High Tech Medical Clinics? 219
Bolus asks: "I am a physician who is setting up a new adult medicine clinic with several other physicians. We are designing our clinic from the ground up with the latest computer technology. This will include computers in every exam room, a paperless electronic medical record, and a T1 for Internet access. Patients will have the ability to e-mail their physician and access parts of their chart online, such as medications and labs. What other kinds of online service would you want your doctor's office to offer? Instant messaging to your physician? A bulletin board for general medical questions? Chat groups? Video conferencing?"
Re:Security (Score:1)
I'd just like to chime in to emphasize this point in a US-specific way. My understanding is that new laws are going to make health care providers liable, both in civil and criminal terms, for protecting patients' medical records.
You should very carefully look into this, and consult with a health-care attorney, before giving any outside access to patients' medical records. Personally, I would just not do it. It's going to be a while before a reasonable standard of protection of medical records privacy is established. Until then, I'd leave the legal bleeding edge to the megacorporations with deep pockets.
Re:urk?! moral qualms a-plenty! (Score:1)
And you are a poor lawyer who gives all his excess income to the poor I presume.
Should we really be supporting this kind of behaviour?
Well, at least now you are given a choice. You already help the poor with your taxes and with the charities you contribute to (which I am sure you do, otherwise you wouldn't be posting this). Are you suggesting that we spend every spare dime we have on helping the poor? If so, why work as hard as we do in order to make that extra money?
These guys don't want to talk about any real uses of technology in medicine, like for curing people. They just want to pad their fees in order to squeeze yet more $$$
Well, that is the general idea, yes. I try to earn as much as possible from my work as well and I don't think there is anything wrong with that. As a matter of fact I think it is good, even for the poor: the more I earn, the more taxes I pay.
Everyone's down on lawyers, but we're freakin' little league parasites compared to this kind of doctor.
Nope. Lawyer are parasites by definition: they don't create value. You only need lawyers because the opposition has lawyers. Same thing applies to people in marketing, PR etc. This doctor saves lives, and I am willing to pay for that.
Not really "e-mail" (Score:1)
Anyway, I am willing to bet that Bolus wasn't talking about "real" email. It's just easier to say "email" than to say "web-based secure messaging system". Our software and the software of most/all of our competitors has a messaging system that allows patients and clinicians (rarely will it be the actual doctor) to communicate in a secure manner. The patient creates and reads messages only within SSL encrypted browser sessions. Messages do not ever really leave the facility (except over these SSL sessions), and certainly not as plaintext SMTP email. Many products do support SMTP email "ticklers" that basically say: "You've got a message, please log in to read it".
Not only is this security common sense, it's required by law. Patient identifiable information can not be transmitted over the internet in plaintext whether it is a list of your current diagnoses or whether it is just that you have an appointment comming up at the HIV clinic. You get the point. Any organization who is using traditional email for this is asking for trouble and an article describing the lawsuit agains them in the wall street journal
Don't forget... (Score:1)
--
Some thoughts. (Score:1)
ttyl
Farrell
Re:What I'd WAnt (Score:1)
It's the insurance company cap on what they will pay (this is MD, folks. Might be better or worse elsewhere). But the costs didn't go down. Now the doc is taking home around $50 per hour.
That is a problem. The doctor bears the brunt of the cost caps because he is the public face of medicine. In a more fair system, as the doctor's fees were capped, his costs for supplies and insurance would also be capped. Pardon the analogy, but it's a case of treating the symptoms rather than the disease.
Re:urk?! moral qualms a-plenty! (Score:1)
That's a ridiculous suggestion! There's no way you can go to school to be trained for everything that you don't want to be ripped off over. IMHO, a modern society should provide the basics of all necessities, which includes free health care for all.
Plus, use some imagination and thought... (Score:1)
...in deciding what and how to computerize.
My druggist just added a web site for ordering refills. I was leery of it until I visited---all they ask for is your name and prescription number, which is then *faxed* to them. The prescription info is not in an Internet-connected system. They use HTTPS for the entry, which is nice, but even better is the fact that any evesdropper will have exactly zero useful info. To know what's going on would require social engineering or a breakin to either the drugstore or my home, at which point any computer involvement is moot.
So, examine your transactions carefully---you can increase security with good choices of what data to expose.
Oh, yeah, and build in checks, as has been pointed out elsewhere. The first time I used their new system, I entered a typo. Within minutes a pharmacist was on the line verifying what I really wanted.
I'll second that! (Score:1)
Unless you and your patient
- only use computers which run the software to actually ship the mail across the net (a Mail Transfer Agent, or MTA, and hint: the web browser that lets you access your e-mail ain't one), and
- keep those computers connected to the net 24x7 so your two MTAs can talk directly to each other whenever they wish, and
- happen to avoid sending traffic through any system (your ISP's, their backbone provider's, or any random router somewhere) on which the sysop is examining traffic for tuning, debugging, or pure enjoyment,
there's gonna be lotsa folks who can read your e-mails.And don't forget any system on which the mail resides momentarily while a backup is in progress (limited by point 1, above, to the two endpoints, but if you slip up...). That means there's a copy of said mail stashed more-or-less permanently on some mag. tape in some unknown person's hands.
There's really a lot to be said for paper. If you insist on digitizing your practice, then don't let any of your systems connect to the Internet, directly or indirectly. (''Oh, we'll just send this to Dr. Kildare, on a floppy---that's safe, right?'' Yeah, until someone breaks into his system.)
Great idea (Score:1)
I would *love* to be able to look at his calendar, just to see what times are already taken, before calling for an appointment.
Email reminders about appointments would be nice too.
Not all doctors are schmucks, just like not all lawyers are schmucks. Find a good one and work with him.
Re:I want... (Score:1)
Firstly, I think a lot of people are reluctant to bring up this issue with their physicians but I'm a forthright sort of person and now that I'm a contractor I'm additionally substantially more aware of how my time is expended (and on this day I *could* have worked an additional hour for a client rather than sitting in the waiting room). This costs me money and I don't like it. I would think that it would be a simple matter of:
It isn't clear why "high tech" needs to be involved to address this issue but should it assist in eliminating it I'm all for it. I realize estimating is hard (I have to do it in my profession all the time) but over the years I've developed a multiplier that I use to account for interruptions/distractions/unforseen problems and as a result my estimates tend to be pretty accurate - surely the variability involved in seeing patients in a timely fashion could be handled in a similar way
Open Source Health Care (Score:1)
Second, if you're in the US, get acquainted with the Health Insurance Portability and Accountability Act (HIPAA) and associated regulations. This means you need to design interfaces to open standards, and, more importantly, design the security first, everything else second (as in massive fines for messing up security so non-authorized people get access to records).
