Tag Archives: phr

Expanding EHRs to Include OTC Meds

My recent post about the Supreme Court’s decision in the case involving over-the-counter Zicam cold remedy got me thinking about over-the-counter (OTC) medication and personal health records (PHRs). PHRs are a logical next step in the evolving application of computer systems to capture, analyze and use healthcare information. In fact, many EHRs, including Practice Fusion, provide patients with PHRs. But, neither the EHRs nor the PHRs I have seen incorporate information about OTC medication and devices yet. How could that be done?

Some EHRs, including Practice Fusion provide two pieces to the puzzle: electronic transmission of prescriptions to my local pharmacy and an electronic file for my data: a PHR. My pharmacy provides two pieces: a frequent shopper card (FSC) and they upload prescription data to my PHR. The basic links and basic data provide a good starting point.

A workable system might look a lot like this: My doctor’s EHR company provides me with a personal health record. The EHR company and my pharmacy enter into an agreement to exchange data. I designate my PHR as the destination for my pharmacy’s transmissions.

Near the end of my next visit to my doctor sends two electronic prescriptions to my pharmacy; I pick them up. No change there, I can do that today. My pharmacist notes that one medication is for high blood pressure and recommends a blood pressure monitor that will transmit the results to my PHR. I pay for the prescriptions, monitor and a magazine using my FSC and credit card. The pharmacy uses the information associated with my FSC to send a confirmation of the purchase of my prescription including the last four numbers of each prescription (just in case I only picked up one of the two prescriptions). The pharmacy uses the same information from my FSC card and their inventory system to report that I purchased a blood pressure monitor that can transmit the readings. It does not mention the magazine. My personal health record forwards the information to my doctor’s EHR.

A month later, I refill my prescriptions and pick up an OTC medication. The pharmacy uses information from my FSC to send a confirmation to my doctor that I picked up my prescriptions. My doctor now knows I am continuing to take the medication. Her electronic health record can track my continued purchases or my failure to continue and recommend appropriate action. My pharmacy uses their FSC tracking system and inventory system to capture the information about the OTC medication and reports that to my PHR which forwards all of the information to my doctor’s EHR.

My doctor’s EHR checks the OTC meds for potential harmful interactions with my prescriptions and any other OTC meds I have reported. It also checks for any alerts such as evidence that Zicam caused people to lose their sense of smell. The EHR alerts my doctor and/or me if appropriate.
On my next visit my doctor sees that I now have a blood pressure monitor that can transmit data and suggests that I check my pressure weekly and send the information to my PHR. My doctors EHR will pick up the data and track any significant changes.
On the visit after that, my doctor is considering a change in my blood pressure medication but notes that there is a potentially harmful interaction with the OTC medication I bought. She now has information that will allow her to recommend I stop taking the OTC meds, she can select an alternative medication, she can ask me to check my blood pressure and send the data daily, or a number of other options. More and better health data gives my doctor and me more options.
So how do I keep my meds separate from my wife’s? My doctor’s EHR sets up a “family PHR.” My prescriptions with my name on them are reported to my PHR and everything else is reported to my family’s PHR. My wife or I or both of us move items from the family PHR to our own with a click of a mouse. My doctors EHR can send an alert to me if it finds a potentially harmful interaction with my medications and some on my family PHR. I can then unlink that med from my name (it was for my wife or one of the kids) or link it to my name so appropriate actions can be recommended to my doctor and/or me.
If I go to another doctor about an unrelated matter and he uses the same EHR I can give him direct access to my PHR. Alternatively, I can have records sent from my PHR to my new specialist and request appropriate records from him so I can update my PHR. If my new specialist uses the same EHR, I now have a medical team that always has current information about my conditions, prescriptions and OTC meds and available devices.
My doctors and I now have better information to provide healthcare at lower cost.
My pharmacy is now contributing information that gives me and my family a strong reason to give them all of our non-medical healthcare related business. Almost any FSC based system will have some capability to analyze purchases vis-à-vis individual card holders. The tabulation and transmission of the required data should be evolutionary, not revolutionary.
OTC manufacturers and distributors should find de-identified information about their products and any side-effects or unexpected benefits valuable. In the Zicam case the record showed that there was no loss of the sense of smell among the members of the company’s research group. Even a symptom with low frequency can be significant if the harm done to a few individuals is substantial, as it was in that case.
EHRs are still in the process of using the full capabilities of the Internet to gather, analyze and distribute data that will improve healthcare and reduce costs. This is just one of many near-term future opportunities.

