- - Wednesday, October 8, 2014


While the federal government and the Centers for Disease Control (CDC) Director Tom Frieden are telling us how safe we are from Ebola and sending 4,000 American troops to help Liberia combat the virus, Americans might want to look at how our federally supervised system is performing on the ground here.

Texas Health Presbyterian Hospital Dallas at first blamed a glitch in its electronic medical record for the release of the Ebola patient who exposed at least 100 others before he was ultimately admitted. Now it is saying the patient’s history was in the record accessible to the doctor after all. Personnel, the hospital said, followed all protocols.

What is the origin of the electronic medical record and the protocols? These are coming from top-down dictates from the federal bureaucracy. The government wants all our medical records available for its supervision, and billions of dollars are going to contractors (like the ones responsible for the EPIC system used by Texas Health and many other hospitals) who have good connections with federal decision-makers and policymakers.

The electronic medical record is supposed to achieve myriad tasks: helping hospitals collect as much Medicare and Medicaid money as they can; helping federal auditors and prosecutors catch hospitals who violate the rules in so doing; collecting “quality” and “utilization” data; and directing therapy so as to meet federal goals.

Federal goals, especially under Obamacare, emphasize optimizing population health on a global as well as national level, and eliminating health “disparities.” The electronic medical record will contain lots of data on race, ethnicity and other factors relating to “inequity.” It will enable the system to reward or punish “providers” on how well they meet goals such as universal annual influenza vaccination, suitable cholesterol levels or smoking cessation counseling. The Texas Health system’s record placed a lot of emphasis on flu vaccine.

The federal Health Insurance Portability and Accountability Act also constrains communication within the system and with families in the name of protecting patient privacy, while facilitating disclosure to some 2 million other “authorized” entities who profit in some way from Big Data.

Accordingly, information from a nurse that a patient came from an area with a raging epidemic of Ebola was in the “cloud” somewhere, but it didn’t get through to the doctor deciding what to do with the patient.

To see how far we’ve come, let’s look at where we were in the 1970s at Parkland Memorial Hospital in Dallas, the Dallas county hospital. In those days, hospitals decided on their own procedures, and doctors — not protocols — determined medical care.

Patients entering the emergency room first saw the triage nurse, one of the best and most experienced nurses. Her job was to quickly assess the nature and severity of the situation and to direct the patient to the appropriate area, based on her own finely honed judgment. A patient suspected of having a contagious disease — in those days usually tuberculosis — would arrive in Medicine A within a few minutes, on a gurney, wearing a mask, accompanied by an attendant who was also masked, and be placed in a private room with the door closed. The “pit boss” (not a credentialed, certified and recertified specialist — just a medical resident, like me) would be informed about him immediately.

Communication was by means of a one-line handwritten note from Triage. The nurse also had access to a telephone, an overhead paging system and human messengers. The doctor was responsible for getting the history from the patient or from whomever was accompanying him. ER doctors were not judged by checkboxes in the electronic medical record (there wasn’t one) but by their record of getting the diagnosis right. Our goal was not to improve global health but to keep patients from dying in the ER. Tetanus vaccine was a necessity if there was a wound, but flu shots were something you got in the doctor’s office when healthy.

If the patient was admitted, the ER intern wrote a note and spoke face-to-face with the admitting intern, who appeared in the ER to meet the patient, look at x-rays and other tests, and personally wheel the patient to the floor.

Technology was primitive by today’s standards, but we were able to talk and to think. We were only able to hurt as many patients as we could see, not millions who could be affected by misguided protocols. The patients were “ours,” not the system’s.

Think about it. Do you want your life in the hands of President Obama, the CDC’s Dr. Frieden and the architects of Obamacare? Or would you like to keep a doctor who interacts with you rather than a computer?

Jane M. Orient, a physician, practices internal medicine in Tucson, Ariz., and is executive director of the Association of American Physicians and Surgeons.

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