Access to a (Score:1)
I see where this is headed... (Score:1)
Booking system (Score:1)
Security? (Score:1)
Vip
medicine for the masses (Score:1)
If I can communicate with my doctor electronically, I might tell him things more often about the state of my health. Like things I would tell the doctor if I were living in some small town in Kansas, and saw him in the street.
Say I complain about specific leg pain sometimes, and minor twitches in my back at others. Or say I regularly report I wake up with a stuffy head, or that (god forbid at 25) have regular bowel problems. This might tell a doctor something else.
These are not things I would schedule a doctor's appointment for - and things I may not remember at a sporadic physical exam - but they are things a doctor may be able to help me with.
Better communication with physicians will help us all live longer, and I for one would be willing to pay for it in higher insurance premiums.
As for the lexus, don't you have one too?
-jonbrewer
Re:medicine for the masses (Score:1)
Bulletin Board (Score:1)
All it would take is one patient mis-quoting you (or another MD) and it's lawsuit time. You would probably have to have some _major_ disclaimers or some kind of click-agreement (not to use the BB in place of a real doctors advice).
Agree! (Score:1)
Run the office like a real business. If I had clients schedule a meeting at my office and they had to wait for 2.5 hours, I would have lost the sale at around 25-40 min...it would have gone somewhere else in a hurry!
Doctors: PLEASE have your office staff just schedule things ON TIME!
-JL
---
Re:Booking system (Score:1)
Provide a patient support forum where messages are posted anonymously - yet requires registration. This way posters aren't easily identifable to each other (unless they want to be), but you have some control over who can or can't post (i.e. trolls).
Access to patient records (Score:1)
Integrated information (Score:1)
In a hospital setting you should be able to see results of blood samples, see the ecg or eeg and even see x-rays directly on screen without to much fiddling around in different applications.
The sequencing side is the possibility to see e.g. blood sugar level through the last 5 years in one screen.
These system do exist, I am not aware of any of them in the US (I live in Europe)
Re:What I'd really like to see... (Score:1)
Use the EMR as a teaching / educational tool. I have seen computers seen as a threat to the patient-doctor interaction, but I see it as a huge opportunity to enage the patient with the doctor. If the EMR is considered a tool to communicate and build together, then it will help the patient understand the condition and the illness at hand. Make sure the patient sees you (the doctor) enter things into the computer so they know what you are writing and can indeed verify that it is accurate. Give them print outs of your diagnosis and treatment plans -- often they are too complex to convey quickly and thoroughly.
I would say that you should stay away from remote access of files / records. This isn't as important as good communication.
Stay away from diagnosis-by-email -- good patient interaction can't happen over the phone or email, so don't try. Bring them in and explain why you need to _see_ them.
Focus using computers where they are good at -- record keeping, planning and calculation. As others mentioned, use them to schedule appointments, keep records, and plan out the treatment regimine.
Just my thoughts.
Colin
what I'd really like online from doctors (Score:1)
Why? Because I"m sick of paying $100+ to discover that my dermatologist doesn't realize that asthma and hayfever are related to eczema, and all three are allergic reactions, my doctor wants to give me prozac for those allergic reactions, since allergies are caused by 'stress', my gyne is telling me I have HPV because she coudln't be bothered to tell me that using tampons before a PAP smear messes it up (she knew which day of my cycle it was, too..) (and no, I don't have HPV, but I had to spend $500 for a biopsy to be sure) or that my (yet another) doctor has decided that tylenol 3 is a really good long-term headache management plan (any headache that requires codeine to kill off that lasts more than three weeks is scary to me -- Turned out I'd just given myself a concussion, but doc #1 couldn't be bothered to figure that out).
Never mind the friend's daughter who has been told repeatedly that her seizures were 'psychological' and been sent to therapists for a year -- finally my friend took her to Stanford -- she has epilepsy!
I'm thinking mandatory informational advertisement could be a good thing, here.
medical records without names or SSNs attached (Score:1)
I will probably refuse to consult a doctor that keeps his notes on a computer, because of the privacy issue. but if I ever decide that my privacy is worth gambling with, then I sure as hell want the copy of the records that *I* get (which I'm entitled to under law) in electronic form, too, not on paper, and not in some proprietary format.
the one security measure that would impress me is if the doctor's office or clinic kept my name, address, phone number, SSN and other "identifying" info on paper. then the computer records by themselves do not betray very much.
Re:HIPPA (Score:1)
Re:Medical arrogance (Score:1)
In other words a tech worker is out of school at say 22, and making around 35,000-40,000 to start-by the time they are 30 they are making as much as 100,000-150,000, if they are lucky, and making more all the time, wheras a doctor at the same age is just starting out, and still has school bills to pay!
Of course all the Doctor's i knew were perfectly willing to live like they made 4X as much as they actually did, and were constantly in debt.
;-}
Re:urk?! moral qualms a-plenty! (Score:1)
patients are grumpy, they're upset, they don't like what you tell them, and nothing will do. why is this? because they're ill. ill people are not happy people.
the fact that general practitioners in particular survive so many years of this never ceases to amaze me. the fact that they can maintain their sympathy, and try to do their best for each patient, is frankly quite stunning, in the face of the abuse and negativity they see directed towards them often daily. and you sir, have displayed quite nicely some of it.
any profession has the right to try and offer a high end service that will be charged for appropriately. that's what these doctors are obviously attempting to do. at the other end of the spectrum their will be (or should be, depending on how fucked your country is) affordable no-bells-and-whistles medical care for those that need it.
let them offer a high end service. there are people out there with the money who want to pay for it.
matt
Re:urk?! moral qualms a-plenty! (Score:1)
i presume nhs stands for 'national health service', a government funding of health providers in your country? well i can tell you this: in the country i live in, the government funding covers perhaps 30% of the consultation fee. and there is no government funding for medical materials, a cost the patient often doesn't see. which is just touching the surface of a much larger issue.
again, i'm not sure of your point, so perhaps i should have ignored you.
matt
Re:Please be careful with email! (Score:1)
Another big concern is non-repudiation. I, the patient, need to be positive that the email came from my doctor. The doctor should want to be sure that only the patient can receive the email. This is why PGP email was suggested in earlier posts. Imagine what could happen if I got used to receiving clear-text emails from my doctor.
