EMRs: More, Better and Quicker Data

Electronic medical records provide value at several levels. The most basic level is a specific doctor/patient relationship. Above that is care by a doctor team and a patient dealing with a complex medical issue such as cancer. Above that is a database derived from those records from multiple doctors and teams.

Large databases already exist. The Veterans Administration has one and so does Kaiser. Just three vendors—Meditech, McKesson, and Cerner—serve more than half of the acute care hospitals that have vendor systems. Practice Fusion is the dominant service in doctors’ offices with more than five million patient records.

We are already beginning to see more and better data quicker.

A large database—more data–has a number of advantages. First, you can look at issues that affect only a very small percent of the total population and still have enough cases to draw reasonable conclusions. Second, you can define “control groups” with very similar characteristics who are not affected by whatever you are studying so you can begin to look for potential causes.

Data collected by professionally trained doctors and nurses in the normal course of their medical practice using structured formats is more reliable and easier to analyze—better data–than most of today’s studies that rely on interviews and limited records. Practice-derived data will be adequate for some studies and will provide the starting point for others. One possibility is to use practice data to find patients of interest and then work with them and their doctors to obtain additional information. The Web site PatientsLikeMe.com has already demonstrated the willingness of people to share treatment and symptom information when they see value to themselves and others.

The processes of most of today’s research require a significant period of time between data collection and publication. Large databases support near real-time analysis of data and reporting—better data quicker. Two illustrations are provided by Practice Fusion’s response to the N1H1 flu using the guidelines published by the CDC and their posting of data on Microsoft’s Azure MarketPlace.

What can happen if we get better data quicker? Here is some of what we can expect:

• Widespread use of standardized quantifiable measures of service, effectiveness and safety; healthcare is not totally quantifiable, but much of it is and the quantifiable part can provide guidance about what works best under what circumstances.
• Identification of significant risks and steps to reduce them such as the risks associated with center line catheter infection.
• New ways to identify, manage, and respond to the potential risks associated with new medications and new uses for existing medications.
• Significant impacts on medical litigation including reductions in the actual harm done to patients with subsequent reductions in compensatory damages plus better standards of care and records to reduce, and in some cases eliminate, punitive damages.

More and better data quicker from EHRs will be one of the major medical breakthroughs in the next few years.

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Health Insurance: reform, stimulus & codes

I have been focusing on electronic medical records from the point of view of physicians and hospitals. The impact on insurance companies may be even greater. An article in McKinsey Quarterly: The new IT landscape for health insurers, August 2010 ends with the conclusion: “… CIOs will need to transform more than 90 percent of a typical payer’s IT architecture and help other executives make the corresponding changes in their business processes.”

The article provides a comprehensive analysis supported by two exhibits that define and illustrate the issues. Excerpts:

Periodically, a dramatic change in an industry enables CIOs to step up and play a decisive role in corporate affairs. We see such a seismic shift in the US health insurance industry, which faces the most sweeping changes in its half-century history. The ranks of the health care payers comprise more than 350 companies, with combined revenues of $500 billion and combined IT spending of $13 billion annually. Three principal regulatory currents are producing the impending change:

Health care reform: The legislation anticipates 30 million new individuals will join insurance rolls, while an additional 100 million will be shifting policies. The law will usher in a fundamental change to the industry’s business model. Today: 90 percent of all private policies are paid for by employers that negotiate prices and terms of coverage. The recent legislation mandates new insurance exchanges, subsidies, and tax credits that will lead millions of consumers to contract directly with the health insurance payers.

US stimulus funding: In 2009, the US Congress passed the American Recovery and Reinvestment Act (ARRA), which contains special provisions for health care IT. These reforms will first affect providers, as over the next decade health care will become rooted in readily available, comprehensive medical records and IT-based clinical decisions. …  payers’ will need to build substantial new systems that can readily interface with health information exchanges and analyze electronic health records.

ICD-10: The modern data format documenting diagnosis and procedure codes—ICD-10—was released by the UN World Health Organization in 1994. But it is overdue in the United States, where it will replace ICD-9 and expand the available number of medical codes by a factor of eight [in some cases by a factor of 144.] This change will enable a much more detailed description of diagnoses and treatments. While ICD-10 promises to improve the accuracy of medical management and claims, its adoption will force payers to undertake an effort likely to exceed that of the Y2K campaign. Yet while the costs of adopting ICD-10 are significant, the potential regulatory penalties for failing to adopt will make it a necessity.

There are concerns being expressed in the medical community about the availability of resources to provide the infrastructure required for electronic medical records. Add the demands for resources required by insurance companies and the outlook is even more grim, unless of course, you are one of those needed resources.

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EMRs: Increasing Complexity and Capabilities II

EMRs, Intel, GE and telehealth for seniors

Intel has been studying technical and societal solutions for problems related to care for the aging for more than ten years. On August 2, 2010, Intel and GE announced the formation of a joint venture that will focus on telehealth and independent living to tackle the increasing global burden of chronic disease and age-related conditions. Said simply, using technology at places other than medical facilities to improve senior health.

