Tag Archives: complexity

EMRs: Increasing Complexity and Capabilities IV

EMRs as networks of networks

The Internet is sometimes described as a network of networks. Electronic Health Records (EHR or EMR), like the Internet, are becoming a network of networks. Just three examples: Practice Fusion provides cloud based EHRs for physicians that facilitate the exchange of information between practitioners and patients, the later in the form of personal health records (PHRs). OmniPACS provides cloud based bio-imaging data services that facilitate sharing of information between bio-imaging service providers, doctors and patients, the later in the form of, you guessed it, PHRs. Surescripts provides e-prescribing software so a doctor can accesses the patient’s prescription benefits and medication history from all of their doctors (including patient visits to in-store clinics)   and route prescriptions to a patient’s pharmacy of choice.

A friend of mine describes it as, “the systems are transparent to the data.” What is important is the ability of the systems to capture the data, store it, protect its privacy, and make it available in various forms to meet the needs of the people who “own it” or the needs of people who are authorized by an owner to access the data. Systems will come and go and others will evolve to meet the needs of the owners and users of the data.

The growth of EMRs began with stand-alone systems and is evolving by adding network capabilities. The simplest level is the exchange of data located on a single computer between two doctors or a doctor and patient. We are rapidly moving to an environment in which the data–wherever it is located–can be shared. Specific patient data can be shared to meet the needs of the patient. De-identified general data about a patient population can be shared for research and public health.  The data can be delivered in multiple formats to meet the needs of a broad variety of users while protecting patient privacy.

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EMRs: Increasing Complexity and Capabilities III

Change-over-time rather than point-in-time

There is an evolving body of services that gather health related data beyond the scope of traditional healthcare and then deliver the data and analysis to your personal health record. They provide a form of diagnosis based on measurement-of-change-over-time rather than the point-in-time-assessment made at your doctor’s office or a hospital in response to an incident. The enabling technology records information about what you are doing or how your body is reacting as it as it happens and then transmits the data to a central computer for analysis.

The data and the analysis are then sent to you and your doctor. Not necessarily better information but additional information for preventative medicine or to supplement the assessment of a medical incident.

The Internet has a history of beginning simple and then adding new capabilities. It is not clear whether need leads to the creation of these new capabilities or the new capabilities awaken unfelt needs. Either way the scope of the information that is available continues to grow and systems become more robust. That kind of future evolution must be built in to each step forward if progress is to continue. Two recent examples:

US Preventive Medicine is offering a preventive “program and it sounds pretty cool: you pay $229 for the first year, complete an online health risk questionnaire, and then go to a local lab to have a panel of blood tests. The company sends your lab results to a PHR, you and your doctor get a custom prevention plan, you gain access to online dashboards and action programs, and a nurse advocate is available to help with health maintenance. Since it’s not tied to insurance or employment, nobody sees the information without your approval.”
DirectLife, a subsidiary of Phillips, provides a, “program designed to help you become more active by setting goals based on your current activity levels. The monitor tracks your movements and, when plugged into the computer, transmits your data to the website where you can track your progress.”

I would be surprised if there are not similar services already available on your iPhone or Android based phone that will expand the amount of data available for diagnosis.

I’ve written on this topic before. The first dealt with the Johns Hopkins University depression mood tracking SMS technology. The second dealt with Intel’s ten year old program studying technical and societal solutions for problems related to care for the aging. On August 2, 2010, Intel and GE announced the formation of a joint venture that will focus on telehealth and independent living which suggests further expansion of these and related programs.

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Health Insurance, Y2K & a PMO

The impact of the change from IDC-9 to IDC-10 for health insurance companies has been characterized as comparable to or larger than Y2K. The linked PowerPoint deck provides background on the issues and a starting point for the development of a Project Management Office for health reform including the change in coding. Health Insurance & Health Reform

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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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EMRs: Increasing Complexity and Capabilities

EMRs and the Internet: evolutionary processes

The Internet is a place where a good idea are expanded and enhanced to make them more and more useful to more and more people. Early email often included links to “cool” sites and then we got Web crawlers that gave us access to more site and then there was Google. Email with lists of recipients grew into social networks that are still expanding.

Tomorrows medical records will be electronic, have formats that include today’s standard codes plus further refinements that make the sharing of existing and new information available for uses we have not even dreamed of.

A recent example: “Many in the medical community believe that those who treat depression would be able to dramatically reduce suicide or medication related problems if the doctors had access to daily mood diary data. Pilot data from John’s Hopkins has confirmed that. … We will use the Johns Hopkins University depression mood tracking SMS technology [the technology of Twitter] and adapt it to connect to the Practice Fusion EHR instead of the current physician standalone system [which will make it available to additional doctors and bring all relevant data to a single patient record.]” http://goo.gl/3R6v

Simply using today’s paper based formats and codes for the creation of medical records does not provide for “daily mood diary data” from cell phones and other SMS devices and the integration of the additional data with traditional medical data.

The history of the Internet argues that whatever is built today must allow for future flexibility for new uses and new technologies. Simply providing faster ways to replicate the faxing of standard code-based-forms will not provide access to the benefits that can be achieved.

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EMR Risk & Opportunities Map

Medical information is rapidly moving from paper records to electronic formats and new sources of information are being added. The electronic formats provide opportunities to capture, store, share and use information in new ways. These new ways create risks and opportunities.

Most of the elements identified and discussed here have been identified and discussed by others. What is new, is a broader view of more elements at the same time and their interdependencies.

It is these interdependencies that pose risks and create opportunities.

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THE MAP