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Arguing For Open Electronic Health Records 111

Posted by Zonk
from the keeping-it-on-the-up-and-up dept.
mynameismonkey writes "openEHR guru Tim Cook, writing in a guest blog at A Scanner Brightly, discusses why Electronic Health Record developers should use open standards. Why are so few doctors using EHR systems? And, as more and more hospital EHR systems come online across the country, what do we have to fear from proprietary databases? It's one thing to find out your social security number was stolen. Now add your mental health and STD results to those records."
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Arguing For Open Electronic Health Records

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  • Companies selling the systems make a killing from the converting of the old, proprietary database to the new, proprietary database that does not look that much different than the old one.
    • Re: (Score:1, Interesting)

      by Anonymous Coward
      I work with 2 EMRs at my job as an IT Director, both of which use MSSQL as the DB. I have full access to the Database at all times.
      • by TheHawke (237817)
        Good for you. Then watch as the asshats on the board want to use something completely different that some salesjerk snowed them on saying that SQL is old and obsolete, selling the company an old version of FOXpro wrapped up in a eye candy shell. I pray that this does not happen to you and your company, fighting it tooth and nail until they email you a pink slip, or worse.
    • by mrbluze (1034940) on Sunday December 30, 2007 @06:14AM (#21855046) Journal

      Companies selling the systems make a killing from the converting of the old, proprietary database to the new, proprietary database that does not look that much different than the old one.

      I think much of the problem has to do with legal problems on the storage of data and its dissemination (privacy laws, legal exposure etc) and that doctors have a general distrust of electronic record keeping without a paper backup. Also, arriving at an open standard on storage of health information is very very difficult as it's not a science and there are as many opinions as asses on seats at committee meetings. Everybody quotes easy stuff like pharmacy orders or pathology requests and results, but a health record can come in so many forms, (and if you look at a hospital record, there are so many types of forms in it) that it becomes difficult to come up with a database design that will cope with such diversity and still be usable. Information on a case can be a few scribbles to an exhaustive analysis.


      That's not to say it won't happen, but it is taking a very long time and some expensive attempts at standardization (eg: NHS) have failed.


      • by h4rm0ny (722443) on Sunday December 30, 2007 @07:06AM (#21855198) Journal

        In the UK, the government has invested vast sums of money into a system called "Choose and Book." It's billed on the slim selling point of offering patients greater choice in hospital care but the most cursory look at the technology involved shows that the biggest effect is that of centralising patient's records.

        Aside from the fact that patients can be offered a choice in secondary care already (by their doctor referring them to somewhere else), the system is buggy and flawed. The doctors don't want it, there have been national campaigns by the public against it, but the government is doing every single thing they can to force it on people up to and including financially penalising doctor's practices for not using it. The motivations are (a) presumed financial interests in the big companies that are providing the system and (b) a burning desire to get hold of everyone's personal medical data for government and police purposes.

        It's not even legal as the responsibility for patient confidentiality belongs to the patient's own GP and if there's a misuse, they will be the ones legally to blame for sharing the data. There's some information on it here

        If there's a need for easily transportable medical records, then this can be resolved by putting the data in the patient's hands. Public-Private key technology, or even hashes of the data, could be used to ensure accuracy. The solution is not that complicated, but in the UK we're having a very hard fight getting it.
        • This is a project chosen for it's visibility. The perfect medical software just works, and the patient never sees it. But this doesn't win you any votes when you've been lambasted in the press for spending $12B of public money on IT projects.

          Patients don't WANT a choice of specialist hospital or doctor. They just want to go to the best one, and they don't have the specialist knowledge to make that choice, so they will ask their doctor.

          The proper implementation of C&B is therefore to give a client to GPs
          • by h4rm0ny (722443)

            The proper implementation of C&B is therefore to give a client to GPs that they can book appointments with. The decision to expose it to the general public is purely to say "hey, look, we made something that works".
            Well for most of the time, they've been saying "hey look, we made something that doesn't work," but I agree with you. I add though, that almost no doctor that I know wants the system either. GPs usually have a pretty good handle on where to send people and can choose differently if there's

        • by finty (1210050)
          The solution is not that complicated, but in the UK we're having a very hard fight getting it. Slovakia is to.
      • Re: (Score:3, Informative)

        by ThreeGigs (239452)
        Google "HIPAA" and/or X12 EDI

        It's a data exchange format that *all* health care insurers and providers must accept or provide when exchanging patient data. It's trivial to add to the spec rules for additional subloops containing text. There are codes and modifiers enough to cover damned near any medical situation.

