Human Behavior

A brilliant post about medical record-keeping by Michael O’Connor:

When it comes to Computerized Health Information Technology (CHIT), also known as the Electronic Medical Record (EMR), the pen is mightier than the computer.
 
Why? Because regulators and billing professionals seek comprehensive documentation, and believe that more information generates a clearer, more useful picture of what is happening (and has happened to) a particular patient. Malpractice attorneys and quality experts lust for this level of detail, as it will afford them the opportunity to point out the myriad failings of the health care system, and serve as a perch from which they can direct the continuous improvement in the quality of care. Patients, anxious that critical elements of their medical story might be lost or unappreciated, are anxious that every caregiver have complete and total awareness of the details and trajectory of their medical history. While noble, this aspiration is part of the problem with CHIT, and perhaps the major obstacle to its being a solution to any problem in medicine.
 
The relentless quest for higher resolution of detail has driven a relentless increase in the detail provided. Unfortunately, the coding available is often a poor fit for the clinical information (a mild dilation of the aorta classifies out as an aortic aneurysm, the former something that bears minding over decades, the later a potentially life threatening medical problem that commands close follow-up). Worse, much of this coding is generated by administrators remote from the bedside, and who typically are deprived of the information required to code accurately. The imperative to code something, anything, invariably trumps accuracy, and little inaccuracies creep in to the documentation in droves at this point. Please note the shift in language from record to documentation in the last sentence. Only outsiders regard such documentation as containing useful information about a patient; you will likely never meet a healthcare provider who has this view. You will never hear ‘Could you please request Mr H’s medical and billing records from his hospitalization at memorial hospital?’ Not gonna happen. In fact, practitioners know that there is more noise than information in this documentation, which is why they do not and have never had any interest in it. It is almost certainly the case that the cost of improving the accuracy of this documentation far surpasses any benefit that might accrue to the patient. The fantasy that you can monitor the quality of health care from this perch, or improve it, is, well, a fantasy. This has not stopped major players from falling for this, hook, line, and sinker:

Read the whole thing.

I know little of medicine. However, it strikes me that O’Connor’s post is an excellent explanation of how information-gathering systems tend to fail unless they are designed with a strong idea of what information is needed, and with careful attention to the incentives created (intentionally and unintentionally) for system users. The general problem is that bureaucratic incentives tend to encourage collection of as much data as possible, regardless of accuracy or utility for practitioners, while databases tend to become decreasingly useful as their scope increases and errors increase. The extreme case is something like the government’s “no fly” list, which is heavily seeded with inaccurate data and does not provide much if any benefit for all the hassles it causes. Medical databases designed by bureaucrats rather than doctors are likely to have similar problems, and O’Connor says that medical practitioners now avoid the electronic system in favor of a “shadow” version of the traditional medical chart.

The top-down imposition of database-driven information systems on medical practitioners is a promised feature of the Obama administration’s health-care reform scheme. O’Connor’s post gives a hint of how destructive such politically driven “reform” might be.