the 21st century. Where is our universal electronic health record? The one where all the medical knowledge about us individually is viewable by any doctor anywhere. You know, you get a yearly flu vaccine at your local drug store, and show up at the nearby emergency room for a sprained ankle, but when you go to your yearly checkup with your doc near work, they have no idea! Forget about it being possibly available when you're on vacation and get food poisoning and go to a non-local hospital.

In the middle of backest-woods China I can show up at an ATM for cash. On a flight 40,000 feet over the ocean I can get wifi to check on who was in that movie with that actress in that TV show. But in Boston, in the best place to get sick in the world, with every hospital connected with multiple medical schools, and every doctor with an MD and PhD and leader of the field that covers exactly your problem, you still have to, after getting a CT scan, walk down the hall to pick up a CD to physically deliver it yourself to your assigned specialist's office next door, nominally part of the same hospital network, but only financially connected, not electronically (oh, it is electronically connected, just not for that one thing. Oh, and the other things too which you'll have to walk back and get).
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What's the point (other than that EHRs suck (and not just for the lack of interoperability))? The point is that the technology, the capability, and the knowledge to implement seamless connection for all electronic health data (images, reports, visits, medlists) was possible in the 70's ... with 60's technology. There is no rocket science here (a little electronics and programming sure). It is about as complex as ATMs. The internet should make things that much easier. But for whatever reason (oh there are reasons) it isn't there.

(that's not Jimmy Carter, it's a made up person for HIPAA compliance)

http://www.theplaidzebra.com/first-manned-mission-to-mars/

It is the year 2015, and there are plans to send people to Mars, so there is no technological reason why an interplanetary health record (IHR) doesn't already exist for use when they show up there. The record of the infection you got training in the desolate arctic landscape of Ellesmere Island. The dosimeter readings while stationed temporarily on the L2 jump-off station. Your monthly wellness-checkup with your PCP (well, remotely).

Right now all you get is your intraoffice electronic health record (that is, within an office, not between). It would work great if your PCP, endocrinologist, and cardiologist all belong to the same practice. Of course they don't. Sometimes you're lucky and a big hospital will be the only center for an area and all docs belong somehow to that one hospital. I'm not saying things are bad everywhere.

Wait. Expletive. I can't go to any local drugstore (again!) to get an over the counter bottle of Sudafed, some batteries for a game controller, and a jug of bleach for my socks without stormtroopers crashing through the windows, hog-tying me, and interrogating me on suspicion for running a meth lab (I mean every time), because I went to another drugstore across town for that very suspicious flu shot. At least somebody can connect systems. I was almost happy that they cared! About me!

Enough idle complaining. My idle blaming is that it is the health care businesses's fault. The docs are doing their job as well as they can. The businesses don't get anything out of making things easier on the patients or docs. I have all sorts of constructive suggestions just no one likes advice.

Even docs replaced by robots? Only for boring operations

Will technology replace us with robots? (us = 'billion year DNA-developed flesh-covered endoskeletal devices')

A new automated anesthesiology device has recently made the news: Automated anesthesiology for colonoscopies. There's the obvious fear of high-priced docs losing their jobs "How dare they assume a machine could replace a physician with years of education and knowledge?'.

But for the moment, what's the situation? Colonoscopies for polyp screening and removal are very routine procedures. For the colonoscopy part, only 5% of patients have a polyp removed. So most of the time the GI doc is doing boring work, looking for polyps that mostly never there.

And similarly for the anesthesiologist except moreso. Even if the GI  doc find polyps that are removable, that doesn't change the sedation. If something is found that needs more than just the colo tool, then hey, we ain't doing that here, we're backing out anyway, no need for more anesthesia. All they are doing is conscious sedation over and over and over again.

