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EHRs, PHRs, PCHRs discussed in the April 17 NEJM

It was one of those late night reading sessions that kept me going till the sun came up. I had taken a nap earlier in the evening, so I was fully awake all through the night. Anyway, I had printed out these articles concerning the electronic health record, mostly about PHRs, published in the April 17 issue of the New England Journal of Medicine.

Here's a brief summary of each, but each is worth talking about to a greater extent in future blog posts.

In the Perspective section of the NEJM, there are two articles, the first "Personally Controlled Online Health Data--The Next Big Thing in Medical Care?" looks at the use of EHRs as they will be implemented by private companies such as Google and Microsoft, and those companies allied with the non-profit consortium called Dossia.

Dossia (www.dossia.org), founded by AT&T, Intel, Wal-Mart, and five other large U.S. employers, plans to offer a voluntary means of storing personally controlled health data to about 2 million employees and 5 million dependents and retirees, as well as making other services available. The platform uses an open-source technology, Indivo, developed at Children's Hospital Boston. Dossia's long-term goal is a portable and secure lifelong record that will be available regardless of a person's employer, insurance plan, or physician; employees who leave a participating organization will still be able to use the system, possibly for a fee. Pilot testing is ongoing.

Mention is made of how these companies' efforts to store online data outside of the health care system are not subject to HIPAA regs. "Dossia, Google Health, and Microsoft HealthVault are not covered entities, the data they store may not be as private as consumers assume, and a person's 'control' could turn out to be limited."

The second Perspective piece, "Off the Record--Avoiding the Pitfalls of Going Electronic" voices some concerns I've been thinking about, that is, there are certain aspects of the electronic that be its very nature tends to lessens the value of clinical information it contains.

The ability to cut and paste previous entries or the use of check boxes or dumping lab data into the record, all produce volume but with little analysis leading to a "Where's Waldo" effect of trying to find a useful appraisal of the patient's condition.

This is what happens when non-clinicians think that any medical record is similar and is as easily created and maintained as banking records.

"Tectonic Shifts in the Health Information Economy" is the first of two articles in the Sounding Board section. It looks at the use of personally controlled health records (PCHRs) for clinical research.

The authors see the while the use of PCHRs "is driven largely by a need to provide assistance with clinical care processes, it will also profoundly affect the biomedical research enterprise."

They see five hurtles that need to be overcome for their in research to be fully implemented:

1. standard data formats
2. hospitals and doctors' practices need to make data available electronically to patients
3. CLIA labs must be allowed to release results to patients
4. structured data must available for analysis and computation, ie, the paper-based records be converted
5. since there is not universal patient identifier in place, new approaches to establishing ID and trust are needed

"Electronic Health Records, Medical Research, and the Tower of Babel" makes the case for the adoption of the standards needed such as a data language in the form of HL7, and clinical research data as envisioned by CDISC.

They mentioned the FDA's Critical Path Initiative for establishing a standard for the collection of research data. Also the Clinical Data Acquisition Standards Harmonization is working towards this goal.

 

NYC's Mayor Bloomberg adds $27 million for EMRs

According to WaPo:

Bloomberg's charitable foundation has put $27 million toward providing New York City  physicians with electronic medical record (EMR) systems that are preprogrammed to emphasize disease prevention.

That donation has been augmented by money from the state and federal governments, insurance companies and the doctors' medical practices, making a total of about $60 million. The goal is to have 1,000 physicians using the prevention-oriented EMR and 1 million patients under their care by the end of this year.

These systems will "display automatically the recommended tests, interventions and therapeutic goals for a person with a specific diagnosis." The problem is that insurance companies won't reimburse for both treatment and prevention services on the same visit. A patient who reports symptoms that might indicate a need for a new workup will have to come back for another office visit.

e-CareManagement blog compares Google Health and Microsoft HealthVault

Vince Kuraitis provides a useful chart showing the the features of Microsoft's HealthVault and the PHR soon to be released by Google.

Vince notes that both products allow the patient to control the data, allowing complete portability.

He also provides a link to his PowerPoint presentation which gives a good overview of the current state of chronic disease management.

Skeptics and competitors anticipate HIMSS '08 keynote by Google's Eric Schmidt

I'm still looking for a blogpost from someone who attended yesterday morning's keynote at HIMSS '08 by Google CEO Eric Schmidt.

