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Arguing For Open Electronic Health Records

Zonk posted more than 6 years ago | from the keeping-it-on-the-up-and-up dept.

Software 111

mynameismonkey writes "openEHR guru Tim Cook, writing in a guest blog at A Scanner Brightly, discusses why Electronic Health Record developers should use open standards. Why are so few doctors using EHR systems? And, as more and more hospital EHR systems come online across the country, what do we have to fear from proprietary databases? It's one thing to find out your social security number was stolen. Now add your mental health and STD results to those records."

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111 comments

Ask slashdot: What's it like to eat pussy? (-1, Offtopic)

Anonymous Coward | more than 6 years ago | (#21854938)

Please discuss.

Hey, at least it isn't myminicity

Re:Ask slashdot: What's it like to eat pussy? (0)

Anonymous Coward | more than 6 years ago | (#21856242)

That's like asking the Amish what it's like to watch television.

I seriously doubt it (1)

TheHawke (237817) | more than 6 years ago | (#21854946)

Companies selling the systems make a killing from the converting of the old, proprietary database to the new, proprietary database that does not look that much different than the old one.

Re:I seriously doubt it (1, Interesting)

Anonymous Coward | more than 6 years ago | (#21855010)

I work with 2 EMRs at my job as an IT Director, both of which use MSSQL as the DB. I have full access to the Database at all times.

Re:I seriously doubt it (1)

TheHawke (237817) | more than 6 years ago | (#21855514)

Good for you. Then watch as the asshats on the board want to use something completely different that some salesjerk snowed them on saying that SQL is old and obsolete, selling the company an old version of FOXpro wrapped up in a eye candy shell. I pray that this does not happen to you and your company, fighting it tooth and nail until they email you a pink slip, or worse.

Re:I seriously doubt it (3, Insightful)

mrbluze (1034940) | more than 6 years ago | (#21855046)

Companies selling the systems make a killing from the converting of the old, proprietary database to the new, proprietary database that does not look that much different than the old one.

I think much of the problem has to do with legal problems on the storage of data and its dissemination (privacy laws, legal exposure etc) and that doctors have a general distrust of electronic record keeping without a paper backup. Also, arriving at an open standard on storage of health information is very very difficult as it's not a science and there are as many opinions as asses on seats at committee meetings. Everybody quotes easy stuff like pharmacy orders or pathology requests and results, but a health record can come in so many forms, (and if you look at a hospital record, there are so many types of forms in it) that it becomes difficult to come up with a database design that will cope with such diversity and still be usable. Information on a case can be a few scribbles to an exhaustive analysis.


That's not to say it won't happen, but it is taking a very long time and some expensive attempts at standardization (eg: NHS) have failed.


Re:I seriously doubt it (4, Informative)

h4rm0ny (722443) | more than 6 years ago | (#21855198)


In the UK, the government has invested vast sums of money into a system called "Choose and Book." It's billed on the slim selling point of offering patients greater choice in hospital care but the most cursory look at the technology involved shows that the biggest effect is that of centralising patient's records.

Aside from the fact that patients can be offered a choice in secondary care already (by their doctor referring them to somewhere else), the system is buggy and flawed. The doctors don't want it, there have been national campaigns by the public against it, but the government is doing every single thing they can to force it on people up to and including financially penalising doctor's practices for not using it. The motivations are (a) presumed financial interests in the big companies that are providing the system and (b) a burning desire to get hold of everyone's personal medical data for government and police purposes.

It's not even legal as the responsibility for patient confidentiality belongs to the patient's own GP and if there's a misuse, they will be the ones legally to blame for sharing the data. There's some information on it here

If there's a need for easily transportable medical records, then this can be resolved by putting the data in the patient's hands. Public-Private key technology, or even hashes of the data, could be used to ensure accuracy. The solution is not that complicated, but in the UK we're having a very hard fight getting it.

Choose and Book is window dressing. (1)

Dr_Barnowl (709838) | more than 6 years ago | (#21857926)

This is a project chosen for it's visibility. The perfect medical software just works, and the patient never sees it. But this doesn't win you any votes when you've been lambasted in the press for spending $12B of public money on IT projects.

Patients don't WANT a choice of specialist hospital or doctor. They just want to go to the best one, and they don't have the specialist knowledge to make that choice, so they will ask their doctor.

The proper implementation of C&B is therefore to give a client to GPs that they can book appointments with. The decision to expose it to the general public is purely to say "hey, look, we made something that works".

Re:Choose and Book is window dressing. (1)

h4rm0ny (722443) | more than 6 years ago | (#21858178)


The proper implementation of C&B is therefore to give a client to GPs that they can book appointments with. The decision to expose it to the general public is purely to say "hey, look, we made something that works".
Well for most of the time, they've been saying "hey look, we made something that doesn't work," but I agree with you. I add though, that almost no doctor that I know wants the system either. GPs usually have a pretty good handle on where to send people and can choose differently if there's a specific need or preference on the patient's part, anyway. The correct approach to implementing this would be to try and decentralise things as much as possible - hospitals show what they've got, GP's book like a hotel room. Okay - you need more sophistication than that, but last I saw, Choose and Book was a monstrous, top-down system that fell over frequently and took everyone else with it. The only reasons I see it being designed the way it has been are to centralise control of the medical records and to feed large sums of money to certain companies. Furthermore, a lot of people's time is being wasted at the PCTs and in the practices either implementing this or checking practices compliance with it.

And it has come straight from Number 10 with zero willingness to listen to anyone who actually does real work in the NHS.

If I sound pissed off, it's because I am.

Re:I seriously doubt it (1)

finty (1210050) | more than 6 years ago | (#21858184)

The solution is not that complicated, but in the UK we're having a very hard fight getting it. Slovakia is to.

Re:I seriously doubt it (2, Informative)

ThreeGigs (239452) | more than 6 years ago | (#21855544)

Google "HIPAA" and/or X12 EDI

It's a data exchange format that *all* health care insurers and providers must accept or provide when exchanging patient data. It's trivial to add to the spec rules for additional subloops containing text. There are codes and modifiers enough to cover damned near any medical situation.

Many small doctors avoided electronic data altogether by doing as they'd done for years, namely keep paper records. That is until insurance companies began deprecating paper... by not accepting paper claims at all, charging a premium for processing paper forms, or cutting staff levels in their data entry pool which has the effect of seriously delaying payment to the physician.

Re:I seriously doubt it (2, Interesting)

budgenator (254554) | more than 6 years ago | (#21856018)

You need to go down into the records storage area and just look at the physical mess there. Some of the forms are flimsies and are going to disintegrate long before the AMA/ADA HIPPA/OSHA specified 30 years are up and those radiographs are most likely to fixer stain into unreadability as well. Most offices pull inactive records and shove them into a "bankers box" which are then shoved into a storage area that isn't climate controlled and keep the boxes in chronological order by date pulled and the internal chart in alphabetical order usually in a rental storeage unit so vermin can nest in the nice warm paper! Now imagine the FBI calling and saying one of your patients from ten years ago got fed to the alligator, please send dental records for ID; you can spend $2,000.00 in wages doing a futile search! Sooner or later we're going to have to do it, paper and film is just to expensive to store for that long.

Arguments for and against. (3, Informative)

spineboy (22918) | more than 6 years ago | (#21857968)

Every week I have some patients who have come in from far away to see me with some X-rays, MRI, CT scans. Often they are on a CD with some strange proprietary program used to display the images. Often I cant open them up and look at them, and the person has made a several hour trip almost for nothing.
In that way old fashioned plain images are better.
Having open source images/records would also eliminate that problem too, as I could display the images, and not have to find/buy/ download some strange/clunky program.

Most radiologists and newer surgeons really like electronic imaging, but it can backfire on you as well.

