Arguing For Open Electronic Health Records

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."

Comments

Re:I seriously doubt it

[Anonymous Coward]

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.

My stolen STD records?

[dmr001]

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/ doesn't look quite ready for prime time) - though I think there's an opportunity here for some enterprising Linux loving propellerheads.

Re:I seriously doubt it

[TCook]

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"?

A Disaster Waiting to Happen

[plusser]

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

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

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.

There's no standard because it's impossible.

[DraconPern]

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.

I'm a doctor and I got burnt by a closed system.

[MMC Monster]

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 seriously doubt it

[budgenator]

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.