Modern Healthcare is reporting skeptical comments from some medical informaticians about Google's involvement with PHRs:

Physician Daniel Masys, who chairs the department of biomedical informatics at the Vanderbilt University School of Medicine, said Google, the Internet search giant, has “no idea of what it’s getting into” with the company’s plans to launch a personal health record.

And:

...[S]peaker Holly Miller, a physician who is vice president and chief medical information officer at University Hospitals in Cleveland and chairwoman of the HIMSS PHR Steering Committee, took a swipe herself, saying that personal medical information stored by Microsoft or Google has no legal protection to guard the privacy and security of the information.

Google already has competition from such companies as Microsoft's HealthVault, Healthline, WebMD and Revolution Health, founded by AOL founder Steve Case.

As the HIMSS conference was opening Monday, Microsoft announced that it was providing $3 million to help attract health application developers to its HealthVault electronic medical records platform.

In particular, Microsoft is interested in applications related to preventive care, acute care diagnosis and treatment, management of juvenile diseases, women's health, and community and social health applications.

Microsoft is also making a gesture towards the open-source software community in an effort to comply with antitrust legal requirements.

MORE: The Wall Street Journal Business Technology blog is just as skeptical:

While researching our article, we came across a number of people who thought the tech companies are naïve — bordering on arrogant — to think they could come waltzing into the healthcare field and settle decades-old turf wars.

And, to close their blog post:

But we’re pessimistic: Tech alone – or even combined with a brilliant marketing strategy – is enough to overcome institutional resistance. That’s true for projects, companies, and yes, industries.

The announcement on the official Google blog by Marissa Mayer, VP, Search & User Products.

The WSJ's coverage of the announcement yesterday.

Google's PHR to debut at the Cleveland Clinic

The NY Times is reporting that the Cleveland Clinic will start a pilot project linking the health records for some of its patients to Google's personal health records (PHR).

Here's an example the points up the need for such a service:

Cleveland Clinic is at the cutting edge of health information technology, and its more than 100,000 patients each has a personal health record. But a sizable portion of those patients are retirees, notes Dr. C. Martin Harris, the clinic’s chief information officer. Many of them, he said, spend about five months elsewhere, typically in Florida or Arizona, and the clinic’s sophisticated electronic health records don’t follow them there.

For my experience covering the ER as a surgery resident, a significant number of patients had trouble saying what meds they were taking, or giving a brief account of their medical history. Some had a slip of paper with the list of meds in their wallets or purse, a very few had a detailed medical history with them also.

It seemed so haphazard in trying to find out very important information, such as if the patient was taking coumadin, an anticoagulant. I would imagine that with the Google system, it would just be a matter of the patient or relative giving permission to access the PHR, then the information would be available immediately.

However, it becomes the responsibility of the patient or the caretaker to create and keep these records up to date. It might happen that their personal MD could upload significant information into their accounts, such as ECGs or recent lab data, but I haven't heard of any program to do this as of yet.

Data such as recent blood glucose levels, blood pressure could be captured via wireless sensors and then stored in their cell phones or uploading directly to the Google PHR site. Making it easy to maintain these records will be a prime consideration.

Will electronic medical records leak patient data to search engines?

In his article  entitled "The virtues and vices of electronic medical records," Barry Chaiken, MD, MPH, FHIMSS [Fellow Health Information Management System Society], suggests that "Without very strict rules and oversight..." patient information could make its way onto the search engines, and therefore revealed to the general public.

He emphasizes the individual patient's role in the oversight process:

Acting passively and allowing others to decide for us how our information is accessed and used, and guarantees that those decisions will not be in our best interest.

In my opinion, as we learn more about the plans for healthcare reform from different political candidates, we find out that the common thread is for the patient population to take a more active role in decision making--the so-called patient-centered health care.

He's right that each patient should be involved in the oversight process to keep their private medical information secure. But it requires education promoting health literacy and leadership that inspires the general public to care about this topic.

Unfortunately, the journalists for the mass media are not attuned to this issue, mostly because their job is a reactive one, waiting for the headline-grabbing event such as when a celeb's records are leaked. (George Clooney Medical Records Exposed via Celebrity-Gossip.net).