Re:I seriously doubt it (3, Interesting)

TCook (66808) | more than 6 years ago | (#21855120)

The question that brought about the guest blog was; "why aren't primary care physicians adopting electronic health records?"
The answer is (primarily) because of misaligned incentives. Open specifications can help solve that problem. Especially ones that are implementable (some specifications are known to be developed in a committee room without being tested in software).

But the above post exposes a truth. Many proprietary companies are making money off of a few customers using the same old "upgrade tax" imposed by some operating system vendors. This is why applications based on truly open specifications can be marketed as being something different.

This is a very complex area with complex issues that vary around the world. However, the two level modeling approach used in the openEHR specs are being used in many places. Are we *brave enough* in the US to use something "not invented here"?

   

Why would...? (0, Redundant)

WED Fan (911325) | more than 6 years ago | (#21856760)

Why would /. geeks be worried about their STD histories falling into the wrong hands? A prerequisite to that would be first a case of a virus jumping from online chat or a hentai pic to human host, then /. readers would be worried about it.

Already Hacked (-1, Troll)

Anonymous Coward | more than 6 years ago | (#21854972)

not a good look when they are trying to defend the security of their database [dwarfurl.com]

What? Me worry? (2, Insightful)

Jorkapp (684095) | more than 6 years ago | (#21854984)

Now add your mental health and STD results to those records.

This is Slashdot. An STD would practically be a trophy here.

Re:What? Me worry? (1)

thegrassyknowl (762218) | more than 6 years ago | (#21855306)

Yeah but the slash virgins would never get STDs even if they were having sex. They'd all be too paranoid about spawning unwanted processes :p to go without App Armour ;)

Re:What? Me worry? (2, Funny)

deniable (76198) | more than 6 years ago | (#21855550)

I can just see some bright marketing type selling condoms as "Personal firewalls."

I dont know, but... (0)

Anonymous Coward | more than 6 years ago | (#21854990)

I am an IT director working for a Billing / EMR delivery company. I can tell you it is much easier to work with EMRs vs paper since it can be "coded" by people who work remotely. It also kills less trees and is a significant reduction on costs.

The IT perspecive is even better because any EMR can be "scanned" for key information and automatically "coded".

However, the end user experience is pretty darn rough. The doctors have to decide which one is best, obtain support for the EMR product, and then train themselves and others on it. Of course this is a large up front investment and they may not be happy with it in the end.

I think this is where our company comes in, we are kind of the middle man and work on creating the best environment for the doctor. We train them and field support questions and also work with the EMR companies we use to make their product better. Some EMR companies are more responsive than others, for sure.

All in all, I would expect to see more companies like mine pop up and provide the assistance that Doctors need and want. Lets face it, the Doctors are too busy with their patients to be concerned about their MR system.

SECURITY (3, Funny)

mboverload (657893) | more than 6 years ago | (#21855024)

Primahealth: How are they secure with open standards? You can't have security without obscurity! THIS IS MADNESS!!!
Stallman: This is GNU/SPARTAAAAA!!!!

I think the problem is more that the (0)

Anonymous Coward | more than 6 years ago | (#21855076)

doctors keep your health records rather than yourself.

If the consumer could keep their own health records, they could perhaps choose which digital format to have it in, which online service, etcetera. The patient could choose after each visit to have the doctor email the information to his address or to a central repository.

Open Standards bad (1)

Jah-Wren Ryel (80510) | more than 6 years ago | (#21855088)

I have every expectation that electronic health records will be abused. And I don't mean simple cases of identity-theft. I mean systemic abuse by organizations which have 'legitimate' access. Call me paranoid. Go ahead and make jokes about my tin-foil hat. But with history as a guide, I believe that such abuses are inevitable.

So, from my point of view, the harder it is to integrate electronic health records from disparate systems, the better. The more proprietary and undocumented these systems are, the less opportunity for abuse. I have no illusion that a lack of common and open standards for these records will prevent ALL abuse. But I do believe they are at least as much of an impediment to abuse as they are to valid uses. And frankly, I don't think there is as much value in interoperability as its proponents make it out to be.

Re:Open Standards bad (1)

Stoertebeker (1005619) | more than 6 years ago | (#21855114)

This has nothing to do with open standards, though. The problem is the absence of privacy protection in the US. Of course, it doesn't help to make it even easier for say a Workers comp insurer to scan through your mental health records trying to prove how that broken leg is all in your head...

Re:Open Standards bad (1)

cheater512 (783349) | more than 6 years ago | (#21855820)

IMHO centralized electronic medical records would be very useful and should be implemented.
Under the condition that no data can be accessed without explicit permission or in life or death situations.

To make it simple, going to the GP would give the GP a brief overall view of your records.
If the GP wants to delve in deeper then you need to 'unlock' the data.
And the GP can access the data for a period of time. Lets say a week.
If you've got cancer or something else with long term treatment then your doctor would get a longer timeout.

Using fingerprints would make it easy and convenient.
If done correctly there wont be a fingerprint db either - it would be hashed and used as a password.

Re:Open Standards bad (1)

IL-CSIXTY4 (801087) | more than 6 years ago | (#21857126)

It may be possible to reconstruct fingerprints from the template data stored about them. There's no documented case of this being done in the field, but there's a paper on it at http://www.csee.wvu.edu/~ross/pubs/RossReconstruct_SPIE05.pdf [wvu.edu]

I really don't like using biometric data as passwords for anything as important as health records, since they're irrevocable.

Re:Open Standards bad (1)

cheater512 (783349) | more than 6 years ago | (#21859280)

They arent irrevocable. You can change it 10 times.
20 if you dont mind that kind of thing. ;)

Re:Open Standards bad (1)

jayp00001 (267507) | more than 6 years ago | (#21857452)

Who cares how long a GP has access to your records- the ones selling your info to insurance companies ( the only winner in using EHR systems) will copy it with one swipe of a mouse or printscreen. I can't think if a single reason to have a centralized repository of private health data that isn't completly offset by the privacy and liability issues attached to it.

Who owns it (2, Insightful)

sane? (179855) | more than 6 years ago | (#21855092)

A better question is who owns your record?

An unsettling issue is that the doctor or hospital generally considers that THEY own your record. Think about that for a second...detailed records of you and your peccadilloes and someone else thinks they own and have the right to do what they want with your data.

In a world where that little vulnerability were straightened out open standards based ways of working with your personal data would come by default. You should be able to store and deploy your data, under your control, will any medical professional only being allowed to access and add to those records with your permissions. The only way to make that work is for hospital systems to use open standards, no more proprietary systems and no corporate data caches.

OpenEHRs are a sideshow next to that.

Re:Who owns it (1)

thegrassyknowl (762218) | more than 6 years ago | (#21855334)

An unsettling issue is that the doctor or hospital generally considers that THEY own your record.

I have only heard one case of a doctor thinking they own the medical records of a patient. All other doctors I know are happy to share records with other doctors once they have confirmed that the patient actually consents to that. I've never had any trouble viewing my record with any of the doctors or specialists I've visited in my time.

The one case I heard of was a deceased doctor. His son took ownership of the doctor's practice and decided to make a quick bob by charging for access to parts of the record. He wouldn't pass on the whole record at once and he was charging some crazy amount like $50 per page scanned and emailed.

The shitty part was that this guy wasn't a doctor and as such wasn't bound by the doctor-patient privilege yet was reading patient files.

That said, I don't live in money-crazy US where I would believe it if someone claimed the reverse was true.

Re:Who owns it (1)

jbengt (874751) | more than 6 years ago | (#21857348)

In my experience, almost every time a new doctor or hospital required records from a previous one, there was a charge for duplicating and sending the records. Though they never gouged me like your anecdote above; it was typically a one-time fee of $25 or so for the entire record.

