Thursday, July 21, 2005

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Blegging for health care experts

As I've said before, health care is one of those public policy areas that I know is really, really important -- and yet I cannot muster up any authentic interest in the issue whatsoever.

So, I'm going to ask my readers to help me out and decipher the import of a recent Medicare initiative, as descibed by Gina Kolata in the New York Times:

There is no one in medicine who does not consider it both crucial and long overdue to have electronic records in doctor's offices and hospitals....

Now, however, Medicare, which says the lack of electronic records is one of the biggest impediments to improving health care, has decided to step in. In an unprecedented move, it said it planned to announce that it would give doctors - free of charge - software to computerize their medical practices. An office with five doctors could save more than $100,000 by choosing the Medicare software rather than buying software from a private company, officials say.

The program begins next month, and the software is a version of a well-proven electronic health record system, called Vista, that has been used for two decades by hospitals, doctors and clinics with the Department of Veterans Affairs. Medicare will also provide a list of companies that have been trained to install and maintain the system.

Given Medicare's heft, the software giveaway could transform American medicine, said Dr. John Wasson, a Dartmouth Medical School health care researcher.

But, Dr. Wasson added, it may take a while. "If you look at it from a five-year point of view, it will make a huge difference," he said....

The Vista project began a few years ago when Medicare officials realized that help for small medical practices was in its own backyard. The federal government had already paid hundreds of millions of dollars to develop Vista, and now uses it in the Veterans Administration's 1,300 inpatient and outpatient facilities, which maintain more than 10 million records and treat more than five million veterans a year. Why not give Vista to doctors?

In fact, though few knew, Vista had been available all along to anyone who submitted a Freedom of Information Act request.

Over the years, the program had accrued a passionate following and even an organization, World Vista, founded in 2002 mostly by V.A. employees to help spread it throughout the world. One reason for their enthusiasm was that no company owns Vista so anyone can modify and enhance it.

It is, said Joseph Dal Molin, director of World Vista, a survival of the fittest. "What's good survives," he said.

One feature, for example, was suggested by a V.A. nurse. Why not put a bar code on a prescription bottle to identify the drug and its dose, put a bar code on the patient's wristband to identify the patient's prescription, and then scan the drug label and the patient's wristband before administering a drug? If there was a discrepancy, Vista could catch it before an error was made. Programmers added that feature, and V.A. drug errors plummeted by 80 percent overnight.

Here's a link to the World Vista homepage.

I have every confidence that the mix of open source software and halth care policy will inspire someone to comment on the importance of this policy initiative.


posted by Dan on 07.21.05 at 02:36 PM


I could see several clear benefits to the widespread use of a common, open source computer system. They fall into two kind of general catergories: prospective benefits -- which deal with the quality of care provided to the patient right in front of you -- and retrospective benefits -- which deal with our ability to audit patient care to looks for ways to improve it and limit costs.

Examples of prospective benefits:

-- The association of lab results and radiology to patient records in the computer system would make it much easier for the physician to look at them quickly and accurately.
-- Prescription orders (as noted above) could be checked for dosing or drug interaction errors.
-- When a drug is prescribed and a generic is available, the computer system could inform you of that availablility.
-- A common system could make it much easier to request the past medical history of a patient from another physician (pending of course HIPPA release by the patient). A common coding system could mean the patient's other physicians could just send you an appropriate files.

Prospective benefits help to alleviate the tremendous tediousness that is involved in getting all the information together required to make a decision about a patient's care and making sure that that decision is the best informed one possible.

Examples of retrospective benefits:
-- Audits to make sure that each patient set of a certain class -- ex. patients presenting with "chest pain" -- are all recieving the standard of care.
-- Evaluations to determine medical errors and seek systematic solutions.
-- Increased speed in Medicare billing. Due to the shared system you could send in the patient's information like you file your taxes online. That alone would save thousands of hours of time and probably save money by making it easier to track fraud.
-- See what generic medications are being systematically underprescribed.

Retrospective benefits help the physician (and any legal oversight who would care to look) ensure the best, cheapest care is actually being provided. Hospitals go through these studies all the time. Now private physicians could very easily as well.

There are probably more but I hope this helps.

Jake Young

posted by: Jake Young on 07.21.05 at 02:36 PM [permalink]

Interesting approach. A couple issues/concerns:

1)Installation and support of complex software (including customization, where needed) can be very expensive. To the extent that it is done by companies that doen't stand to make anything from the software per se, it will probably be even more expensive. The savings from using free software may be less than it appears at first sight.