Worst-case-scenario: Somebody intercepts my HIV test results that say I'm positive for the virus. The message gets modified before I receive it to say that my HIV test was negative.
Actual Security Implementation (Score:1)
A lot of posts bring up security, so as somebody who actually worked
on an electronic medical record several years ago, here is one of the primary
problems with implementing security:
Docs (and other people with high opinions of themselves and their time)
don't want to have to type in their username/password everytime
they approach a machine (in the hallway, at the nurse's station, in the docs
lounge) to retrieve/update patient info. If they have to key this in all the
time, you will have a bunch of pissed off users who don't even use/like the
application.
With much hindsight, I realize the solution is some kind of security card
or pin containing a microchip that will authenticate the user via
RF transmissions. I think Micron makes these things. It's not a perfect
solution, but it will certainly go over better than having to key in junk
all the time. If anybody has implemented a system like this, I'd be
interested to hear what pros/cons you discovered once it was pressed into
service.
Three necessary security measures (Score:2)
1) If you are planning on using the web to let patients see charts and other portions of their medical records, you have *GOT* to make sure that you are using SSL to prevent sniffing of the data.
2) you need to make sure that patients cannot access each other's records by simply changing the patient identification number (or SS#) in the URL. Mistakes like this are *VERY* common in web development, and you don't want to get slapped with a HIPAA audit because your developers didn't grok the magnitude of the problem.
3) Don't allow your developers to give users a "save my password" (i.e. save a permenant cookie on their PC) option; cookies should expire within an hour, and users should have to log in each time they access their data. (I know that seems like a pain to some users, but it is worth the effort. I'd wager that they *will* check their records from work, and that co-workers *will* check those same records if you don't force the use of a username and password every time)
Re:Medical arrogance (Score:2)
-Paul Komarek
Listen to your nurses!!!! (Score:2)
1) Paying attention to workflow in a medical setting is =key.= Life and death decisions are made based on the accuracy of the data in the system. If the system is difficult or unweildy to use, the care providers won't be able to make proper use of it.
Have your developers follow around your nurses, therapists and physicians. Have them carefully note how things are done now, and why. There may be some pre-packaged software that will work fine... but there might not be. Or you may have to modify it heavily to meet your user's needs.
The little details count for a lot of productivity. For instance: when checking off lab tests to be run, the care provided may have to go through sixteen screens to pick what she wants to run, and might miss one, or include another by accident! If she could check off a "test suite," or bundle of the most common tests run in a certain situation, labor is saved and lifesaving accuracy is increased.
Ask your nurses what they want and need, and =listen= to them!
2) Accordingly, you should budget most of your money on software and development.
3) Go to a "thin client" model... wireless PDAs that talk to fault-tolerant, high-availability servers locked in a backroom only the Chief Geek has the key to. In an environment as hectic and fast paced as a medical establishment, you want the "hot water" data model. The servers are the "hot water heaters", and the PDAs are the "faucets." Whenever a nurse or doctor walks into a room with her PDA, she has data on-tap, hot water. When the battery begins to run down, she grabs another one from the recharging cradles, logs in, and has "hot water," or the same data she was just working with.
This will work with fixed systems at the bedside (like notebooks), but you'll have a problem with people forgetting to log out, etc. Look into a "key-card" access system instead of a traditional login if you go with fixed systems in every room.
The fewer things run on local PCs or workstations, the fewer things your administrators will have to configure and maintain. This translates to higher security and uptime.
Running a medical facility is a much more complex and critical undertaking than running a web site or ISP. Lives =are= on the line. Engineer your site for 1) practicality, 2) utility and 3) robustness.
SoupIsGood Food
Re:Please be careful with email! (Score:2)
Now I think that would be very unethical on several levels, but it is the best example I can think up now.
Adult (Score:2)
You mean nude doctors and nurses?
__
Re:What I'd WAnt (Score:2)
XML is a lovely thing but let it get a bit more established before we go dropping the existing standards. I don't know of many systems that accept XML right now.
You'l need special safety cert for all HW (Score:2)
You'll need all kinds of special safety certification for all of the in room equipment, right? That sounds to be the most expensive part of the whole deal.
E-mail appointment reminders (Score:2)
Of course, there are privacy implications, so you'd want it to be opt-in - and you'd have to be extra paranoid about security.
Seriously: Why? (Score:2)
But seriously, in your case, it sounds to me as if you are trying to set up all this stuff just because it's cool, not because it is actually needed. Does this really give a benefit to your patients? How soon will this stuff be outdated?
You should seriously reconsider how far you want to go with techno-gadgetry. You might end up working too much on keeping your network working and not having time to work with your patients...
------------------
Healtheon? (Score:2)
merger with WebMD had this business model.
Jim Clark found SGI and Netscape.
Healtheon/WebMD is still floundering.
Re:I want... (Score:2)
This ain't gonna happen. I write/maintain scheduling software, and one thing I have learned is that, in order to max their productivity, the docs multiple book several appointments at a time. In other words, if you have an appointment for 9:00, there are several other people who also have an appointment (with the same doctor) at 9:00.
The doctors are expensive to run, sort of like expensive processors. You have 'em multitask in order to keep 100% utilization. That way, if a patient cancels, the doc doesn't go idle. The side effect is that even when the job is ready, it still doesn't get full use of the processor.
---
Shared experiance Forums (Score:2)
A forum where people with a certain experiance can share thoughts, fears, experiances, can be a big help for someone who is 'new' to the situation. It can be a great relief to hear ppl are living normal lives with bad alergies
Ofcource pls do make sure troll's dont find a place on forums like that, that could lead to very hurtfull experiances.
-- Chris Chabot
"I dont suffer from insanity, i enjoy every minute of it!"