Re:Who owns it (1)

HangingChad (677530) | more than 6 years ago | (#21855488)

You should be able to store and deploy your data, under your control, will any medical professional only being allowed to access and add to those records with your permissions.

Then how do you prove something like Medicaid fraud? Which is rampant. Or be alerted to people clinic shopping for pain meds? Also rampant. Many times hospitals have to comply with laws that make them or your doctor responsible for someone else getting silly.

Generally I tend to side with your viewpoint but I've also come into contact with those in rehab when dealing with a close relative with addiction issues. Some of them are relentlessly imaginative when it comes to gaming the system to get drugs. Collectively we lose hundreds of millions to Medicaid fraud. A lot of times hospitals and doctors are caught between their patient and law enforcement. And that doesn't even touch the insurance companies. If there's data abuse going on anywhere in the medical system, it's on the insurance side.

Personally, I think we could get by with a lot less law enforcement involvement in medical care. But to get there we need a mechanism for the primary care provider to alert authorities to the more egregious abuses and that's at odds with the privacy of your medical records. Solve those problems and I believe the interchange data format becomes much less of a mountain to climb.

Re:Who owns it (1)

budgenator (254554) | more than 6 years ago | (#21856172)

Actually they do own the records and can do anything they want with the information in the records consistent with the laws and usually more stringent industry customs and personal ethics.

One small problem with that... (1)

NIckGorton (974753) | more than 6 years ago | (#21857158)

Say the patient has been diagnosed with schizophrenia, but doesn't believe that diagnosis is valid because he knows the real problem is that its really that the video game industry in an unholy alliance with the DoD and is out to get him?

Or many other diagnoses or bits of information that patients do not want providers to access but which are important to their care. Like drug abuse, blood born or sexually transmitted disease, or other mental health problems. A pregnant woman with pelvic pain with a history of chlamydia PID is at much greater risk for having an ectopic pregnancy that will kill her, however that may not be divulged by the individual if she's able to manage her medical records.

There are other rights as well to consider. If I am suturing your laceration and you move suddenly and cause me to stick myself with the bloody needle I was suturing you with, do you think its unreasonable for me to want to know whether you are HIV or Hep B or C positive?

In addition, what if you arrive to the ER after a motor vehicle crash and cannot give the critical information that you are on a strong blood thinner.

So its not that simple.

Nick

Re:Who owns it (1)

jbengt (874751) | more than 6 years ago | (#21857306)

I would assume that the doctor/hosptial/insurance company owns the records.
That's why we have laws about access to them and privacy concerns about them.
The medical practice is the one that makes the records, puts them in a form (hopefully) most useful to them, and needs to reference them and share them with other caregivers in the course of caring for you.
Most people wouldn't have a clue what they contained even if they read them.

Re:Who owns it (1)

trenobus (730756) | more than 6 years ago | (#21858082)

It's a mistake to assume that information, particularly information assembled from a multitude of sources (such as an EHR) can be owned. Any system which purports to give you "ownership" of your EHR is also giving you a false sense of security. Nevertheless, some kind of access control is imperative for EHR's, both for reading and writing. But it needs to be flexible enough to avoid impeding the sharing of information about a particular patient between potentially many caregivers for that patient. A system that does not provide this flexibility will be routinely circumvented, or will fail. The system that will succeed is the one which improves on current practice.

This is not just a technological issue but a legal one as well. In the long run the best legal strategy may be to focus on the abuse of information, rather than how someone comes to possess it. And I'm thinking that for most types of information, having the information would not constitute abuse.

You own it (2, Informative)

peacefinder (469349) | more than 6 years ago | (#21858506)

At least in the US, HIPAA [hhs.gov] says the contents of your medical record are yours, and the healthcare provider is a custodian of that data. That said, there are some caveats.

* Not all data in an EHR system relating to you is actually part of your medical record. There may be - probably is - some internal clinical communication attached to your chart in the course of clinical operations. Basically an EHR system usually tracks both your record and the providers' own record about you. These different classes of data are pretty straightforward to distinguish most of the time; you own the former and you don't own the latter.

* Providing you with a copy of your record has some cost, and custodians of records are allowed to recover reasonable costs from you to cover those expenses.

* Some data about your records may be disclosed as necessary for Treatment, Payment, or healthcare Operations; these disclosures are limited to the minimum necessary and (generally speaking) are also limited to other entities coveredby HIPAA.

* The government can get what it wants, when it wants, and you and your records custodians have f--k all to say about it.

Within those broad costraints, though... it's yours and your provider should treat it as such.

My stolen STD records? (3, Interesting)

dmr001 (103373) | more than 6 years ago | (#21855094)

1. I don't get the article summary. Are my STD results somehow more vulnerable to theft if they are in a proprietary database format rather than an open one?
2. In my practice, we use an EHR (electronic health record) because I'm an employee of a big enough group that has the resources to purchase one of these expensive, bloated, not very well-maintained systems. (They're still working on making cut and paste work, and the group has to pay a bucket of money every month for ongoing support.) When I was a medical student in Ireland, I marveled how the GP I worked with in West Clare had a simple system he paid something like $300 which did everything he needed it to do, like track progress notes and lists, and keep track of drugs. That amount here covers about 30 seconds of use of our current software. Which is barely interoperable even with itself - if we see a patient from an affiliated private group using the same software, interoperability means they can email us a progress note, and then I can spend my afternoon hand-entering the medications and problems from their chart into my state of the art software's database to make sure grandpa doesn't crump over the holiday from a drug interaction with the cardiologist's new pills.

There isn't much incentive to make this software as easy to use as iTunes - the players seem to make plenty of money already with their proprietary storage formats and circa 1991 interface. There is no viable open source alternative (http://oemr.org/ [oemr.org] doesn't look quite ready for prime time) - though I think there's an opportunity here for some enterprising Linux loving propellerheads.

Re:My stolen STD records? (1)

TCook (66808) | more than 6 years ago | (#21855638)

You make some good points. However, oemr.org is far from the only player in this arena. Check out the following sites:

Linux Medical News http://www.linuxmednews.com/ [linuxmednews.com]

OSHCA http://www.oshca.org/ [oshca.org]

Openhealth mailing list openhealth@yahoogroups.com

There you will find that there are several ongoing projects as well as companies providing support.

Still the issue remains (in the US) around who is paying and who is benefiting.

Once the various vendors (open or proprietary) realize that they MUST work together then and only then will there be serious uptake in EHR usage.

Security is an important implementation matter but has nothing to do with information exchange standards.

Re:My stolen STD records? (1)

yuna49 (905461) | more than 6 years ago | (#21858534)

There is no viable open source alternative (http://oemr.org/ doesn't look quite ready for prime time) - though I think there's an opportunity here for some enterprising Linux loving propellerheads.

I wish I had your optimism. I spent some time discussing open-source options with IT people in US community health centers, organizations with small budgets and difficult patient loads. You would think that, of all people in the medical community, CHC's would be among those looking for low-cost solutions like open-sourced software. In reality, they were just as tied to proprietary solutions as any large medical organization, perhaps even more so.

In many cases providers like these are tied to large hospital networks, so whatever their hospitals implement becomes what they implement. Next, there's the usual, "if it's free, it can't be good," syndrome at work. Because medical practitioners have become so used to dealing with large IT providers like GE Healthcare, they simply can't imagine alternatives that don't come with a lot of corporate backing and corporate support. Remember that most medical professionals are looking over their shoulders at potential lawsuits. Regardless of whether in reality it makes little difference whether those records were stored in OpenEHR or in some large provider's proprietary system, it probably does make a difference when you're testifying on the witness stand.

Finally if you're short on funds, you might actually prefer the proprietary solution with a support contract over an open-source solution that requires a level of IT competence, particulary competence with Unix/Linux, that still doesn't exist in most IT departments where Windows rules the day.

