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.

Right now,  healthcare organizations have to go through some pretty tricky maneuvers to link patient data across varied systems and settings.  It’s possible to connect patient info electronically through database hacks, but more often than not, matching patients to clinical data gets done by hand.

Given the insane complexity of the existing system, would it make sense to create a national patient identification number for every U.S. patient?  The question is worth revisiting, given the immense level of error and wasted time generated by the existing system. After all, not only would putting an NPI in place make it easier to track patients within a hospital or health system, it would simplify the rollout of HIEs dramatically, wouldn’t it?

Dr. Robert Rowley of EMR vendor Practice Fusion notes that the biggest enemies of establishing a National Patient Identifier are privacy advocates who feel that an NPI would expose patients to greater risk of breaches or misuse of data.

But is that a realistic concern? Probably not. I agree with Dr. Rowley, who asserts that it’s hard to imagine that PHI would be at greater risk simply because of how it’s indexed.  As he notes, PHI breaches are nearly always often haphazard affairs in which a laptop is stolen than Big Government or corporate conspiracies. (If you’re afraid the government is covertly siphoning your health data off to study it, not having an NPI won’t protect you, anyway.)

No, the real barrier to this kind of administrative simplification measure is time, money and resources, the same barriers that hold back any other proposed HIT project.  It’s hard to imagine the resources that would be involved in instituting such a system — the idea makes my head hurt — and I have to assume it’d be several years before it was anything like mature.

Still, it’s good to bear in mind that at least some members of the public are afraid that creating an NPI would compromise their privacy. If the only barrier to improving patient matching in our EMRs is technical, that’s one thing — but if it’s patient fears, that’s another thing entirely. Sometimes, it’s good to remember that most of the world doesn’t think like a health IT exec.

I recently saw a tweet to the National Conference of State Legislatures (NCLS) list of “Top 12 Legislative Issues of 2012.” It’s an interesting look into issues that state legislatures will be dealing with in 2012. Plus, it makes an interesting observation at the outset that state budgets have been cut so much in past years that lawmakers won’t have to focus all of their initial energy on budget shortfalls.

Most of the list is not surprising with managing the state budget and jobs are at the top of the list. However, there are a couple healthcare and health IT related sections in their list of top government issues as well.

One of the issues is Medicaid: Efficiencies and quality. It talks about how the tough economy is making the Medicaid budgets in states a real challenge and many are looking for cost containing actions. Plus, it points to ACO type reimbursement based on patients’ health outcomes, medical homes and streamlining services. The ACO part was quite interesting to me. I wonder how much of an effect lack of Medicaid budget will push forward a new model of healthcare.

The disturbing part of the report comes in the “Health: Reform in the states, health care exchanges, technology and benefits. Here’s the section on health IT, the EHR incentive money and HIEs.

HEALTH INFORMATION EXCHANGE: One focus for state legislatures in 2012 will be how to move health care providers, especially those participating in the Medicaid program, toward the adoption of certified electronic health records (EHRs). Essentially, instead of having a different health record at each doctor or provider you visit, an EHR will serve as one file that all of your doctors can see. EHRs, once fully implemented, are expected to provide doctors and health professionals with easier access to patient histories and data, resulting in cost-savings and better health outcomes by removing costly errors and duplications in services.

I love how this basically assumes that by having widespread adoption of EHR software, that we’ll then have one patient record that each doctor you visit can see instead of having a different health record at every doctor. Of course, those of us in the EHR world know that this is a far cry from the reality of EHR software today. In most cases you can’t even share a patient record with someone using the same EHR software as you let alone sharing a patient record with a doctor who is using a different EHR.

The sad part is that whoever wrote these legislative issues must have realized that there was some issue with EHR software exchanging information, because then they wrote the following about the state HIE initiatives.

