Home Forums Discussions General Discussion My Opinion: The Future of the EHR

Any future changes to Electronic Health Data Management which does approximate true DATA MANAGEMENT is doomed to produce nothing but cost and expense.

The primary issue, in my opinion, with health data management systems, is the approach to the organization and structure of the health data being managed. In medicine unlike any other industry, the management of the data does not follow the rules for good data management. As a result we have disjointed and fragmented, difficult to transfer patient data.

In well designed data management systems there is only a single copy of a record for a particular "thing." It does not matter whether that "thing" is a widget, a person, or a car.

In health care, where a patient will see multiple providers, each provider holds, maintains, and manages a portion of the patient's health data. Records, which exist in electronic form with one physician, are transferred to another physician as PAPER RECORDS. As a result there unless the patient is only seeing a single doctor, there is no provider who can produce a comprehensive and complete electronic medical record for a patient.

To fix this there must be a single standard medical record for a patient. Suffice it to say that this medical record should not reside with any provider or entity but in an electronic file over which the patient has the ability to grant access to.
The record can exist either on a portable drive/device or online.
Digital signatures should be used to ensure authenticity, and non-repudiation of each entry to the record.

EHR systems can interface with this Health Record by reading from and writing to it. EHR vendors will be free to write their software to PRESENT the patient data in as fancy a way as they want to. They will be able to write to the record in the pre-defined way.

They structure of the record cannot be left to private industry, as we see with Google and MS today. Each will try to leverage their own BUSINESS interests in the creation of the record, this will again lead to a fractured system.

From a health care perspective, the provider will be able to see the entire patient record, WITHOUT the need to transfer records from one doctor to the next.

@gk: I have been enjoying your posts.
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gkfahnbulleh, I agree that any Health Record should not be created and run by MS or Google, or the insurance industry for that matter. (Although some would argue that the govt. would be the same as the insurance industry.) But, I don't see why it would be best to have things this way. It sounds like it would cost a lot to build this system and for everyone to support it. Would there be a forced coding system? Would it cost money or be free, or would the government step in and pay a private company for it? I'm thinking about something called Medcin; I hear it's expensive.
We're taking into account systems that want to stick to free text right?

If ideas like the medical home are where we are going (did it use to be this way?), and the documentation a doctor creates is what they sell. Then wouldn't it be against their interest to allow this as a requirement? It does seem that there should be some unified system to pass records around, but what does a doctor need but to have the primary physicians last note and all relevant labs, labs should be easy. Why can't these just be patched into a central repository and checked out when a referred doctor needs them? Then each system keeps there information and it can be easily transferred when needed.

As an aside, I came across someone who thought it would be nice if EMRs had a more unified interface. Figuring Doctors would like it. ...! Why would that be good for EMRs? I don't think we know what really works, and that is what EMR companies compete on. Restricting the interface could only be a bad idea. OTOH, improving the back end in some way such that it became easier for Docs to move from one system to another would help weed out the bad ideas.

Docs, is my intuition unfounded? (or wrong)

Benjamin, let be start from the end. "The window is not the view, the window allows the view." The interface is not the data, it only allow us to see the data. Tinted glasses do not change the substance of view, they only reduce the glare.

That being said, everyone knows TODAY, from a database perspective, what comprises a patient record. For example: First Name, Middle Name, Last Name, Date of birth, Sex, SSN, compose the identification of the patient.

However, if you look across multiple EHRs at how the data columns are represented (column name and length) you will see The "First Name" column as FName, FirstName, F_Name, First_Name, NameFirst or any other designation. The length of this column(number of characters) will also be wildly different.

The problem then is how do you transfer your FirstName column to another system that identifies the same column as First_Name, so that the transfer is seamless?

If however, there were a single medical record, the physician's EHR would only have to UPDATE that system in a manner that insures the integrity of the data.

The internal revenue service manages your single tax account. Yet QuickBooks, PeachTree and any other accounting system allows you to file your business and personal taxes electronically. The cost of those PROGRAMS has not increased, because the standardization means a reduction in the code that handles it.

There seems to be this apprehension about "the government" managing data...yet look around you, government manages your data every day, electricity, water, driver's licenses, property taxes, vehicle registration. Who do you think builds those systems for the government? PRIVATE INDUSTRY. But the government owns and manages it. So the retort that "private entities" can do it better is a canard. When private entities do it their goal is to perpetuate the financial interests of their companies.

Even Adam Smith, said that some functions must be the responsibility of government!

Think about it like your bank account. You can use your bank card at nearly any vendor in the world that accepts Visa/MC.
Your account info is only kept at in a single location: the bank with which you have the account. Each of those vendors do not keep a copy of your bank statement. They simply update (debit or credit) your account IN A STANDARD FASHION. The advantage is that any given vendor is able to query (submit a charge) for approval WITHOUT having to have your entire account history FAXED to him. The vendor's cost? 2% and a machine!

Ben, another advantage of this is that Software Component Vendors would build and sell components that make this easy and inexpensive to do. For example I recently worked on a project that included a shopping cart. The company needed to integrate the shopping cart with their QuickBooks accounting software.

