How Did Our Medical Notes Become So Useless? • Hacker News Board

Re: How Did Our Medical Notes Become So Useless?

#181

Post by balfirevic » Sat, Jan 05, 2019, 12:43 PM UTC

Spooky23 wrote: post #158

giobox wrote: post #136

Earlier quoted context omitted.

I'm not entirely convinced the UK/NHS should ever be used as a good example for handling medical notes, at least by today's standards. As a Brit who left the UK a while ago, I recently had cause to request my "medical records" from my former GP. Of course such data can presumably be requested via the UK's Data Protection Act, but the lack of any kind of standard process or checks really shocked me, given the care the…

Don’t worry, US medical practices will give you a big show about doing anything in the name of HIPPA. Rest assured, it is a show, and most of your information is fed in real time to a half dozen different entities whom you have never heard of. The people who sell prescription data provide it to the pharma company before your insurer even gets the claim.

Is what they're doing illegal or is that behavior not prohibited by HIPPA?

Re: How Did Our Medical Notes Become So Useless?

#182

Post by cperciva » Sat, Jan 05, 2019, 12:49 PM UTC

arkades wrote: post #159

tdeck wrote: post #156

Here's a fun thing about our system in the US. If you're taken to the emergency room, they'll ask your medical history. And not just once - they'll ask it in the ambulance, radio it ahead to the hospital, then make you wait while they ask you the same questions again and enter them into their system at the hospitsl. Then the next 3 doctors or nurses who come into your room do the same thing, asking you questions you'…

We do this for a reason. Not only do different people ask specific questions that try to elicit different things, but patients stories evolve with each repetition. People don’t realize how much, but by the third time you’re getting that history, the picture is usually quite different from what the first history depicted. And since history is 90% of diagnosis, this isn’t some little quirk. It plays a huge role in help…

As a patient, I've been guilty of doing this deliberately. At ER triage, my priority is "get into a bed". Once I've been admitted, my priority is "get well". (And once I'm feeling better, my priority is "get out of here"...)

As a type 1 diabetic, if I have high blood glucose and nausea, I'm going to say the letters "DKA" to the triage nurse. I'll never bring it up again -- because the first blood chemistry test answers that question one way or the other.

Re: How Did Our Medical Notes Become So Useless?

#183

Post by Spooky23 » Sat, Jan 05, 2019, 12:55 PM UTC

balfirevic wrote: post #181

Spooky23 wrote: post #158

Earlier quoted context omitted.

Don’t worry, US medical practices will give you a big show about doing anything in the name of HIPPA. Rest assured, it is a show, and most of your information is fed in real time to a half dozen different entities whom you have never heard of. The people who sell prescription data provide it to the pharma company before your insurer even gets the claim.

Is what they're doing illegal or is that behavior not prohibited by HIPPA?

It is legal. HIPPA protects you from chatty employees and gross incompetence.

Re: How Did Our Medical Notes Become So Useless?

#184

Post by appleflaxen » Sat, Jan 05, 2019, 1:13 PM UTC

tivert wrote: post #70

rhcom2 wrote: post #10

Earlier quoted context omitted.

In the US you're legally entitled to your medical records too but every time I've done it the response is always defensive, ie "why do you need them", "send me the doctors information and I'll fax it to them myself".

> In the US you're legally entitled to your medical records too but every time I've done it the response is always defensive, ie "why do you need them" Whenever I've been asked, I just say "I want them for my files," and I've had no problems. Sometimes questions like that could actually be an attempt to be helpful. For instance to send along only the needed records rather than a fat file full of extraneous info or sa…

this is probably just because there is a pop-up dialog box the secretary sees when she puts in the request, and they are obligated to ask. there is no answer that will result in your request being declined, including "I'd rather not say".

Re: How Did Our Medical Notes Become So Useless?

#185

Post by appleflaxen » Sat, Jan 05, 2019, 1:14 PM UTC

theseatoms wrote: post #49

nradov wrote: post #31

Earlier quoted context omitted.

Support the OpenNotes movement. Patients have a legal right to view their records (with some limited exceptions). But it needs to be easy and happen by default rather than as a special request. https://www.opennotes.org/

Forget "view". I want to own my records. It's my personal data that I've enlisted a professional to gather on my behalf.

can you elaborate on the distinction you are making between viewing and owning?

Re: How Did Our Medical Notes Become So Useless?

#186

Post by bookofjoe » Sat, Jan 05, 2019, 1:52 PM UTC

rhcom2 wrote: post #10

arielweisberg wrote: post #3

Medical notes are largely fiction IME. You should request all your medical records from any doctor you have seen and start demanding they correct them. You will be shocked at the lies they tell about you. You will be even more shocked down the road when you find out how these lies can hurt you.

In the US you're legally entitled to your medical records too but every time I've done it the response is always defensive, ie "why do you need them", "send me the doctors information and I'll fax it to them myself".

