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Back To Faxes: Doctors Can't Exchange Digital Medical Records
nbauman writes: Doctors with one medical records system can't exchange information with systems made by other vendors, including those at their own hospitals, according to the New York Times. One ophthalmologist spent half a million dollars on a system, but still needs to send faxes to get the information where it needs to go. The largest vendor is Epic Systems, Madison, WI, which holds almost half the medical records in the U.S. A report from RAND described Epic as a "closed" platform that made it "challenging and costly" for hospitals to interconnect.
The situation is bad for patients and costly for medical works: if doctors can't exchange records, they'll face a 1% Medicare penalty, and UC Davis alone has a staff of 22 dedicated to communication. On top of that, Epic charges a fee to send data to some non-Epic systems. Congress has held hearings on the matter, and Epic has hired a lobbyist. Epic's founder, billionaire computer science major Judith Faulkner, said that Epic was one of the first to establish code and standards for secure interchange, which included user authentication provisions and a legally binding contract. She said the federal government, which gave $24 billion in incentive payments to doctors for computerization, should have done that. The Office of the National Coordinator for Health Information Technology said that it was a "top priority" and just recently wrote a 10-year vision statement and agenda for it.
The situation is bad for patients and costly for medical works: if doctors can't exchange records, they'll face a 1% Medicare penalty, and UC Davis alone has a staff of 22 dedicated to communication. On top of that, Epic charges a fee to send data to some non-Epic systems. Congress has held hearings on the matter, and Epic has hired a lobbyist. Epic's founder, billionaire computer science major Judith Faulkner, said that Epic was one of the first to establish code and standards for secure interchange, which included user authentication provisions and a legally binding contract. She said the federal government, which gave $24 billion in incentive payments to doctors for computerization, should have done that. The Office of the National Coordinator for Health Information Technology said that it was a "top priority" and just recently wrote a 10-year vision statement and agenda for it.
Google care or appleMed
Some drink at the fountain of knowledge. Others just gargle.
Working with EMR systems for small clinics has shown me that unless fines are given out to these companies developing this software they will make it as difficult and expensive to exchange records with different systems as possible. It is far more profitable for them to make it hard to exchange and then make their clients convince other offices to use the same software if they want to make it easy.
I thought this was the point of HL7?
When I worked for a major medical practice software company we spent a lot of time insuring HL7 support for hospitals...
We take the penalties. It's not worth dealing with all of the requirements the Feds throw at the small practice to try and comply.
The owner / primary provider has attempted to cut back on the number of federally insured patients in order to avoid dealing with all the crap they attach to their payments. Private insurance is easier to deal with.
As far as I'm concerned, the Federal government hasn't been able to effectively manage a large project since about the Second World War. I'm not entirely certain why anyone thinks they can manage health care, looking at all Federal projects past about the time of the Interstate Highway System.
Invoke eminent domain to seize the right to share the data, for the common good of citizens health and safety
Note that the feds gave docs/hospitals $24 billion to digitalize, of which over half of went either directly to EPIC or to epic contractors.
And this is the source of success of EPIC. Their software is pretty much crap. They hire fleets of college grads, work them for 60+ hour work weeks, burn them out in under 2 years, and replace them with the next lot of inexperienced automatons. The genius isn't in the code, it's in cornering the market of a federally subsidized effort.
"Most people in the U.S. wouldn't know they live in a tyrannical state if it walked up and grabbed their junk." - MyFirs
I live in Madison, Right next to Epic actually. Pretty much all medical facilities in the area use them of course.
The problem is, every time I go into the doctor they tell me about how they can now pull in all my medical history from every other system. It's so great! Yay! The doctors are sooo giddy and I roll my eyes because I know what's coming...
So according to this you have Herpes... no? Strange...
And multiphasic drug abuse? No?
Open heart surgery? Really? No?
and on an on it goes.
