Welcome to EMR and HIPAA

Future Health IT blogged about RFID’s in Healthcare. Here’s a quote from his post:

RFID application is still as much an art as a science. Even when readers are suitably located, tag and antenna alignment is still a problem. In addition, even if RFID could be used to trigger alerts, say in the operating theatre, they would have to compete with ambient stimulae and the noise of anaesthetic equipment, staff coming and going, respirators etc.

I am convinced that radio technologies are important in the evolution and integration of healthcare IT; I am still to be convinced that RFID will be any more than one of many of them.

I like the idea of what an RFID could do for EMR’s, but I agree that the technology is new and still needs to be developed a few more years. Now if inventory could all be done with RFID’s I would do it now. Too bad RFID’s cost still restrict it to palet level inventory.

Here’s a very interesting article on open standards and let me preface this blog post by saying I’m not trying to bash open standards. However, whenever you see that someone from IBM is talking about open standards you have to take it with a grain of salt. That is just like someone from Microsoft talking about how great Microsoft products are. IBM has been investing and positioning itself in the open source market for a while now.

That said, I also disagree that not having an open system is going to shut you out in the future as described in the article. Windows is still around right? More importantly, open source software is best when you are building a standard product like a web server. Sure, there are a few different features that people like, but in the end it is a pretty basic idea. You request a page and it delivers it. Healthcare and EMR is a very dynamic field and product and each person practices medicine a little bit different. This makes open source difficult to implement in the healthcare field and open source EMR in particular.

I do hope that many of the open source packages develop into a viable EMR option, because it could be a great piece of software for many doctors that don’t want to spend as much money up front. At least open source EMR could be great if CCHIT certification doesn’t kill open source EMR packages altogether.

I’ve wanted to find some more information about medical PDA software since I think it would be a nice addition to my blog. I haven’t completed my research, but I recently saw a nice post by Alborg which talked about some free medical PDA software. This is a nice review I’ve been looking for so I could learn a little more about what’s out there. Here’s what was said about the free software and a link to the review of the software.

Chris Helopoulos, the Chief Editor of pdaMD, did a review of all of the software titles available for download. Read his article at:

http://www.pdamd.com/vertical/articles/article-483.xml

In my search for understanding medical pda software I also started a thread on a nice forum called Doctor’s Gadgets. The basic idea is that I am interested in knowing what are the 5 most popular pda software for doctors? The list is quite enlightening. You can check out all the comments here. Otherwise, I’ll include some of the lists below. My list below has links to the different medical pda software just because I love my readers so much. Let me know if any of the links are wrong.

1. HanDBase - not really specifically medical but lots of very useful medical applications
2. Epocrates - new UK version is just the job until the BNF decide to release a free PDA version
3. Oxford Handbook of Clinical Medicine - essential reference for junior docs
4. 5 minute ortho consult
5. Archimedes - free medical calculators - in a nice format and linked to OHCM (if you get the skyscape version).

From an anaesthesiologist.
Top 5 free medical software - freeware
* medcalc
* ABG pro
* epocrates ( has a free version)
* infusicalc
* rca logbook

(1) High Wire View (High Wire Press, Stanford University) for professional journals. I love having the latest editions of journals put into my PDA when I synchronise and I don’t have to do a thing.
(2) Clinical Medical Consult (www.clinicalmedconsult.com) as my medical reference book. This is a wonderful resource - referenced, updated 2 or 3 times a year, relatively cheap and aimed at practising doctors rather than students.
(3) iSilo (www.isilo.com) makes a great job of importing any kind of document into my PDA with no fuss.
(4) Mobile Merck Medicus
(5) Skyscape

What a collection of different medical pda software that’s available! I’m sure there are plenty more. Let me know if you have other medical pda software by commenting here.

Right now I’m feeling quite overwhelmed. If it weren’t for this boring class I’m in I probably wouldn’t have time to even post to my blog. I’ve been participating in the HIT Blogposium which I haven’t been able to participate as much as I’d like. I’ve tried to keep up on my own EMR blog and my EMR and biometrics article. It’s been a fun experience participating in the blogposium experience. I’ve learned some very interesting things during the collaboration and hope they do it again when I have more time.

My EMR addiction has also left me in a vulnerable position because a local doctor has asked me for some help in choosing an EMR and more importantly ordering all the equipment that he needs to purchase to start a brand new office. It’s quite overwhelming even though I love EMR and helping him. I just wish he and I had more time to think through all the options. Weighing the I need it now with I want it done right is a real challenge. At least he’s selected an EMR and I think we have all the most important equipment ordered. We’ll see how good my off the cuff suggestions end up.

This EMR (and probably blogging) addiction has also really gotten in the way of a business plan that I submitted to a contest. My idea is pretty good and looks even better on paper and has nothing to do with EMR. I’m one of 6 finalists and I present on Wednesday. I’m pretty overwhelmed since a 20 minute presentation will determine a large difference in cash prizes. I’m stuck. Work on my blog and EMR which I love or polish my business plan. Unfortunately, I can’t work one dimensional. My mother always told me, “You can’t do everything.” I always replied, “You’re right…but I’m sure going to try.”