In addition, states are responsible for building and implementing health information exchanges (HIEs) where those EHRs can be accessed by health care providers. HIEs function like an online file cabinet where your medical record is securely stored, and can be accessed by any doctor or health care professional you visit. By mid-year 2012, every state should have Medicaid EHR Incentive programs in place and will be working toward building an HIE by late 2014 or early 2015 as required by deadlines attached to federal cooperative agreements.

So, wait. If EHR software has created one file where any doctor can access our patient record, then why do we need “an online file cabinet” for our medical records? We know the answer is that we need the online filing cabinet because EHR software isn’t connected and there isn’t one patient record. Each doctor maintains their own patient record and that’s not going to change any time soon.

The above quote also implies that every state is working towards an HIE program per the federal program. I must admit that I haven’t gone through every state, but is every state working on an HIE? I certainly know there are a lot of states working on some sort of HIE project, but I didn’t think that every state had funding for HIE. I guess maybe the question is whether there is any state that doesn’t have some sort of HIE program in the works.

Reading issues described like this, you can understand how government passes legislation with limited understanding. Based on this resource, EHR software creates one patient record. Wouldn’t that be nice if it were the case?

I am sort of ashamed to admit it, but I’m the sort of person who recently pointed my husband to this New York Times story and this Daily Mail (UK) story, and told him that if I should ever be comatose, he should not jump with glee and pull the plug, but instead try giving me Ambien.

Jokes aside, advance directives are things I think about fairly frequently, and yet… I’ve done squat about it. Like many of us – relatively young and relatively healthy people – I assume that I have a reasonable amount of time before such things become absolutely necessary. Which is why it so reassuring to read this AMED News story about some states giving physicians’ online access to an Advance Directives directory. According to the story, Virginia will now allow physicians to access advanced directives of patients online, without having to request the patients’ families or care providers.

I dug up Virginia’s advanced directives website. Turns out you have to fill out an online form where you specify who acts as your primary agent and is authorized to take decisions on your behalf. You can also specify if and how long you want treatments of any sort to continue if anything untoward should happen.

I’m trying to think of how physician access to advance directives can be a bad thing, but I can’t see doctors willfully misusing this info. Maybe I’ve just been blessed to have been taken care of by some really decent doctors on the rare occasions that I’ve been sick. Maybe I don’t know enough rogue doctors.

But the one deterrent I see here with Virginia’s current implementation is that the patient identification is based on parameters such as name, phone number and address. I’m not saying it will happen, but I can totally imagine a situation where a wrong John Smith’s directives are accessed and followed, to the detriment of the actual John Smith. No, it’s not a stretch. If John Smith and his son, John Smith Jr. share the same physical address and phone number (think landline), you can easily visualize the sorts of problems that are just one medical misstep away from happening.

I guess what I’m saying is that I don’t expect doctors to willfully misuse the information, but I do believe that accidental mistakes can happen. For this reason, I believe we have to start thinking in terms of a Patient ID, which will not only be useful for things like advanced directives, but also for ease of identification and data portability. It makes sense why John wants a True Patient Identifier.

All that said, if you’re a lucky resident of Virginia, Idaho, Montana or West Virginia, please go fill out your state’s advanced directive form. From what I’m seeing of Virginia’s forms, it’s relatively straightforward.

I wonder if EHR vendors with presences in these states will start pulling in advanced directive information into their EHR software for easy access by physicians. If it’s not automatically pulled in for the doctor, it is likely that some advanced directives will be missed. I wonder what other outside services could be pulled into the EHR automatically in the future as well.

Time for the next entry covering Shawn Riley’s list of 101 Tips to Make your EMR and EHR More Useful. I met someone at a conference who commented that they liked this series of posts. I hope you’re all enjoying the series as well.

15 Avoid multiple sign-ins if possible.
One thing seems abundantly clear to me: healthcare IT will be a heterogeneous environment. This is particularly true in the hospital world. Even the biggest behemoth of an HIS can’t satisfy all of the healthcare IT requirements of a hospital. So, getting a great SSO (single sign on) solution will be really important and turns out to be a great thing for your users and your help desk.

