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We at Medscribbler think having a “standard” for information exchange between electronic medical records (EMR) and other medical records and electronic devices would be a very good thing. We also think that having a certification standard for EMRs would be a good thing. We also believe that standards and certification as a national policy are NOT obtainable within even a few decades or even desirable as long as electronic technology and medicine is progressing.
The standardization of data interchange implies there is a standardization of healthcare knowledge in general. The components for the exchange and manipulation of data need to have a standard base of knowledge input to be compatible. For example, to say, “Joe is sharp” may mean: Joe dresses well or Joe is intelligent or maybe even Joe has a pointed chin. For the electronic system there is no way of determining which unless there are extensive “vocabularies” that finely determine through verbosity the exact meaning. The old computer adage “garbage in, garbage out” is as true today as it was in the beginning of the computer era.
To avoid “garbage in” healthcare terminology must be precise and current. Because of the consistent advances in medical treatment and knowledge this poses two problems. First, the constant changing of any electronic terminology set with the lag time to implement into software. Secondly, not only is there the learning of the changing terminology by the physician inputer but the medical knowledge and treatment skill of the physician has to match every other physician inputer AT THE SAME TIME so what goes in matches every other physician input.
Standardization and the resultant call for certification is really a step to medicine by the lowest common denominator. We at Medscribbler will not pursue this path. We prefer to make a system that allows for and helps physicians do what they do best, use medical insight to creatively and innovatively treat patients individually. This will mean we will never be a “point and click” and do “automatic coding” but it does mean that every physician can chose Medscribbler as a tool, not a whip.
Following is a list of recognized “standards” and “standards organizations” It is not a complete list. Some of these “standards” date back more than twenty years. The number of these organizations and the failure of every single one of them to become the recognized standard attest to the reality that no electronic standard is possible in a dynamic and innovative field like medicine. Some of these organizations have sued other organizations, some of these standards have multiple variations of the same standard, there are many competing standards in the same discipline.
ASTM International Continuity of Care Record - a patient health summary standard based upon XM.
ANSI X12 (EDI) - A set of transaction protocols used for transmitting virtually any aspect of patient data. Has become popular in the United States for transmitting billing information, because several of the transactions became required by the Health Insurance Portability and Accountability Act (HIPAA) for transmitting data to Medicare.
CEN - CONTSYS (EN 13940), a system of concepts to support continuity of care.
CEN - EHRcom (EN 13606), the European standard for EHR systems.
CEN - HISA (EN 12967), a services standard for inter-system communication
DICOM - for representing and communicating radiology images and reporting
HL7 - HL7 messages are used for interchange between electronic systems and devices. There are two different versions in use.
ISO - ISO TC 215 has defined the EHR, and also produced a technical specification ISO 18308 describing the requirements for EHR Architectures.
openEHR - public specifications based on a complete separation of software and clinical models.
Current Procedural Terminology (CPT): A classification system for coding ambulatory care.
ELINCS - EHR-Lab Interoperability and Connectivity Standards: An standard for reporting laboratory test
IEEE 1073 - Institute of Electrical and Electronics Engineers: The 1073 standard is used for integrating a medical device to a clinical information system
ICD-9 - International Classification of Diseases: is used for diagnosis and procedure coding; many are pushing for adoption of ICD-10 (a good example of the need for verbosity to determine a common medical knowledge set)
LOINC - Logical Observation Identifiers, Names and Codes: A code set covering laboratory tests
Medcin - A terminology for clinical care.
SNOMED International - A terminology for clinical care.
NCPDP - National Council for Prescription Drug Programs: A suite of standards governing prescription transactions.
NDC – Federal drug agency standard drug identification system
Multum - standard drug identification system.
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Al Borges, M.D.
duplicate
Some level of standards are necessary to make features of an EMR useful. I mean "useful" from a users standpoint and from a marketing standpoint. To say an EMR has certain features to attract customers is simple to do and during demos some doctors just might not ask the right questions. They end up buying an EMR that looks easy to use in a demo but miss the mark when it comes to actual workflow. Standards should be there to protect doctors from this disappointment and the marketing hype put out by vendors who know what doctors want to hear but lack the technical/medical know-how needed to make the technology work.
What exactly does document management mean? Does a user have to scan paperwork into 3rd party software then import it into the EMR? Are there other necessary steps like converting that image to a different file type? Do faxes have to be manually imported from a file on the server? Again, do users need to convert the file types? Do the users have to make any marks on the paper before scanning it in because the EMR does not support inking or other method of data entry on the image? Can users fax out the paperwork directly from the EMR?