EVERY time I go in, all that stuff shows up under my name. No, I do not have a common name like John smith. My real name is very unique. Yet, records that have nothing to do with me get pulled in every time. But the only data transferred is the diagnoses. There is no info on where the data came from, when it happened... nothing. I'm pretty sure I'd remember heart surgery or herpes.
People lie about their names at hospitals all the time to avoid billing, law enforcement, etc... I suspect that's what happened to me. I had a rather unsavory roommate in college. But since the system lacks all detail of the event, I cannot even get it removed. This needs to die... and die theroughly. I should get to chose which records are kept about my health.
The one thing the Feds can and should do and they are asleep at the switch.
When Fascism comes to America, it will call itself Anti-Fascism, and tell you to give up your guns.
When Bruce Perens was getting questions from slashdot, I asked whether Obamacare should have mandated the use of open source software.
He replied with some BS answer about how great Obamacare is because his children with preexisting conditions can now become independent contractors.
I admit that modifying the system so that healthcare is not tied to your job is a good thing, but it shows how pathetic and how much greed has pervaded politics.
He should have instead focused on what the question was about: requiring open protocols, and open software as a part of Obamacare would go a great way to alleviating cost problems in certain sectors.
Make no mistake that I think that companies should not make money developing medical software, but they should not be making artificially large amounts of money by erecting proprietary walls.
A lot of these vendors are locked into their own technologies.
I had interviewed at Epic once (didn't feel like moving to Wisconsin... sorry) and realized that they used M for most of what they did... not much interconnectivity there.
Quo usque tandem abutere, Nimbus, patientia nostra?
I worked on a project that wanted to take in a bunch of data from a hospital's EMR and essentially do some analysis on it. The project was canceled before we ever managed to get data out of an EMR because it turns out to be nearly impossible.
"But aren't there EMR data export standards?"
Why, yes, yes they are! Multiple ones, in fact!
Unfortunately, the formats are complex enough that basically every single EMR has the ability to format a perfectly standards-compliant document representing the exact same data in an entirely different way.
And that's ignoring that, as I recall, we discovered that ultimately the data we were looking for were entered into the hospital's EMR as PDFs. The EMR could locate the PDFs, but it didn't "know" the data they contained.
So I'm not at all surprised to learn that doctors are resorting to faxing records. It's almost certainly easier than trying to exchange them digitally.
You are in a maze of twisty little relative jumps, all alike.
HL7 lacks a lot of features and the upgrade model is expensive. The larger problem is the smaller disparate medical offices that can't stay compliant or afford to invest in a comprehensive IT infrastructure. Microsoft tried to come out with an XML based standard but couldn't get enough widespread support. There is also still a major problem with the taxonomy between specialists and generalist, hand written documents (so we need better improvements in Natural Language Processing). A top down approach has been tried time and time again. Its time to explore a distributed solution where the patients take ownership of the data.
There is a standard in place (HIPAA EDI). That they aren't using it seems to be on EPIC.
"A person is smart. People are dumb, panicky dangerous animals and you know it." - K
they used M for most of what they did...
No wonder this is screwed up. What does M, head of the British intelligence agency, got to do with American health records?
that is exactly what those of us who have to use EPIC refer to it as, an EPIC failure!
The interface was obviously written by people who have not worked in a medical office, and all the staff complain about it, but we're stuck. It would be too expensive to get another one and retrain everybody to use a new system and transfer information etc...
The Feds made a big mistake by not specifying and requiring interoperability as the very first item.
Now that they have paid for people to install all of these different systems, it's very difficult (expensive, time consuming, kludgy) to bolt on interoperability to the installed base.
Big mistake.
I don't read your sig. Why are you reading mine?
Surely nations that have universal healthcare have this stuff worked out!
(No, seriously.)
.
Prisencolinensinainciusol. Ol Rait!
