When implementing an EMR you are very likely to also implement an EMR interface. The most common type of EMR interface is with your lab, but you might also have an interface with radiology, pharmacy, vital machines, ekg machines, spirometry machines, etc. The fact is that you are very likely to run into an interface in the process of implementing an EHR.

Interfaces with your EMR software are your very best friends, but also can be incredibly frustrating. Sounds a lot like my children. Here’s a short list of ways that EMR interfaces are like kids:

• Some people just know they want one, but others debate getting one all together. In the end, most people end up with one.
• They often will cost to implement and also cost (time if nothing else) to maintain.
• A lot of time is spent at the beginning taking care of the interface and making sure that it’s working properly.
• Most people love them and can’t imagine life without them.
• When they work your life is wonderful, when they don’t you wonder why you got one in the first place.
• They cause you serious headaches and usually those headaches happen at the very worst times.

Ok, so it’s not a perfect analogy, but I think this feeling about interfaces is shared by most people involved in them.  All of this said, I think our interface with our lab is one of the best reasons to use an EMR.  It’s so seamless and beautiful to see the orders get sent and the results returned with the lab signed off electronically.

If you’ve been reading my blog, then you know that I’ve started a pretty interesting and complicated discussion about EHR and EMR sharing of patient data. I first posted an example of sharing data with an EHR and then followed it up with some challenges associated with sharing of EHR data.

In my interoperability challenges post, Bjorn from Health Xcel posted a lengthy comment discussing some challenges of data sharing and made the case for RHIO (Regional Health Information Organizations) and HIE (Health Information Exchanges) as a means for sharing patient data between hospitals and doctors offices.

His comment was so well done that I’m copying it below for more people to see and read it. I don’t personally agree with everything that was said. I also think he didn’t address the funding challenges of RHIO and the policy problems. Maybe Bjorn will return with some comments on how those might work. Enjoy Bjorn’s take on RHIO and HIE (emphasis added):

I think Google Health and MS HealthVault will be good awareness catalysts for the quiet e-health revolution that is taking place. However, I do not think the defining change we need lies with their business model. A patient-centric model sounds good but we’d be assuming that everyone has an account with one of these systems and that they know how to use them. How will the data about a patient that is stored in a hospital be reconciled with Google Health? Which of course leads to interoperability concerns.

Web 2.0 does not lend itself to creating a reliable e-health solution either as service A is dependent on service B and if service B is down, service A won’t function and has no power to fix it by their own volition.

I think so far the industry, aka hospitals, has been trying to solve the problem by adding a patient interface to large hospital systems so patients can see their records. It’s also a step in the right direction but again it is not the golden calf we are looking for.

So what is the ideal system of the future?
A patient should be able to enter any hospital in the world, conscious or unconscious, and the hospital should have all the information they need about the patient to administer correct treatment and to notify the right people.

How do we do this?
I am a believer in the HIE / RHIO model. In the [not too distant] future, hospitals should concern themselves with healing people and not how to spend their IT budget. Hospitals, insurance agencies, smaller providers and patients will all be connected to an RHIO (Region Health Information Organization) where they will have a wealth of services; either to enter sensitive data or to discover data about one patient or the entire population. RHIOs will be connected to a larger e-health backbone consisting of HIEs that are the great data aggregators of the world. RHIOs would be responsible for conforming to regional regulations. This model is similar to how we connect to the Internet today. We don’t jack directly into one of the main Internet hubs of the world but go through an ISP that can provide us with an email address, a web page AND connect us to the rest of the world.