2)This may be a real inhibitor to companies, especially startups, that are trying to innovate in this area. It's really hard to compete with something that's given away free and paid for with government dollars, even if your product is better.

posted by: David Foster on 07.21.05 at 02:36 PM [permalink]

So the government wants all my medical records in their computer files? No thanks. Remember Ollie North and his video rental records? Does Senator Schumer need to know whether John Roberts takes 50 mg or 100 mg Viagra? The upside looks plausible but the downside is even more predictable.

posted by: Whitehall on 07.21.05 at 02:36 PM [permalink]

David Foster: Query why, as a matter of economics, we should be worried about companies whose software doesn't add enough value over the free product to make it worth the price.

Whitehall: The program provides a format and retrieval system for medical records that are stored on the doctor's or hospital's own computers, not a government-run database.

posted by: alkali on 07.21.05 at 02:36 PM [permalink]

This is a complex and difficult issue.

Physician services is still very much a "cottage industry." The average physician office is 4 doctors, the range is from 1 doctor to 400 or so, and if you look at the management of 100 different offices you will find 100 different managment models.

Physician offices are overwhelmed with billing issues, which are complicated and "life-and'death." Without a good billing operation, no cash flow. This requires a dedicated specialty system, specialty trained staff and is a chronic headache.

The standard means of creating medical records is still some sort of dictation, which may be transcribed on site, across town, or in India. Added to the chart of doxens of forms, lab slips, x-ray reports, etc.

In other words.....

This does have some value, but will be an immensely complex task with a high probability of a cluster-mess.

There are a number of EMR (electronic medical record) systems available, some tied to the billing software mentioned above and some not.

I spend much of my time fixing dysfunctional physician offices - it is a tough business.

Tom (

posted by: healthcarethinktank on 07.21.05 at 02:36 PM [permalink]

The most important fact here is that Vista has been available all along and almost nobody wanted it. Why do you suppose that is?

I actually have some experience with this monster, albiet many years ago. (I checked out the Vista download site to make sure that my information is not too out-of-date.) It's not your usual open-source project. It was written by thousands of government employees and contractors over a period of 30 years and designed not by committee, but by hundreds of govt committees all arguing with each other. It's bloated, complicated, and difficult to install and support. It is written in a language that almost no one uses any more (MUMPS). And it requires a Linux server, which most offices do not have.

In spite of this, I'm sure doctors all over the country will be training their staffs how to use Vista by Monday morning -- NOT!!!

posted by: Larry on 07.21.05 at 02:36 PM [permalink]

I agree with Tom Healthcare.

Good idea but hard to make work in practice. It would be better implemented in stages from the top end down, with only financial incentives for using the proposed whatever, as opposed to penalties for not doing so.

And, as Larry pointed out, Vista has major, major problems. It sounds like a spinoff of FBI attempts at database standarization.

posted by: Tom Holsinger on 07.21.05 at 02:36 PM [permalink]

I have some recent experience with VISTA and it is, without question, a useful system. The criticisms raised in the prior posts are valid. There is a larger point which is not in the NYT article, though it has been discussed in the NYT previously. The Bush administration has touted information technology innovation as a means for health care improvement, specifically improving care and reducing costs. VISTA has had some real successes in the former area and perhaps modest impact in terms of cost reductions. To claim that efforts like these will make a big impact on health care costs is ridiculous, but you will see administration spokesmen touting this effort as part of a major initiative to reduce health care costs.

posted by: Roger Albin on 07.21.05 at 02:36 PM [permalink]

The NYTimes article mentions that there is a special version if Vista for small offices so it may have not have some of the drawbacks mentioned above.

Large packages of this type (SAP, Oracle Applications) do tend to be hard to use and sometimes use obscure languages so that should not by itself be a problem.

The use of Linux would make it harder for small offices, but much open source softare is on such platforms. There is probably an opportunity for a vendor to package all this software together into an easy-to-use small office suite.

posted by: erg on 07.21.05 at 02:36 PM [permalink]

This will assist turning a doctor's service into a commodity. This is happening and will continue given the money involved and the rapid growth rate in the business.

posted by: Huggy on 07.21.05 at 02:36 PM [permalink]

A government agency will provide the server via internet to small offices. Offices will be required to hook-up for legal/insurance reasons.

Small officies will not do it voluntarily for a host of very good business and personal empowerment reasons.

My bet is less than 10 years.

posted by: Huggy on 07.21.05 at 02:36 PM [permalink]

I a not in any way a healthcare expert, but for quick takes on these things, including an excellent post on VISTA (along with a link to his newsletter article) you can't go wrong with Matthew Holt's The Health Care Blog.