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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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Cathedral & Bazaar Revisited: Healthcare Information

One of the problems we face when we talk about electronic medical records, personal health records, etc. arises because we think and talk about them as systems. A recent post on LinkedIn says:

What was apparent from the first 23 comments is that opinions and perspectives are all over the place. It’s not clear folks are all of one mind with respect to WHO constitutes the users, WHAT constitutes an EHR, what constitutes usability, and/or HOW one should be assessing usability. Many look at usability only from, ultimately, the safety perspective (decreasing medical errors), but how about efficiency, including impact on overall workflow? User acceptance/satisfaction? What are the appropriate usability measures by which to evaluate EHRs?

These are systems related questions. Systems lend themselves to being defined, developed, deployed and used. That is not the case with healthcare information. The information requirements of healthcare providers, patients, and the supporting infrastructure are evolving rapidly as we learn what works and what doesn’t. Supporting technologies – iPhone and iPad to name just two – are evolving and enabling new cost effective services to be provided. The economics of health care are changing because the current medical business model doesn’t fit any economic model that makes sense and the economics of health care are what will provide much of the funding for information solutions. The problems and opportunities of health care information don’t lend themselves to the discipline required for traditional systems.

In 1997 Eric S. Raymond published an essay called The Cathedral and the Bazaar that described the traditional system development process as centrally managed and built to last like a cathedral as contrast to a bazaar that is constantly being modified by its users to meet their evolving needs—in his essay: Linux. The article was sold and is now copyrighted and available only for a fee.[1]

Eric now points to In Praise of Evolvable Systems by Clay Shirky which points in the same direction. I think Shirky’s definition of Evolvable Systems provides and apt description of what is required to realize the benefits promised by improvements in health information:


Evolvable systems — those that proceed not under the sole direction of one centralized design authority but by being adapted and extended in a thousand small ways in a thousand places at once — have three main characteristics that are germane to their eventual victories over strong, centrally designed protocols.

  Only solutions that produce partial results when partially implemented can succeed. The network is littered with ideas that would have worked had everybody adopted them. Evolvable systems begin partially working right away and then grow, rather than needing to be perfected and frozen. …

  What is, is wrong. Because evolvable systems have always been adapted to earlier conditions and are always being further adapted to present conditions, they are always behind the times. No evolving protocol is ever perfectly in sync with the challenges it faces.

  Finally, Orgel’s Rule, named for the evolutionary biologist Leslie Orgel — Evolution is cleverer than you are. …  it is easy to point out what is wrong with any evolvable system at any point in its life. … However, the ability to understand what is missing at any given moment does not mean that one person or a small central group can design a better system in the long haul.

Evolution is messy, brilliant ideas don’t work, money is wasted, efforts are duplicated, but the Internet has shown that the process is capable linking growing requirements with expanding capabilities to produce solutions to problems we don’t even know we have. The Internet is a better model than traditional, cathedral like systems for what we are dealing with when we talk about converting and sharing medical information in an electronic format.

It’s dinosaurs vs. mammals, and the mammals win every time. … Infrastructure built on evolvable protocols will always be partially incomplete, partially wrong and ultimately better designed than its competition.

There will be some large systems to deal with complex environments. Small systems to deal with special needs. “Apps” to deal with general needs, and forms we haven’t imagined to deal with opportunities undreamed of. We need to recognize that lack of clarity and structure is just part of the process. We need to learn to live with it and occasionally laugh at it, curse it, and celebrate it

[1] Eric S. Raymond (1999). The Cathedral & the Bazaar. O’Reilly. ISBN 1-56592-724-9.