What about intraoffice messaging/alerts? Is the alert a generic message that simply lists the patients name within the body of the note? If the alert/message is related to labwork or a consultants note, does the recipient then have to pull up the patient's chart and dig up the referenced material? Or, is the message attached to the patient's chart and the references material in question? Are the messages stored in the chart so users can easily retrieve patient specific messages? Can the alerts be set to go off on a certain date, in a recurring time frame or only when the chart is opened? Maybe the alert is of ultra high importance and doctors do not want the alert mixed in with the reminders of low importance. Is there a way to make the critical alerts stand out?
If we break out of basic EMR functions and look at things like the CCR we will find that standards will become more important. Vendors will have to come together and make something happen before the government does this. Going back to a point Robert and I briefly discussed, proprietary servers that share CCR files amongst only one vendor will only hurt the CCR movement.
>>> Vendors will have to come together and make something happen before the government does this.
What is so wrong with the government doing it? The main problem I see with CCHIT is that it represents a powerful wealthy group of vendors abusing the system to their gain.
When the Medicare came up with the National Standard Format for billing I thought that they did a great job, and their free credentialing process was a success. They should build on this success to bring together EMR systems under one institutional basic manner.
Mike Leavitt, the HHS secretary, recently said that CCHIT is essentially promoting interoperability. It is comments like that that make me think, "He has no clue about this industry..." I think Leavitt is a smart guy and watching/listening to his interviews are enjoyable. But, when it comes to healthcare IT he lacks a fair amount of technical knowledge. The private sector is far ahead of the government in terms of EMR's (just look at VistA). Why would we want the laggards dictating the standards?
>>The main problem I see with CCHIT is that it represents a powerful wealthy group of vendors abusing the system to their gain.<<
Is this to assume politicians do not use the system to their own personal gain? On the front page of today's New York Times I read this:
http://www.nytimes.com/2007/03/07/us/politics/07obama.html?_r=1&hp&oref=slogin
The private sector can still make the credentialing relatively low cost but probably not entirely free. I do agree that we need a basic institutional manner, at least for commonly advertised features. I also believe the private sector could do a good job of setting up guidelines.
alborg: >>> Vendors will have to come together and make something happen before the government does this.What is so wrong with the government doing it? The main problem I see with CCHIT is that it represents a powerful wealthy group of vendors abusing the system to their gain. When the Medicare came up with the National Standard Format for billing I thought that they did a great job, and their free credentialing process was a success. They should build on this success to bring together EMR systems under one institutional basic manner.
Private industry governing itself well ? Uhh .. no .. market economics is more influential than "do good" standards. If you can lock doctors into your system, that makes good economic sense.
As discussed before, CCHIT is a marketing tool and an artificial attempt by larger cap companies to pretend robust long-term standards are here.
It is clearly obvious that Insurance Companies and Medicare want to control costs as the American Healthcare system is entirely unsustainable financially. They both believe that the untraceable paper trail that Medicine is contributes to wasted health monies. They want things digital so more accountability is accomplishable. There is also the unproven idea that digital health information may improve patient health management. All of these factor culminate to a climate where there is a general willingness to help doctors go digital - ie. get an EMR.
So, now there is some government or payor monies available to help doctors. The EMR companies see this as an increasing revenue stream, so they band together and pretend "We have standards, This is the future" (CCHIT) to help provide some reassurance to the body forking up the dough that their money will be well spent.
This is the atmosphere that created CCHIT. It's silly to believe they are do gooders. The EMR industry needs major governmental intervention. The main need is to make records 100% interchangeable such that I can EASILY ditch my current vendor if I choose to do so. When CCHIT helps me ditch my current CCHIT vendor seemlessly, I will know they are useful, until then, they are a bloated, unhelpful, self-serving industry lobby group pretending to be useful.
There are no meaningful interoperable digital standards in healthcare, nor will there be for the forseeable future. Focus in on an EMR that provides value and smaller offices should entirely ignore the CCHIT list.
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bbchase: Mike Leavitt, the HHS secretary, recently said that CCHIT is essentially promoting interoperability.