And of course, outside this EMR addiction my wife and son like to see me too. Imagine that! Besides me being stressed I think I’ve done a good job shielding my family from all that I’m trying to do. Sometimes I fail, but overall I think it’s not affecting my time with my family since I do most of it in boring classes or late at night. Family’s really what’s most important anyway. Maybe I just need to get my wife interested in EMR and blogging.

My last post is my first draft of EMR and “Biometric Integrations - Facial Recognition, Fingerprint Recognition, Palm Recognition, Retinal Scan. Authentication and Signatures Using Biometrics” for the Healthcare IT blogposium. Here’s a list of other Healthcare IT bloggers that are participating in the blogposium. Please visit them and offer your feedback and comments on their posts and mine.

I’ll be including a detailed link for each blog as they start being posted. I stayed up until Midnight so I could be the first to post my Blogposium post.

UPDATE: Here’s links to other participants.

* Christina’s Considerations on Regional Health Information Organizations
* Conmergence on Telehealth
* Drugwonks on FDA Critical Path Initiative
* eHealth on Integration of Personal Health Records and Electronic Medical Records
* Envisioning 2.0 on The E-Patient-Provider Relationship
* HealthNex Three topics: Patient Experiential Data, Genetic Privacy Issues and Biobanking
* HITsmit on e-MAR Systems
* HIT Transition on RHIO Startup Funding and Finance
* Informaticopia on International Perspectives on Clinical Informatics
* Medical Connectivity on Integrating Medical Devices into EMRs
* Marketplace.MD on the Consumer-Driven Health Care Movement
* medmusings on Mobile Access to EMR/EHR/PHR for Providers and Patients
* Usemed on Ongoing and Completed EHR, CPOE and CDS Implementation Projects

We’re getting some press coverage also from eWeek and Business Innovation Insider.

EMR and Biometrics Integration
Biometrics (ancient Greek: bios =”life”, metron =”measure”) is the study of automated methods for uniquely recognizing humans based upon one or more intrinsic physical or behavioral traits.

In healthcare information technology, biometric authentication refers to technologies that measure and analyze human physical and behavioral characteristics for authentication purposes most often used with an EMR. In healthcare, the most common physical characteristics include eye retinas and irises, fingerprints and facial patterns with behavioral characteristics inlcude signature and Voice.

Other examples of physical characteristics include facial patterns and hand measurements, while examples of mostly behavioral characteristics include gait and typing patterns. It can be argued that all biometric traits share physical and behavioral aspects.

Biometric Methods

The consensus is that iris scans are superior for accuracy, followed by fingerprint scans. Hand and facial geometry, voice and dynamic signatures generally rank much lower except for the newer technologies which are designed with healthcare in mind and consider environmental conditions as part of the biometric matching.

Iris Scans
Iris scans are currently the “gold standard” for biometric accuracy. Critics, however, are likely to mention that people get edgy when asked to position their eye near any device. Critics are thinking of retinal scans, which require closer proximity (2-4 inches) to a camera and a quick, concentrated beam of light. Iris scans can be performed from farther away at a distance of up to 3 feet.
Fingerprint Recognition
Fingerprint recognition is becoming even more common as many laptops incorporate fingerprint readers into the standard laptop package. Even the new UMPC is being offered with fingerprint recognition.
Facial Recognition
Facial recognition was first implemented for identifying people of interest in large crowds. The government and casinos were the most common users. Some new facial recognition vendors have focused on the privacy and security necessary to be used in healthcare. Facial recognition’s continuous authentication creates a nice framework for ensuring security of clinical workstations. It also paves the way for true single sign on.

Operation and Performance

All of these technologies involve sensitivity trade-offs. Set sensitivity high and scanners will keep out people you want to keep out, but they’ll probably also keep out some who should be allowed in. In healthcare this could mean preventing access to a critical patient’s record. Set sensitivity low and fewer authorized people will be denied access, but so will fewer unauthorized people. This creates a large HIPAA violation.

These tradeoffs in performance of a biometric measure is usually referred to in terms of the false accept rate (FAR), the false non match or reject rate (FRR), and the failure to enroll rate (FTE or FER). The FAR measures the percent of invalid users who are incorrectly accepted as genuine users, while the FRR measures the percent of valid users who are rejected as impostors. In real-world biometric systems the FAR and FRR can typically be traded off against each other by changing some parameter.

Benefits and Problems of Biometrics

Benefits of Biometrics:
Speed of Login - Biometrics is significantly faster than a password login.
Unique Identifier for Patients - In order to avoid duplicate patients in your system a biometric match with previous patients can be used.
Lost Passwords - Costs of managing lost passwords is almost completely removed with biometrics.
Digital Signatures - Biometric authentication can be used to digitally sign electronic documents found in EMR systems. These can range from consent forms to prescriptions to privacy agreements.