Re:My stolen STD records? (0)

Anonymous Coward | more than 6 years ago | (#21859966)

I used to work on a patient tracking system. It was fairly awesome and robust. The real problem is who owns most of these places. They are mostly either 'large groups' or small 1-2 people affairs. The large groups have no interest in changing as they usually already have something that works. The small guys dont have the cash to drop on something the nurse up front can take care of (ie its not their problem and not their job).

There are TONS of awesome software out there. The problem is most do not care.

The alternative is worse (1)

rastoboy29 (807168) | more than 6 years ago | (#21855106)

Shall we not computerize the health care industry, then?

We can keep our data very safe if they never input it into computers.  After all, there would be no benefit to correspond with the risk, yes?

Non sequitur (2, Insightful)

edittard (805475) | more than 6 years ago | (#21855108)

what do we have to fear from proprietary databases? It's one thing to find out your social security number was stolen. Now add your mental health and STD results to those records.
I don't see the connection here. Generally users interact with applications and the applications interact with the DBMS. So while it may be true that some are more secure than others, it's largely irrelevant. The organisation's policies anmd procedures are much more important, given that the weak point is usually the carbon units.

A Disaster Waiting to Happen (4, Interesting)

plusser (685253) | more than 6 years ago | (#21855122)

The UK has spent the last 5 years trying to build a common Health Record Database for all NHS patients. Those of you that are aware, the HNS is a public run service that covers the health needs of the entire population, although Private medical Insurance is available if required at extra cost. So far this "Database" has cost the UK Taxpayer £12 billion ($24 US Dollars) and has delivered nothing but chaos, confusion and a lack of investment in frontline databases that are currently in use, meaning that records go missing, data discs with confidential data get lost etc... http://news.bbc.co.uk/1/hi/uk/7158498.stm [bbc.co.uk]

The fundamental problem is that politicians think that databases are the answer to everything, being handy for issuing speeding fines, holding criminal records and identity details of everybody in the country, but they haven't quite got round to the concept that the accuracy the data within a database is the most important aspect and it is often the data processing factor that often falls down. They forget the basic fundamental questions like:-

How long does the data take to propagate into the system properly? If I tax my car late on Friday will the computer database not be updated until Monday, meaning that I'm going to be constantly pulled over by the Police and threatened with my transport being impounded for the weekend, even though it is perfectly legal?
What happens if the data is incorrect? Our beloved UK government wants an all encompassing ID card system, which will reference a number of different databases. How can they be absolutely sure that the data is at least 6 sigma (3.4 defects per million records) if not 100% correct (note that the old saying 99.9% doesn't even being to recognise the real accuracy required).

If the data is incorrect who is responsible? If there are many bodies involved, you can guarantee that none of them will agree who is at fault until lawyers get involved, especially if they are civil servants and/or politicians.

Who ensures that the data is secure? We in the UK had ZIP encrypted discs containing details of 25 million people (about 2/5 of the UK population) lost by the HRMC recently. http://news.bbc.co.uk/1/hi/uk_politics/7117291.stm [bbc.co.uk]

One the face of it using an open system for designing a database is a good idea in principle, but it is the people that are responsible for these databases that need to know exactly why they are important and why reliance on such databases is a recipe for disaster if proper considerations are not made. Part of the problem is that many of the people choosing these databases probably don't have a first clue in how a database works, that is the problem we face.

I did notice that this week the new Australian Prime Minister Kevin Rudd cancelled a National ID card system that was planed by the Howard Administration. This move appears to come from somebody that appears to understand the complex nature of such a system, its cost and its lack of benefit. There are many ways that can be used to determine somebodies identify (bank cards, passport, birth certificate) and having all of them referenced at the same place isn't the most cost effective solution.

Re:A Disaster Waiting to Happen (1)

SigILL (6475) | more than 6 years ago | (#21855374)

£12 billion ($24 US Dollars)

Wow, the pound sterling obviously isn't the stable currency it once was!

Britain has a culture of incompetence, alas (0)

Anonymous Coward | more than 6 years ago | (#21858072)

Unfortunately I think the U.K. itself is part of the problem. Even more than the United States, in the UK there's a glorification of management, contempt for technical knowledge, and misplaced faith that their class-based system will somehow muddle through.

Other than Richard Branson (Virgin Air) all the UK managers and executives seem hopeless.

They already do use open stardards (0)

Anonymous Coward | more than 6 years ago | (#21855146)

Look up "HL7" (Health Level 7). Unfortunately, in practice, everyone uses a slightly different flavour of HL7, which is a pain in the backside when developing.

Re:They already do use open stardards (1)

Cerberus7 (66071) | more than 6 years ago | (#21856206)

Also, HL7 is only designed for interfaces. It's not about storing information, it's about moving information from system A to system B. You could, I suppose, design a storage system based upon the HL7 spec, but as you said, you have to decide which version you're going to use, and what you're going to do every time HL7 gets updated. Fortunately, HL7 is designed for backwards compatibility, and a part of the header specifies which version the segments being sent are using.

Re:They already do use open stardards (1)

ArikTheRed (865776) | more than 6 years ago | (#21856498)

Too bad HL7 is a complex piece of shit. Sure - you can encode anything... in the same way that I can encode anything with this interface: "Stuff"... just extend "Stuff" and away you go! Point is, it's way too generic and vague to be of much use (I worked in HL7 for years before our company had to ditch it - there was literlly no upside to the over-complication... ever try to transport a clinical event? Can take 50 objects where one would suffice before).

That said - there is one good thing to come from HL7 (through not directly from it - inspired by it): Metathesaurus [nih.gov] . Forget about HL7... let's focus on a common grammar first. That's the true weak point here.

Re:They already do use open stardards (1)

Dr_Barnowl (709838) | more than 6 years ago | (#21858036)

Too bad HL7 is a complex piece of shit
You're thinking of HL7 v2. HL7 v3 is to HL7 v2 what a mighty herd of elephants is to Dumbo.

Re:They already do use open stardards (1)

ArikTheRed (865776) | more than 6 years ago | (#21859624)

Yeah - except I am talking about the complexity of RIM, which is purely a v3 construct.

Confusing two thinsg (1)

houghi (78078) | more than 6 years ago | (#21855174)

It's one thing to find out your social security number was stolen. Now add your mental health and STD results to those records.


Security and theft are not the same as open or not. You can steal my data on closed format, like Word and everybody can see it. You can steal my plaintext gpg files and have no idea what they contain.

Security must be an extra layer. The main difference mostly between open and closed is that closed formats handles mostly with security through obscurity.

Use encryption!

There's no standard because it's impossible. (4, Interesting)

DraconPern (521756) | more than 6 years ago | (#21855238)

It's impossible to store in a structured manner health information because it's so complex and individualized. Think about how to store the following.
1) "My arm hurts right here!" "Show me?" "Here!" "Wait, it's here now" "No no, it's here now"
2) "It itches sometimes" "when?, where?, duration? during aligment of planets!?"
3) "You need to take xyz, twice a day for two weeks. Come back in 3 month, and let's do another check up."

If anyone wants to know how complex it is, try reading the DICOM standard which is just for medical *image* storage and exchange. It's about 3500 pages. The code for medical billing, which the article mentions, is already the size of a dictionary. And all it contains is entries for a simple code and a one or two sentence description.

Realistically, the best approach may be PDF's and full text search. Anything else is just not going to capture the full extent of the medical history.

This "openEHR" thing is a meta-standard (1)

m0llusk (789903) | more than 6 years ago | (#21855430)

Whether successful or not, the openEHR [openehr.org] standard discussed in the article attempts to solve this problem by creating a kind of meta-standard where descriptions of data and documents are used in a flexible way. This manner of organizing storage is extremely open ended. There is a graphic overview covering this that can be downloaded from the "Quick links for ... IT professionals" link on the right side of the main page (PDF [openehr.org] HTML [openehr.org] . The design is object oriented and general such that it could be applied to other contexts as well, especially repair and upkeep of buildings and equipment. This level of generality bears a significant cost in complexity, yet the standard itself is extremely simple relative to monsters like DICOM and is not constrained to any particular document representation or database.