That's a pipe dream perpetuated as a marketing tool. As I said before, when a patient's data from Praxis can be piped through a Centricity database, then through Greenway and returned to Praxis - seemlessly with no data loss - we can say EMRs are interoperable and CCHIT is the way to go. Everyone should know that's entirely impossible and will never happen.
CEOmike,
Are you going to seek certification? http://www.cchit.org/
The answer is NO - until CCHIT figures out there are better ways of documenting than by multiple screens, drop down lists and structure terminology.
If you look closely at the roadmap for the "features" that will be requiremented for 2009 and going forward CCHIT is obviously out of control.
There is an interesting chapter by CS Lewis in Pilgrims Regress in which the beauty of art degenerates into grotesqueness through each artist trying to out do the other. It is a parody of the cultural "bandwagon" effect. This is what is happening to CCHIT - 96% of small offices had trouble with the2006 standard - what makes anyone think 2009 certification will make it any easier for the small office to comprehend all the drop down lists, screen openings and obtuse terminology that 2009 CCHIT will force into certified software.
But with that said, we are very close to doing all of the functions of CCHIT without the structure, ie we now auto code but we do not use format of CCHIT - it is done in the backgound as the doc free form handwrites. So maybe CCHIT may accept that we do not meet the manual entry "features" but get the result required? But again, at the moment there is no business case to spend money on a certification that is quickly moving to absurdity.
Are you going to seek Obama "certification", aka meet "the standard" ?
This is a great dis-service to EMR adoption unless the "standard" is something that adds SIMPLICITY not layers of technical requirements. For example, a standard that says all EMRs must have the ability to dump out and import individual patient basic demographics into a text, excell or HL7 and the remaining information into or import of a PDF would go a long way to giving confidence in the industry, allowing innovation and experimentation without the risk of an EMR vendor disappearing and taking your patient records with them with no way to change to a different horse. This kind of standard we will embrace. Making CCHIT or something similar we will avoid because it will go nowhere, except in the short term for some "insiders"
The Ontario example is instructive - $150 million for the 22,000 doctors to adopt a "certified" EMR - Less than 10% applied for the money and there is a ton left over in the fund. THUD! Basically, doctors are not morons and are more technically astute than the government gives them credit for -in fact it is the unwashed masses of the government that are technologically challenged - Doctors will not buy crap, period! So in Ontario they proved it was not the money - or confidence in a "certified" feature product - it is EMR design!
They want to get adoption to be better give the money directly to EMR vendors in design contests or universities for medical software chairs etc. But then again Allscripts is Obama's advisor.
CEOMike: The Ontario example is instructive - $150 million for the 22,000 doctors to adopt a "certified" EMR - Less than 10% applied for the money and there is a ton left over in the fund. THUD! Basically, doctors are not morons and are more technically astute than the government gives them credit for -in fact it is the unwashed masses of the government that are technologically challenged - Doctors will not buy crap, period! So in Ontario they proved it was not the money - or confidence in a "certified" feature product - it is EMR design!
In Ontario, only docs whom are a part of Primary Care Reform could apply for the money. That isn't alot of doctors, especially because Ontario would only allow a certain number of Groups to apply - you had to be approved by the government to be a part of the Reform. Recently, the .gov allowed anyone whom wanted form a Group (of at least 3 docs) and there has been some very significant momentum. Many docs are teaming up and making their own FHO groups. http://www.healthforceontario.ca/HealthcareInOntario/PrimaryCare.aspx
This will make many more doctors eligible for the EMR funding, which is $18,000 per year per doctor for 3 years. (FYI, I am eligible for the money but I wouldn't use an EMR on the OntarioMD approved list if I could help it!)
Having been on the committee that helps make the standards (OntarioMD) for around a year, I know much about how the decisions are made regarding the standards. I "signed up" because of my interest in EMRs and I quit because of my interest in EMRs. When I realized that people higher up were just going to make the decisions they thought were the right ones anyway, I stopped participating. As well, they were pressuring reminding me to actually sign the NDA which I never did. I also saw/read about other provinces making better decisions than Ontario and I couldn't put my good name to bad decisions being made in Ontario.
I think the failure rate of these government-funded EMR deployments will be over 50%. Especially when you define a "Meaningful use" of the EMR. Just using it to print prescriptions falls short of meaningful use.
Medscribbler certainly is a usable EMR and is a great way to avoid paper charts. I look forward to re-demoing it in 2009. Medscribbler is likely the EMR closest to my own setup (Synapse + ink notes).