HIEs and RHIOs run on a software platform where health IT vendors can deploy their software applications. Some required components:

- User discovery
o Any one node on the system should be able to query the other nodes to find a user and her data
- Portable user
o This goes with the first bullet point in that a user should be able to log in to the system anywhere in the world and even though the user does not have an account with the RHIO she is directly interfacing with, RHIO should know how to authenticate her correctly
- Interoperability / Standards / Data aggregation and discovery
o The key to any successful e-health venture. Services need to be able to talk to each other. It shouldn’t matter whether the services reside within the same application or in different parts of the world. I believe the semantic web (web 3.0) will be a key facilitator of making this possible.
- Federated security
o If we take the previous examples of Google Health and MS HealthVault, they would all have to have their own security scheme and user authentication and access control. Multiply that by a dozen and suddenly a lot of money is being spent on recreating the wheel over and over. We need a unified system for this.
- Updates
o All applications should reside server side and users should have thin-client access only. When the applications are being updated, it should happen across the board overnight. If something goes wrong, there should be a way to undo the upgrade without hospitals or anyone else having to do anything.
- Data sharing
o The patient-centric network will definitely happen as users become more educated. But hospitals still need to be able to have access to patient data even though they have not been granted access, in case of emergency.

Ok, this suddenly got really long There is a lot of work to do for everyone in order to get true e-health solutions to work. The biggest obstacles aren’t technical but political and also the willingness to adopt a new way of interfacing with your health.

Cheers
bjorn

In my recent post about hosted EHR versus client server EHR Dr. Rowley commented on the various scenarios that could occur for sharing a patient record. The comment was so worthwhile that I wanted to make it it’s own blog post and add a few comments of my own. Here’s Dr. Rowley’s comments on data sharing scenarios with various EHR:

Whether you are an enthusiast of free, hosted, web-based EMRs, or an enthusiast of local client/server installations (or a wait-and-see skeptic), the question of data sharing is one that is important to us all.

Maybe the discussion can be best moved forward by considering a real-life scenario and examining how data sharing can occur in different situations. Let’s say that I am the Family Practitioner taking care of Mr. Chest-Hurts, who just was released from the hospital after a heart attack, and you are the cardiologist who saw him there. Mr. Chest-Hurts is in my office for post-hospital follow up, wants a referral to see you as an outpatient, had numerous tests done (which I don’t have in my records when I see him), states that you changed several of his medications on discharge and is confused as to which ones to take (and did not bring them with him for his visit). I just did some lab test and found his cholesterol to be not-quite-at-target. Let us assume that the referral is a simple administrative matter that happens anyway. What is important for patient care here is for us to share our records with each other – we need to reconcile his meds lists, you need the labs I just got, I need the cath report from the hospitalization, etc. Now let’s explore how we share data, given different scenarios:

1. Neither of us have EMRs; we both use paper charts. In this case (the traditional one in medicine), we copy and fax information to each other from our charts. We take each other’s faxes and make them permanent parts of our own separate charts.
2. I have a client/server EMR and you use paper charts. I generate a fax to you from my EMR, which you place in your paper record. You fax records to me, which I scan and import into my EMR.
3. I have Practice Fusion, and you use paper charts. Several options exist here: (a) I can generate a fax to you, like scenario #2 above; or (b) you sign in to Practice Fusion (after all, it’s free, and with “Live in Five” provisioning, you will be able to have access almost immediately). You can then print out what you might need, for inclusion into your own paper chart.
4. We each have client/server EMRs (maybe the same one, or maybe different). Like with paper, we each have separate chart records, and there is no unified patient identifier. A few options exist here: (a) we each have our systems fax out the desired records to each other, and import the data as scanned documents into our separate charts; (b) we each output a Continuity of Care Record (CCR), and somehow push it to each other. There are some efforts (like Relay Health, for example) who are trying to build an infrastructure to be an intermediary for CCRs – I push out a CCR and post it to Relay Health, and you look there and import the CCR directly into your EMR. This need to build a connection between local installs is a challenge (weakness, in my view) of local client/server systems, and will take effort and money to build. There is a lot of activity here.
5. I have Practice Fusion and you have a local client/server EMR. Several options can take place: (a) we each fax our information to each other; (b) we exchange CCRs (like #4 above); (c) I give you access to Mr. Chest-Hurts’ chart (like #3 above), so that you can see the record, and copy-and-paste between the systems if desired.
6. We each have Practice Fusion. We can share the same record on the same patient, and with the right permissions, can see each other’s notes, shared lab values, meds lists, etc. No uploading or downloading of CCRs required. No faxing needed. This is the most compelling scenario.