Re:This "openEHR" thing is a meta-standard (1)

DraconPern (521756) | more than 6 years ago | (#21859244)

DICOM is not constrained by any particular database. It specifies a wire protocol for network exchange and file exchange. It is up to the application to determine where and how the data is stored for internal use, there are implementation that uses dBASE IV. The DICOM standard also does not force a representation. It even says you can use JPEG, jpeg2000, motion jpeg, wave files, pdf, etc. The DICOM standard is designed from the ground up to be object oriented, hierarchical and expandable. There have been several updates to it since 1993, the last one in 2007.

Re:There's no standard because it's impossible. (1)

TCook (66808) | more than 6 years ago | (#21855612)

You correctly point out some of the complexity here. But, it is NOT impossible to create systems that use terminologies (like LOINC and SNOMED-CT) that are computable.
Frankly, NLP just isn't there YET. Even using proximity rules etc. it is just too imprecise to develop a context from natural language from a document (like PDF) that can be used for analysis, decision support, etc.

 

No mod points, sadly... (1)

DrYak (748999) | more than 6 years ago | (#21855868)

"It itches sometimes" "when?, where?, duration? during aligment of planets!?"

THOSE kind of consultation. Yes, I know and understand, and show all my sympathy.

VistA. 30 years old -- Mature and Fully Featured. (1)

mikelieman (35628) | more than 6 years ago | (#21855930)

Available via a FOIA request, excepting some showstopping components, of course.

Re:There's no standard because it's impossible. (1)

swillden (191260) | more than 6 years ago | (#21856538)

Realistically, the best approach may be PDF's and full text search. Anything else is just not going to capture the full extent of the medical history.

It's not that bad. Sure, there are cases where symptoms have been reported but no solid diagnostic conclusion reached that can only be stored as text, but there are plenty more cases where a diagnosis can be made, and IDC-9 codes (or whatever -- the lack of standardized coding is a real pain) can easily express the result.

I've spent some time working with the AAFP group who is developing the Continuity of Care Record [wikipedia.org] (CCR) data format, and while there are some areas in which it can be improved, an inability to capture parts of the history isn't one of them. Basically, it relies on coding where that can be used (optionally clarified with text) and text where coding can't be used. It's an XML-based format, so mixing of computer-friendly data and human-readable stuff is easy.

If you'd like to see what the CCR can store, and how, there is an online demo [solventus.com] that allows you to create your own (or a fictional one, if you prefer) and export it as XML or PDF. The PDF format is particularly interesting because although it's a nicely-formatted, human-readable document on the surface, it contains the XML in a sort of hidden layer which can easily be retrieved by tools for processing by a computer.

Of course, the CCR is just a format to allow patients to transport their own medical history, rather than being a full EHR solution, but IMO that's a *better* approach. A well-standardized data interchange process will make it easy for medical history to move from one system to another when needed, without any need for a common database.

The area of CCR development that I'm working on is providing strong security. I think it's important to be able to selectively encrypt sensitive sections of the CCR, and I'd also like to use the CCR to transport links to data that is stored in Internet-accessible systems, but in encrypted format (for imagery and other large files that are too large to be conveniently included in the CCR itself).

Re:There's no standard because it's impossible. (1)

Blahbooboo3 (874492) | more than 6 years ago | (#21857150)

My understanding is that the first version of CCR was easy to use and wonderfully focused on the needs of clinicians wanting to exchange data for the CURRENT encounter. The second version where they tried to make it as powerful as CDA made it a royal pain in the ass to use.

In any case, thankfully the powers that be (i.e. the two separate groups making CDA and CCR) came up with a new combined standard called CCD which is essentially the CCR record packaged into a format that the CDA carries.

I am surprised you're not moving to use the new CCD rather than the soon to be defunct CCR.

Re:There's no standard because it's impossible. (1)

swillden (191260) | more than 6 years ago | (#21858368)

My understanding is that the first version of CCR was easy to use and wonderfully focused on the needs of clinicians wanting to exchange data for the CURRENT encounter. The second version where they tried to make it as powerful as CDA made it a royal pain in the ass to use.

You must be thinking of something else. The CCR was never about an encounter, it was always a portable history. Not only that, the second version of the CCR hasn't yet been released.

In any case, thankfully the powers that be (i.e. the two separate groups making CDA and CCR) came up with a new combined standard called CCD which is essentially the CCR record packaged into a format that the CDA carries.

There has been an effort to combine CCR and CDA, but it's an abysmal failure. Meanwhile, the CCR workgroup is still active and energetic, working on improving the standard and on getting more real-world systems to support it.

Re:There's no standard because it's impossible. (1)

Blahbooboo3 (874492) | more than 6 years ago | (#21859520)

Correct, it is not really an encounter, but it is not the entire medical record. CCR was designed as a way for clinicians to share information about a specific incident/episode of care and not the entire medical record. I sort of think of it as a new "medical document" (i.e. just as problem list is another document type), rather than a real data exchange mechanism.

As for CCD being an abysmal failure, I think you may be incorrect. CCD was just approved by HITSP and is moving forward. From article http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20071023/FREE/310230003/0/FRONTPAGE [modernhealthcare.com]

"The CCD is in effect a CCR implementation within HL7's Clinical Document Architecture. The CCD was approved by HL7 in January. HL7 has since dropped work on its own Care Record Summary."

Check john halamka's blog reviews HITSP approval for CCD:
http://geekdoctor.blogspot.com/2007/12/standards-for-personal-health-records.html [blogspot.com]

You should also check out this critical review of the CCR and CDA. They authors claim that the CCR v1a (which I called v2 in my prior post) is very complicated and not at all a step in the right direction. Interesting read:

http://www.jamia.org/cgi/content/full/13/3/245?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=Hammond&andorexacttitle=and&titleabstract=ccr&andorexacttitleabs=and&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&fdate=1/1/1997&tdate=1/31/2007&resourcetype=HWCIT,HWELTR [jamia.org]

Re:There's no standard because it's impossible. (1)

blach (25515) | more than 6 years ago | (#21858180)

Is that the actual product?

I see major problems: chief among them are the medical problems listed under "my problems."

"Heart disease" is extremely ambiguous. CHF, or coronary disease?
"Blood pressure, low" ? How about "Blood pressure, high" which is not listed and a far more common problem.
Kidney disease which is EXTREMELY common is not listed.

Was this part designed by physicians or computer people?

Otherwise I think you're doing a fine job.

Re:There's no standard because it's impossible. (1)

swillden (191260) | more than 6 years ago | (#21858394)

Is that the actual product?

It's a demo of one sort of interface that can be used to populate a CCR.

I see major problems: chief among them are the medical problems listed under "my problems."

You're just looking at the UI. The CCR format stores diagnoses as ICD-9/SNOMED/etc. codes, so anything that can be coded can be represented, and anything that can't be coded can be described textually.

Was this part designed by physicians or computer people?

I have no idea who put together the demo.

That one's easy... (1)

oddaddresstrap (702574) | more than 6 years ago | (#21857182)

"My arm hurts right here!" "Show me?" "Here!" "Wait, it's here now" "No no, it's here now"

The patient's finger is broken.

"Why are so few doctors using EHR systems?" (2)

XNormal (8617) | more than 6 years ago | (#21855418)

You probably know that big IT projects often fail. But for some reason patient record projects tend to fail more than other projects. Administrative systems for setting appointments work. Automation for lab tests works. But projects for actual patient records keep failing.

