February 16, 2021

Snow from my balcony

Snow day! Or at least some white stuff on the ground and some ice on the roads day. I woke up this morning to white flakes drifting dreamily down past my windows, told the VA that they could call me if they needed me, and rolled over and went back to sleep for another four hours. I haven’t been that busy or that active recently so I assume it was some sort of destressing mechanism on the part of my brain, especially as those last few hours were full of wild dreams including a visit to Disney in which I could not figure out how to get inside the park, some sort of cruise to an unpleasant destination and even worse people and a sequence where I kept breaking into my pastor’s house in order to find a nice quiet place to read and recuperate. She kept coming home and chasing me out again – politely, but firmly setting her boundaries for family time.

It would have been nice if I could have spent the snow day in some mindless activity, but alas a phone call from an attorney stating he needed a report in writing tomorrow on the case I have been revieiwing put paid to that idea, and I had to dive back into 2500 pages of mainly unreadable electronic health records trying to extract nuggets of fact that would support my opinions. Success as I found what I was looking for, wrote up five pages, and got it to him by close of business Eastern time and now have the evening to myself. I really should charge more for rush jobs. Reviewing medical records is nowhere near as fun as it was when I first started decades ago. Then I would get a bankers box shipped parcel post full of barely legible photocopies of physician handwriting to deciper. Now I get access to a drop box full of perfectly legible electronic records spat out by some computer, most of which are useless garbage when trying to reconstruct what happened around a particular incident or illness.

There has been some speculation that at least some of the issues of response to Covid and Covid vaccination are tied up in the electronic health record that has become so pervasive. The groundwork for such records was laid in the late 1990s after the invention of the World Wide Web as medicine, along with other industries embraced the ability for information exchange this allowed. Some bad actors early on who were buying and selling health information led congress to pass the Health Insurance Portability and Accountability Act (HIPAA) in 1996 under the Clinton presidency. This law explicity protected the privacy of health information so that it could not be used in inappropriate ways. Unfortunately, it also tied a lot of information exchange to 1990s technology which is why health care, as an industry, still depends on the fax machine. It’s considered HIPAA compliant while newer methods of information exchange are not addressed in the legislation and it has yet to be updated. In the early 2000s, various private companies becan to get into the electronic health record business, knowing it would be the wave of the future. (Cerner and Epic are the biggest but there are lots of smaller ones out there). The VA actually offered it’s in house EMR, known as CPRS, free of charge to the country so that there could be a national standard and all records could be easily traded between states and institutions without difficulty, but the Republican president and congress of the time preferred to let private enterprise take precedent over the public commons and this idea was abandoned in favor of dozens of incompatible systems incapable to talking to each other, leading to a dramatic increase in siloing of health systems along information lines.

Another complicating factor regarding electronic health records is what they are asked to do. When clinicians sold control of the health system to industry and administrators in the late 70s and early 80s, there was a shift in the power dynamic. Where before, the needs of the physician were paramount, after the needs of the industry as exemplified by revenue generation became the most important thing in terms of data management. As administrators were in charge of purchasing health information systems, they looked for systems that could assist with capturing charges, identifying utilization trends, and assisting with quality metrics. The actual needs of an individual provider/patient encounter became subservient to these big data analytic requirements. Administrative systems were modified to fulfill clinical requirements instead of vice versa. This was all put on steroids by the HITECH legislation signed by Obama in 2009 as part of the recovery from the great recession where the health care industry was offered financial incentives to adopt electronic health records and pretty much everyone went digital over the next decade, each in their own way.

The end result is millions of data points that can be spit out at the touch of a button but none of the logical thinking and cohesiveness that a physician mind uses to take all of that and turn it into an understandable narrative. A set of vital signs or a set of lab values taken in isolation don’t mean much. It needs to be combined with clinical reasoning skills, an understanding of the prior medical history of the patient, the unique circumstances of life surrounding the patient, and occasional serendipity to be made to mean anything. You learn to look at voluminous records and recognize that there are only a few sections, those where a clinician is entering data by free text or dication, that can really let you know what you need to know and, when meeting a new record system, learning where those few areas can be found makes all the difference.