Pardon my long-windedness here, but my belief is that the discussion of data sharing is very important, and vital to unlocking the true potential of e-tools in improving health care in this country.

I’ll be posting my comments on these scenarios in my next entry.

Today I came across the HHS Secretary Mike Leavitt’s blog. To be honest, I saw Mike Leavitt’s picture on the blog and I felt like I was meeting an old friend. No, I don’t really know Mike Leavitt from the next person on the street. We have never met before and the closest I’ve been to him is probably when I watched him pass by in numerous 24th of July parades in Utah. However, he was the governor of Utah for many of the years I lived in Utah and so I feel like I kind of know the man.

Reminiscing aside, I find Mike Leavitt’s blog completely captivating. He currently has been writing about his trip to China. For some reason I’ve always had an inner itch whenever I heard about China. I don’t know what it is, but I find the place completely fascinating. So, you can imagine my fascination with the HHS secretary’s interaction with the Chinese government. Plus, these posts about HHS and China give Mike a real personal quality that I find real and interesting.

Of course, I couldn’t begin to read the HHS Secretary’s blog without making sure to find some post about EHR or EMR. I quickly found a post entitled Value-Driven Health Care Interoperability which I think could more aptly be entitled “Electronic Health Records (EHR) Progress Report.” Of course, he is in government so that explains the title.

I’m grateful that the HHS Secretary is willing to engage the public in a discussion about EHR and EHR adoption, but unfortunately the post I found is so filled with political rhetoric. It sounds really good, but really has very little substance.

First, I’ll start with the good.

Three years ago, there were 200 vendors selling electronic health record systems but there was no assurance that the systems would ever be able to share privacy protected data in interoperable formats.

I think the concept of a certification for interoperability is good. It just makes sense that every EMR software vendor should be able to interact with another. Establishing a quality standard for this interoperability is valuable and even worth certifying.

Unfortunately, I think the HHS Secretary has been getting bad information when he says the following:

Since then, we have made remarkable progress.

An EHR standards process is now in place, and we are marching steadily towards interoperability. We created the CCHIT process to certify products using the national standards and it is functioning well. More than 75% of the products being sold today carry the certification.

Where to begin? First, Mike has suggested that there were 200 vendors selling EHR systems 3 years ago (It’s probably a few more than 200 EHR, but we’ll let this one slide). Mike asserts that “75% of the products being sold today carry the certification.” If that’s the case, then simple math tells us that there should be 150 certified EHR software, no?

If you look at the 2006 CCHIT Certified Ambulatory EHR list I count 92 EHR software products. Let’s see, that’s only 46% of EHR products that are certified. Plus, my count of 92 EHR counts some of the software multiple times since a number of the EHR software vendors certified multiple versions of their product. That sounds like less than 75% of EHR products sold to me.

Of course, Mike Leavitt certainly could say that 75% represents a percentage of actual products sold. Certainly the certified eMD’s has a lot more installs than any of the free open source EMR products out there. However, I think it’s a bit deceptive to say 200 EHR and then 75% of products sold if they aren’t the same thing.

I also love how it says 75% of products sold. I think we’re all aware of the outrageous failure rates of so many of the EHR products out there. It’s unfortunate that we don’t have a percentage of products installed. Then, you’d have a much better idea of how many doctor’s offices really have the possibility of interoperability.

Wait a minute! I was being extra generous above when I said that there were 92 Ambulatory EHR CCHIT certified. Why? Because it was 92 EHR certified with the 2006 CCHIT Certification. Correct me if I’m wrong, but I think that interoperability was taken out of the 2006 CCHIT Certification (along with the joke of the pediatric requirements). I’m pretty confident about this, because I work on one of the 2006 CCHIT Certified EHR and I have no way of sending a chart to another clinic other than manually going through the product and printing out the chart.

What does all this mean? That means that instead of 92 interoperable CCHIT certified EHR, there are only 31 EHR CCHIT certified in 2007. That represents 15.5% (not 75%) of the 200 EHR products on the market today are interoperable according to number of certified EHR.