I have a friend in the healthcare IT business who claims that they are actively sabotaged. Many more are derailed before they ever get started. Doctors prefer paper records that cannot be efficiently mined for malpractice lawsuits. Paper records that can be conveniently lost.

Re:"Why are so few doctors using EHR systems?" (1)

Rezazur (677119) | more than 6 years ago | (#21855562)

Although it's true that doctors often actively resist the EHR systems, I'm pretty sure this will be the hallmark of the medicine in the 21st century. The possibilities are endless: mining for epidemiological data or adverse events, for instance.

Re:"Why are so few doctors using EHR systems?" (1)

8KidsCronie (724585) | more than 6 years ago | (#21857370)

I have to call you guys on this whole string. Like a few other respondents, I am an actively practicing surgeon, and a programmer in my spare time, so I know what I am talking about.

The main problem in EHRs is that they are designed by programmers. They are built around databases, and force doctors to change their practice in order to fit the database. ARGH!!! Dumb, DUMB, DUMB!!!

I have been using a huge, nation-wide EHR for 3 years. From the get-go we found that the input was unusable: we had to type about 100 different data elements for each and every patient encounter (think 35 patients/day x 100 data elements: how much time does that leave for the patient exam, or for talking to the patient?) And then the database encounter report was unreadable, leading to real patient safety issues.

The only way my staff (the doctors in my department, of which I am the chairman) could use it was to bypass the database altogether. We now scan in paper notes, or text from a Word document (my preference at present). Neither of these gives searchable data. Sorry folks, get over it.

EHRs should be designed by doctors, to match their practice. PLEASE listen to this. PLEASE start with physician needs, or you will never get a workable product

Re:"Why are so few doctors using EHR systems?" (1)

blach (25515) | more than 6 years ago | (#21858200)

As a resident physician at a large US teaching hospital, I wholeheartedly concur.

Many of the systems we're forced to use were clearly designed by programmers (a group of which I include myself) but NOT by physicians (or nurses).

Re:"Why are so few doctors using EHR systems?" (1)

peacefinder (469349) | more than 6 years ago | (#21858780)

"But projects for actual patient records keep failing."

As a statement of simple fact, this is true. As an emotionally-loaded blanket condemnation of EMR systems, this is bullshit: it fails to mention that projects for actual patient records also keep succeeding.

I'm a technical guy working in a midsize primary care clinic.

We've been on EMR since late 2000. Yes, there was resistance to EMR, but not because of the nefarious motivations you postulate. It was more that the older providers had been practicing with paper charts for twenty years, and there was a lot of inertia to overcome. The computer-friendly providers were enthusiastic, the computer-averse ones were resistant. (Add to that the fact that we tried to go wireless from the start, and the state of 802.11b in 2000-2001 was pretty hideous.) But by the end of 2002, even our most reticent provider actually shuddered when I suggested he go back to paper charting. :-)

I concur with 8KidsCronie above: In order for an EMR to succeed, it has to be customizable by the end users to closely match the way their clinic works. This is not optional. EMR rollouts are hard even if things go well and most docs are on board. Our clinic was wise in its EMR choice and my predecessor did a wonderful job of managing the clinical customization process, so our rollout was relatively painless. That said, it was still a painful transition for at least six months, and the transition of all processes was not substantially complete and painless for a year. It's important to manage expectations so no one will be tempted to write off the project prematurely.

" Doctors prefer paper records that cannot be efficiently mined for malpractice lawsuits."

This is also bullshit. Patient privacy laws make such postulated data mining projects basically impossible for anyone who does not have legitimate access to the data. In practice, the only people who could manage it - without an existant, specific malpractice complaint in play in the courts - are internal clinical QC people for pretty large provider groups or hospitals tasked with policing their own providers. (And I think most everyone would regard that as a good thing, especially most physicians.)

Your friend seems to have a lot of dire fantasies, and does not strike me as a reliable source.

needed, constrained by responsibility and security (1)

m0llusk (789903) | more than 6 years ago | (#21855458)

That some kind of solution other than paper records is needed is obvious to anyone. Most existing systems have limitations, but compared to paper records which take up large volumes of space, are highly vulnerable to loss and theft, and can't be easily indexed almost anything is an improvement.

The main obstacle to adoption pointed out by the article is responsibility. Systems would most likely be put in place by providers who would have the most to loose from the costs and the least to gain from the improvements in service. Others here have pointed out that one possible solution to this is allowing people to manage their own records. This raises some important issues about correctness and trust, but potentially puts the costs and benefits where they are most appropriate.

Another issue that comes up is security of computer records. Any system is vulnerable, but keeping records encrypted is an obvious good first start. Another option that comes to mind is to implement any such system such that all access of records is logged. This would not necessarily prevent abuse, but it could provide information to allow abuse to be investigated, tracked, and eventually stopped at the source.

Why doctors are reluctant to use medical software (1)

dhasenan (758719) | more than 6 years ago | (#21855506)

Up until, well, the last year or so, medical software went like this:
An entire hospital payed over twenty million to one organization. That organization provided an integrated solution for all the hospital's needs. It took five years to get it installed and working, and no part of it worked particularly well. All the staff that might interact with it is also required to attend training sessions for the software. The individual departments have no say in the purchase, and a lot of them refuse to use it.

And there are only a few such organizations, and since they charge so much, hospitals are reluctant to admit defeat and switch to someone else.

Really, it's prime time to start offering subscription-based software to these hospitals, starting with individual departments and working your way up. Of course, if you're holding their essential data, they might not be so happy.

VA system is public domain (1)

barista (587936) | more than 6 years ago | (#21855636)

Didn't RTFA, so you take this with a grain of salt...

The system created by the Veteran's Administration is public domain software, though it is called VistA, so it can be a bit confusing now. I work for in a department within a medical school and have thought about testing it out, though IIRC it uses Delphi for the database and was created using an obscure scripting/computing language called M. Still, it's used to link all VA hospitals and clinics, so a veteran can go to a clinic across the country and the doctors there will have access to the patient's medical record. Since it's free and presumably robust (lots of clinics, hospitals and records) it seems like a good starting point for any open standards.

The docs I work with all have training on the VA's software since they each spend time at our local VA. I don't know how well it handles billings stuff, but from what I hear, it handles imaging, prescriptions, and the rest of the record fairly well.

Re:VA system is public domain (1)

TCook (66808) | more than 6 years ago | (#21855682)

Though VistA is public domain, there is an open source version of it that has been converted for use in clinics and is now called WorldVistA EHR VOE see: http://www.worldvista.org/ [worldvista.org]

The "obscure" language is MUMPS now called M and has been around since the early 1970's when it was written specifically for health care and is used throughout the health care industry as well as many major financial applications.

VistA does have some of it's front end written in Delphi. Much of it can be ported to be used as a web application if the effort is put into doing it.

The problem with VistA as well as any other stand alone application is that they lack any real way of exchanging information with other applications. This is where selecting openEHR can be a benefit. In fact there are discussions going on about retro-fitting VistA to use openEHR archetypes. We'll see how that goes.

Remeber that openEHR is not an application but a set of specifications that can be used by anyone.

 

Re:VA system is public domain (1)

mikelieman (35628) | more than 6 years ago | (#21855954)

"M" *is* the Database. Billing, Scripts, and Imaging are issues, as they generally rely on Closed, Strictly Licensed and Expensive components. ( Medical Imaging is regulated by the FDA, as any problem can seriously screw up patient care... )

Re:VA system is public domain (2, Informative)

SaffronMiner (973257) | more than 6 years ago | (#21855968)

The oldest medical database systems are based on MUMPS, now called M by some, which is still used by the VA. They have
updated it to "VistA", which predated Microsoft Vista (wonder if Microsoft chose that name for a medical reason?).