Every patient needs oversight. Things go wrong. "I didn't know the patient would have a seizure, allergic reaction, is used to the sedation drugs" These things need tweaking. For the most part, the every day stuff and these few weird things are extremely well-known (there's been a high tech assembly line of patients getting colonoscopies forever!). So this is the perfect place for automation to both reduce cost and time and effort. And the machines are going to have extra sensitive alarms, a good buffer to stay away from the bad situations.

There'll still be a need for lots and lots of physicians, don't worry about it, freshly graduated MD. Hopefully family practice, where the real medicine happens, will become more respectable = more highly paid, because it is already high in demand but nobody is going into it because it won't pay for med school tuition loans.

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The whole point to science is to make things repeatable.

The trend then is that if you do something enough times and for what variation there is, it can be parametrized, then it can be automated and packaged.

We do it for medications: an expert gives very simple instructions on use, and then you do it yourself. Simple first-aid for even life threatening situations doesn't need to be handled by a full physician. Anyone who can read directions and gets a couple hours training can do CPR and use a defibrillator.

Medicine is progressing towards knowledge constantly. Radiology is miniturizing image taking to the point where soon you really could have a Star Trek tricorder to wave over someone to see and judge any internal problems.

Look, there's already the DaVinci robotic surgeon. Of course it doesn't do every thing and needs to be operated by a full surgeon.

(from Medical Devices)


But, soon enough you'll be able to go to your local drugstore and go down the pain-relief aisle, turn on the cough and cold section, then come to the Surgeon-in-a-box aisle:

• Wart-Removal-In-A-Box - wait, don't they have these already, some freezing solution?
• Stitches-In-A-Box - for non-serious cuts that are too deep to heal themselves, place the box opening over the wound and the sensors will be able to see where to close up. Applies flesh knitting goop reducing scarring (Dermabond, based on superglue, it's real).
• Colonoscopy-In-A-Box - you'll still need to take the prep, robots can't see through poop either. Send to the lab any polyps removed in the enclosed vial.
• Lasik-In-A-Box - just place against the affected eye for ten seconds and hold your breath.

OK for most of these you'll need a prescription for them. But still you'll be administering them at home yourself.

Yes, I agree, the last three I'm not sure I'll ever be comfortable with. But none of them exist so I'm off the hook for now.

My colonoscopy!

What really happens in a colonoscopy.

I went in for a 50-yr-olds screening colonoscopy. I got the usual medical euphemising in the patient education stuff they give you. Here is what really happens:

  - you have a diet the week before ('low fiber' which means mostly food that's not usually considered healthy, no fruit or vegetables, yay BBQ and mashed potatoes!) and the night before (and morning of) you drink about a gallon (4 liters) of saline water (w/ PEG)  in order to cause extreme emptying diarrhea (the good kind?) to clean your digestive tract of everything, everything, mostly poop. Nope, not mostly. All poop. You'll spend a lot of time on the toilet with a grumbling abdomen wondering if maybe you're gonna... oh... oh... just went. Don't try to judge if it's a fart or poop. It's gonna be poop. Drinking the prep is not bad at first, doesn't taste bad at all. Just nearing the finishing mark on the humongous jug, you just really don't want the next swallow, twice as worst as the last.

And then they put a tube up your butt.

(from UVA Health, there's a camera and light to see, and tool to cut off a polyp. How they get it back  out for a pathology analysis  I'm not sure, I don't see a grabber)

- The instructions and descriptions say things that are recognizably true from a technical point of view or afterwards (oh... that's what they meant) but are confusing, misleading, or incomprehensible without that experiential knowledge. So here goes for full disclosure:

• the procedure is they put a long metal snakey tube up your butt, slowly, for about 6 feet (roughly the length of your large colon up to the cecal valve to the small intestine. The tube has a camera on the end to look for abnormal growths (polyps). If they find one, they have a tool at the end (next to the camera) to cut off or burn off he growth.
• the 'prep' is to clean out your intestines of shit. All those instructions are to make sure that you can get rid of any shit. When they say 'low fiber' in the diet and on food packages and all that? Fiber just means 'isn't digested' or more literally 'comes out in your poop'. You think your shit don't smell? You'll realize it does.
• Make sure you do the prep right. Because if there's shit in your colon, and the doc can't see the walls of your colon well, then they'll say 'fuck it, bad prep, I'm taking a smoke break' (ha ha, they don't take a smoke break, doctors as a whole don't smoke). And you have to do that prep all over again. 
• But don't freak out about the prep. (I'm using the prep' for the few days of preparation by eating a low fiber diet and the gallon of liquid to drink the night before and morning of). Not eating, and only drinking the day before wasn't bad at all. I had jello for meals and italian ice for dessert. But you kind of forget about hunger. People would be polite and say 'Oh this pulled pork BBQ sandwich with hot sauce and a side of collard greens and butter smothered garlic mashed potatoes isn't very good." I knew it's great, but I can take a day off. Also, despite it not having a taste at all, you'll get a but sick of the liquid by about quart two. But that's why you take it in stages, half the night before and half the day of.

- the process and procedure at the hospital I went to was frankly luxurious,  I felt like I was at a Marriott. OK, I probably have low standards. You get a gown (that's the embarrassing butt-exposing one) and a robe (that's the one that makes you feel like a king even though it is essentially the same material and color as the gown just opens the other way. Full disclosure, I spent a lot of mental time trying to distinguish the gown and the robe, both the words and the objects. I agree with what the nurses claimed, that the prep was the words except for maybe putting the IV on my wrist (it hurt, and people kept coming up to shake my hand and I really didn't want to use that right hand). Oh also, I didn't care for the vital stats monitor which, though accurate (says I) on my blood O2 and pulse (both excellent!), gave me HBP (I don't think I was nervous about the procedure), and the respiratory rate monitor whose alarm kept going off as though I was inhaling at 6 times the normal rate. I believe the monitoring that makes me look good.

- the forgetting medication (Versed) really worked. Before the drug was administered, I vaguely remember the nurses all talking real fast, when giving me info or even small talk (so the drug was not retroactive, erasing events before ). At some point in the procedure room, I was laying on my side joking with the nurses. The joke was... dammit, I can't remember! was it about how I said I had practiced subtracting by 7 starting from a hundred and they said "oh, you won't have to do that", and I blinked and I was a bit woozy on my back with a nurse telling me it was all over I could go now. Presumably my hour in the recovery room after the procedure (I mean extremely invasive butt tube exploration) was already over. As an experiment, I had my son (who drove me back) ask me (I asked him before hand) three random words for me to try to recall later in the afternoon without internal repetition techniques. I remember asking him to tell me the words in the car. But later that afternoon, I could only remember one. I remember asking him to ask me this (on the drive back, and I also remember most of our conversation then). So essentially I remember most things about after I 'woke' up, except maybe a few details. I'm writing this only a couple hours afterwards (in case the forgetting drug is actually working and at some point the whole day will be erased (or never fully stored (or whatever the current metaphor is))

The words he came up with were 'big giant possum', and I could only come up with "the second word is 'big', the third word is weird, and the first is sort of boring like the second one".  It seems strange that I wouldn't remember the one word that really stands out. Maybe it stood out that the first two words weren't weird (I know... weird right?) But for the most part, I am fairly confident I remember the car ride back home with him, telling him which lane to be in to be prepared for the exit, not this one but the next.

Anyway, the whole process is a great mix of low-tech and rocket science (drink salt water? camera on a tube? where brain surgery is all rocket science), and it saves peoples lives. If you have polyps, which are what become things that are cancer (technically: polyps are precursors to adenomatous neoplasms), then the polyps are removed, and that's that. You may have a predisposition to them, so you'll probably be scheduled for a follow-up colonoscopy much sooner if you have polyps (in three years rather than ten. But the magic (sorry, the science) is that it's sort of .. cured. Like skin cancer, if you remove it early (and that's the whole point of the colonoscopy), you're removing the cancer before it has spread so it is 'taken care of'.