14 Make sure security is solid, but not prohibitive.
One thing about healthcare security and HIPAA that’s often misunderstood is that it should protect patient’s information, but it should also not get in the way of a clinician doing what they legitimately need to accomplish. Many security policies go too far and make legitimate healthcare work too hard. This is a huge mistake.

13 PDSA – Use it! Plan – Do – Study – Act
In this one, Shawn talks about the idea of continuous improvement which is a really good one. I also think far too many companies get stuck in the planning and do far too little doing and acting. All four steps of the process are important and useful, but don’t over think it either.

12 LEAN
Lean isn’t about being cheap. Lean isn’t about providing substandard care. Lean is about spending where it matters most. It’s about focusing on what’s most important and creating value from the things you spend money on. I’d love to see more LEAN concepts used in healthcare.

11 Buy MORE printers
Yep! Printing increases dramatically with an EHR. Almost all those forms that you use to print in bulk will now be coming out of your printer. Also, just because somewhere is fully electronic doesn’t mean that they are paperless. Paperless is a mythical creature that will likely never be achieved in our lifetime. Make the printers accessible for your providers.

If you want to see my analysis of the other 101 EMR and EHR tips, I’ll be updating this page with my 101 EMR and EHR tips analysis. So, click on that link to see the other EMR tips.

Amid all the dog-bites-man type health IT news, here are some not-so-positive EMR/EHR stories that have been reported:

- An EMR in Lifespan hospital group gave incorrect prescriptions to some 2000 patients. The article in the Providence Journal says that

The hospitals have placed calls to nearly all the affected patients, although not all have called back, Cooper said. Most patients reached had already obtained the correct medication because the error was noticed by someone at the hospital, or a pharmacist or doctor outside, she said. So far, Cooper said, there is no evidence that any- one was harmed.

Thank goodness for that.

- Incorrectly calculated MU thresholds (GE Centricity). I’m not going to rehash the story, but you can check out Neil Versel’s article in InformationWeek, the spirited discussion on my previous EMR and EHR blog post and John’s EMR and HIPAA blog post.

It might be just be my skewed viewpoint, but GE Centricity related issues are nowhere on par with people being prescribed the wrong prescription. In one case, a few practices may not be able to demonstrate Meaningful Use. Wrong medication could actually be life-threatening to you. So if I had to rank my problems, I’d rather be short by 44K than worry about my EMR inadvertently killing my patients off.

What we need is a governing body, similar to the National Transportation Safety Board, to police EMRs, says Paul Cerrato in a recent InformationWeek Healthcare article.

Cerrato writes:

“An NTSB-like organization for EHRs would at the very least provide a reporting mechanism to keep track of incidents and life-threatening consequences of misusing e-records. More importantly, it could police vendors and healthcare providers who repeatedly ignore these dangers.”

Cerrato goes on to say there are only 120 EHR-specific problems reported to the FDA over the last 18 years. That figure, if correct, to me shows:

• EMR users don’t know how/where they can report EMR related errors or don’t expect any action to be taken – this certainly is credible, because from all quarters, it seems as if the focus is just to get the healthcare field into electronic data capture, not on whether the experience delivers any tangible and useful benefits
• Maybe they’re willing to give EMRs a pass assuming the healthcare IT to be in infancy
• They’re too overwhelmed with the EMRs’ capabilities/inabilities to really see what’s going on

For a national database of EMR problems to be truly relevant, here’s the information I would look for, on problems I’m facing:

• How critical was the error? How many people did it affect, and in what ways – medically, financially?
• How was it handled?
• How common is it – are there others who’ve faced similar problems?
• If the problem was not sorted, what raps on the fingers did the vendors face?

Read the article here.

