Could a single, mammoth database solve all our health data needs? Margalit Gur-Arie, whose writing and ideas I greatly admire, has been arguing for one quite passionately on her personal blog in a couple of recent posts (part I, part II).

The crux of her posts is this:
- There should be a single, standardized national database to which physician practises, and ultimately EMR vendors, must submit mandatory data, “in real time”. The requirements will be along the lines of current Meaningful Use requirements.
- This database will be accessible to vendors and entrepreneurs alike, and can have multiple EHRs or apps built atop them.
- Since the patient data is available, and easily accessible (no one “owns” the data, they only own the proprietary bells and whistles they perform on the data), this is a near perfect patient utopia.

It’s a great idea and perfect for an ideal world. Except:
- Massive databases cause massive headaches, as commenter Omowizard pointed out. There is a price to pay for data available at all times, all places, and by everyone. And if I may add, in Gur-Arie’s model, it’s not clear who’s left holding the bag. Presumably the government. Which opens a entirely different can of worms about data ownership.
- Real time updates of data is no joke. At my current place of work, we perform quasi-real time (twice daily) updates of patient visits to client databases from a central repository. The sheer volume is enough to bring down the database servers for a good hour or two.
- We haven’t been able to agree on a standardized schema passed for a healthcare database. What are the odds of this idea ever catching on?
- How are we going to mandate data population? After physicians and care organizations, will EMR vendors be the next recipients of government bribes/largesse/sops to induce them to populate the database?
- Gur-Arie herself points out that American enterprise being what it is, if there are no financial benefits to data ownership, they’re going to be a hard sell.

And while it’s easy for me to write a smart alecky blog post about the infeasibility of the mammoth database idea, I shudder when I think of what we have now: disjoint EHRs that don’t “speak” to one another, walled gardens and proprietary ownership of data that pretty much lock physician office in, PHR offerings from companies like Microsoft who will do God knows what with OUR health data.

I don’t think there are any easy answers. I’m leaning more towards an open source health “OS” platform rather than a single database. But at the very least, Gur-Arie offers some great food for thought.

I’ve always got my eyes open for news of healthcare facilities marketing their healthcare IT systems to patients. To me, explaining the new high-tech gadgetry at check-in and the new computers/laptops/tablets in each exam room goes a long way towards making patients feel more comfortable before, during and after a visit to the doctor or even hospital.

I came across two recent examples of patient outreach that I think are great ideas, and would certainly get my attention, and perhaps even get me to consider switching providers.

The first is an ad from Martin Memorial Health Systems in Florida, promoting their transition from paper-based records to an electronic medical records system (Epic, if you must know.) News of the implementation in a recent HISTalk post mentions that the ad is part of a campaign announcing the system’s transition starting in December. I couldn’t find any mention of the campaign, or the transition, on the hospital’s website, so I’m not sure where exactly this ad will appear – hospital hallways, local newspapers, etc.

The second comes from Kay Gooding, Project Director of the Region D Health Information Technology Consortium at Pitt Community College. She alerted me to HealthIT.gov’s Campaign Toolkit – a variety of online resources that organizations can use to educate the general public about healthcare IT. The toolkit includes a short video (see below) on Ensuring the Security of Electronic Health Records. I could see this being played in hospital lobbies, doctor’s waiting rooms, or even embedded in some sort of physician-sponsored new patient welcome site, which could also house medical history/personal health records, consent and privacy forms, and the like.

I’d be interested to know from a marketing perspective, whether patient-facing educational campaigns result in an increase in new patients who are attracted to more technically advanced facilities, and if these same patients experience better clinical outcomes and satisfaction as a direct result of new HIT systems. If you hear of anything, let me know.

So, Google Health’s slow collapse — akin to a tire with a slow but obvious leak — has finally come to an end. This week, Google officially ended the project, one of the pioneering efforts in the Personal Health Records space. While GH will stumble along through January 1, 2012, the jig is finally up.

Why did a high-visibility project backed by one of the world’s premier Internet companies fail so miserably? Well, according to former Google employee Adam Bosworth, who first launched GH, the effort failed because “it’s not social,” TechCrunch reports.  Another pundit, more convincingly, argued that unless PHRs are tied to reimbursement somehow, they’ll be “irrelevant” for most providers.

So, why should we care about the failure of a project that, I’d argue, was pretty much pie in the sky from day one? And more importantly, is the failure of GH relevant to people who care about the future of EMRs?

