Thursday, January 17, 2013

Half Gov Half Degov Venti EMR Lite

Somewhere between the 20th century Bank ATM and the 25th century Tricorder, lays the EMR that we should have today. Somewhere between the government-designed Meaningful Use EMR and the Holographic doctor in Star Trek, there should be a long stretch of disposable trial-and-error cycles of technology, changing and morphing from good to better to magical. For this to happen, we must release the EMR from its balls and chains. We must release the EMR from its life sentence in the salt mines of reimbursement, and understand that EMRs cannot, and will not, and should not, be held responsible for fixing the financial and physical health of the entire nation. In other words, lighten up folks…..

A patient’s medical record contains all sorts of things, most of which diminish in importance as time goes by. Roughly speaking, a medical record contains quantifiable data (numbers), Boolean data (positive/negative), images (sometimes), and lots of plain, and not so plain, English (in the US). The proliferation of prose and medical abbreviations in the medical record has been attacked a very long time ago by the World Health Organization (WHO), which gave us the International Classification of Disease (fondly known as ICD), attaching a code to each disease. With roots in the 19th century and with explicit rationale of facilitating international statistical research and public health, the codification of disease introduced the concept that caring for an individual patient should also be viewed as a global learning experience for humanity at large. Medicine was always a personal service, but medicine was also a science, and as long as those growing the science were not far removed from those delivering the service, both could symbiotically coexist. Fast forward to today. Medicine has developed significant heft and doctors are now mere “frontline” workers in the “trenches”. This implies the existence of something large and controlling behind those frontlines, and everybody comfortably positioned away from the trenches has been watching Moneyball. So the health care chameleon, morphing from an ATM into an airplane just to shrink back into a cheesecake, is now curling up into a baseball, and demanding all sorts of data so Billy Beane can miss the World Series more efficiently. There is of course a slight problem preventing medical ex-players turned general managers from gathering data for medicometrics. In health care, the players have to record their own stats, and they don’t like doing that because it is a bit difficult to hit and run while holding a computer.

Another reason why gathering data in health care seems to be a tall order is the lack of something called “interoperability”, or in layman words “EMRs don’t talk to each other”. But talking is not a good analogy, because this is America and everything should be likened to a car. So using the car analogy, it seems that the government is buying everybody a big huge SUV and making sure the proud owners load it to the hilt with health care data, but in its infinite lack of wisdom, the government neglected to build suitable interstate roads and bridges, so all those lovely SUVs are idling in people’s garages, raring to get out and hit the open roads. This governmental failure is inexplicable considering that we have a long history of building infrastructure first. So first we built the oceans and then we built the ships; we created the trails just before we tamed horses; we first built all the railroads and then someone built a train; we built the Autobahn and then they invented cars for it. Makes perfect sense…..

There is only one problem with this convenient version of history. Those SUVs supposedly sitting idle in health care’s garages are making very profitable night runs all over the place, because the roads and the bridges are really there already, and all sorts of other cars and trucks are jamming the interstate of technology all day and all night, and some funky contraptions are even flying. Imagine that. But imagination doesn’t seem to be the strong suit of health care analysts and advisors, so the attacks on government failure to build infrastructure for interoperability are incessant. We have technology savvy Congress members writing selfless indictments and the folks at the RAND corporation who at the behest of EMR manufacturers, predicted seven years ago that EMRs will save the nation, just came out with an explanation for the failure of their prophecy to materialize, blaming the same lack of interoperable infrastructure. The AMA in its thoughtful comments on Meaningful Use proposals is reiterating the need for government to pave the roads because its members cannot possibly be expected to bear the expenses of building highways from scratch. Using all the right words and a proper measure of righteous indignation, the government is reaffirming its commitment to build said infrastructure any day now. And round and round we go. As long as there is the faintest chance that the government will allocate a little more taxpayer money to build health care interoperability infrastructure, the chorus of complaints will not be silent.

In the meantime, out on the existing slick networks of interoperability for all but health care, activities are bustling with seemingly something new every day. What if the government just told all complaining and procrastinating health care stakeholders to literally take a hike and hit the road? What if the government told EMR vendors to go figure out what their customers want on their own, instead of providing a sanitized version of what the government believes EMR customers should want? What if instead of spending the newly minted trillion dollars coin on a brand new interoperability system for health care, the government would allow EMRs to travel on existing technology highways, and leave well enough alone?