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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:

CloudSo, 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

EMRs: Brass Ring for Insurance Companies

A brass ring is a small grabbable ring that a dispenser presents to a carousel rider during the course of a ride. Usually there are a large number of iron rings and one brass ring that can be exchanged for a prize. An opportunity to achieve wealth or success.

There are values to electronic medical records (EMR) in a standalone system. Those benefits have been available for years and have provided only limited incentives for doctors to use them. There are significant additional values from sharing the information in these systems but most of the networking has been motivated by good intentions, not market forces. This post describes a way to bring a combination of good intentions and market forces together to hasten the adoption of networked EMRs.

This proposal plays on the interests of two participants at the edges of most of the current work being done on EMRs: consumers and health insurance companies. Consumers have been given only limited tools with limited links. Insurance companies haven’t seen, or at least haven’t exploited, the opportunities.

The initial step is for insurance companies to recognize the benefits of better patient care and potential cost reductions through networked medical record systems and then offer two new services, one for consumers and one for doctors.

In neither case will the insurance company access, store, or transmit personal health information (PHI.) In the scheme of doctor/patient relationships there is no reason for the insurance companies to take responsibility for this information and, as a practical matter, the level of public distrust of large corporations is so high that direct participation by insurance companies would probably be more of a hindrance than benefit. The consumer will own their data and any data they receive from their doctor; the doctor will own the data from their EMR system including the data they receive from their patient.

The proposed services for consumers and doctors provide new ways for insurance companies to differentiate their service offerings. One of the reasons for me as a consumer to chose company “A” could be they let me know which of my doctors is able to access my personal health record (PHR) to improve the information available for decisions about my health or, if I am looking for a doctor, which affiliated doctors offer those services.

As a doctor, affiliation with company “A” could give me access to better information about some of my patients and provides incentives for new patients to call me. The insurance company that moves first will gain a first mover advantage; the others will have to play catch up.

consumerThe service for consumers will allow me to contact my insurance company and inquire about affiliated doctors and their EMR systems and services. I can then use that information as part of the process of selecting a doctor.

I will also be notified by my insurance company if a doctor I have used in the last n months improves their EMR related services. This will allow me to take advantage of those improvements or allow me to feel better about recommending my doctor to a friend.

From a patient perspective, the primary advantage will be that I can contact my insurance company and inform them that I now have a PHR and specify which doctors will have access to it and under what conditions.From the insured’s point of view it might look like this: I log on to a secure Web page provided by the insurance company (think of a home page for online banking).

  • I indicate my desire to participate in the medical record exchange program sponsored by the insurance company and specify the terms of my participation. This could includeAuthorization to send a notice to an affiliated doctor that I have a PHR and want to share information: (a) if the doctor inquires about a covered service, (b) or inquires about a service whether covered or not, (c) or if they have provided services to me during the last n months, (D) or if they are on the following list, etc.
  • As part of that notice include the name of my PHR, e.g., Google Health, Health Vault, and provide instructions to gain access.

Options to gain access could include: call me, call a trusted third party in case of an emergency, remind me during my next visit to provide this information, access the insurance company’s secure site and log on to get more information, etc. There are a number of ways the options for access can be expanded to include access to all or parts of my PHR for emergency medical services, or for doctors overseas if I am on a trip, etc. The providers of PHR systems will almost certainly develop additional options.

doctorThe service for doctors will allow a doctor to log on to a secure Web page provided by the insurance company (again, think of a home page for online banking) and authorize the company to let current and/or prospective buyers of insurance know that the doctor has an electronic medical records system for his practice and will make test results and medical records available to patients in (a) an electronic format, (b) hard copy, or (c) both.

When any doctor’s office contacts my insurance company to confirm coverage, the company’s response will include information about my PHR if I have authorized the company to share that information.