Well, for one thing, Google Health does offer some pretty interesting insights into what doesn’t work in the world of patient-centered clinical data. As I see it, they include the following:

*  Clinical data projects that aren’t interoperable are eventually going to wither away.

I think it’s telling that Google is, at the last possible moment, rolling out the ability for patients to transfer health data to other services supporting the Direct Project protocol.  Also notable is that Google is offering patients the option of downloading data that meets the Continuity of Care Record format. (That’s ASTM E2369 – 05e1 to any standards geeks out there.)

Does that imply that EMRs that don’t share data are going to be outmoded or a waste of time?  Certainly not, as EMRs can potentially solve many in-house problems that providers face, and serve a far more expansive purpose. That being said, the failure of siloed PHRs should be a warning.

* Without a live, fluid source of data, PHRs don’t matter.

In this cynic’s mind, the idea that patients would suddenly begin to post data to PHRs on their own was, to put it simply, pretty dumb.  Why would they?  Consumers seldom think about their health data unless they’re at a doctor’s office, if at all, and they don’t exactly know what do do with the data once they’ve compiled it.

Since day one of the PHR craze, I’ve been wondering who thought they’d change patient behavior en masse by dangling a technology carrot. What were they thinking? I’m not just slamming Google, I’m targeting pretty much any PHR that isn’t linked to an EMR or other clinical data source directly. (I’m talking about you, HealthVault, and probably Dossia too.)

* PHRs must be run by a trusted intermediary, and marketed vigorously to patients, before patients will take heed.

I think it’s no coincidence that while Google’s PHR, and possibly Microsoft’s, haven’t won over many consumers, patients are beginning to pay a bit more attention to PHRs provided by providers and health insurers.  (OK, I don’t have hard data on this, just a strong gut feeling — can any of you provide stats that support or contradict this assumption?)

A case in point: While they’ve arguably spent way, way too much to get there, Kaiser Permanente has built what may be the largest PHR user-base in the world — 3 million users as of spring 2010 — linked to KP’s big Epic installation.  True, Kaiser had to spend millions in advertising and other forms of outreach to get patients on board, but what’s telling is that patients seem to have stayed once they arrived.

So, I’m just wondering when the managers behind HealthVault will throw in the towel. Hey, MS, just turn out the light when you leave, OK?

I found this recent post by Howard J. Luks, MD very intellectually stimulating. It’s a great read. Particularly if you’re a doctor or someone who tries to understand some of the various physician perspectives.

Here’s one section that sounded all too familiar to me:

Discussions about physician dissatisfaction occur at every water cooler, in every operating room lounge, and that every dinner many of us attend. But I often wonder if any of my colleagues are actively pursuing workflow changes, office efficiencies, or changes to their daily habits which may improve their level of job satisfaction. Interestingly, when I pose that question to my colleagues… the answer always seems to focus on finding another job… hmmm.

I can’t tell you how many doctors I’ve had come up to me with some hair brained website/internet idea and they want to build it. The story is so often the same. They make good money as a doctor, but they have to do it forever to make that money. They see the internet as this font of wealth. I try to let them down easy when I describe what it really takes to do what they’ve described. Ok, maybe I’m not that gentle in my description. I don’t want to crush dreams, but I do want them to understand what it really takes to do what they want to do. I digress…

Here’s another powerful part of Dr. Luk’s post:

Last week in my office, I received 5 emails germane to this topic. Three simply mentioned how satisfied they were with their encounter in the office in terms of the time they were given, the time I took to listen to their complaints, and the time I took to explain the natural history of their disease. Two of the e-mails came from long-term patients who are many years out from surgery — yet ventured onto my website and decided that they would touch base.
…
That simply makes my day.
From a work perspective, there’s no greater level of satisfaction that I could ask for.

The whole post is great since he covers the challenges of medicine as well and has a great golf analogy about how the perfect shot makes up for all the bad shots kind of like the grateful patient makes up for the bad ones.

Of course, all this discussion of patient and doctor satisfaction makes me wonder what role things like social media, PHR and patient portals can play in a doctor’s satisfaction. Many doctors fear the idea of being connected to their patients in some sort of social media. I’m not saying there aren’t reasonable precautions that need to be taken in our litigious society. However, I wonder if many doctors are missing out on some of the satisfaction they could get by using social media.

I have first hand knowledge of the job satisfaction you get when someone sends you a kind email in response to your blog post, tweet, or other communication. I know I can recount many such experiences because they were so satisfying that I’ll never forget them. I’m sure many doctors are missing out on similar experiences, because their afraid to open a channel up for that communication.