        Many small doctors avoided electronic data altogether by doing as they'd done for years, namely keep paper records. That is until insurance companies began deprecating paper... by not accepting pap
      • Re: (Score:3, Interesting)

        by budgenator (254554)
        You need to go down into the records storage area and just look at the physical mess there. Some of the forms are flimsies and are going to disintegrate long before the AMA/ADA HIPPA/OSHA specified 30 years are up and those radiographs are most likely to fixer stain into unreadability as well. Most offices pull inactive records and shove them into a "bankers box" which are then shoved into a storage area that isn't climate controlled and keep the boxes in chronological order by date pulled and the internal
      • by spineboy (22918) on Sunday December 30, 2007 @02:26PM (#21857968) Journal
        Every week I have some patients who have come in from far away to see me with some X-rays, MRI, CT scans. Often they are on a CD with some strange proprietary program used to display the images. Often I cant open them up and look at them, and the person has made a several hour trip almost for nothing.
        In that way old fashioned plain images are better.
        Having open source images/records would also eliminate that problem too, as I could display the images, and not have to find/buy/ download some strange/clunky program.

        Most radiologists and newer surgeons really like electronic imaging, but it can backfire on you as well.
    • Re: (Score:3, Interesting)

      by TCook (66808)
      The question that brought about the guest blog was; "why aren't primary care physicians adopting electronic health records?"
      The answer is (primarily) because of misaligned incentives. Open specifications can help solve that problem. Especially ones that are implementable (some specifications are known to be developed in a committee room without being tested in software).

      But the above post exposes a truth. Many proprietary companies are making money off of a few customers using the same old "upgrade tax"
    • by LesFerg (452838)
      I don't know how often you have witnessed this, but even if true, that is the purchaser at fault, not the company selling the solution.

      In 20 years of Health IT development, the majority of hospital deals I have been involved with have been thoroughly planned by the purchasers chosen overseers, who have specified what data storage and sharing standards they desired. Most of our solutions have been implemented in sites that have a number of different systems, a base PMS for instance, which the IT solutions i
  • What? Me worry? (Score:3, Insightful)

    by Jorkapp (684095) <jorkappNO@SPAMhotmail.com> on Sunday December 30, 2007 @05:53AM (#21854984)

    Now add your mental health and STD results to those records.

    This is Slashdot. An STD would practically be a trophy here.
    • Yeah but the slash virgins would never get STDs even if they were having sex. They'd all be too paranoid about spawning unwanted processes :p to go without App Armour ;)
      • Re: (Score:3, Funny)

        by deniable (76198)
        I can just see some bright marketing type selling condoms as "Personal firewalls."
    • An STD would practically be a trophy here.
      What would the trophy look like? A limp, leaky dick with warts around the base?
  • SECURITY (Score:3, Funny)

    by mboverload (657893) on Sunday December 30, 2007 @06:09AM (#21855024) Journal
    Primahealth: How are they secure with open standards? You can't have security without obscurity! THIS IS MADNESS!!!
    Stallman: This is GNU/SPARTAAAAA!!!!
  • I have every expectation that electronic health records will be abused. And I don't mean simple cases of identity-theft. I mean systemic abuse by organizations which have 'legitimate' access. Call me paranoid. Go ahead and make jokes about my tin-foil hat. But with history as a guide, I believe that such abuses are inevitable.

    So, from my point of view, the harder it is to integrate electronic health records from disparate systems, the better. The more proprietary and undocumented these systems are, th
    • This has nothing to do with open standards, though. The problem is the absence of privacy protection in the US. Of course, it doesn't help to make it even easier for say a Workers comp insurer to scan through your mental health records trying to prove how that broken leg is all in your head...
    • IMHO centralized electronic medical records would be very useful and should be implemented.
      Under the condition that no data can be accessed without explicit permission or in life or death situations.