Because if the government had not mandated EMR, the various EMR systems would have had to convince health care providers that what they were offering made their jobs easier or improved the care they gave their patients in order to get adopted. As problems like this cropped up, those health care providers would have pressured the vendors they dealt with to resolve it. There would have been one of two outcomes: everybody would have ended up using the same company, or everyone would have ended up using those companies who made it easiest to build a system that could talk to other EMR setups. If the Feds did their job enforcing Anti-trust laws, it would have been the latter.
The truth is that all men having power ought to be mistrusted. James Madison
I've done some consulting in the realm of medical software and while I don't know every major in-and-out, the real problem is the market.
Here's an example of bringing a piece of software to the medical market:
- Come up with the idea for some software, write, debug, document it. **This is not the problem**
- Find a hospital or clinic, meet with the board (3+ months wait) to see if you can petition it's doctors/nurses/whomever to use your software.
- Find a group of medical staff that is willing to use said software, free of charge, on the side. You probably have to 'pay' them to do it somehow - give it away for free, or discount, when you actually start selling the software, or just a lot of business lunches. These people cannot legally use your software for actual medical purposes. They're just doubling their workload by using your system next to whatever the current mechanism they use.
- 6+ months go by. Now it's time to approach the board of directors of the hospital - make a presentation with the recommendations of the software users
- Now, hire an independent software analyst to review your software, while working with a lawyer - who themselves will work with one or more of the hospital's lawyers - to ensure that you're following all the legal requirements and hopsital software requirements. 1-6 months before you're certified for that hospital.
- Unfortunately, there may be other requirements that supersede the hospital's individual requirements, usually municipal, state, federal regs. You'll need to get certified on these (0-3 years duration).
- Finally get it rolled out to the hospitals and sold in the wild (note: repeat the certification steps for each new hospital/hospital group, but they'll be expedited)
Okay, so that's the general process. One part software development, 82 parts legal wrangling, red tape, and butt kissing.
You're also not going to make this thing very open. You won't use public libraries, because they need to be certified. You won't have common data, because every hospital wants different things. You're not going to use new technology or standards because it takes years to get it live, and when you make changes like that you have to start over.
You're also not being paid to add the features to make this externally accessible to god knows what.
Imagine the extra requirements involved in providing legal access to medical records to third parties. It's not a technological barrier; it's almost all legal. They must be certified, the two must have a contract, etc, etc. You can't just give it to anyone who asks - you have to have a legal relationship with each asker. That will have to be signed off on by the board too. And so on, and so on.
The project I did some consulting on? They're basically a sort of spreadsheet with calculations. It's been ~4 years, and it's still bouncing around, not yet fully certified and ready to open for sale. If they went back and added 3'd party export functionality, it'd be another 4.
What on earth could you possibly have against M??? A Case of the MUMPS
My experience in studying Medical Informatics is that they had no idea on how to create an ecosystem. Firstly, they were wrongly insistent on the need for everything to be coded. Take a look at things like SNOMED and LONIC as an example.
HL7 is a completely over engineered mess and it's a standards process driven by too many doctors and other health professionals and way too few computer scientists. It tries to capture the process of health care as a protocol. Completely wrongheaded. By the way, I worked on the UML 2.0 standard committee, which I think is reasonable by comparison to HL7, which is a major user of UML. Let that sink in.
HIPAA also has completely outdated and overly complex requirements as well. It was well intended, but it needs replacement. The law standardized technology, not requirements and that's a mistake.
Epic is a total mess. A local hospital system in my state adopted it and (surprise), it was horribly over-budget and there are still issues. And it's legacy code out of the box. It's all based on MUMPS and bits and pieces hacked on top of it.
Overall, the main problem is insisting that the problem be solved all at once, versus step by step. Step one, establish a system for identification for health providers and patients. This includes a system to get a identity of a patient via known data while providing a high level of confidence that the requestor of information is a health provider. Solve this, and then you can start talking about interchange. And start simple. Forget highly coded documents. Exchange vital history, procedure history, problem list and notes. That's it. Then move forward based on actual user demands.