Here’s an interesting effort aimed at enriching the health IT idea pool.  A diverse group of players, ranging from universities and investors to officials with HHS, have come together to create an initiative intended to support health and wellness entrepreneurs.

The venture, StartUp Health, will be run by former Time Warner Chairman and CEO Steve Krein. The initiative will be part of Startup America Partnership, a private sector initiative working to foster U.S. entrepreneurship throughout the U.S.

I must admit I’m not particularly impressed to hear that StartUp Health’s first official efforts will be a series of three roundtables. While discussing challenges and opportunities in developing a roadmap for health and wellness startups, I tend to be more impressed by direct action (such as cutting checks).

On the other hand, maybe I’m being narrow-minded. I am intrigued by the second planned roundtable, dubbed DC to VC, which will be hosted by HHS CTO Todd Park. DC to VC will link senior officials and entrepreneurs. If I can swing attending that one, you can be I’ll be there.

And you can’t beat the roster of technical, creative and financial minds involved, including IT visionary Esther Dyson, Digitas Health Co-founder Linda Holliday, Health 2.0 co-founders Matthew Holt and Indu Subaiya and health technology startup accelerators Rock Health and Blueprint Health.

While the kind of stuff this group will foster might not connect directly with the topic of this blog — e.g. mainstream EMRs and their users — from what I’ve seen health and wellness 2.0 startups are having a big influence on consumer use of health data.

Eventually, as such demand crests, EMR designers will need to consider everything from PHRs to sharing aggregated data to providing patient analytics tools. So it’s wise to keep your eye on such ventures, even if they’re more into touchy-feely consumer technology at present. The time will come when these kind of sites and tools will be just as important to medicine as clinical decision support tools. Mark my words on this one.

Yesterday I started testing out a new idea where I’d film some original EMR and EHR videos where I answer questions about healthcare IT and EMR that people have sent to me. I’ll post the first video here and possibly another one this weekend. Then, I’ll probably start posting the videos on my new EMR and EHR video website. Although, I may do some updates with links to the latest videos that are posted.

It’s a low budget production as you can imagine. I also was streaming it live on the internet, so you’ll see me look down a number of times to check how many were viewing it live. Those things aside, hopefully you’ll find the content of the video interesting and useful.

This first video tries to answer the question:
Does the EMR allow data sharing with the patient’s PHR and/or Social Net account(s)?

As always, I’m interested to hear your thoughts on the subject as well. Was there anything I missed? Was I wrong about anything? What else is important about EMR data sharing? Should we be able to share our EMR data with social networks like Facebook, Twitter, etc?

Also, if you have other questions you’d like me to answer in a future video, be sure to leave a comment or let me know on the contact us page.

The always insightful John Moore (so many great John’s in Healthcare IT), posted a great blog post back in September of 2010 about Google Health hitting the reset button. The post was interesting as it tried to show Google Health going in a new direction. The irony was that almost a year ago John had posted about Google Health’s irrelevancy in the PHR market.

Despite the up downs of Google Health, today John put Google Health in Stasis. He sights a great list of yellow and dark orange flags that are a bad sign for those who love Google Health. Here’s one section from his post:

Beginning in late March 2011, we started hearing the rumors of the impending demise of Google Health once again (is this becoming some sort of annual thing with Google Health?). We waited a few weeks to see if the rumors would die down, they did not. We put a call into Google Health to set up a briefing, get an update. Response back was slow (one yellow flag). When they did get back to us, they said it will be at least a couple of weeks (two yellow flags). Next, our Google contact told us by email that they were going to hand Chilmark’s inquiry off to Google’s PR department (screaming dark orange flag). And now today, we received an email from one of Google Health’s most visible spokespersons, Missy Krasner that she is leaving Google.

He then projected that we shouldn’t “expect anything new out of Google Health for at least the next 5 years.” That’s quite the projection. However, I’d take it one step further. I don’t expect to see anything really mainstream out of PHR software for another 5 years either.

I do think that PHR software is going to have a strong showing in chronic patients. I could also see an interesting niche in secondary caretaker healthcare management using a PHR (I’ve got an interesting announcement about baby boomer healthcare coming soon). I definitely want an online means for tracking my parents healthcare. Not to mention, then all of my brothers and sisters could participate as well. A few other niches are likely to be successful as well. Not to mention, other consumer PHR-like applications for healthcare that will become popular like the Nike+.