      To make it simple, going to the GP would give the GP a brief overall view of your records.
      If the GP wants to delve in deeper then you need to 'unlock' the data.
      And the GP can access the data for a period of time. Lets say a week.
      If you've got cancer or something else with long term treatment then your doctor wou
      • It may be possible to reconstruct fingerprints from the template data stored about them. There's no documented case of this being done in the field, but there's a paper on it at http://www.csee.wvu.edu/~ross/pubs/RossReconstruct_SPIE05.pdf [wvu.edu]

        I really don't like using biometric data as passwords for anything as important as health records, since they're irrevocable.
        • They arent irrevocable. You can change it 10 times.
          20 if you dont mind that kind of thing. ;)
      • by jayp00001 (267507)
        Who cares how long a GP has access to your records- the ones selling your info to insurance companies ( the only winner in using EHR systems) will copy it with one swipe of a mouse or printscreen. I can't think if a single reason to have a centralized repository of private health data that isn't completly offset by the privacy and liability issues attached to it.
  • Who owns it (Score:3, Insightful)

    by sane? (179855) on Sunday December 30, 2007 @06:31AM (#21855092)

    A better question is who owns your record?

    An unsettling issue is that the doctor or hospital generally considers that THEY own your record. Think about that for a second...detailed records of you and your peccadilloes and someone else thinks they own and have the right to do what they want with your data.

    In a world where that little vulnerability were straightened out open standards based ways of working with your personal data would come by default. You should be able to store and deploy your data, under your control, will any medical professional only being allowed to access and add to those records with your permissions. The only way to make that work is for hospital systems to use open standards, no more proprietary systems and no corporate data caches.

    OpenEHRs are a sideshow next to that.

    • An unsettling issue is that the doctor or hospital generally considers that THEY own your record.

      I have only heard one case of a doctor thinking they own the medical records of a patient. All other doctors I know are happy to share records with other doctors once they have confirmed that the patient actually consents to that. I've never had any trouble viewing my record with any of the doctors or specialists I've visited in my time.

      The one case I heard of was a deceased doctor. His son took ownershi

      • by jbengt (874751)
        In my experience, almost every time a new doctor or hospital required records from a previous one, there was a charge for duplicating and sending the records. Though they never gouged me like your anecdote above; it was typically a one-time fee of $25 or so for the entire record.
        • It is one thing to charge a small fee to cover someone's time to stand in front of the scanner/copier and feed in pages from your record. It's another to claim ownership of the record and extort the rightful owner of the record (the patient) to access their own information.
    • You should be able to store and deploy your data, under your control, will any medical professional only being allowed to access and add to those records with your permissions.

      Then how do you prove something like Medicaid fraud? Which is rampant. Or be alerted to people clinic shopping for pain meds? Also rampant. Many times hospitals have to comply with laws that make them or your doctor responsible for someone else getting silly.

      Generally I tend to side with your viewpoint but I've also come into c

    • Actually they do own the records and can do anything they want with the information in the records consistent with the laws and usually more stringent industry customs and personal ethics.
    • Say the patient has been diagnosed with schizophrenia, but doesn't believe that diagnosis is valid because he knows the real problem is that its really that the video game industry in an unholy alliance with the DoD and is out to get him?

      Or many other diagnoses or bits of information that patients do not want providers to access but which are important to their care. Like drug abuse, blood born or sexually transmitted disease, or other mental health problems. A pregnant woman with pelvic pain with a hist
    • by jbengt (874751)
      I would assume that the doctor/hosptial/insurance company owns the records.
      That's why we have laws about access to them and privacy concerns about them.
      The medical practice is the one that makes the records, puts them in a form (hopefully) most useful to them, and needs to reference them and share them with other caregivers in the course of caring for you.
      Most people wouldn't have a clue what they contained even if they read them.
    • by trenobus (730756)

      It's a mistake to assume that information, particularly information assembled from a multitude of sources (such as an EHR) can be owned. Any system which purports to give you "ownership" of your EHR is also giving you a false sense of security. Nevertheless, some kind of access control is imperative for EHR's, both for reading and writing. But it needs to be flexible enough to avoid impeding the sharing of information about a particular patient between potentially many caregivers for that patient. A sys

    • You own it (Score:3, Informative)

      by peacefinder (469349)
      At least in the US, HIPAA [hhs.gov] says the contents of your medical record are yours, and the healthcare provider is a custodian of that data. That said, there are some caveats.