Here are a few things that could happen:
  • Nobody would need to “send” prescriptions electronically to pharmacies. If you had the dubious pleasure of flying somewhere lately, you would know that ticketing is now very different. No, they don’t send your ticket electronically to the gate. They just send it to your mobile phone as a 2D barcode that is scanned at the security checkpoint and again at the gate. A patient friendly EMR could generate the same type of barcode for your prescription and send it to your email so you just have the pharmacist scan your mobile device. All security information can be embedded and you can get a refill at a pharmacy of your choice. If you are now formulating objections in your mind because of possibility of fraud and abuse (and because you are invested in the current system), relax, all your worries can be addressed.
  • You don’t like barcodes? No problem. Instead of killing half the Amazon forest in an attempt to give you “clinical summaries” and instead of whining about interfaces with other facilities, what if your doctor swiped a magnetic card and “loaded” it with your clinical summary, while at the other end the hospital or specialist would use one of those Intuit or Square gizmos to read it in, and then “reload” it for your follow up visit with your PCP? Perfectly doable, and applicable to prescriptions, lab tests and even imaging.
  • Still not convinced? Buy a Samsung Galaxy phone and find a friend that has one too. Try to exchange some information with your friend, like pictures, files or music. It’s called S beam and all you have to do is gently bump the phones. Would you like to bump the doctor’s mobile device on your way in, and bump it again on your way out to collect all the new information? This is not fully baked, but it could be if our well-meaning government relaxed its grip on EMRs just a tiny bit.
Comic relief: Not directly related to interoperability, but instead of having to choose between looking at your patient and looking at your computer, what if you could do both at the same time? A couple of years ago Samsung came up with transparent AMOLED displays (see through screens). There didn’t seem to be any good use for the technology, but they forgot health care. Right now if you have a laptop in the exam room, all you can see is the screen and all your patient can see is the cover of your laptop. What if you could see the patient through the screen and what if the patient could see (and touch) the same things you are seeing? Would be pretty cool if liberated EMRs would be allowed to find creative ways to take advantage of such hardware, and there must be hundreds and thousands of better ideas out there, suffocated by pre-adjudications and pre-authorizations and slowly withering away under the Meaningful Use lid.

Does government have a role in health care technology and interoperability in particular? Of course it does. First the government is the largest health care insurer in the country, and as such it has an interest in reducing costs, and since this is (still) a representative government, it should also have an interest in the wellbeing of its citizens. Governmental agencies should rightfully expect a certain level of (reasonable) electronic reporting from those it pays for services and it makes perfect sense to require that certain levels of service be provided, including coordination of care between facilities, which may involve interoperability to various degrees. And finally it is incumbent upon the government to ensure that tools used to provide health care, including software tools, should be safe, just like it ensures that drugs, devices and all other medical paraphernalia are safe (and using the same agency for this purpose). Public health is another domain where a government concerned with the health of the nation can find opportunities to affect positive change. And that’s about half the work required.

The other half should be left to professionals in the “trenches”, whether doctors providing direct patient care or (deep breath here) technology people who can actually write code to support patient care, if patient care is what we want to support. These folks with massive expertise in navigating the all too real interoperability highways are currently wasting their talents on making your washing machine interoperate with your Twitter account. Can you imagine what they could do with your charts and your “workflows” if we let them lose in health care? It’s not the data that needs to be liberated. It’s our collective imagination that must be set free, or at least half free.


  1. Unfortunately, healthcare people love one-stop turnkey solutions, and they believed all the proprietary vendors who said they could deliver that. Interoperability was the victim. And the turnkey solutions weren't such great shakes. I would love to go back in a parallel universe and see how this would look if healthcare as an industry had decided to work on a collaborative open-source solution central solution with the profit to be made through each organization's interface with it.

    1. That's one way and most likely best suited to a parallel universe indeed, but there could be other ways. I do like turnkey solutions as well, but I am not so sure about which door that key should open, or who decides which doors are the preferred doors, and exactly how the key should operate and how we should turn the key, and exactly when and who should operate such key, assuming there is only one key... :-)