I’m embarrassed to admit this, but over the last week I’ve become addicted to a hideously cute little iPhone app called Shopkick.  The app locates where you are geographically, spits out a list of retailers for you, and when you click on the retailer’s name, typically rewards you with “kickbucks.”

The more kickbucks you get, the higher “level” you’re at, whatever that means — and when you collect, say, thousands of points you can get a $25 gift card. (Yippee!)  In truth, the rewards Shopkick offers probably average out to about 3 cents an hour. Who cares?  I keep playing with the stupid app until I’m out of offers to click.

Now can anyone tell me why the same type of scheme wouldn’t motivate at least some consumers to add data to their PHR on a regular basis?  Small cash rewards are already proving effective at improving medication compliance, after all, and for most people, updating their PHR would be no harder than taking a pill.

In the past, I’ve scoffed mightily at online schemes which reward people for participating in communities, filling out forms or otherwise doing what they’re told.  After all, why should anyone care if a site names them an “explorer” or a “champion” or a “grand poobah”?  But there I am, getting psyched when Shopkick promotes me from level 3 to level 4.  Hey, I can’t help it — every time you level up you get such a cute little chime and a big green bubble to pop…  (Yes, I am otherwise a mature, responsible adult.)

But I’m being taught, by playing with this app, that rewarding people — even with very small incentives — can do an amazing job of getting them to repeat behavior.  Offer patients relevant reinforcement and patients are likely to take the PHR maintenance job more seriously.   What if, for example, a health plan teamed up with a pharmacy retailer to offer discounts on products if patients maintained their data? It could be huge.

But don’t make the rewards too exciting. Hey, you might have to keep releasing new, updated versions of your gaming system to satisfy fans.

The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician’s workflow. The EHR has the ability to generate a complete record of a clinical patient encounter – as well as supporting other care-related activities directly or indirectly via interface – including evidence-based decision support, quality management, and outcomes reporting.

An electronic medical record (EMR) is a computerized medical record created in an organization that delivers care, such as a hospital and doctor’s surgery. Electronic medical records tend to be a part of a local stand-alone health information system that allows storage, retrieval and modification of records.

So, there you have ‘em — the two major terms that compete for attention in our business.  The top definition comes from HIMSS and the second, from Wikipedia.

In the circles where I travel, “EMR” and “EHR” are used interchangeably, but not everyone agrees they should be.  In my mind, for example, the two terms shouldn’t exist — only EMR does the trick.

Why?  To my knowledge, the term “medical record” has a widely-accepted definition, but the term “health record” has no formal place in medical care. And there’s no reason to toss an imprecisely-defined term into the mix when we’re struggling to define so much about digital healthcare. (For what it’s worth, Wikipedia defines the EHR as an “evolving concept.”)

Good Lord, toss in the even more poorly defined term “PHR” and you’ve officially created a conceptual traffic loop which could create traffic crashes for years to come.

But  I know not everyone cares about terminology the way a slightly-obsessed editor does.  What do you folks think?  Do you care which acronym the industry uses?  Does it matter?

Recently, I wrote a piece for this blog arguing that the PHR model was at a turning point — and didn’t hide my doubts that this approach had much of a future.

In response, one of our readers was kind enough to tip us off to a massive PHR project which had never shown up on my radar. Apparently, the Australian government is well into building the infrastructure to support a nationally-available PCEHR (personally controlled electronic health record).

The $467 million project, which is undergoing its second wave of testing and development, will make PCEHRs available to consumers by July 1, 2012.  Nine sites are running related projects, including:

*   A system making prescribing and dispensing data available to 2 million citizens and their providers

*   A project targeting data sharing among palliative care patients and clinicians

*   A site focused on improved health for a population of about 9,000 mothers and newborns

*   A consumer-oriented portal, serving chronically-ill patients, integrating patient-entered medical data into a “Health Book”

The PCEHR project comes as Australian health officials undertake a package of national health reforms, including efforts to increase access to primary care and a $20 billion investment in improving public hospitals.

While I still doubt that the current US approach to personal health records makes sense — who decided consumers would bother with a sort of “extra” set of records designed to make key data available in a poorly-defined emergency situation? — rolling out PHRs aggressively as a key component of a primary care-oriented national health reform makes a great deal of sense.

I’m eager to see how Aussie citizens respond next year when the PCEHR goes live.  If consumers are convinced that the personal record is the key to better health, I’m sure they’ll jump on board.