I recall reading perhaps 30 years ago that in China people (from birth) possessed their original medical records and brought them to the doctor's office or hospital. I have no idea if this was/is true. I remember thinking how wonderful this would be, as opposed to the U.S. system (I'm a retired neurosurgical anesthesiologist with 38 years of experience — UCLA/USC/UVA). As a rule, I administered anesthesia to people whose records were often lacking very important information from outside physicians/other hospitals that was simply unobtainable in the time frame available to get it: i.e., patients were admitted the evening before craniotomy/brain tumor resection etc. scheduled for the next day, and their previous records — other than those from the hospital I/they were in — might as well have not existed.

Re: How Did Our Medical Notes Become So Useless?

#187

Post by bookofjoe » Sat, Jan 05, 2019, 1:56 PM UTC

arkades wrote: post #159

tdeck wrote: post #156

Here's a fun thing about our system in the US. If you're taken to the emergency room, they'll ask your medical history. And not just once - they'll ask it in the ambulance, radio it ahead to the hospital, then make you wait while they ask you the same questions again and enter them into their system at the hospitsl. Then the next 3 doctors or nurses who come into your room do the same thing, asking you questions you'…

We do this for a reason. Not only do different people ask specific questions that try to elicit different things, but patients stories evolve with each repetition. People don’t realize how much, but by the third time you’re getting that history, the picture is usually quite different from what the first history depicted. And since history is 90% of diagnosis, this isn’t some little quirk. It plays a huge role in help…

Reminds me of what an attorney once said to me (I'm a retired neurosurgical anesthesiologist with 38 years experience; I occasionally served as an expert witness): "The client's story never sounds better than the first time you hear it."

Re: How Did Our Medical Notes Become So Useless?

#188

Post by bookofjoe » Sat, Jan 05, 2019, 2:02 PM UTC

sxg wrote: post #40

Thriptic wrote: post #12

This EHR data problem is something I've pondered for a bit. One "simple" solution is to have departmental standardization of note format with thoughtful inclusion of what fields are typically pertinent. This doesn't solve the problem of care transitions but it might help standardize review in a hospital context. The other thing that I've been pondering is something resembling a formalized data structure and language…

Many departments do standardize their note formats. The problem is that the note is directly connected to billing, and the billing requirements are absurd. I'm a medical student, and I recently visited my PCP for a medication refill. I have no significant medical history whatsoever, and the visit took no more than 15 minutes as expected. A month later, I was given a bill for $330 stating my hospital visit was level 4…

FWIW, my psychiatrist calls in my medication Rx (3 drugs taken PO daily) every December, with 11 refills. I've been on exactly the same Rx for 18 years, so it's not as if he's going out on a limb. Sure cuts down on appointments to see him.

Re: How Did Our Medical Notes Become So Useless?

#189

Post by lowercased » Sat, Jan 05, 2019, 2:30 PM UTC

theseatoms wrote: post #49

nradov wrote: post #31

Earlier quoted context omitted.

Support the OpenNotes movement. Patients have a legal right to view their records (with some limited exceptions). But it needs to be easy and happen by default rather than as a special request. https://www.opennotes.org/

Forget "view". I want to own my records. It's my personal data that I've enlisted a professional to gather on my behalf.

Then their interpretation/diagnosis would be their information, arrived at by processing your raw data through their experience and education.

Re: How Did Our Medical Notes Become So Useless?

#190

Post by skwb » Sat, Jan 05, 2019, 6:37 PM UTC

VikingCoder wrote: post #124

skwb wrote: post #74

Earlier quoted context omitted.

1. There's an old saying in healthcare that patient care is always first, but money is a close second. 2. Sort of yes, but I've heard it more time from managers who use it more of an excuse for not wanting change rather than it being a legitimate argument (i.e. from people with little to no legal training). 3. This is changing slowly. The Affordable Care Act and it's little known cousin MACRA have started to shift th…

3. No, it's not. If you go in for a wonky heart, and you get some kind of imaging done on your chest, and then spot something in your lungs, they SHOULD ignore it. Outcome-Based Medicine says that's what they should do. They CAN'T ignore it. Cardiologists actively want the lungs REMOVED from the images they order, because they don't want to accidentally notice any lung nodules. That's crazy! And that's just one examp…

Yes, it is. You appear to be conflating my point of how healthcare is changing with regard to payment structures with clinical guidelines which tend to have potentially more subtleties.

There are some areas of healthcare where it is very cut and dry what defines good healthcare management. These are where we've developed good reporting outcomes that tie closely to clinical and resource utilization outcomes from the published literature. Think of your high volume routines cases such as diabetes (monitoring of A1C)[0] and knee replacements [1] that make of a large portion of health care cases. These are certainly not covering all healthcare episodes, but represent areas where significant fat can be trimmed.

With regard to your above clinical case, there are specific approaches for (what I assume is an incidental finding from a coronary CTA) reporting lung nodules and requesting follow up studies [2]. However, this represents an area where there is significant good faith professional disagreement of reporting.

I will agree that high-evidence clinical guidelines are not always followed, and payment reform has not been influenced all medical professions equally. The way healthcare is delivered is changing, and is being highly influenced by national policy level decisions.

[0]: https://www.healthaffairs.org/do/10.1377/hpb20121011.90233/f... [1]: http://files.kff.org/attachment/Evidence-Link-FAQs-Bundled-P... [2]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5903561/