I’m not really blaming Mike Leavitt for this. I’m sure him or his office was given a nice executive report with a bunch of data and they made it look as nice as possible. Reminds me a lot of what I call EMR sales miscommunications. Sometimes the data just gets lost in translation. Let’s just hope my trackback to Mike Leavitt’s blog gets read.

You thought I was done. Nope. Still plenty more to say and I’m just hitting the major points.

In addition, a National Health Information Network will start testing data exchange by the end of the year and go into production with real data transmission the year after.

This concept I really find intriguing. I look forward to seeing this go public and I’m glad it’s on the agenda. However, I fear that this isn’t more than political hyperbole. I’d love to see how they plan to address any of the following: unique identifier, the ultimate hacker’s health information paradise, economic model, motivational model and that’s just the list off the top of my head.

The primary reasons for low adoption rates among small practices are predictable: economics and the burden of change.

I’m glad you pointed out the obvious. If this was so obvious, then why did you support the implementation of a certification that costs so much money that EHR will inevitably raise the cost a small practice pays for an EHR? That doesn’t make much economic sense. Not to mention you missed what I think is the biggest factor in lack of implementation: fear. Not fear of change. Not fear of the expense. Certainly those are two major factors, but I believe that adoption rates by small practices are so low because most doctors have seen too many of their colleagues fail at implementing an EHR.

Let’s start waving the CCHIT certification flag again. Many will be willing to make the case that CCHIT certification helps supplant a doctor’s fear that their EHR implementation will fail. It may even supplant some fear, but what it doesn’t do is decrease the number of failed EHR implementations. It’s a problem I’ve discussed many times on this blog. Certifications don’t certify usability. They never have and never will.

I actually have a thought about what should have been done instead of CCHIT, but I think I’ll save that for a future post.

Thanks Mike for opening up the lines of communication with your blog. Now it will be interesting to see if Mike Leavitt and HHS have really embraced new social media and participate in the discussion they started. I’m certain that Mike’s blog is going to become one of my favorite reads.

I’ve been following the Google Health announcements for quite a while now and today Google Health finally went live.

It’s been a long time coming and so it will be interesting to finally take a look under the hood. I haven’t personally had enough time to do a full analysis of Google Health myself, but techcrunch posted the announcement live and an initial review.

I think that techcrunch summed up a major part of Google Health and its meaning for EHR software in the following:

Google is planning to open up APIs to Google health to make it easy for other partners to tap into its health platform. And make no mistake about it. That is what this is: a platform. Health apps anyone?

Sure does make for some interesting thinking about how an EMR or EHR could integrate with Google Health. Depending on how my next couple days go, I may see if Google Health has given any sort of specifications for importing a patient record into Google Health from an EMR or EHR software program. In my previous posts it was said to use some form of CCR to integrate Google Health with EMR and EHR software. I hope this is the case. If it is, I think I’ll try to be the first to integrate Google Health with my EMR. I don’t think most of it would be that difficult.

My guess is that many of you are using an HL7 interface between your EMR and your lab. How does your EMR handle the signing of lab results?

We worked for an entire year testing, making requests, testing, more requests and more testing before we were able to launch an interface between our lab and EMR, but it’s been one of the best things we’ve done. The reason it took so long is the topic of another post, but it was for good reason.

One of the best advantages to a lab interface with your EMR is that you don’t have to worry about what to do with all those paper labs that you’ve signed. Inevitably all those signed paper labs will have to be scanned and attached to a patient in your EMR.

Really, that’s why a lab interface is so much better. The interface inserts the lab info right into your EMR so you don’t have to worry about:
1. Losing your lab results (before or after you sign it)
2. No need to scan your signed lab results into your EMR
3. You can run really cool reports on the data from those labs in your EMR (ie. blood sugar change over time)
4. Most EMR will notify you that there are lab results to read, so there’s no more waiting for the paper to somehow make it to you

In our EMR, a lab result gets easily signed off with the click of a check mark. Actually our labs our grouped into batches according to labs that were ordered at the same time. This makes it so all our lab results appear on one nice lab report as opposed to one lab report per lab. All doctors have to do is highlight all the labs and click “Mark as Read” and that whole batch of lab results are signed electronically in the EMR.