So, I guess now is the time to promote discussions on topics like this one on the Web, and come up with specific actions that patients can take routinely to ensure privacy of their medical records.

Medical Records Institute (MRI) announces its new HIT ConsultantCompare program

The Medical Records Institute, well known in the medical informatics community for their yearly Towards the Electronic Patient Record (TEPR) conference, are announcing their new HIT ConsultantCompare program. It consists of two Microsoft Excel spreadsheets listing general information about these consultants, and then their services. I would prefer to see these generated in a database program such as Access, which could merge these two tables via a relational database, instead of two flat-field databases, but I guess not everyone has this program. Besides, it's easy enough just to print out these files since there are only ten consultants listed, at least for now.

From their press release:

Medical Records Institute (MRI) announces the launch of its newly designed HIT ConsultantCompare program to guide ambulatory and inpatient providers in selecting consultants to assist them in the transition to, utilization of, and expansion of health IT and EMRs in their settings.

Similar to EMRCompare, which allows comparison of EMR products, HIT ConsultantCompare helps potential clients compare and select consultants to assist them in selecting, implementing, managing, or otherwise working with

• EMR/EHR systems
• e-Prescribing systems
• Practice management systems
• Data document storage, retrieval and destruction
• Patient portals
• Personal health records (PHRs)
• Continuity of Care Record (CCR)
• RHIO interoperability or health information      exchange
• Document management/scanning
• Dictation/transcription/speech recognition
• Other healthcare documentation methods
• Hardware/software
• Workflow engineering
• Security/confidentiality
• Medicolegal issues
• Coding/reimbursement/compliance
• Joint Commission preparation
• Strategic Planning

In addition to identifying services provided, HIT ConsultantCompare also includes consultants' locations, years in business, speaking experience, contact information, and more.

Speech recognition: will it promote the use of EMRs?

Yes, I think so.

This story on eWeek, "Speech Recognition Makes a Statement in Health Care: Is data entry the hurdle blocking electronic medical records from wide adoption?," is about the Dragon NaturallySpeaking Medical speech recognition software produced by Nuance Communications.

I've been using their professional version for dictating technology and oncology articles with much success. It's amazing how little training is needed.

Stanford School of Med: Hand-held computers prod older adults to exercise more

Researchers at the Stanford Research Center, working with several departments within the Stanford School of Medicine, have published a paper based on their study which "showed that specially programmed PDAs, or personal digital assistants, can prod middle-aged and older Americans—the most sedentary segment of the U.S. population—into increasing their physical activity levels."

Description of the study from the abstract:

Community-based study of 37 healthy, initially underactive adults aged 50 years and older who were randomized and completed the 8-week study (intervention=19, control=18).

The intervention involved providing Dell Axim X5 PDAs (Dell no longer makes) and instructing the subjects in their use, then using the software to "monitor their physical activity levels twice per day and provide daily and weekly individualized feedback, goal setting, and support."

The control subjects were given "standard, age-appropriate written physical activity educational materials."

Questionnaires were used initially, and at the end of eight weeks to evaluate the effectiveness in promoting physical activity. "Satisfaction with the PDA was reasonably high in this largely PDA-naive sample."

I feel PDAs are pretty much a thing of the past being replaced with smartphones. In fact Dell no longer manufactures the Axim line, and Palm's involvement with PDAs seems to be dwindling. The news release at the Stanford School of Medicine Web site mentions that the next step would be to design a study using cell phones.

While this study didn't involve wireless telemetry or feedback, this option could have the added benefit of using a wireless sensor to monitor vital signs in the case where the subject might experience some adverse event.

"Smart" hospital rooms at University of Pittsburgh Medical Ctr Shadyside

This is an altered photo from a piece in a Pittsburgh online paper about the use of monitors in hospital rooms at UPMC Shadyside.

The type of information displayed depends upon the type of access given to each healthcare worker, and in the case of sensitive information, the patient's permission is required.

There's another monitor on the opposite wall for the patient to view.

I can see this as being very useful in showing the patient and family members either x-rays or diagrams showing the current concerns about the patient's care.

I think it would follow to have selected information available to the family outside of the hospital using encrypted e-mail or some other secure client.