VistA® / CPRS Demo Site:
http://www1.va.gov/CPRSdemo/ [va.gov]
The code:
http://www1.va.gov/CPRSdemo/page.cfm?pg=1 [va.gov]

http://www.innovations.va.gov/innovations/docs/InnovationsVistAFAQPublic.pdf [va.gov]
http://www.va.gov/VISTA_MONOGRAPH/index.asp [va.gov]
http://www.va.gov/vdl/ [va.gov] is the library.
http://www.va.gov/vdl/section.asp?secid=3 [va.gov] covers your Financial question.
http://www.va.gov/vdl/application.asp?appid=144 [va.gov]
VistA Data Extraction Framework (VDEF).

http://openvista.sourceforge.net/ [sourceforge.net]
"OpenVista is the open-source version of VistA, which is an enterprise grade health care information system developed by the
U.S. Department of Veterans Affairs (VA) and deployed at nearly 1,500 facilities worldwide."

1,500 is not all that many considering the market.

Intersystem's Cache' http://www.intersystems.com/cache/ [intersystems.com] is the contemporary equivlent to MUMPS, a database that claims it can
run rings around things like MySQL in the number of transactions per second.

There are a number of Open Source Medical Databases,they are summarized here:

http://www.linux.com/base/ldp/howto/Medicine-HOWTO/record.html [linux.com]

My very first job was writing medical software, this is when few people even knew what computers were in 1977. Still have my DEC
MUMPS badge that I got at the very first MUMPS conference in DC. Have always felt I should get back into that field. To bad
Dr. Armor and I didn't patent what we were doing then. The pharmacists called up the office in disbelieve asking if these
computer printed prescriptions were real, because *THEY COULD READ THEM*.

The other side:

"VA DATA AND INFORMATION SYSTEMS:
1. FY07 Year-End Med SAS and DSS CNDE Files Available
The fiscal year 2007 (FY07) year-end Medical SAS (Med SAS)
Inpatient and Outpatient files are now available."
http://www.virec.research.va.gov/References/DataIssuesBrief/2007/DIB-0712er.pdf [va.gov]

Requesting Access to VA Data:
http://www.virec.research.va.gov/Support/Training-NewUsersToolkit/ACRSrequest.htm [va.gov]

"Click this button for information, guidance, and FAQs relating to the VA Research Data Security and Privacy initiative."
http://www.research.va.gov/resources/data-security [va.gov]

VA system is a single payer designed system (1)

Blahbooboo3 (874492) | more than 6 years ago | (#21857188)

One big problem is the VA system is designed for and by the VA. I went to the VA Vista booth at HIMSS and asked the attendant what they did to fix or handle the single payer mechanism in VA Vista, he said "uh, what's a single payer system?"

That's the problem. It is built for a military hospital, not a real world hospital, and shows in all aspects of the system (not just it's severely limited billing module).

I'm a doctor and I got burnt by a closed system. (3, Interesting)

MMC Monster (602931) | more than 6 years ago | (#21855644)

I'm a doctor who joined a small practice a few years ago. The senior partner of the practice created his own EMR system. It's actually quite good and we use it exclusively. Our office isn't paperless, but everything coming into the office is scanned in or phoned into the virtual fax and never printed. We are able to access it from different offices and from the hospitals we go to via a VPN setup, and it significantly improves our efficiency.

Now the senior partner left. He didn't use a standard database format (but fortunately used Microsoft SQL), and we'll probably have to pay a fortune to have it converted to an open format. Fortunately he's being good about not charging the office for a license for his code, so we have time for the transfer.

Re:I'm a doctor and I got burnt by a closed system (1)

MMC Monster (602931) | more than 6 years ago | (#21855744)

As for why EMRs haven't spread, there are a couple tidbits:

1. The security is barely on the radar. Any office that can set up an EMR can do so securely. That's part of the setup costs.

2. There was an interesting case I heard about recently (I'm not sure if it happened in 2007): A cardiology office in one of the south-eastern states of the U.S. data-mined their patients to find out which ones would benefit from implantation of a defibrillator. (This is a fairly expensive procedure that is covered by just about all insurance plans if you meet certain criteria. The doctor can charge the insurance carrier a hefty bill and expect to get paid.) The sudden spike in defibrillator implantations lead to an investigation that revealed that it was due to data-mining of an EMR. Now the office is being sued for not data mining to make sure all their patients are on the right doses of various heart medications. This had a chilling effects that prevented a large group near me from going forward with the translation to an EMR.

3. There is a lot of inertia in paper charts. There is also a great fear in the extra time needed for entering data into an EMR. My office has dedicated transcriptionists and individuals to scan in data. That being said, the entire EMR is managed by our IT guy and we save on "runners" moving charts all over the office and hospitals.

Re:I'm a doctor and I got burnt by a closed system (0)

Anonymous Coward | more than 6 years ago | (#21855956)

What do you mean by "open format"? Do you mean the database file itself (i.e. MS SQL) or the manner in which the data is stored in the database (i.e. everything has a data-type of VARBINARY or something)? If it's the former, I just can't bring myself to get upset for using Microsoft SQL over one of the open source alternatives; also, why fix something that isn't broken? If it's the latter, then the senior partner is a douche. You say yourself that the system has significantly improved your efficiency, so if the system currently works how does the senior partner leaving force you to pay a fortune to convert it to an open format? Seriously, you have piqued my interest.

Re:I'm a doctor and I got burnt by a closed system (1)

swillden (191260) | more than 6 years ago | (#21856702)

What do you mean by "open format"? Do you mean the database file itself (i.e. MS SQL) or the manner in which the data is stored in the database (i.e. everything has a data-type of VARBINARY or something)?

LOL. I suppose this is progress, that someone is apparently incapable of realizing that data can be stored in anything other than a major DBMS product. Although I don't know what the OP was talking about, here are some other options: The data could be stored in:

  • A homegrown database built on flat files
  • Excel files or similar through horrible contortions
  • A database built using obscure, low-level tools like B-trieve
  • An actual database product that reached end of life 10 years ago
  • An database product that is inadequate to the task (i.e. MS Access) and has been horribly abused to make the system work, mostly.

I could come up with several more if you'd like.

This sort of think is *extremely* common in the medical industry. Doctors are generally smart, often somewhat geeky, people with lots of leisure time, plenty of money to spend on gadgets and little to no exposure to the world of real IT. That means that in the 80s and early 90s, there were lots of doctors with PCs, problems that would clearly benefit from automation, and no off-the-shelf solutions. What they did was predictable: they built their own, using whatever tools they happened to know about.

Unfortunately, not being CS guys, they had no notion of elegance, no clue about the importance of maintainability and no knowledge whatsoever of the many tools available. I made a little money years ago by converting spreadsheet-based "systems" to Foxpro/dBase solutions. The docs thought I was a genius for being able to create a much more usable solution; I thought they were (twisted) geniuses for being able to figure out how to make the stupid thing work in the spreadsheet in the first place. I'm not sure I could have.

Anyway, not using an open source DBMS, or just botching the implementation of the schema, are the least of the problems that you'll commonly find in small-office EMR and PMS systems.

Re:I'm a doctor and I got burnt by a closed system (0)

Anonymous Coward | more than 6 years ago | (#21857196)

But the OP explicitly stated that the senior parter used MS SQL, so none of your options really apply. He makes it sound like everything works fine as is, then after the senior parter left he complains that he will have to "pay a fortune to have it converted to an open format". What does he mean by "open format", and why does the senior partner's departure require this conversion? I have worked (briefly) in a closely related industry, so I am genuinely curious. If you've got a decent schema in MS SQL that works consistently, then I don't really see the point of going to an open source database just for the sake of using "open formats". There has to be more to it than that.