Very useful (Score:2)
I worked in a hepatology (liver disease) clinic for a while, and was responsible for filing all the lab reports and other patient information that came into the office. We would get several hundred, sometimes almost a thousand, different sheets of paper a day. All of these had to be sorted and placed in the patient's chart (If the chart was even in the office. Oftentimes it would've been set out in any of a dozen different places). Based on the volume and the fact that I was only there part-time, there were some labs that didn't get filed until weeks after they were received.
In most clinics, the paperwork can come close to burying people. There's vast amounts of information passing through, most of it unnecessary and a lot of it being misplaced. An electronic system would not only save a lot of paper, but a lot of headaches and would expedite many areas of doctor-patient information exhange.
Re:Please be careful with email! (Score:2)
-George
Re:What I'd WAnt (Score:2)
Yes, it seems to everyone that doctors are rich SOBs who hardly work for a living. I have that opinion, and I work with 7 of them:) But seriously, profit margins are very tight amongst primary care doctors, especially in CA and MA. The money is barely there to hire competent physicians, and there is even less to hire competent computer folks.
Now, if patients (or, often as not, their insurance companies) would pay a reasonable rate for services rendered, this would be possible. Unfortunately, the trend over the past five years, and into the forseeable future, is for less money to be paid to doctor's.
Take a normal cold/flu visit. Takes about 15 minutes. Charge (in this office) is $45. Sounds like a lot, but that is only $180 per hour. That has to pay for insurance, staff, rent, and the doctor's salary. Still, after figuring overhead, it winds up in the neighborhood of around $100 for the doc. Except that no doctor (primary care, mind you, in the US) ever sees more than about $130. It's the insurance company cap on what they will pay (this is MD, folks. Might be better or worse elsewhere). But the costs didn't go down. Now the doc is taking home around $50 per hour.
Now, let's here from all the consultants (computer) who would do that. Better yet, let's take $25 per hour (probably not a terribly capable and/or competent computer type) to run the doc's computers. Now the doc is making $25 per hour. Time to go sell shoes.
Not to blast you, but rather the US medical system. Computers do help (we are on the slow march to a completely electronic record) and the long term costs are LOWER with computers. But getting over that short term hump is a serious pain.
Currently managing this... (Score:2)
First, as has been stated elsewhere, is security. I don't think it needs to be expanded upon. If you haven't already grokked this point, stop everything else.
Second is money. I'm not sure what you specialty is, your payer mix, your clinical setting, or anything else, but each of these affects how much money will be available to you. Most of the commercial solutions are big money with big service contracts and big maintenance requirements.
I cannot stress this enough: beware the vendors! I started work here after the EMR had been pronounced 'live' by the vendors. To tell the truth, it wasn't live until at least 15 months after I started working.
Your idea for computers in every exam room is a good one. We found that they were much cheaper than wireless solutions, and are proving much more sturdy in the long run. Most important to our head of medicine, they are MUCH faster. You just can't compare 100Base-T to 802.11. There's also the fact that the wires are more secure (IMNSHO).
Hire a lawyer. Look into the legality of sending patient emails. This is beyond security. The laws are vague. Imagine this scenario (places made up): you live in Ohio. Your practice is in West Virginia, and that is where you are licensed. Your patient lives in Pennsylvania. You sit at home at night and compose an email telling Ms. Smith that her strep culture was positive and that she should continue taking the amox. You send the email from your machine in Ohio, it uses the SMTP server in your practice in WVa., gets bounced through a router in Va, and winds up in Pennsylvania.
While you and I, and the rest of slashdot think nothing of this, the district attorneys in Ohio, Virginia, and Pennsylvania can now sue you for practicing medicine in their state without a license. There is not really any merit to the case, but that might be over the heads of: the DA, the judge, and the jury of your 'peers'.
Rather than full pt. access to charts, I would think to implement a fax back system. IOW, Mr. Jones wants to see his last three cholesterol test results. He emails/web-forms a request. This goes into your system, and the machine emails or faxes back the requested information to whatever email or fax address Mr. Jones has on file. This must be filed in person, in writing. Mr. Jones must also sign a waiver saying that by having this service (faxback of results) available to him, there is the possibility of this information falling into the wrong hands. IANAL, but this is the view that my practice has taken.
Beware IM's. First is the possibility of hijacking a nick. Second, if a patient IM's you instead of calling your answering service, you will be more liable if his chest pains are a heart attack, and not indigestion. Opens up a world of liability.
If you must email, insist upon crypto. It's the only chance of being sure of identities (both ways).
Back to the money question: while video conferencing might be nice, how many of your patients will have access to DSL/cable? How much time will be spent doing that, when you can spend some time doing a flesh and blood visit? Which has more value to the patient? Can you code a visit for a teleconference? Can you get reimbursed, even if you pick the correct code?
Much of this is directed to primary care, but that's where I work. Naturally, you'll have to answer a lot of these questions for yourself. Unfortunately, the technical answers are the easiest to get, yet they are the most trivial. What you need most is legal and business help. Most of the legal concerns would be zero if you used a telephone or letter. But many aspiring young ADAs are trying to catapult themselves into the limelight with computer cases. And don't forget that all of these toys must pay for themselves in one way or another. The best people to ask are not techies who want to play with cool new toys. The best ones to ask are your patients.
And they will surprise you. In our office, the oldest, least educated are often the most interested in having a computer in the exam room. They have been more patient with working bugs out.
Above all, keep this in mind: do it to improve patient care. That must be the end result. If it is not, your are wasting your time.
Computerized Food Menu (Score:2)
The computer keeps a standard menu on hand, and tracks ingredients. The dietician says how many calories, when, and what limits the patient has upon them. The patient then can make a choice (from what they're limited to), and the kitchen does up the order.
Whomever takes the dirty dishes back can note how much the patient ate. You're then on the way to tracking caloric intake, nutrition, etc. etc.
Re:urk?! moral qualms a-plenty! (Score:2)
Gimme a break! MD, MPH, AOA, credential, credential, blah blah blah. Most docs view the MPH as a joke. A throw-away degree for people who still can't decide what they want to do in medicine, or for those self righteous types. But it's only partially true. You've got a jaundiced eye on this subject and a little humility would serve you well. Your inexperience in the real world of medicine shows.