Of course, many of you will probably ask how we handle abnormal results. Well, I guess you’ll just have to wait to learn about that.

UPDATE: Google Health Beta is now LIVE!

Today I saw an article on TechCrunch that talked about how Google Blogscoped found a Google Health login page (UPDATE: The Google Health Beta Landing Page has been taken down) for the hopefully soon to be released Google Health. Of course, there isn’t really anything all that special about the login page. It looks just like almost all the other Google login pages. However, the Google Health page did include the following information:

With Google Health, you can:

* Build online health profiles that belong to you
* Download medical records from doctors and pharmacies
* Get personalized health guidance and relevant news
* Find qualified doctors and connect to time-saving services
* Share selected information with family or caregivers

Too bad none of the other links work, but it does give some interesting information about what Google Health will be like. The part that is most concerning to me is downloading medical records from doctors and pharmacies. How are they going to do that? The answer is that they aren’t really going to do it. There are going to be a handful of the thousands and thousands of doctors and pharmacies that will be able to work with Google Health.

I hope that Google Health does the right thing and integrates with something like CCR since it is already beginning to be established in many Electronic Medical Record software programs. That would be a huge boon to CCR, but it would also open up an entire set of doctors that could support upload to Google Health. This could definitely be a nice differentiator from Microsoft Health Vault which can’t do this either (unless it’s been added since I looked).

If Google Health decides to create their own standard for a clinic to be able to upload to Google Health they are crazy. Doctors have almost no motivation to support Google’s standard for uploading medical records. I’m not sure many EMR companies will support it either. I can see a few of them do it as a PR move, but I’d be very surprised if many of them bit on this. Doctors don’t buy EMR software because their patients can get their record out easier. It just doesn’t make business sense for EMRs or doctors to really do any sort of uploading like this to Google Health.

Of course the good thing for this all is that having another big player like Google interested in helping the healthcare system with some Health 2.0 solutions is great by me.

You can see my previous coverage of Google Health and also the Google Health Co-op.

Update: Here’s a screen shot of what Google Health could look like.

Update 2: What CEO of Google Eric Schmidt said about Google Health at HIMSS08.

I mentioned in a previous post on Windows Vista’s Voice recognition that I needed to comment on Microsoft’s aquisition of Azyxxi showing their interest in entering into the Healthcare industry as a software provider. I still haven’t had much time to read abouy that Azyxxi is going to do for the healthcare industy. When I read the announcement of the purchase of Azyxxi and the following post by Dr. Bill Crounse (he works for Windows) on Health Blog, I made the following comment:

I agree that this is a very interesting play into HealthcareIT for Microsoft.

Neil Versel reported:
“”Microsoft sees it as applicable to clincians and integrated delivery networks, not just a hospital system,” Washington Hospital Center ED chair Mark Smith, M.D., said at a press teleconference this morning.”

One thing I don’t understand is how this is going to affect anyone but hospitals and large group practices. If it can’t apply to small practices then it won’t have nearly the effect on healthcare that people are describing.

Maybe you could help me understand how this will apply to the small doctors offices.

Dr. Bill Crounse responded:

First and foremost, the system was built by doctors, for doctors. While it does not replace existing HIS/CIS systems, it does make them more useful by freeing the data locked up in disparate systems. It provides clinicians with an intuitive, extremely responsive way to view patient data. It is truly a world-class iteration for the era of knowledge-driven healthcare.

To the extent that data can be normalized, assembled, and securely distributed via web services, clinicians in all kinds of settings large and small, will have access to information that has previously been unavailable or locked up in silos. Patients could benefit as such systems populate their personal health record. The scenario I envision isn’t all that different than the way my financial services institutions populate information in my brokerage or retirement accounts.

Granted, this must play out in stages and we have a lot of work to do. But I am hopeful that we are on the right course, for clinicians and the patients we care for.