A little knowledge is a dangerous thing (1)

Hognoxious (631665) | more than 6 years ago | (#21857536)

But the OP explicitly stated that the senior parter used MS SQL, so none of your options really apply.
Seemed to me was making a general point about software produced by people who know just enough to do it, but not enough to do it right. And it's not just doctors who are guilty of this - you should see some of the homebrew tripe accountants come up with.

Re:I'm a doctor and I got burnt by a closed system (1)

swillden (191260) | more than 6 years ago | (#21858412)

But the OP explicitly stated that the senior parter used MS SQL, so none of your options really apply.

My apologies, I missed that.

What does he mean by "open format", and why does the senior partner's departure require this conversion?

No idea. Perhaps he used a homegrown diagnosis/procedure coding system?

Open Standards != Open Records (1)

walterbyrd (182728) | more than 6 years ago | (#21855654)

The article seems hopelessly confused.

The article seems to suggest that if open standards are used, all of your medical records will be wide open. That does not make any sense at all.

The openness of the standards has nothing to do with the openness of the records.

Re:Open Standards != Open Records (1)

TCook (66808) | more than 6 years ago | (#21856166)

Which article are you referring to? My blog post does not suggest those things at all.

So many reasons ... (2, Insightful)

DarthBobo (152187) | more than 6 years ago | (#21856212)

EMRs are a great idea, but the medical world is poorly adapted to build them and integrate them. Its dysfunctional system where billing is becoming increasingly critical, while what you get for is divorced from what you actually do. So we wind up with schizophrenic EMRs that can't decide whether they are generating billing tickets, documenting patient care or preventing a lawsuit.

1) They are expensive for a small practice - think that a primary care docs office is rolling in cash? Think again. Most of them are barely scraping by, which is why your doc needs to see 30+ patients a day. Otherwise the rent doesn't get paid and he/she can't make payroll. If a new tool doesn't make the office more efficient, it can't be justified. Sound odd? Next time you visit your doc, ask him who determines how much he/she gets paid. Its not you, its not the market and its not actually the insurance companies. Its the federal government when they set payment guidelines for Medicare/Medicaid which the insurers follow. Free market my ass.

2) They are slower than paper - few docs can type as fast as they can dictate or write. Most of us can take notes on a piece of paper while interviewing a patient - no one I know can talk to a patient and type into a form.

3) Many are designed to maximize billing, not care - we get paid based on how many indicators of complex care we hit. How many "systems" asked about, how many organs examined etc etc - not by our time or skill. So in order to bill we have to document all of these. Some EMRs are designed to force the MDs to check many boxes for billing and audit purposes. Unpleasant and slow.

4) Many are slow and perform poorly - my hospital switched recently from a physician designed an written EMR from the 80s that was text/terminal based and blindingly fast, to a web-based system. The new system is slow, and doesn't really do much that the old system did. The difference was that the first system was built by MDs who ate their own dog-food, the second by teams of very smart, very committed programmers who don't practice medicine.

5) They are the camel's nose under the tent - my hospital based practice was recently instructed to begin doing "medication reconciliation" on all outpatients. That means at the start of the visit I have to type in all of a patient's medications into the EMR. Sounds fine for you, right? Now imagine your grandmother. As a sub-specialty consultant I see most of my patients once to twice a year and they are on 20+ medications, over the counters, vitamins and herbal supplements. It can take 6-7 minutes out of an already short 30 minute visit. Sure its great for safety, but it means we are running an additional 45 minutes late at the end of the day. Not so great for you if you have a late afternoon appointment.

another critical issue (0)

Anonymous Coward | more than 6 years ago | (#21856882)

Most patients like the idea of having their doctor be able to easily access their records. Except for when they don't. I work in internal medicine and we like to know everything we can about a patient's history. Routinely, patients withhold information that they think the doctor doesn't need to know. I think it is a bad idea, but it is their right.
  Here is an example - one of my HIV infected patients came in to get his blood pressure checked. Our nurse entered that data in our EHR. Our particular system displays a summary list of the patient's diagnosis down the right side. The patient was pissed. "Why does the nurse need to know?" You could argue it either way.

There's only one REAL argument (1)

ArikTheRed (865776) | more than 6 years ago | (#21856564)

for centralized medical records: reducing fraud. Unless you have some central repository of records that doctars can connect to - there is nothing stopping Joe Schmoe from going to 5 doctors and getting perscriptions at 5 pharmacies. The fucked up way billing works is he could bill some to his insurance company, some to medicade, some to medicare, and never pay a dime - none would even know about it. The cost of fraud is a HUGE percentage of healthcare costs - far more than malpractice insurance.

Then there is item #2. Chew on this: 34% of healthcare cost in the US clerical... this percent should come as no shock to anyone involved in the process - but most people think it's far more automated than it really is. I don't know if centralization will reduce that much... but it's certainly an argument for computerization of healthcare records in some form.

Open standard - not Open access (1)

Forget4it (530598) | more than 6 years ago | (#21856998)

Ideal situation is when the treating medic has the patient's details in hand and *can* readily read them. Put them on USB pen round the patient's neck 24/7 in a truly open format - then 90% is achieved.
The other 10% - like external exams and reports - need the network up and running and the interoperable database world. Backup could be on any encrypted cloud disk.

Come on guys this isn't rocket science, its human lives, "stupid".

open standard? No way. (0)

Anonymous Coward | more than 6 years ago | (#21857114)

I work for a state health dep. We have lots of computer thingys. All the health records are stuffed inside and sometimes
we get health records from other people like hospitals, hmo, insurance, etc. All are different, none talk to each other without
huge amounts of tax money being efficiently administered by program managers that know various health fields, but alas,
have many unknown computer thingys and equate electronic health records with a spreadsheet. So they contract the money out
to proprietary software thingys that do not talk to the other thingys. Sometimes these systems work, many times they don't,
but if they do work, then it is time to propose a new standard so they won't work.

There is no leadership from the Feds in standards, just lobby guys. So no real standards, unless it is an attack on someone else's
product. Kind of like MS and standards.

EHR - trainwreck for your privacy (1)

pcause (209643) | more than 6 years ago | (#21857580)

Electronic health records will be a privacy disaster. It isn't about open standards, it is about the ease of access that will be created and the fact that security is *ALWAYS* an afterthought or cut/put off to "get an initial release out, but we'll fix it later". What we'll have is a hodgepodge of poorly implemented systems with a TON of security holes and NO ONE'S privacy will be safe.

What is needed is an initial focus on the security of the systems, access rules defined, complete auditing of all actions, unforgeable/unmodifiable logs of the actions, sever criminal penalties for leaking any health records WITHOUT a press shield, etc. And we need a separate organization to create tests, hacks, etc to audit the implementations and make sure the security is correctly done.

But all of this won't happen. Politicians are making promises of great efficiency and other benefits. There will be political pressure to rush something out. Software vendors and the systems integrators will reassure everyone that things will be OK because they will see a HUGE opportunity for years to come and will want to reduce fears and concerns, all the while knowing better, etc.

And, we all know that projects of this scale and scope take a long time to build and get right. The specs are never right and there is incessant haggling over the specs, the tests, the contracts, who pays, etc. The Big Dig will look like a well managed project and of high quality compared to a national EHR system in its first decade or so of life.

This is a train wreck waiting to happen. The political types are too ignorant to know what to do. The industry types want the money. You will be the victim.

Open standards already exist (2, Informative)

KillerCow (213458) | more than 6 years ago | (#21859972)

There are two standards called DICOM and HL7. DICOM handles binary data, and HL7 handles more of the process and is the primary integration point with EMR.

With these a PACS (Picture Archive Communication System) forms the "database" of data. The PACS is actually more work-flow based which then stores the actual data on some type of highly-reliable data storage system.

These two protocols make up the totality of your health care experience at a hospital. Your hospital certainly uses these two protocols, so why invent a new one?
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