In the 1980s, when I began in medicine, pretty much everything was handwritten. That’s why doctors’ penmanship is so notorious. Years and years of having to write so much so fast. In the 1990s, the handwritten notes tended to be interspersed with dictations, especially of summary notes such as admitting histories and discharge summaries. When I first came to UAB, there was no centralized medical record on the outpatient side. If I wanted to know what cardiology was doing with one of my patients, I had to go down to the cardiology clinic, pull their chart, and take a peek. That started to change in the early 2000s where more centralized records became the norm, with dictated notes being accessible throughout the health system and electronic medication lists coming into being which could be updated and modified by any provider. In the 2010s, the full electronic health record went into play. Notes pull information in from various places in the system but, as it is done automatically, there’s no real understanding of relevance and many notes become pages and pages of extraneous numbers and information with no clinical bearing on care. Who knows what the 2020s will bring. I’m hoping for systems programmed more to respond to clinical needs than administrative ones where physicians and other clinicians are part of the teams that develop the programming so that it becomes more intuitive.

Back to the Covid issues: As these systems are now everywhere, but are decentralized, when a national emergency such as the current pandemic hits, it’s difficult, if not impossible, to get health systems to pull together as one as their data systems are completely incompatible. As a UAB physician, I have no way to know what happens to my patients at St Vincents or in the Baptist system unless the providers there are kind enough to send me records of the visit. (It happens sometimes). Those records can be scanned in to the UAB system but they cannot be converted into a format where the data can be taken up and integrated with UAB data. It can make life very interesting when I have a patient who wants to get their primary care from me but still sees their cardiologist at St Vincents and their endocrinologsit at Brookwood and their neurologist at Grandview. With these fault lines, I don’t know how the administrative folk at the Alabama Department of Public Health or at the upper echelons at UAB are supposed to coordinate their efforts or know how well they are doing vaccinating 5 million Alabamians, half of whom fall into a risk group of some sort. That things are going as well as they are is a minor miracle.

Joan Burgess receives an injection of her first dose of the Pfizer-BioNTech Covid-19 vaccine in her car at a drive-in vaccination centre in Hyde, Greater Manchester, northwest England on December 17, 2020. – Covid vaccination at the drive in vaccine hub in Hyde started on December 16 with over-80s registered with a GP in the area being the first to be invited. The British government were set on December 17 to announce their decisions following a planned review of the coronavirus tier restriction allocations for the whole of England amid surging infection rates in London and parts of the southeast which have already resulted in the captial being moved into the highest tier. (Photo by Oli SCARFF / AFP)

A lot of people remain angry that they or their loved one have not yet been able to get scheduled for a Covid shot. The limitation is the amount of vaccine coming into the state. It’s freeing up and supplies are better than they were. Given that it’s a commodity with far more demand then supply, people are turning their frustration on each other. Why is so and so able to get a shot when I have not. Why is this risk group deemed more important than that risk group. The anger is misplaced. It shouldn’t be leveled at vaccine recipients (it’s the sort of divide and conquer that keeps propblematic social structures in place). It should be leveled where it belongs, directly at the previous administration who did little to make the vaccine available in a timely fashion. If they had used the powers of the federal government back in Decemeber when the vaccines were first approved to accelerate manufacture and to coordinate distribution, it’s likely that everyone at risk would be vaccinated at this point. They didn’t, meaning that a true ramp up of vaccine delivery didn’t start until after the change in administration a month later. We’ll get there. I am very optimistic that those at significant risk will all be vaccinated by Easter. That’s forty days from now. (I know this as today is Mardi Gras or, given the temperatures outside, Mardi Froid might be more apropos). It’s going to take more than fractured information systems and the ineffectiveness of administrations past to keep the American people down.

In the meantime, you know what to do: Keep your hands washed, keep your distance, keep your mask on, keep out of indoor locations with lots of other people, keep on keeping on.LikeCommentShare

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