In my ongoing series of Major EHR Developments from John Halamka (see my previous EHR In The Cloud and Modular EHR Software posts), his third major EHR development from the Technology Review article is: A Network of Networks.

Halamka basically says:
-Most people think doctors and hospitals exchange healthcare information (they don’t)
-New standards are being integrated with EHR that will make it happen
-There won’t be one large database of health records
-Many regional data exchanges are happening
-There will be multiple Health Information Service Providers (HISPs)

I agree with most of these ideas. Although, I think it still faces two major challenges.

The first challenge is the standards challenge. Sure we have CCD. Oh wait, we have CCR. Oh wait, they merged, kind of. Oh wait, now CCD has multiple flavors. Oh wait, what kind of standard is it if there are multiple standards of the standard? I think you see my point.

The second challenge is whether HISPs and the other regional data exchanges have a viable future. I’ve talked to a lot of people about these exchanges and I have yet to hear someone clearly articulate a viable model for these exchanges. My favorite was the HIE expert who told me they’d figured out the model for HIE. So, I asked what it was and they gave me some convoluted answer that made no sense to me. Maybe I’ve just missed it, but I’d love to hear someone try to describe a viable HIE model.

I do predict we’ll see Fax slowly phase out over time. Although, I think it will more likely be replaced with a fax like service on the internet (Direct Project?) as opposed to some other sort of Data Exchange. It will probably best be described as Fax 2.0.

The American Health Information Management Association’s (AHIMA’s) annual show is right around the corner. HIM professionals will gather in Salt Lake City next week for a few days of educational sessions, exhibits, networking opportunities and even off-site visits to local healthcare facilities such as Intermountain Medical Center and the University of Utah and Cancer Registry.

It will be my first time at an AHIMA show, and truth be told, I couldn’t be more pleased that I’ll get to see Salt Lake City in the Fall. I’ll of course be on the lookout for the latest and greatest healthcare IT, particularly those technologies related to electronic medical records (EMRs). I’m also hoping to chat with AHIMA’s new CEO, Lynne Thomas Gordon, about how AHIMA will be helping its members transition through healthcare reform in the near future. (Look for a wrap up in next week’s post.)

Most of my time will be spent on the show floor, learning about these new technologies and finding out what health information management challenges and solutions providers are dealing with. James Watanabe, Director of Healthcare Business Development at Perfect Search Corp. – a first-time exhibitor this year, recently shared with me his thoughts on what’s he’s expecting and hoping to get out of the event.

What health information management challenges are your customers currently facing?
JW: “At Perfect Search, our clients are typically utilizing our unique indexing and search technology to deal with the challenges associated with extreme data growth and complexity. One of the challenges in the industry is that in addition to the explosion of digital data, there seems to be no clear direction in terms of standardization and policy. Given this uncertainty, vendors must not only help facilitate compliance now, but be nimble enough to support changes in the future. We see Perfect Search as a core technology that can be utilized to help organizations deal with these challenges as they come, and believe that the implications for such a technology are truly deep and profound.”

How does your team plan on addressing these challenges at the AHIMA show?
“We will be demoing our deep data-mining tools and highlighting some of our key strategic partnerships that showcase how the technology is being utilized today. We are able to provide at least a 10x improvement in indexing and search speed, be much more comprehensive in terms of the data we search (structured EMR, unstructured clinical notes, lab data, DICOM radiology images, etc.), and operate on up to 90% less hardware. Using our solution, clients gain real time insight into their data to improve quality scores, help mitigate fraud, improve billing processes, better facilitate clinical trials, and any other deep data mining they might require.”

What does Perfect Search hope to get out of the show as a whole?
“Despite some key partnerships such as Dell, Fujitsu, CA and Nuance, Perfect Search is relatively unknown in the healthcare space. We intend to use AHIMA as a way to raise awareness of our unique technology, it’s many applications in healthcare, move business deals forward, and seek out new partnerships in the space.”