Some of these technologies, particularly the diagnostics, will be heavily data oriented. As an example, monitoring and tracking the ways a person uses the telephone to detect changes that are predictors of Alzheimer’s and Parkinson’s 5 to 10 years before clinical symptoms appear. The analysis is based on subtle changes over a period of time. For an engaging explanation link to a TED MED presentation at http://goo.gl/vALK

More and more data over an extended period of time. Almost certainly, additional providers serving the same or related areas. The providers will deal with the data collection and analysis and then what happens? It needs to be linked to other medical data, both historic and current, analyzed, and made available to the person being monitored so they can be responsible for their own health to the fullest extent possible, to their doctors – seniors almost always have multiple doctors – and the person’s caregivers, and concerned family members. Different forms and presentations of results based on the same data for different uses and users. Complexity and capabilities way beyond the scope of the systems being installed today.

Intel and GE are preparing to do this now. It will be a few years before the impact becomes a major issue but now is the time to design our EMR systems and networks to deal with the increasing need as the population ages and as the technology to assist them advances.

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Six Tech-Enabled Business Trends to Watch

The August 2010 issue of the McKinsey Quarterly is titled: “Ten tech-enabled business trends to watch.” http://goo.gl/cpqN  Six of the trends are related to EMRs and EHRs. I took advantage of an invitation to be a guest blogger to write about these six trends. The post concludes:

EMRs/EHRs started by addressing a limited opportunity: moving from paper to electronic files and to then sharing the data. The Internet is full of examples that started small and evolved in ways undreamed of. That will happen to EMRs/EHRs and, like all other changes on the Internet, it will happen with increasing speed. The six items above provide an “outside the box” look at some of what is on the horizon.

The post is at: http://goo.gl/bYy0

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Electronic Tower of Babel II

“Friday, July 30, 2010: When the Veterans Affairs and Defense departments began testing health information sharing for their joint virtual lifetime electronic record (VLER) project, they could not initially exchange patient data successfully using the very standards specified by the Office of the National Coordinator for health record formatting. …

“Dr. Doug Fridsma, acting director of ONC’s standards and interoperability office, used the experience of VA and DOD as an example of the trickiness of getting standards right so healthcare providers can exchange health information properly. C32 is among the requirements of ONC’s recent final rule on standards and certification of electronic health records (EHRs).” Government Health IT http://govhealthit.com/newsitem.aspx?nid=74346

Two agencies of the Federal Government encounter the electronic Tower of Babel. Can 200+ vendors who are focused on individual healthcare providers with little or no financial incentive to deal with the networking of data beyond insurance do it better?

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EMRs & “The Cloud”

I ran across a Webinar from March 4, 2010 the other day about “the cloud.” The presenter was Steve Ballmer, CEO of Microsoft. It changed my understanding of where the cloud is and where we are going. He didn’t address EMRs specifically, but it easy to see how the cloud will be part of the solution to networking EMR and health information to make it useful, reduce costs, and improve outcomes. Excerpts from the transcription:

So, I’m going to give a little bit of perspective on the cloud really from the standpoint of people who get a chance to use it, to drive it, to shape it, to make something of it. …

First principle, the cloud creates opportunities and responsibilities.

The amount of invention that needs to happen is high. The world is still not a perfect place in terms of the commercial infrastructure. Yes, you can create a Web page and put on an AdSense ad. But, we certainly haven’t fulfilled the sense, the opportunities to create technology that empowers the creator. …

Immediately people get nervous, particularly when you talk about advertising. They get nervous, what about my privacy. And that’s why I think we have to talk about the opportunities and the responsibilities. The responsibilities for creators, for business people to respect the consumer, to build technologies that really do allow the user to be in control. … And yet I think we have a responsibility, all of us, not just to socially respect the user, but to build the technology that will protect the anonymity, the privacy, the security of what I say, who I say it to, where I go, what’s important to me.

Second dimension of the cloud: The cloud learns and helps you learn, decide and take action

The world is a large, complicated place. So, the first thing that got built to help people navigate was essentially directory services, search services. People built tools to help you navigate and find information, pull it all together, et cetera. And yet, we’ve got to go further than that. The cloud needs to learn about you and it needs to keep learning and figuring things out about the world that has been described virtually.

It’s great to know about 83 million Web sites on the planet, but if you’re actually trying to find something specific … I’ll put my hand up, as part of the U.S. healthcare debate I decided I should actually understand what we spend money on as a society. Try that one out for size. Pick any search engine you like and go give it a whirl. You’ll get a bunch of links, you’ll find a bunch of data, you’ll probably try to cut it, copy it, paste it, but you won’t be able to just sort of describe maybe like a simple, little chart that you would like to see populated. How much money do we spend on healthcare, how much of it gets spent on older people, younger people, poorer people, richer people, people in the last year of their life.