For super quick info, Joe Paduda at Managed Care Matters is pretty great too.

posted by: Abby on 07.21.05 at 02:36 PM [permalink]

See also medical connectivity

posted by: Abby on 07.21.05 at 02:36 PM [permalink]

Arnold Kling has taken a critical look at computerized medical records and raised some important questions that some of the others here have also raised.

posted by: Juri Saar on 07.21.05 at 02:36 PM [permalink]

>Large packages of this type (SAP, Oracle
>Applications) do tend to be hard to use and
>sometimes use obscure languages so that should
>not by itself be a problem.

The majority of deployments of such enterprise applications fail, achieving no business value in spite of enormous effort and expense. I can't imagine the problem will be any better given the likely levels of support available at a medical group's offices.

posted by: dave on 07.21.05 at 02:36 PM [permalink]

When considering a VA computer system to improve health care, it might help to see if it is working for the VA. Here is an article that suggests the VA is doing pretty well with it.

I can also say that I have personnally experienced VA care for minor surgery and it is at least as good or better than anything I have received on the outside.

posted by: Donald on 07.21.05 at 02:36 PM [permalink]

I don't know of a single medical office with a Linux server, most are Windows-based to support the billing software.

I'm (educated) guessing 90% of offices have no full or even part-time IT person, they tend to rely on the local computer fix-it guy.

Most physicians think of the federal government as Satan anyway, so don't look for mad rush.

posted by: healthcarethinktank on 07.21.05 at 02:36 PM [permalink]

I've never in my life received a prescription for anything that wasn't scribbled on a small sheet of paper.

I just thought I'd mention that. Certainly abstract concerns about privacy and the practical considerations of running a small doctor's office are relevant here. But from the medical community itself I hear a lot of commentary strongly reminiscent of what I had to listen to 10 years ago from heating contractors who didn't want to computerize any of their records or use software tools on any of their jobs. They'd been trained, they knew what their training had taught them they were supposed to know, and everything else was someone else's problem.

Really successful businesses don't get very far with that attitude, and their customers don't get better service by indulging it. I don't discount the technical problems with VISTA upthread at all, but in this industry a substantial number of proprietors will just be looking for excuses not to change the way they have always done things. Medicare has thrown out a carrot, which I think is great. I hope that is not all it is thinking of doing.

posted by: Zathras on 07.21.05 at 02:36 PM [permalink]


I think most physicians would agree with your concept.

Somehow in their 80 hour weeks and the deluge of paperwork and phone calls they have to find time to be business managers, innovators, and upgrade thier business practices, including medical records.

Physicians have seen so many failed IT systems come and go that they are a bit jaded.

About everyone agrees on what an ideal system would do, no one has a good grasp of how to get there (in the real world not the government world).

Probably 50% of prescriptions are now done on the phone and via fax (some controlled substances still require paperwork) so some progress has been made.

posted by: healthcarethinktank on 07.21.05 at 02:36 PM [permalink]

One great benefit I can see of this is the prospect of cutting down on Medicare fraud by the healthcare industry. I live in a town with a majority of citizen over 65, I am one of them, and I am sure fraud is going on with many medical equipment suppliers, a phenomenal amount of unnecessary tests,
perscriptions, home visits by care providers,etc. I have seen ladies (?) who got household help by pleading bad shoulders, wrists, and so on who on a regular basis have household help and can well afford the help they get. But somehow if Rosa or whoever needs some time off then the home health services will do it. I'm getting very cynical here.

posted by: Ruth H on 07.21.05 at 02:36 PM [permalink]

Nicrosoft just announced the name of their next generation.


Is this funny or what?

posted by: healthcarethinktank on 07.21.05 at 02:36 PM [permalink]

Make that "Microsoft"

posted by: healthcarethinktank on 07.21.05 at 02:36 PM [permalink]

A while back I had a serious medical issue in Madison Wisconsin.

Shortly thereafter my Dad started a bout with cancer that ended in his death in the Venice Flroida area.

My medical care was head and shoulders above that of my Dad -- not because of better doctors, or better hospitals, but because my records were semi-computerized. As a result specialists communicated with one another, plans of treatment were carried out, and oddities in tests were discussed and passed on.

With my father it seemed as if we ought to maintain our own records, because managing his care again and again consisted of me saying "no, that test was already run" or "Before you start this medication, you should know that Dr. X discontinued it rwo months ago because..." We constantly had problems with missing records that were in transit , etc.

I don't have any question that computerized records can dramatically increase the quality of care.

posted by: John Lederer on 07.21.05 at 02:36 PM [permalink]

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