How does Perfect Search’s Medical Record Search technology integrate with providers’ interoperability efforts?
“Perfect Search is the only indexing and search technology that is able to deal with both structured EMR content and unstructured clinical notes data equally well, to produce true semantic search. There is currently a disconnect between what most EMR vendors are pushing and what physicians and other users are wanting. EMR vendors push structured data, and clinicians are interested in utilizing their existing business practices, which for many means producing and utilizing unstructured clinical notes data. We believe that the ability to connect to all critical data needs to be a component of any good EMR or health information exchange (HIE) solution and is something that we can provide today.”

Can this technology search or be integrated into EMRs or HIEs?
“Absolutely.”

It would also seem that this technology might be useful from a business intelligence perspective – a much-needed solution in terms of providers determining what healthcare IT systems might be right for their facility.
“Definitely. 80% of business intelligence reporting and analytics is connecting to data. In large pharma and research, the deep data-mining tool we have created enables users to create and run complex ad hoc queries in real time and without IT. This tool is the difference between getting data now versus 12 hours from now, tomorrow, next week, or even next month, which is standard for most companies of significant size.”

How do you see Perfect Search technology evolving to meet the needs of healthcare providers?
“The Perfect Search team continues to work with industry experts to build new applications around the technology and strengthen existing products. Ours is a unique technology that enables users to connect to critical data at least 10 times faster, be much more comprehensive in terms of the content we search, and operate on up to 90% less hardware. “

I’m looking forward to speaking with the Perfect Search folks from the show floor. Know of any other exhibitors I should check out? Salt Lake sites I should see? People I should bump into? Let me know in the comments below.

John’s Comment: Along with Jennifer, I’ll be at AHIMA as well. I’m definitely happy to meet with people at AHIMA also and enjoy attending the event for the first time.

There seem to be three big acronyms when it comes to healthcare IT and interoperability – EMR (electronic medical record), HIE (health information exchange) and ACO (accountable care organization). Implementing one does not always necessarily lead to the implementation of another. I’m sure everyone will agree, however, that an EMR most likely leads to connectivity to a HIE, which increases the likelihood of participating in an ACO or coordinated care program. I consider these technologies and concepts to be the interoperability triumvirate, if you will.

Of these three, the HIE seems to have seen its day in the sun. Enthusiasm for the concept and its surrounding technologies – at a fever pitch at tradeshows and in the media last year, in my opinion – seems to have been eclipsed by Meaningful Use incentive payments for EMRs and the general consternation related to ACOs. Which is why my interest was piqued when I came across news from a company called NexJ and its new Health Exchange solution.

In order to learn more about the product, touted by the company as one that “brings together the numerous electronic health records systems and applications that exist within healthcare organizations – many of them old, out-dated legacy systems – into one place so that healthcare providers can deliver better, safer, more comprehensive care,” I reached out to Oz Huner, Vice President of Health Solutions at NexJ Systems.

JD: What type of healthcare facility would be the typical customer for your new HIE solution?
OH: “The NexJ Health Exchange solution facilitates the sharing of patient information between healthcare organizations such as hospitals and healthcare providers, ACOs, HIEs, and public health and government agencies.

“Our customers are choosing our solution because it enables them to move from paper-based workflows to electronic workflows and gain such benefits as complete access to accurate information, improved quality of care and patient empowerment.”

Can you give me a specific example of how this HIE can potentially (or has already) improve patient outcomes at a client facility?
“In a current project we’re working on, NexJ is helping meet the challenges emergency department physicians and staff face by providing timely access to the patients’ primary care provider records when they arrive at the hospital admitting department. The NexJ Health Exchange solution connects the patient’s medical record directly with the emergency department systems, improving information sharing between community health providers and the hospital, and improving patient safety.”

Is there a limit to the number of EMRs and applications that can be connected within the NexJ health exchange?
“No, there is no limit to the number of EMRs and applications that can be connected using NexJ Health Exchange. It is highly scalable and can address the needs of the even largest healthcare organizations.”