It’s only about eight numbers, there happen to be eight numbers that you can’t learn by following the public debate. But, there were eight numbers that I felt as a citizen I ought to know. But, the ability of the cloud to actually learn from all of the data that’s out there, and the ability of the cloud to learn from me what I’m interested in is not what it will be two, three, four, five years from now.

I happen to be a numbers thinking guy, I would create that little healthcare thing as a little spreadsheet. I would want Excel to just go get that stuff from the cloud. And so this notion of learning, learning about me, learning about the world, making conclusions, and then helping me to decide and take action, I think is a very big idea.

The cloud itself needs to learn. It’s got to collect new data. It’s got to sense new data. It’s got to represent the real world, and keep getting smarter and better, so that it can help me learn. … [demonstration using maps and photos to bring information from multiple sources together, including real time sources, e.g hospital, doctors, labs, pharmacies, personal health records.]

I hope the demonstration does a couple of things. Number one, I hope it kind of wets your whistle for some of the kinds of things that can be done. And number two, it really helps bring together this notion about learning about the world, how do we learn from others, how do we pool the data that’s available on the Web to learn about the world, and then map it and make it of interest to somebody in real life.

Third dimension. The cloud enhances your social and professional interactions …

Dimension No. 4, the cloud wants smarter devices.

The way in which we can learn about you, the sensors, the cameras, the voice, the gestures, today. This year, we’ll get about 10 billion utterances, speech utterances, submitted to us in the cloud through something called our TellMe Service, which handles call centers, and Bing kind of phone voice response searches, and the like. And so, the ability for the device to participate in connecting to the user, providing a richer interface, to get data back from sensors, and use that to improve the cloud experience on behalf of the users is really quite strong.

Later this year, we’ll ship a thing that we call Project Natal. It’s a camera that comes with the Xbox, and it recognizes you, and your voice, and your gestures. … The great smart device hardware is going to bring together the best of what we think of today as rich clients, and the best of browsers, and the best of a next generation of natural user interface, voice, touch, speech, et cetera, all in one unit. [EMRs and the user interfaces.]

Dimension No, 5, the cloud drives server advances that, in turn, drive the cloud.

Cloud Computing Remarks by Microsoft CEO Steve Ballmer
Paul G. Allen Center for Computer Science & Engineering, University of Washington Seattle, Wash. March 4, 2010

Webinar: http://www.microsoft.com/presspass/presskits/cloud/default.aspx

Transcription: http://www.microsoft.com/presspass/exec/steve/2010/03-04Cloud.mspx

The problem is in the data

Legacy computer systems were almost always funded by one department and developed to meet that department’s needs. There was little incentive to make them compatible with earlier systems except to provide necessary means to exchange results of computations.

EMR systems are now attempting to bring together information based on the treatment of a single patient from systems that were designed to manage a single clinical or business process. Two choices: standardize the data or develop a system solution. Standardizing the data just from this point forward would be huge and expensive project and would of course make all of the historic data essentially worthless. Microsoft’s Amalga system has been receiving a great deal of press coverage as a system solution to deal with disparate data formats and types. The system was developed in 1996 at Washington Hospital Center and was acquired by Microsoft in 2006.

Amalga’s Web site focuses on the stand-along organization:

Microsoft Amalga HIS EMR consolidates data from across the organization to tell the complete story of a patient’s history, condition, and progress.

Complete story within the organization, but hardly the “complete sorry of a patient’s history.”

On the other hand, another Amalga Web site says: information in the patient’s EMR can be sent “to the patient’s personal HealthVault record” where the patient can share it with other health care professionals.

Maybe we are not to far away from a system solution to the data problem. Microsoft has a well publicized solution. There are probably other solutions that are not well publicized but can also assist in dealing with the problems in the data. Microsoft has often been a dominant player but has seldom been totally free from competition.

While on the topic of Amalga there is one other part to the story. The uses and users of EMRs have become diverse enough that it is almost impossible to fully define what is wanted and needed – even if we could, it would change. By analogy, who would have expected that the iPhone would have led to more than 50,000 applications? How many unforeseen applications will there be for ERMs?

One example of an unforeseen need is a response to swine flu and the need to track cases and exposure in the emergency department of El Camino Hospital:

Within a matter of hours, clinicians at El Camino modified a few fields within Amalga to capture information specific to possible flu cases coming through the hospital’s busy emergency room. The result is a real-time dashboard that is keeping hospital officials appraised of possible swine flu cases at El Camino and will help them respond appropriately should one or more cases be confirmed. Clinicians are praising Amalga for the solution’s flexibility and the way it can be adapted to meet specific organizational needs as they arise.

Microsoft has announced plans to provide guidance to other Amalga customers so they too can immediately begin using the solution to monitor flu activity. This could prove especially valuable where Amalga has been deployed to gather community-wide clinical data. One example of that is the Wisconsin Health Information Exchange where more than a dozen emergency rooms in the state are now able to share real-time clinical data thanks to Microsoft Amalga.

In one product there is a possible solution to part of the problems with the data and an excellent example of the need to build flexibility into EMR systems.