All the freakin irq channels on sickle cell anemia isn't going to cure it, and the money that went into the hospital chat rooms are sure as hell better served ELSEHWERE.
Lesson two, from someome who's been in your shoes. Our goal is to treat the patients, not the disease. The whole patient, body and mind. Support groups, irq or otherwise, further that goal. And an irq server can be assembled for less money than it takes to perform a single MRI scan. Lose the tunnel vision.
Reality check for you--health care is already a significant portion of the US's national expenditure (steadily well over 10%, I think approaching 20% as of 2 years ago). The money could well be used elsewhere.
Tautological thinking like that doesn't advance your argument. Defense money could be spent on the arts. Money for the arts could be spent on roads. Ad infinitum.
For example, computerized patient records (CPRs) have been shown to *reduce* cost of care--they save on cost of paper, time to search records, and lower the chances of film and patient records being lost (which resulted in lab work and imagery (xrays) to be redone)).
./ers did. One doc friend of mine does custom dsp programming and is starting a medical device business based on this. Another employs about a hundred people in a software company he founded with his own code he hacked together while burning the midnight oil for a year. Many come from engineering and other technical degrees. I hate to see people painting the profession with such broad strokes.
I agree. Several of the hospitals I practice in are completely computerized - charts & xrays included. They are very convenient and can save time when properly implemented. And time is our most precious resource. But I don't think they should ever be placed online. It's just not necessary. Secure transmission of medical data between offices and hospitals - yes. Open to the general public with passwords - no. If a patient wants to read their chart, it's worth the effort to stop by the office and not have to worry about millions of people inadvertantly learning the intimate details of their health.
And another misconception that must be put to rest is that all docs are technically clueless. The fact is that docs are perfectly capable of programming computers as much as anyone else. I started programming my vic-20 about 20 years ago and haven't stopped. C,C++, Pascal, FORTRAN, lisp, tcl, perl, Java, etc. I moved from TRS-80 -> VAX -> Mac -> Sparc -> Linux, like a lot of other
Re:I want... (Score:2)
Re:Neural Networks to predict Outcome (Score:2)
It just isn't that simple in a vast number of cases. You aren't admitted to the hospital these days unless there is some very real concern for your health, or you are being admitted for a procedure. The optimizations you are talking about have already been made inside the neural networks we carry in our heads. The extra time in the hospital has been squeezed out already. If a procedure can be done outpatient, it is already being done that way. Now we are in a position where we know many patients are being sent home too early because the system has become so obsessed with efficiency.
If you are actually dealing with a sick patient, your neural network is about as effective at predicting 5 days into that patient's future as it would be predicting the weather 5 days out. The consequences of an incorrect weather prediction are that you get a little wet. The consequences of sending someone home who was too sick to go home (but the neural net said it was 'OK') are not so good. There are way too many intangibles that these neural nets do not take into account. Just the very 'look' of a patient conveys very important information that current neural net implementations are completely oblivious to.
Re:In response to posts about improving patient ca (Score:2)
That's a bit overstated. Most aspects of practice are no different today than they were 8 years ago. Real medical progress that is applicable to patient care actually advances quite slowly. I agree wholeheartedly with all of your other points.
Re:Security (Score:2)
Last year, e-commerce sites got cracked, including one that was exclusively credit cards. These companies presumably know a lot more about IT than a medical facility does, and I'd rather have my credit numbers stolen than my med records.
Knowing what I do about computer security (I have been an e-commerce crypto-jockey), I would avoid any medical facility that allowed me to access my records from my home. I would tell my friends to do the same.
That being said, having those records online in an intranet (visible only inside the clinic) poses very little security risk, certainly nothing that would scare me. And having a public Web site that did things like give brief bios of the physicians ("Cool! My urologist came from Harvard!") and directions to the facility would make the clinic more attractive without increasing risks.
Data Critical, WebChart, PocketChart (Score:2)
Almost Forgot ... (Score:2)
Every Wired Doctor's Office Needs... (Score:2)
I can't believe nobody's posted that yet (at my threshold.)
In response to posts about improving patient care (Score:2)
If it is well designed and easy to use, then most definitely yes.
If it is poorly designed and hard to use, then most definitely no.
Almost 1/2 of what a physician does these days is paperwork. You must document every detail of the patient encounter. You must then look up the code for your diagnoses. (Did you know there is a code for being hit with space debris? Yep. There is.) These code books are huge. The more of a generalist you are (Family Practice, Internal Medicine, Pediatrics, Emergency Medicine), the wider the set of possible codes you will use regularly will be. Computers are great at finding this stuff and coding it for you.
Prescriptions. Man, there are so many freaking drugs, and so many drug interactions, it boggles the mind. What better way to keep track of things like doses, dosage forms, and drug interactions than a computer?
Computerized medical information would also be helpful in an EMR. Your doctor doesn't know everything. It's humanly impossible. Medical Information doubles every 8 years, *and* in that 8 years, 1/2 of what you knew 8 years ago was proven wrong. That is the kind of database that your physician deals with every day. To put that stat in prospective, On the day you start medical school to the day you finish residency (averages 8 years), there is now twice as much stuff, and half of what you knew is now wrong. And you're just getting started.
And to those of you bitching about the money a doc makes, let me remind you it isn't the truckloads you imagine. Medicine in the U.S. takes approximately 12 years of higher education. 4 years university, 4 years medical school, 4 years residency. The first 4, you might have a job at Arby's or something. Not a lot of income there. The second 4, you probably don't have any paycheck, and you're adding at least $20k in debt per year on top of whatever you were in for undergrad. The third 4, you're getting paid - but only about 35-45k per year. That sounds like a good chunk of change, until you compare it to the hourly wage, and then realize that you're only making about 3 dollars an hour. Once you finally get into the real world, if you're in a general specialty, you're looking at a paycheck of about 150k - which if you're lucky is slightly more than the amount of debt you are facing. Oh, and you're 30 years old now.
People aren't physicians because they want to make truckloads of money. It's better to pursue a business career for that. Physicians want to make some money for their SERVICE, for that is what Health Care is - a service industry. You pay us to give you the best health care advice possible. It's up to you how much you are willing to pay for that, and how you use that information.