Does it work with some EMRs better than others?
“No. NexJ Health Exchange provides open, standards-based integration to any EMR system. Its secure, Web-based portal and flexible architecture enables connectivity with legacy and proprietary systems, support for global messaging standards (HL7v2.x and HL7v3.x), exchanging of clinical document formats (CCR and CCD), and support for multiple standardized clinical terminologies (SNOMED, LOINC).

Based on your interactions with providers, do you feel that more and more are finally coming around to the idea of adopting EMRs and eventually HIEs? Or do you find that many providers still think they aren’t worth the expense?
“It is our opinion that EMRs have historically been of great value to healthcare organizations, but since they’re often siloed, such information technology has not been ubiquitously adopted. As an element of a HIE, however, we believe there will be greater EMR adoption as government incentives and programs encourage healthcare providers across the country make the switch to EMRs. As more physicians move to EMRs and become net receivers of patient information, they will realize the benefits of access to accurate information, improved quality of care and patient empowerment.”

Are you working with any regional extension centers around the country to promote your EMR and HIE solutions?
“Indirectly, yes. Through our partnership with Open Health Tools, NexJ is a member of the Platform Implementation Project (PIP), which is working on an open HIE solution for state agencies. The focus is currently on southeast Texas, but is by no means limited to that region.”

NexJ will be at the Health 2.0 conference in San Francisco next week. If you plan on going, stop by their booth and let me and your fellow readers know what you think about this new health exchange solution. Is HIE the buzzword worth bringing back?

In celebration of National Health Information Technology Week –  proclaimed by President Obama earlier this week in an effort to “urge all Americans to learn more about the benefits of Health IT by visiting HealthIT.gov, take action to increase adoption and meaningful use of Health IT, and utilize the information Health IT provides to improve the quality, safety, and cost effectiveness of health care in the United States – I’m hitting the road and heading to North Carolina.

Actually, it’s pure coincidence that my annual Fall road trip to Charlotte and Chapel Hill coincides with this newly official week of celebratory activities. (You can view a list of events here.) But it did prompt me to ponder the state of North Carolina’s EMR and overall healthcare IT utilization. My first stop was the HIMSS State HIT Dashboard, a handy resource that provides an overview of all 50 states’ utilization of healthcare IT.

According to HIMSS, as of September, 2011, North Carolina has six Health Information Exchanges (HIEs):

•  NC Healthcare Information and Communications Alliance Inc. (NCHICA)
•  Carolina HIE
•  Coastal Connect
•  Western NC Health Network (WNCHN Data Link)
•  Southern Piedmont Partnership for Public Health (SoPHIE)
•  Sandhills Community Care Network

The state’s regional extension center, which assists the state’s physicians with selecting and implementing EMRs, has at this point recruited 50% of the providers in its target group of 3,500 priority primary care providers, according to the NCHICA website. The NCHICA seems to be the main governing/advisory body over the state’s HIT activities. Its 239 member organizations will converge in just over a week at the Grove Park Inn in Asheville for its annual conference and exhibit. The lineup of sessions looks pretty interesting, especially “So You’ve Decided to Implement an EHR, Now What?” I’m sure conference attendees will have a great time at the Brews Cruise as well.

My next stop was Google, where a quick search yielded the fact that North Carolina, and the Duke Center for Health Informatics in particular, is home to MindLinc, an EMR for behavioral health. It is now the world’s largest codified behavioral health database, and provides information for research and benchmarking purposes.

My last stop was YouTube, where I found an interesting video created by Janet Apter, an RN and member of the faculty at the Duke School of Nursing, for Duke’s Doctor of Nursing Practice Program. Entitled “Electronic Health Record – a Promising Solution,” the video shares the perspective of one nurse/patient’s frustration with a lack of interoperability between facilities in the same health system, and makes a simple case for the need for a nationwide EHR system.