I’ve had a number of people ask me my thoughts on this Wall Street Journal article which talks about open source EHR and in particular the open source EHR developed by the VA hospitals called Vista.

I must admit that I’ve been enamored by the concept of free EMR. One of my most popular blog posts was this guest post about Free EMR by Medicare. Turns out that Vista is one of those open source (free) emr software that keeps popping up. I imagine it will continue to pop up for a long time to come.

Let me offer three points that I keep hearing over and over when I hear people talk about open source Vista.

1. (We’ll start with the good) Those that go to the VA are quite happy that no matter what VA hospital they go to, they have their information available. I’ve heard this on multiple occasions. I’m not sure if people are saying this because they’ve actually experienced it (which is likely considering the transient nature of veterans) or because they’ve had the concept drilled into their head. Either way, this is the major perception and considering it’s all one nice package I’m inclined to think it’s a huge advantage of Vista in the VA hospitals. I’d love to hear someone address how this “EHR interoperability” using Vista would work in commercial hospitals.

2. The users of Vista really don’t like using the program. It’s clunky, unwieldy and not the friend of the user. I’ve heard this multiple places and not just from doctors, but also from nurses and the IT people supporting the software.

3. The “database” that Vista uses, MUMPS, is a piece of junk and a major anchor on what could be an otherwise interesting open source project. I’m sure there’s some really interesting history behind the VA’s decision to use this MUMPS “database” system instead of one of the current SQL based database systems. Unfortunately, I’ve seen numerous people talking about the pains of MUMPS and the problem it creates for the future of open source EHR Vista.

I’ll admit that I’m not an expert on Vista, but I’m just telling you about the common themes I’ve read over and over again. Any other ones we should know about or other perspectives on Vista EHR?

A reader recently commented about something called openEHR. Maybe I was a little swayed by anything that says open since open source has used the term open so much. The idea of an open EHR sounded really interesting to me. I’m still not sure I completely understand the plan of openEHR, but I was put in contact with a fine lady named Heather Leslie who is working with openEHR on a product called Clinical Knowledge Manager (CKM).

I must admit that when I read the various information on clinical knowledge manager’s attempt to create clinical archetypes I was pretty lost. Maybe I’m just dumb or maybe across the pond (the project started in the UK) they are just using different terminology. Possibly it’s a little of both.

When I got this email about clinical knowledge manager the concept of creating clinical archetypes was new to me. I could be wrong, but reading it now they should have just said their creating standards for clinical data. That’s a concept I can understand and appreciate.

From what I can tell, it seems like CKM is essentially a wiki-like platform for displaying and improving these clinical standards (or archetypes if you prefer). I really think that the power of the crowd is the only way clinical standards are going to be defined, so the idea of a wiki-like website where people can collaborate around clinical standards sounds exciting. My only fear with it all is that if I’m having trouble cutting through much of the technical jargon, I wonder how many doctors will want to participate in this discussion. This seems like a really noble goal, but I can help but question if CKM and openEHR are not keeping EHR interoperability simple.

Time will tell how many EHR choose to adopt the clinical archetypes that openEHR creates. That will be the true measure of how valuable CKM will be to healthcare. I will be interested to see how this rolls out and if they can garner enough EHR interest and participation to make it a viable standard.

The following is an email about participating in clinical knowledge manager and more information on how it works:
Read more…

I think that anyone that is in this industry had to be struck by the story of ePatientDave pulling his medical history into Google Health (see my previous ePatientDave post). It’s not that we didn’t already know that it was a problem. I think that most in the medical industry know the problems associated with our data right now. However, I feel like we’re all (including myself) in a little bit of denial about this fact. The story of ePatientDave just painted a picture of how bad the data really is going to be.

The takeaway I have from ePatientDave’s experience is that we’re still a long way from having interoperable patient records. In fact, it makes my previous post about ICD-10 and EHR interoperability even more significant. Not to mention the need to simplify Health Information Exchanges.

Honestly, if we don’t simplify I’m not sure we’re going to get any of this healthcare data exchanged in my lifetime.