Medical arrogance (Score:2)
Re:Security (Score:2)
Start with security, and build everything around it. You CANNOT add security later and expect your system to be secure. Security is the foundation. This should include access control obviously, but also encryption, server AND client certificates (which need to be secure too) etc. etc.
Don't fall into the trap that certain info can be made publically available. I showed with the above project, that by assembling several sources of "anonymous" data, then performing analysis, it was quite easy to end up having a good idea who the patient was, how old they were, what they were suffering from etc.
Be careful. Get some EXPERT advice, maybe from two or more independant aources.
Statistical Process Control (Score:2)
Good variables might be the error in the start time of the exam (Visit_planned - Visit_actual) as well as the duration (probably track the type of visit with the duration since certain types of visits probably always take longer)
Then produce standard Xbar, R SPC charts and use them to adjust patient scheduling.
SuperID
SPC isn't just for machine shops :)
Security, Security, Security... (Score:2)
--
Re:Medical arrogance (Score:2)
I was kind of wondering about that too. Last time I saw a doctor who wasn't the quack at the campus clinic it cost me $75. Taking into account a 1/3 overhead factor for the office and such we'll call it $50. The doctor probably spent 6 minutes with me or 0.1 hour. That makes an hourly rate of $500. If you're making four times that you're pegged at about $2k/hour or estimating to a 2000 hour working year about $4 million a year. If you're pulling in that kind of dough based entirely on your own labor (paper gains don't count) you can probably afford to hire your own doctors and dispense with the waiting room entirely.
_____________
Re:Medical arrogance (Score:2)
Click here for $50! [dangifiknow.com]
Re:records online (Score:2)
In fact, I can think of some people that would pay me to find your records online.
Click here for $50! [dangifiknow.com]
A really good firewall! (Score:2)
Re:Security (Score:2)
Its a shameless plug for my employer but you might want to consider the XML-based forms technology provided by PureEdge Solutions [pureedge.com]. It lets you blend interactive XML-based forms with digital signatures, and could have several applications in such a setup.
Smirk (Score:2)
Neural Networks to predict Outcome (Score:2)
The only thing left to computerize is the one thing that can't be (totally) automated, the doctoring. However, artificial neural nets are fairly effective (99.99899%) in predicting how well patients will recover, and what kinds of specific things they will/won't be able to do. The process is quite frightening actually. A company that I know of is doing this, check them out at http://www.arcon-inc.com [arcon-inc.com].
Also, once this is established, doctors and patients can both save money. For example, if the neural net predicts that someone is going to make a full recovery in 5 days, send them home now with a living assistant. This saves you money for obvious reason, and saves them money. After a certain number of days in a hospital, the likelihood of getting a new disease becomes almost certainty. But I digress.
Eventhough the company I mentions earlier is on windows, it is worth checking out.
Aren't computers cool?
Good Luck
--Alex FIshman
Minor note WRT T-1 (Score:2)
T-1s are, in general, fuckin' expensive. You may wish to look at SDSL or some other form of xDSL for that amount of bandwidth for (again, generally) much, much less cost. True the T-1 can be more reliable, but since the only things you should be sending out across the wire are non-critical things like "hello bob, your appt. is at 11 am tomorrow" you can probably deal with some downtime. Another alternative is to get something cheap for the officewan bandwidth like a cable modem (hey, free waiting room cable), or low end xDSL, and do your serving from colocation. Especially if the local hospital has a server room you could cut a deal with.
Good luck!
--
Fuck Censorship.
Re:I want... (Score:2)
Bottom line is: Pull your self-important head out of your self-important ass and realize that you are not alone in this world. People don't exist to serve you. I can just see you getting out of your car in a traffic jam screaming at everyone "Get the hell out of my way! I make more money than you and you are costing me profits!"
records online (Score:2)
rr
SurgeryCam! (Score:2)
rr
Re:Please be careful with email! (Score:2)
Given that workplace email has zero expectation of privacy [nolo.com], I would not use it for sensitive personal stuff. Not that public email servers are all that secure, but they'll do for mildly sensitive things like "Your turn to bring the Bundt cake to the next Elders of Zion" meeting.
Anyway, you should give medical office workers some credit for discretion. At least I hope they already know not to give sensitive information to phone receptionists!
__________________
Physical Doctors versus Email (Score:2)
If you're so healthy that you can resolve all your health issues in a 15-minute appointment, more power to you. But some of us have chronic problems, and have to do a lot of back-and-forth with our doctors. If you have a lot of complicated information to exchange, office visits are expensive and inconvenient, and the existing alternatives (voice mail, faxes) are slow, clumsy, and subject to garbling.
The big risk with email is that doctors might be besieged by lengthy messages from all their patients. That's probably best anticipated by carefully educating patients before handing out email addresses.
__________________
Medical records online downunder (Score:2)
Whoa - cool question (Score:2)
- What can the 'net do to improve your transcription/dictation process? Digital dictation: audio securely transmitted to off-site transcriptionists, text securely e-mailed back, etc.
- It can help doctors and patients both if doctors could access films/MRIs from home. Think about those late-night calls when you wish you could see that x-ray again before making a recommendation or prescription over the phone.
- Heck, extend the above to accessing your full patient records and charts from home. This would really help on-call docs make better decisions, especially when the caller is another doc's patient.
- In addition to allowing patients to see a list of available appointment slots before calling, good scheduling software could be used to help generate statistics on the promptness of appointments and average wait times. This could streamline the patient experience by helping you identify places where your schedules tend to fall behind, thus helping you make allowances for them in the future.
- Hire a web jockey (hey, I'll offer...) to put together web pages and links to information about the conditions you treat. Have terminals available in your lobby for patients to review this info and/or email parts of it to themself. This information could me much more complete and interactive than those ubiquitous "about your condition" pamphlets. Just review the content yourself because there's so much crap on the web these days...
Hope these suggestions inspire thought, good luck with your new office!Things I'd Need as a Patient (Score:2)
These are just some of what I can think of, since this is a brainstorming question. I think an overall theme of my list is to keep some of the more tedious things on-line, and try not to impersonalize the face-to-face things. Most importantly, if this could somehow streamline the waiting time, it would be appreciated.