Problems with Biometrics:
Register Biometric Identity - In order to recognize your biometric identity you must register your identity. Some biometric registration is done over time during login, but it still requires storing your biometric data in order to recognize you in the future.
Solution or Substance on Your Hands - Healthcare clinicians are often coming in contact with various solutions that make biometrics unable to recognize you. Lotion on your hands is one example using fingerprint authentication.
Speed of Recognition - If you move to quickly you won’t be recognized by the biometric scanner. While still faster than a password this causes relative frustration.
Remove Gloves - Gloves or other equipment may make you unable to use various biometric authentication.
Physical - Some believe this technology can cause physical harm to an individual using the methods, or that instruments used are unsanitary. For example, there are concerns that retina scanners might not always be clean.
Personal Information - There are concerns whether our personal information taken through biometric methods can be misused, tampered with, or sold, e.g. by criminals stealing, rearranging or copying the biometric data. Also, the data obtained using biometrics can be used in unauthorized ways without the individual’s consent.

Active Directory Integration

Most biometric devices can be integrated with active directory to easily manage users and profiles across multiple workstations. There are two possible methods of active directory integration with biometrics. A very common practice is to extend the schema to include new biometric attributes. After extending the schema this change can never be undone. The other method is to use existing active directory attributes for authentication.

Another new feature of biometrics directed to healthcare is shared/kiosk workstations. Active directory integration is usually necessary to create a shared workstation environment with proper security and prevent time spend logging on and off windows.

References

EMR and Biometrics

[[Category:Blogposium]]

I initially announced the Healthcare IT Blogposium for April 18-19. It was since expanded a day to April 20th. I’m very excited to participate. This does mean that over the next few days I will just be posting and updating my posts for the blogposium. I think the good part is that it should have a group of Healthcare IT bloggers coming to my site to post comments on my post. I’ve chosen EMR and Biometrics Integrations. Should be fitting considering my recent rash of biometrics posts. I think it is also beneficial to put my previous posts into a nice document to contribute to the Clinical Wiki.

You can see all the contributors that have signed up at the Blogposium sign up page. Looks like there should be some interesting posts.

FOR ALL LURKERS - I love that you are reading my blog, but get out of the box and post some comments tomorrow on my biometrics article. Your feedback, ideas and criticism will certainly make it much better than what I could contribute alone. Don’t worry, you don’t have to register or give out any private information. You won’t get more spam if you participate. I will love you forever though.

The National Committee for Quality Healthcare has put out a CEO Survival Guide to EHR(sorry I hate pdf files too). If you are quite familiar with EHR then you’ll be able to skim through a good portion of it. However, it does a pretty good job covering the issue of EHR’s.

The thing I found most valuable in this EHR Guide is a checklist of things you should consider when implementing an EHR. Use the checklist to help you avoid mistakes, but don’t let it overwhelm you. There is a lot to consider with an electronical health record, but you can do it. You’ll be happy you did. Just take your time and do it a step at a time. This guide will give you a good start.

I’d wondered what products we could hook directly into an EMR and it made a lot of sense to me to have an EKG machine connect directly into your EMR. I finally found that it is definitely possible.

Here’s what was said at EMRUpdate about this type of connection:

The most popular EKG machine for EMR users is
the IQmark Digital ECG by Midmark. They also
have a spirometer and holter. The results of the
study are placed right into many EMR’s.
If an EMR doesn’t have this capability yet, you end
up scanning it in like other documents.

Here’s a link to the EKG, spirometer and holter offered by Midmark. Now I just have to check some pricing to see if and when we will be replacing our existing equipment. At least if I can export it to a document format then I know I can integrate it with my EMR.

I’ve had the chance recently to demo a number of different EMR programs. One thing I’ve found is that there are a lot of EMRs that are just downright ugly. Yes, I know they are fully functional, a book shouldn’t be judged by its cover, man looks on the outward appearance the lord looks on the heart and all that. I also agree that a pretty EMR that isn’t functional vs. an ugly EMR that functions is a no brainer. However, there are a number of functional EMR’s that are very attractive also.

Think about this. I believe that having a workstation(tablet or desktop doesn’t matter) in the exam room is the best and most efficient way to document a visit with an EMR. In fact, my friend JCP has a picture up showing his patient watching him chart in his EMR. Maybe you aren’t as open as JCP, but either way patients are going to see your EMR screen. Some of the EMRs I’ve demoed looked like they came out of the 70’s. I hate the idea that a doctor spends a large sum of money purchasing a brand new EMR and they receive something that looks old. Does the patient really care? Maybe not so much, but I believe it does create a certain impression as to your level of professionalism. In fact, if functionality is comparable then the pretty product is definitely going to win.

EMR Vendors: I think that looks are important for an EMR and a good professional graphic artist is worth every penny you pay them.

EMR Users: Functionality is more important than looks, but the way your EMR looks will give a good or bad impression to your patients. What kind of impression do you want to give?