The doctor will get the same number of messages from the insurance company as they get today. They will get a message about my PHR only when they inquire about my coverage and the message will be a bit longer only if I have a PHR. Doctors who do not have an EMR will get a sense of the potential value of having one and they will be able to access my PHR, print a copy, and add it to my paper file in their office. Whether or not the doctor has an EMR, this is an added service for me and my doctor.

When one of my doctors gets a new or upgraded EMR and is ready to share information, they will have the information they need to get copies of my medical records and to send test results and medical records to me. Neither they nor I will have to register with the insurance company or do anything else to share information. Nobody has to remember to do anything or wait for action by anyone else. A doctor who makes an inquiry about my coverage will get the information they need to access my PHR, get information, and post information.

Doctors who find benefit in the networking capability will encourage their patients to get PHRs and will recommend the services that provide the best interfaces to and from the doctor’s system. Providers of PHR services will have incentives to interface to popular EMR systems. More subscribers will give providers of PHR systems additional incentives to continue developing features and functions. EMR system providers will have incentives to provide interfaces to the leading PHR systems to support their efforts to sell new or upgraded systems to doctors. Market forces will be aligned to support the wider adoption of EMRs.

Solving the problems with America’s medical delivery systems will require a number of changes. This is one that can be implemented fairly quickly without regard to any regulatory requirements other than HIPAA security and with limited investment. Many of the required capabilities are in place already. Required changes to computer systems can probably be accommodated through additions to existing systems rather than costly new system development. Most system and operating changes can be implemented incrementally to spread costs and minimize risks.

Insurance companies that provide these two services will contribute to better medical services and lower cost and earn a public relations brass ring.

One small step for electronic medical records; one giant step for better health care at lower cost.

Endless barrage of information

I love it when several lines of thought come together and provide some new insights. Not an answer or answers, but suggestions about more fertile places to look. A July 4th post by Cindy Throop planted a seed of thought that sort of nagged at me but didn’t immediately lead anywhere:

“Apparently, I’m not the only one feeling overwhelmed by information related to health care reform. Others have reached a saturation point as well. … In addition to an endless barrage of information (and discussions and debates regarding various combinations of information), trying to find a voice in the midst of the chaos is intimidating. Is anyone listening? Does what I say matter? If I spend endless hours of my “spare time” learning everything I can about health care reform, will the effort be futile? Will my opinion be heard?

There is an incredible amount of information and opinion about electronic medical records (EMR.) Almost all rational but not much of it that is actionable. Each element is part of something valuable but too fragmented to see what that something is. Too many competing interests and points of view with almost no participation by those who will realize the real value—patients.

Then Barbara Duck posted Twitter comment about clinics at CVS and Walgreens using Google and Microsoft’s patient health records (PHRs) to facilitate service for patients and to report back to the patient’s doctor. Providers—mini clinics–at the disruptive edge of the medical establishment and outside much of the debate are using the personal forms of the healthcare industry’s electronic systems to provide better service and more value to their patients.

Value drives technology. Technology didn’t drive the innovations of the Internet. Technology facilitated them but value drove them. CompuServe and AOL developed proprietary systems but Netscape went after an open format that drove value. The value of the open system was recognized in the marketplace. Netscape lost but showed the way and was soon followed by Firefox. AOL tried to play catch-up but lost its luster. Others saw value and went to the marketplace with browsers, email, blogs, Twitter, etc. A variety of choices to respond to a range of needs but all able to interoperate based on worldwide industry driven standards.

EMRs are about providing value. Can information and debate facilitate the creation and delivery of value? Yes. Can we see where the value will lie and the form it will take? Only dimly. We weren’t very good at figuring out where the Internet would take us. But value—usually real value and sometimes just the possibility of future value—continues to drive innovations and increase the value of the Internet.

In an “endless barrage of information (and discussions and debates regarding various combinations of information”) there isn’t anyone listening in a way that will make a difference, the effort may be futile, one more opinion probably won’t matter. Maybe some new ways of looking at the issues will help. Stay tuned.