The Electronic Medical Record Stimulus Fiasco: Part 1

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  Jay Beaulieu • May 28, 2009

  As an IT worker I am also worried about the President’s Healthcare IT reform. First thing I’d like to set straight is that you presented a serious series of issues about Healthcare IT and I’m going to try to address them. I don’t stand to benefit at all from my solution. I also tried contacting the Obama administration and sent the following viewpoint that implied SOA (XML contracts, workflow) and DITA (data views, procedure workbooks) both are open source, but received no response:
  I want to keep this letter at the concept level and not get into a technology whitepaper, but rest assured everything I’m about to suggest is at the cell-phone level of cost for physicians, a little more at the hospital level because of different needs but most importantly the technology already exists.
  There are currently three basic types of medical records, paper medical records, the folder we all know so well, the electronic medical record used mostly at hospitals, think of a printout from a computer system and the Electronic Medical Records (EHR) which are XML-based records that have the ability to reduce costs and errors because they are programmable and can be validated (checked for accuracy and completeness.)
  The first discussion we need to have is who should hold these records. If the goal is to fight disease, find new cures, to identify epidemics and to use these records as a basis for an unparalleled growth of healthcare knowledge over the next ten to fifteen years, we need the records easily and securely accessible. There are two groups that I think have the ability to deal with the billions of pages of medical records. The first is the Federal Government but due to the boom and bust of the budgetary process I prefer the telecoms because they are big enough, have the redundancy, the geographical reach, the competition, the bandwidth and their business model is based on providing reliable services at a low cost.
  Next we need to look at what is the correct paradigm to use for our medical records. This is simple it’s an electronic loose-leaf notebook that mimics a paper folder but has pages that can be forms or entire computer systems like an MRI system. A simple example would be using the Kindle II to access medical records. Because most physicians medical records are in paper form we need to get them scanned into electronic form and sent to the telecoms. This is labor intensive but requires little training; we could use the workers already being assembled for the 2010 census, providing a very quick stimulus effect across the country. This is not make-work because the unfiltered raw data is the most valuable form of information to researchers if searchable. The census worker leaves behind a scanner, a printer driver (to write to the telecoms) and an electronic certificate of use that allows secure and audited, reading and writing to the medical record. The electronic certificate of use controls the type of information the holder can view or update. For instance, a state worker that monitors lead levels may be able to add a report to the book but never read any information and the same would be true of a Department of Children and Family welfare worker. This information could have a direct impact on treatment choices. The census worker also performs an audit of what software systems that are currently in use at the office, for later when we convert to XML.
  At the hospital level we could use the same type of system as at the physician’s office but here since money is available we want to make use of it for future efficiencies. So the first step is to think of each computer system, medical device and medical personnel’s duties as steps in a workbook. The goal is not to run out and replace every computer system you have but rather to identify workflows and steps so that you can layer with an enterprise software service on top of whatever systems and procedures you are currently using. This is the best way to keep integration and training costs to a minimum. This first step sets the basis for measuring metrics across the hospital and after careful analysis selected systems could be replaced. The idea is that the use of EHR records can be implemented outside or on top of your current systems. Disk space is cheap and redundancy of information is not always a sin.
  At this point we’ve minimized the risk of movement to XML. The physician’s office has had time to adapt their workflow to electronic records, has probably replaced the paper folder racks with another examination room and may have had some cost savings. And they no longer have to worry about marrying an IT person to practice medicine. The telecoms are trying to sell all sorts of services like billing, automated reminder calls, electronic prescriptions the list is endless. The hospitals have identified its different workflows, decided where XML would benefit them and possibly received bids from different software vendors to wrap the individual systems either wholly or partially to take advantage of XML. Now it’s time to move to XML.
  The largest cost savings and reduction of medical errors comes not from the EHR record but from the workbooks. This type of workbook is really a best medical practice workflow, in it’s infancy it’s just an electronic record of symptoms, treatment and justification, sent to a third-party like a telecom. The purpose is to prevent a remake of the “Verdict” with Paul Newman except on the History Channel. But to do that the workbooks need to be created and maintained not by an individual software vendors or physicians but by a consortium of interested parties like the medical manufacturers, pharmaceuticals, medical associations, physicians groups and finally the Federal Government for an effectively rating. This allows for the creation and refinement of many backend programs that can check on the validity of treatments in so far as medical errors and options are concerned.
  Next up are the healthcare insurance providers. Because the medical community has its own very precise terminology, what’s covered, partially, wholly or not at all by an insurer can be conducted in an XML contract in a matter of seconds. This would require a law to be passed requiring it from the insurers. But it should also allow the insurers to provide an alternative treatment to the patient. This provides the patient a cost with an effectively rating and maybe a couple of different optional
  treatments so the patient in consultation with their physician makes the judgment.
  We left the medical records as electronic medical records earlier we need to get them into EHR but I’m of three minds here. The first is that we could have done the conversion when the records were scanned in and using software and our census workers create the EHR, this provides the greatest stimulus to the most people. Or we could scan them in and have the conversion done in places like Elkhart, Indiana or other areas hard hit by this recession, because most people that have worked in a factory or assembly line already have the skills needed for XML. But we could also write software programs to parse, categorize, and convert the data to EHR which would produce valuable programs that could be used outside of our medical records, to XML and Artificial Intelligence programs in general. The programs are re-executable whereas using the census workers is more of one shot deal. The other thought is that when designing the XML processing procedures it should never be pigeon-holed into what we expect to collect for information. A notebook can have anything in it but a page or maybe even a chapter could be validated but it needs to be remembered this is a data collection system that must change frequently with the pathogens and treatments out in the field. Layered from the unknown but collected (notebook) to the known (page) outside in.
  Now the medical office worker, physician and patient all check the accuracy of the EHR. From the physician’s point of view, forms can now be filled out on the hand-held device, new features or workbooks appear tailored to their specialty and particular treatments. Perhaps a table of relatives allows access or just querying the patients relative’s books for pertinent information, but of course this is up for discussion. The hand-devices could now have barcode readers, GPS units and biometric fingerprint readers for drug auditing, security and for access auditing. Deceased people’s books are constantly being sent to the National Archives or CDC for storage and research, a little like donating your body to science without the yuck factor.
  Hospitals have spent there monies wisely, have color-coded hand-held devices so they don’t bring the wrong one into the operating room. But most importantly, they’ve changed from, a who can pay and who can’t, to true cost accounting and I don’t mean in the IRS sense. But we as a society need to actually advance not to just pay as you go. So therefore, charging ten dollars for an aspirin from an IT perspective, I can’t help you. However, if the reason you’re charging ten dollars is to
  offset the fact that you have a separate DBA for each database or you need 24/7 support there I can reduce your costs significantly.
  Finally, we’ve created a series of checks and balances in our healthcare engine that should help it stop leaking oil. We’ve given everyone a haircut to one degree or another but we’ve refocused on the fact that the goal of our healthcare engine should be on providing better healthcare for ALL Americans and that profits should be earned though innovation and hard work not just by exploiting leaks in the system or clever accounting.

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  EMR Medical • February 25, 2010

  Thanks for the view through this blog. A major US survey has shown lately that majority of doctors think implementing electronic medical records is necessry at this time.

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