There are a bunch of myths being perpetuated right now around ARRA and the HITECH act. I’ve been on a number of conference calls and read a number of people perpetuating these myths. Some might call it poor communication and others might call it downright unethical talk. I’ll leave any judgment to someone else, but I believe these myths could lead to major problems in HIT.

Here’s the first myth I’d like to debunk here and now:
Myth: The EHR Stimulus bill (often referred to as ARRA or the HITECH Act) REQUIRES doctors to use EHR and be interoperable.

Reality: The government has no ability to actually require the use on an EHR. ARRA and the HITECH act do require you to use a certified EHR and show “meaningful use” IF (that’s a big IF) you want to receive the potential $44k in stimulus money avoid the 1-5% medicare/medicaid penalties that will go in force a few years down the road.

That means that if you’re not interested in the government stimulus money then you’ll need an EHR. However, I have a feeling that a large number of people are going to sit back and take the penalties and forget about the stimulus money. In fact, don’t be surprised if many just stop taking medicare/medicaid in response. The point being that it’s a requirement to get money, but not a legal requirement that a doctor use an EHR. I have a feeling those not using an EHR will still have lots of company for the forseeable future.

The interoperability falls under the same story. However, you may not even have to have an interoperable EHR at all if interoperability isn’t part of the EHR certification and “meaningful use” requirements. That part we’ll just have to wait and see.

Moral of the Story: Select an EHR because it makes sense for you and your practice. Don’t focus on the stimulus money and you’ll be much happier in the end.

I’ve been hearing a bit of discussion about ICD-10 really helping to solve some of the problems of interoperability. Their contention is basically that ICD-10 is more precise in its description of the diagnosis and so therefore the information that is coded using ICD-10 will then provide more specific codified information that can then be rather easily shared. If you haven’t read about the transition from ICD-9 to ICD-10, here’s a good article about the transition.

In theory, this is completely accurate. If everything went as outlined, we could really get a lot of interesting information for studies and for interoperability of health data out of our ICD-10 codes.

The problem is that in reality ICD-10 is just going to cause even more problems for sharing quality data. Not because we can’t share the data. That’s a topic for a different discussion. The problem is that we’re never going to achieve quality input of diagnosis codes.

I’m not a doctor and so I’m not going to give a specific example here. However, I think all we have to do is look at the current ICD-9 diagnosing patterns. I’ve seen from first hand experience that often a doctor gets stuck searching for the right ICD-9 code. Right or wrong, they end up picking a code that may not be exactly the right code for what they’ve seen. Maybe they choose NOW (Not Otherwise Specified) instead of the specific diagnosis that would be more appropriate. Add in the complexity of diagnosis requirements for getting the most out of your insurance billing and I don’t think anyone would disagree with the assertion that ICD-9 code entry is far from accurate.

I’m not trying to place blame. I believe this is a chronic problem in our health system that those in the trenches have known about for years. My point here is that if we can’t get the rather “simple” set of ICD-9 codes right, then how can we ever expect the much more complex set of ICD-10 codes right?

Everyone knows the common phrase of garbage data in produces garbage data out. When we’re talking about interoperability of EHR software, doctors really have to think if they want other people’s garbage in their system.

ICD-10 really could produce some awesome information if used properly. The challenge we face is producing systems that codify the data properly so we have meaningful interoperability of healthcare data.

A lot of talk has been done lately on the importance of interoperability of EHR software. Many people point to health information exchanges when talking about this EHR interoperability. I must admit that almost all of the interoperability and health information exchange discussions I’ve seen recently leave me lost. Maybe I’m just not that smart, but I also think it’s possible that people are trying to bite off more than they can chew.

I’d like to see a simplified method for exchanging health information. Let’s break it down into bite size increments where we can actually have achievable goals and solvable problems. For example, let’s start with something like prescriptions, allergies or labs. Let’s get those right and then add on top of those functioning standards.

I previously posted the comparison of the Transcontinental Railroad to EHR interoperability. The reason it was so successful with the railroad was because they only had to standardize the gauge of the railroad. We should apply that same type of simplicity to exchanging patient information and we’ll see better results.