----------------------
Someone probably gave it a lot of thought (Score:2)
order supplies online (Score:2)
I'm a diabetic. Although I can not order insulin online (it is only available on prescription), I can order blood-sugar tests, needles and other supplies at Hermedico [hermedico.nl] in the Netherlands. They send me the stuff in my office and charge it immediately to my health insurance. It is one of the online services which I rely on and the have not let me down yet
If can get some of these services together, not only would you help your patients, you could also use the feature to get more traffic to your site, thus getting more potential new custommers.What I'd really like to see... (Score:2)
A clinic where patients did not wait more than 15 minutes from the time of arrival to see the doctor
A clinic where appointments were not scheduled so tightly that nurses have to explain diagnoses and prescriptions because the doctors are already on to the next patients
A clinic where doctors address patients at the same level of formality which they expect (i.e. don't call my 75-year-old mom Millie but get huffy when she calls you Dave)
A clinic where I'm allowed to read my own medical records and obtain copies
A clinic which will see me even though I'm self-insured (i.e. I pay my entire cost because I don't have health insurance)
A clinic which places more emphasis on patient care than on whizbang technological innovation - or at least where the doctors appear to care more about patients than about their tech.
I find it really hard to believe that doctors will enter their own case notes on the computers in the exam rooms. That's what $8-an-hour receptionists and fileworkers are for. Seeing a computer in an exam room (especially one on which we cannot check my e-mail during the 40 minutes we're waiting dressed only in a flimsy gaping robe) and all the other fancy stuff will only make your patients think "I wonder how much I'm being overcharged for this?"
How about (Score:2)
Security (Score:2)
Make it secure...
No wait,
make it really secure....
My medical data, accessible from the Net, that could be a major problem. (for you and me)
Now I remember why I hate building systems..... (Score:2)
Hello Bolus: Why should we know what functionality your patients want? They are your patients; why don't you ask them? Are you implying that "geeks" are sickly by nature and therfore more in touch with what patients really want?
My advice to you Bolus is to abandon your system development effort right now -- save yourself some money; you clearly don't know what you want to build so don't start building.
Remember: Although we geeks are savvier these days (we will charge you outrageous rates to build your system using free software), we still don't do strategic consulting on the medical field.
If you want someone to dictate your system requirements to you, try a bunch of overpriced MBAs.... I hear they are being laid off by the dozens by consulting companies across this great nation of ours.....
Re:Security from an Aussie Doctor (Score:3)
... and most important of all: (Score:3)
© Copyright 2000 Kristian Köhntopp [koehntopp.de]
All rights reserved.
Re:Medical arrogance (Score:3)
Your hourly rate is set by a free market. Doctor's rates are not, thanks to all kinds of weird regulations, quasi-socialism (e.g. Medicare), big insurance carriers, the bizarre tradition of charging by procedure instead of charging by time, and a lot of other things that I don't know about (and don't want to know about). If they were able to charge what the market would bear, I suspect that their service would improve.
But perhaps some of it is arrogance too. ;-) I'm not going to defend
them; I was just trying to explain.
---
Time to Rehash what has already been said. (Score:3)
I'm currently a 4th year medical student that is doing an independent project on Electronic Medical Records (EMRs) and what I have seen so far scares me.
Medicine as a whole has an absolutely horrid track record embracing business technologies. Inventory Control is a good example. You and I both know that I could walk into your hospital and walk out with a Cath Tray, and no one would be the wiser. Keeping this in mind, you aren't going to have much local help setting up and/or maintaining your setup.
Second, make it secure. Very secure. As in don't even connect it to the internet. You should be under the assumption that if it is on the internet, someone has already seen it.
If you want to keep your EMR from being hacked, don't have them on machines that can access the internet. Don't have machines that can access the internet access the EMR. It's that simple.
Once someone (insurance company, employee's corporation) hacks your system and gets data about your patient, you have violated their privacy, and there is absolutely no way that you can ever restore it. And believe me, Insurance Companies have a large incentive to find out who the financial bad apples are and remove them from the system.
Don't connect it to the internet. Don't allow internet accessible machines to access your medical records. Understand that these are two separate things.
EMRs have already been hacked [sercurityfocus.com] at institutions that will have a much larger budget than you.
Feel free to email me - miracle at procyon dot com if you want to discuss the matter further. I'vee travelled the country this year interviewing for residencies, and I assure you this problem is nation wide.
Re:I want... (Score:3)
This is only necessarily true if 100% of a doctor's work requires a time slot.
The truth is that it need not be the case. There are a lot of things that can be done at almost any time: email, telephone calls, paperwork, evaluating test results, journal reading, and so on. If they actually end up with a few spare minutes when somebody skips an appointment or doesn't take so long, other work could fill in.
According to a very interesting article in the New York Times on Jan 4 called "Remedy for Waiting", some clinics have redone their scheduling to serve the same number of people with the same doctors without the standard technique of massive overbooking. The article is now in the for-pay archives, so I can't quote from it, but it made a convincing case that it was doable. People were stunned when they could get an appointment the same week and actually be seen on time.
I agree with the original poster in this thread; the #1 thing I want is knowing that I don't have to wait six months to see a doctor, and where I don't have to spend two hours reading copies of "People" from the late 70s.
Re:I want... (Score:3)
What? You mean you didn't bring your laptop with you?
Security (Score:3)
If there is to be any involvement with the internet then I suggest your number one priority be security. You don't want people leaking confidential data about your patients.
AussiePenguin
Melbourne, Australia
ICQ 19255837
you forgot the MOST important thing (Score:3)
"My doctor's ready to see me? But I've only been here ummm...four hours. Couldn't he let someone in ahead of me?"
--
urk?! moral qualms a-plenty! (Score:3)
Should we really be supporting this kind of behaviour? These guys don't want to talk about any real uses of technology in medicine, like for curing people. They just want to pad their fees in order to squeeze yet more $$$ out of the insurance industry, which will then have to cover its costs, so some poor schmuck gets his coverage cut. Everyone's down on lawyers, but we're freakin' little league parasites compared to this kind of doctor.
one question... (Score:3)
Please be careful with email! (Score:4)
Even just "Your appointment is next tuesday at 10:00" could cause problems if you are not a GP. I might not want my employer to know that I had an appointment with a Psycatrist or a specalist of one kind or another. There is still a major stigma attached to mental illness in many places.