Frankly, Clinton had the right idea with the national health id. If we could create an ID that everybody had that was only used for medical identification, that'd be great. But I doubt that'll happen, so we will be stuck with a huge data deduplication problem.
It's not easy, but it's more doable than people think. And heck, open source as a means of standardization is a fine part of this equation that is completely ignored.
Problem # 1 - Whomever thought that a self-service machine for check-in with a bunch of old people trying to use it needs to be shot. They had a paid employee babysitting the machine because most of the people trying to use it were clueless.
Problem 2 - Even when you're knowledgeable about technology, it's still not easy. You type your first and last name, and then click the button. Fine, seems easy enough. Except once you click the button, the screen refreshes, and it gives you no indication whatsoever that you successfully checked in. The only reason I knew was because the babysitter told me that it went through.
It all really scares me. Human error is limited in scope, but human error with a technology multiplier (and probably will) wipe all of us out.
Ah, yes, Judith Faulkner:
http://dailysignal.com/2011/08...
A major donor to the Democratic Party has received favorable treatment from the Obama administration, including a choice appointment to a federal advisory committee, and lavish praise from the president himself.
Yet health information technology vendor Epic Systems Corp. opposes a key administration position on health IT. Its founder, Judith Faulkner, has spoken out on numerous occasions against “interoperability” in electronic medical records technology.
So why was Faulkner appointed to a 13-member panel charged with recommending how $19 billion in stimulus money be spent? One can’t help but notice that Faulkner and other epic employees have given nearly $300,000 to Democrats since 2006.
Read the rest of it.
Do you have ESP?
Under HIPAA regulation (The Privacy Rule to be exact), you have the right to make changes to innacurate information of any PHI (Protected Health Information) they have about you.
So, yes, you may demand some information be removed by law, and they are legally obliged have a procedure in place for it.
The shiny side of the foil needs to be on the outside of the hat. The problem here isn't government intervention, rather a lack of same. The problem is corporate sociopathy and lack of standards. The standards should have been set up before anybody started building equipment. Where government fell down was not mandating that. Not a surfeit of regulations but a lack of them.
And had there been a monopoly there would have been no compatibility problems, but would have caused worse problems.
Free Martian Whores!
>Every protocol that runs over RS232
Protocols that run over RS232 are not RS232. RS232 is the interface spec.
I should use this sig to advertise my book ISBN-13 : 978-1501515132.
I have read a fair number of the comments posted here. And, the prevailing consensus is that there really isn't a standard when it comes to sharing health data and medical records between EMR systems.
Somebody mentioned HIPAA EDI in a previous post - those standards, however, are for passing information between entities for claims and not medical records. Why are the records themselves not specified in a publicly published format?
When I worked in the public safety software business, we were involved in many data sharing initiatives across the country. Many states had established their own platforms (Ohio and Wisconsin were pretty far along). But, on the federal level, they introduced GJXDM followed by the more comprehensive NIEM (National Information Exchange Model). The states moved towards this standard. While fairly big and deep, it make it fairly easy for NIEM compliant system to share data with one another. And, while the states built their own "free" records management systems, LE wanted their preferred vendors and the platforms with all the bells and whistles to support NIEM. So, we did.
Outside of this arena, we have HR-XML (for use by Human resources and NOT free). But, if you want to play in that game, you join the group and write systems compliant with it. At least there IS a standard.
What is criminal, in my mind, is that health care systems do not have a standard for describing this information. Nor, do they have a secure infrastructure for passing EMR data even if they did. It should have explicitly detailed as a provision in the ACA (aka Obamacare) so that healthcare providers and insurance carriers to interoperate. EMR vendors and insurance carriers should be REQUIRED and their software certified to comply with data interchange standards (which, may need to be formulated).