Written from scratch, this part of the project would have taken 6 months easily. Instead we purchased the nSoftware Quickbooks Integrator (www.nsoftware.com) for less than $500.00 and delivered the solution in under 4 weeks. This is what standardization gives you. The ability for vendors to develop reusable components that make software development easier.

The first paragraph is what I was trying to say in my last paragraph, the paragraph you replyed to first. The specifics are fuzzy, as I havn't experience, but the idea that it would be a good thing if business were unable to compete using lockout is something we agree on. Also, the view not being the data _was_ my objection to the suggestion, which I read elsewhere, that the interface be standardized. I had overlooked that first paragraph above and didn't communicate it clearly.

I guess the EHR is a more general thing than I was imagining and if it's going to happen, just as I said, I wouldn't want a private entity (google, MS, insurance) to control it. The government would be the best choice, but I would prefer if each state kept there own based on a common national subset. Banks instead of IRS. If so, I think I would be ok with your view.

I was trying to consider a system where every bit of info ever gathered by a doctors office on a person was stored in a single place. But that isn't needed.

I do object to your characterization of the argument for private entities as a canard. It may not fit here, but it's a very natural thing to mistrust the government whenever it takes a little more influence. The difference with electricity, water, driver's licenses, property taxes, common carriers, and vehicle registration is that these all require a certain infrastructure, I don't believe it is obvious, yet, that health needs one too. (at least not the national kind, yet)

Ben because of what I am proposing the record does not have to be KEPT by any state. If the format is universal, an individual can carry his/her medical record around on a smart card, USB device, or host it with MS-Health or Google Health.

When I go to see the cardiologist, I present my card the cardiologist and his/her system can read the card and write to the card. The cardiologist can also make a snapshot copy of the record. When I return to my PCP and she puts the card in her system. The data entered by the Cardiologist is there.

Let me throw in another scenario. My wife, the doctor rounds at 4 hospitals in a 20 mile radius. 3 of the 4 hospitals are owned by different entities: Iasis, Banner and Catholic Hospitals. Now even though she can get online and see patient information from all the hospitals, imagine what happens when PatientA is discharged from a Banner hospital on Friday and shows up in the ER of the Iasis Hospital a week later. She now has to use TWO DIFFERENT SYSTEMS, in addition to her own, to see the patient's history over the past 3 weeks.

If there is a universal health record format, and the data is written to a single place, be it the Microsoft Health, Google Health or a USB Drive, she will be able to access all the information in one place with one system.

Now talk about "common carriers" apply the current cacophony of health care to phone companies: There are at least 20 different phone carriers in the country, yet you can buy ANY KIND of phone you want, with any carrier: iPhone, Windows Phone, VOIP, Vonage. whatever. Yet all of these phones are able to complete a call to one another irrespective of which network you are on.

Why?

Because there is a standardized protocol for making and receiving a phone call and whether you believe it or not, the government is involved in that process. Believe it or not EVERY PHONE on the market today, has to go through FCC testing, and no it does not stifle innovation because there are newer better phones being marketed every week.

Oh Ben, want to talk about private insurance? It costs my practice $35000/year to take private insurance. Look at the myriad of health plans we take. United Health Care has about 15 different plans they offer. HMO, PPO and any other alphabet soup you want to throw in. We have to have a person who KNOWS INSURANCE to ensure we get paid. Heaven forbid we "miss something..." they send us a big envelope telling us to resubmit...30-60 days to collect $11.65.

Now this is just my 2 cents: we could run a much smoother practice if we sent the bill to a single entity and did not have to worry about who was covered and who was not (because everyone is)! I know for sure our practice would save 35,000/year and at least 10,000 sheets of paper.

Oi, I'm not completely against government involvment, I'm just scepticle until I agree with how things are going to be done.

I LOVE the idea of open standards. And, government is one of the few groups that can mandate them.
I think at this point it's clear that your thoughts on the subject are less restrictive than I had imagined and are similar to mine, such that it makes no difference.

...how long do you think it will be and how can we hurry the process?

Well now is the time for Physicians to get involved. The issues are mainly TECHNICAL, not medical. If healthcare is going to be redesigned then we must go all out to get it done!

I would have to agree with George. It is very much like my KeyBank online account. I can access it. I can actually read/write. Withdraw, etc. and it is instantly updated. Now, I am the only one along with KeyBank and god knows who else that can access it. But, how simple it would be for me to give one day or five day or whatever access to another provider. The other provider could have read or read/write privileges. But, no matter how many people accessed it, the complete product would always be in one place.

It's really a joke the way things are done today. Actually, George, the latest PCP should have all the data and can pass it all along legally in Maine anyway, but even here we have FQHCs which take advantage of the same law which allows them NOT to send the entire document. How stupid is that. We also send CDs to consultants. Some love them, some won't take them, one person didn't even know how to use it. It's unbelievable.

One thing is certain. No matter what the change, if you make it mandatory, it will happen. People will learn -- they will have to.

And, when you think about it, the records would be more detailed and complete, because you would know others would be reading it more often if that makes sense.

Missed this and:
No, no, I'm satisfied that I agree with you and I don't want to speak about insurance. I just don't know anything about that system. Several of the plans I've heard of sound more like scams. But I haven't looked into getting insurance, so I don't know.
I'm fairly sure I don't like the idea of employers paying for health care, but the rest of my thoughts haven't clear shape.