What I'd WAnt (Score:4)
Hmmm. (Score:4)
He didn't go into medicine for the money, though. His brother is making 12 times the money as an attorney in Chicago. His family has a business he could have gone into and bought 5 Lexi [plural of Lexus?]
I met him for breakfast last year. At 8 am, he had been at the hospital for 2 hrs already with a patient. I wanted to buy him a cup of coffee, but he told me had had sworn off caffiene because he could not afford a tremor in his hand, no matter how slight. He got minimum 8 hrs sleep every night and had to give up woodworking [which he loved] so his hands weren't callused.
I would GIVE this guy a Lexus if I needed someone to put his hands in my brain: I would want him. Who the fuck wouldn't?
Ever see that commercial for the Discover card? Dad buying his daughter a dog, says the $600 beagle is too expensive. Asks about the $25 hyena, which in turn eats the store clerk. Dad thoughtfully reconsiders beagle. Tag line - some things are worth more.
I'm a lawyer, kids. If you have a transaction for $100 million and you will make $10 million, do you mind paying me $500 an hour to make it work? Not likely. You get what you pay for.
I do work for neighborhood merchants and my church for free. Not to mention my entire extended family. Not everything is money.
Re:Security (Score:5)
So do your homework. Buy and read Schneier's Secrets and Lies and any other book like it you can get your hands on. Read the Privacy Digest and the Risks Digest. Don't read just the current issues - read the archives going back at least ten years. Don't read just the medical stuff - read it all, including stuff about the plane crashes, ATMs, 911 systems, banking systems, e-commerce systems, etc., etc. Reading those archives should scare you silly about the system you're trying to design. Armed with these fears, make sure you ask your security consultant lots of hard, pointed questions. Grill him. Make him sweat a little. If he has all the answers, he's bullshitting you.
Remember Scheier's motto "Security is a process not a product." Just because you buy a "secure" web server and a "secure" operating system and "secure" application software doesn't mean a thing. Your whole system needs to be designed from the beginning with security in mind, end to end. Furthermore, everyone who uses the system has to know and respect the security procedures. Does your receptionist know she can't hand out passwords over the phone, for example? Your people are going to be your weakest link if they don't know and respect your security system.
Some other random thoughts about security:
Do you know not to store passwords verbatim in the system, and not to have default passwords like the user's last name or SSN?
The machine that houses your online system should NOT be the primary system you use to store your permanent records. If someone breaks into your online system, they can compromise your database permanently! Your primary system should never ever be connected to the Internet, nor should it be connected to the online system while it is connected to the Internet.
Your system should be opt-in only. If a patient hasn't signed up for online access, his/her information should NEVER enter the online machine. It should be on the primary machine ONLY.
To illustrate the above: assume you store ALL your patient records on the online system, but you only enable passwords for those patients who opt into the online system. You're safe, right? Records can be accessed online ONLY for those patients wha have opted in, because the others have their passwords disabled... right? Right, until the day that sameone breaks into your online machine, then ALL the records are vulnerable. Or suppose your programmer makes a mistake so that a patient's web page accidently displays records for other patients? If ALL your records are on the online machine, mistakes like the above can compromise them ALL. The online records should be copies, should be online ONLY for opt-in patients, and should probably, just to be safe, be read-only copies.
Your online system should be non-critical. You should be able to run your office, diagnose and treat patients, etc., without it. Assume it's going to be broken into. Assume you're going to need to work without it, and BE ABLE TO DO SO.
Have backups of your critical primary records. Have hardcopy. Practice your backup procedures, so you know that they work. (My favorite kind of episode in the RISKS Digest is the instutition that has backup procedures, only to discover that they don't work when needed. Because they've never practiced them, never had a dry run.)
Make sure your office personnel are resistant to "social engineering" techniques. If a hacker can sweet-talk your office administrator, secretary, and receptionist into giving out a password, it doesn't matter how good the rest of your security is.
Bottom line: Security is a hard problem. That's why there are so many stories about people who get it wrong (again, read the RISKS digest). My advice would be to forget the online access to records. If you HAVE to go online, limit yourself to taking appointments, so you don't have to worry about securing sensitive information. (Even if you do take appointments online, do it from a separate, non-critical system.)
--Jim
I want... (Score:5)
Personally, everything else is secondary. I don't need to see my charts and meds on-line. Other doctors or specialists might, I don't need on-line video conferencing or email - and I doubt "you" would either. Why? There is a good chance that more time will be spent setting up/maintaining/playing/fixing/teaching the technology then helping the patient.
When I see a doctor-I want to physically see the doctor on time. If possible, give me a accurate diagnosis, then I can be on my way doing whatever I need to do to get better.
Re:urk?! moral qualms a-plenty! (Score:5)
Or:
"I am a plutocratic [programmer] trying to make enough money to buy a fifth Lexus. Myself and a couple of other blood-sucking leeches had the idea of kitting out a [web site] with fancy-schmancy computerised bells and whistles so that we can jack up our already stratospheric fees into the ionosphere. We don't really have a clue about [making a profit], so we thought we'd ask a bunch of [consumers] what they'd like, and more importantly, be prepared to pay for. Meanwhile, malnourished kids and the homeless? Fuck 'em."
Get this straight: we are not each others' slaves. You were not born to be a slave to your fellow man. I was not born to be a slave to my fellow man. Doctors don't become doctors so they can be your personal nose wiper. If you don't wany to pay a doctor for medical help and advice, then go to medical school and you won't have to.
The fact is, you don't know jack crap. How many lives have you saved? Probably zero.
This habit of villainizing people who want something in return for what they do for others is just plain evil.
WHERE IS YOUR SENSE OF RECIPROCITY? Are you telling me that you wouldn't give a man who saved your life a Lexus is you could? Would you even give a "Thank you"?
The truth is, you probably wouldn't do anything if you could help it. People like you are the very reason people ask for money for what they do instead of accepting a vague promise to recipricate some time in the future. When you give money in return for a service, that person has some reasonable chance of being able to get something in return for what they did for you. When people say, "Hey, thanks. I'll have to help you out some day" they really mean, "thanks sucker."
I don't write this to be cynical. This is just the way it is. The fact is, paying someone for something they have made for you or done for you is the most sincere way you can tell them "thanks."