I’m still not catching the vision of how Azyxxi works. It really sounds like this is only going to beneficial to hospitals. I guess I could see a doctor’s office possibly getting access to information about hospital visits aggregated using Azyxxi. However, I don’t think that is the intent of this product. Please correct me if I’m wrong. So far everything I’ve read has only deal in vague details about how Azyxxi is able to aggregate disparate data. This is much easier said than done. Let’s see what you’re talking about.

One comment that did catch my attention was by Mike C:

“1/8th of a second access time to data housed within a 13TB database though… that is quite impressive =)!”

Despite catching my attention I’m still not sure how this applies to a doctor’s office. A doctor with 13 TB’s of data has their scanner resolution set way too high.

I am interested in listening to the Microsoft and Azyxxi audio cast. I think I’ll download it to my iPod tomorrow.

Electronic Prescribing(e-Prescribing) in Las Vegas
I’m not afraid to say that I live and work in Las Vegas. I don’t think I would call it completely home, but possibly home for now. Well, my third favorite Healthcare IT blog Just recently posted an interesting link to the local Las Vegas newspaper. I will admit that it is really the only newspaper that people read in Las Vegas. There are a few other that try to challenge, but really it is all about the Las Vegas Review Journal or “RJ” as it is affectionately known. I digress. Neil points out that an article on what the RJ called news is in his opinion stale news since he personally wrote about the same story in October in a Health IT World article. It’s interesting what can be considered “stale” news to one might be great news for another.

More importantly I was grateful that Neil pointed this article out to me since I’m very interested in getting Allscripts for free. I’ll have to see how it integrates with my EMR package and how Allscripts works, but I’ve wanted to use it for a while. One other problem I may have with Allscripts is that we have our own pharmacy. I wonder what is involved in getting Allscripts to work at our pharmacy. Does the e-Pescribing in Allscripts integrate with our pharmacy software ProPharm from Kalos Inc? These are all questions that I’ll have to be looking at soon. I’m also interested in how the alternative works when a pharmacy is not Allscripts compliant. I’ve heard it just sends through the fax which is something I’ve been looking into myself as an interim solution. Now if I could just find the time to work on all these fun projects. Thanks Neil for pointing it out to me. I guess I should have become part of the healthcare IT blogosphere sooner.

EMR Money in Rochester, NY
I recently ran into some other EMR news in my wife’s home town of Rochester, NY. I’m always interested in what’s happening there since I’m sure we’d consider moving there one day if the opportunity is right(despite Kodak pretty much leaving Rochester). The EMR article’s first line went as followed:

Two local coalitions will use $4.6 million in state grants to expand the use of electronic medical records. They hope the result will improve the quality of care for patients.

However, as I delved into the article I found that almost no amount of the money is going towards actual doctor’s implementations of EMR. In fact, almost all the money is going towards the development of an RHIO in Rochester. I think this is a great thing I can’t wait to see what a full working RHIO looks like. This type of money should give them a good start. Maybe some of you could disagree and say that RHIO’s are EMR. However, I would disagree with you. I will agree that RHIO’s are linked to an EMR and that an RHIO is very beneficial when you have an EMR. I’ll even say that an EMR becomes infinitely more important when there is an RHIO available. However, an RHIO is not an EMR. So, I was disappointed to read what I thought was a bunch of cash to support a nice EMR project in the Rochester area turn out to be a bunch of money for an RHIO. Maybe I should start working with an RHIO in the Las Vegas area. Is there one? I best find out.

I’ve doing more reading on EMR and the likes since I finished a business plan I was writing. Here’s a few articles/blog posts that I found interesting:

Face Authentication Software
The Healthcare IT Guy posted an interesting review of some auto-recognition and auto-login system for healthcare workstations called FastAccess by Sensible Vision. A standard web cam, easily installed software that can recognize my face to log me in. I need to get me a demo so I can try it out.

US Healthcare System
This is a nice article saying that although the media describes the US Healthcare system as broken down, many “better” healthcare systems aren’t immune to problems.

Mirth Project
I really like the idea of an open source project that supports HL7 messaging. I just can’t get my head around what exactly this means and how they are making the wretched HL7 messaging any easier.