EPIC is in a position to set the standard. But, they won't because it means other vendors can get in the pool. So, somebody with really deep pockets and altruistic mindset needs to fund the development of a public standard, set the certification standards, and make it happen.
Change the penalty terms.
if doctors can't exchange records, they'll face a 1% Medicare penalty,
Make that read "If records produced by a medical record system cannot be read by another system, the vendors of the producing and reading systems will face a 1% Medicare penalty".
We could probably get that change legislated by slipping it in a farm subsidy bill someplace.
Have gnu, will travel.
The Office of the National Coordinator for Health Information Technology said that it was a "top priority" and just recently wrote a 10-year vision statement and agenda for it.
Sorry. Vision isn't covered by the ACA.
Have gnu, will travel.
"HIPAA EDI" is ANSI ASC X12 (specifically committee "N") which is a collection of file formats for communicating business transactions (in this case, generally submitting charge or payment information among providers and insurers), and has very little to do with medical records.
HL7 has created the Consolidated Clinical Document Architecture which hopes and dreams to one day capture provider documentation in an electronic format. The government incentives mandate certain pieces of this document to be supported by certified software, with the pieces differing between the phase 1 (now "2011 Edition") and phase 2 ("2014 Edition") certifications.
These pieces are nowhere near enough to actually transmit something resembling a legal patient record.
Deep down, though, the problem with communication is that every provider has their own style, from the wet-behind-the-ear doc who writes out all their SOAP notes long form over two pages mentioning every little thing like they're still trying to impress their professor, to the 40 year old doc who has made up a single page template with 40 checkboxes for the most common exam findings, a few checkboxes for diagnosis, and a box to write a plan, to the 60 year old who writes "ros/pe:wnl,pt well,flu shot,rtc 1y" on the line below where the nurse wrote the vitals and calls it a day.
What all of the above doctors have in common is that they do NOT want to deal in "structured data". They do not want to deal with SNOMED (or ICD-10, or hell, most of them don't even use ICD-9 that's what they hire billers for). Nobody deals with LOINC (good luck finding out the process used for your urinalysis dipstick so you can code the results correctly. I've got two major national labs that use LOINC for their test results, zero local labs, and zero labs that use LOINC order codes at all. For vitals at least someone in the government bothered to arbitrarily pick codes for height, weight, blood pressure and a few others out of the list of different ways of measuring each of them).
That would be illegal. Ted Kennedy made it so in the "Patient's Bill of Rights" known as HIPAA
In addition, The IT support staff told her that the vendors "super secure" remote access software would only run on a Windows PC. When she's on-call she has to update patient records. Their plan is BYOD, of course. So... she took her old, crappy Vista Netbook in. All they set up was the RDP client, defaulting to their server on the public internet. She clicks the link, Remote Client starts, 2 user/passwords and she gets a 800x600 Windows desktop. It's got a solitary icon which starts the native application. Yup... Super secure. Scrolling, mousing, cursoring and clicking to get to the form elements take more than half her time charting. It was painful to watch.
She prefers to use her Mac laptop, so I set up a Mac RDP client to use their URL and she was able to login. I watched her for a few minutes and noticed that all the controls and text were low contrast and used tiny, fuzzy fonts in the tiny 800x600 window.
I asked her; "Why do you have it configured to be so small with tiny fonts?" "That's the way it's always been. Everyone complains about it at work". Sigh.
I show her how she can expand the desktop by increasing the size of the client window and full-screen the app window to expose more of the forms. "Wow! we didn't know you could do that. That will really help! Critical stuff is always hiding off screen" Control Panel is available so I select a high contrast theme and larger, default fonts. "Wow, now I'll be able to read what's on the charts from my exam stool." Their clinic had lots of training and "experts" on site to help them learn and use the system in the first weeks, so there's no excuse for the poor default configuration they gave them.
I don't understand what has happened to the software industry. We seem to have forgotten the basics and now make the people serve the tools.