      * Not all data in an EHR system relating to you is actually part of your medical record. There may be - probably is - some internal clinical communication attached to your chart in the course of clinical operations. Basically an EHR system usually tracks both your record and the providers' own record about you. These different classes of dat
  • by dmr001 (103373) on Sunday December 30, 2007 @06:32AM (#21855094)
    1. I don't get the article summary. Are my STD results somehow more vulnerable to theft if they are in a proprietary database format rather than an open one?
    2. In my practice, we use an EHR (electronic health record) because I'm an employee of a big enough group that has the resources to purchase one of these expensive, bloated, not very well-maintained systems. (They're still working on making cut and paste work, and the group has to pay a bucket of money every month for ongoing support.) When I was a medical student in Ireland, I marveled how the GP I worked with in West Clare had a simple system he paid something like $300 which did everything he needed it to do, like track progress notes and lists, and keep track of drugs. That amount here covers about 30 seconds of use of our current software. Which is barely interoperable even with itself - if we see a patient from an affiliated private group using the same software, interoperability means they can email us a progress note, and then I can spend my afternoon hand-entering the medications and problems from their chart into my state of the art software's database to make sure grandpa doesn't crump over the holiday from a drug interaction with the cardiologist's new pills.

    There isn't much incentive to make this software as easy to use as iTunes - the players seem to make plenty of money already with their proprietary storage formats and circa 1991 interface. There is no viable open source alternative (http://oemr.org/ [oemr.org] doesn't look quite ready for prime time) - though I think there's an opportunity here for some enterprising Linux loving propellerheads.
    • by TCook (66808)
      You make some good points. However, oemr.org is far from the only player in this arena. Check out the following sites:

      Linux Medical News http://www.linuxmednews.com/ [linuxmednews.com]

      OSHCA http://www.oshca.org/ [oshca.org]

      Openhealth mailing list openhealth@yahoogroups.com

      There you will find that there are several ongoing projects as well as companies providing support.

      Still the issue remains (in the US) around who is paying and who is benefiting.

      Once the various vendors (open or proprietary) realize that they MUST work together then
    • by yuna49 (905461)
      There is no viable open source alternative (http://oemr.org/ doesn't look quite ready for prime time) - though I think there's an opportunity here for some enterprising Linux loving propellerheads.

      I wish I had your optimism. I spent some time discussing open-source options with IT people in US community health centers, organizations with small budgets and difficult patient loads. You would think that, of all people in the medical community, CHC's would be among those looking for low-cost solutions like op
  • Shall we not computerize the health care industry, then?

    We can keep our data very safe if they never input it into computers.  After all, there would be no benefit to correspond with the risk, yes?
  • Non sequitur (Score:2, Insightful)

    by edittard (805475)

    what do we have to fear from proprietary databases? It's one thing to find out your social security number was stolen. Now add your mental health and STD results to those records.

    I don't see the connection here. Generally users interact with applications and the applications interact with the DBMS. So while it may be true that some are more secure than others, it's largely irrelevant. The organisation's policies anmd procedures are much more important, given that the weak point is usually the carbon u

  • by plusser (685253) on Sunday December 30, 2007 @06:38AM (#21855122)
    The UK has spent the last 5 years trying to build a common Health Record Database for all NHS patients. Those of you that are aware, the HNS is a public run service that covers the health needs of the entire population, although Private medical Insurance is available if required at extra cost. So far this "Database" has cost the UK Taxpayer £12 billion ($24 US Dollars) and has delivered nothing but chaos, confusion and a lack of investment in frontline databases that are currently in use, meaning that records go missing, data discs with confidential data get lost etc... http://news.bbc.co.uk/1/hi/uk/7158498.stm [bbc.co.uk]

    The fundamental problem is that politicians think that databases are the answer to everything, being handy for issuing speeding fines, holding criminal records and identity details of everybody in the country, but they haven't quite got round to the concept that the accuracy the data within a database is the most important aspect and it is often the data processing factor that often falls down. They forget the basic fundamental questions like:-

    How long does the data take to propagate into the system properly? If I tax my car late on Friday will the computer database not be updated until Monday, meaning that I'm going to be constantly pulled over by the Police and threatened with my transport being impounded for the weekend, even though it is perfectly legal?
    What happens if the data is incorrect? Our beloved UK government wants an all encompassing ID card system, which will reference a number of different databases. How can they be absolutely sure that the data is at least 6 sigma (3.4 defects per million records) if not 100% correct (note that the old saying 99.9% doesn't even being to recognise the real accuracy required).

    If the data is incorrect who is responsible? If there are many bodies involved, you can guarantee that none of them will agree who is at fault until lawyers get involved, especially if they are civil servants and/or politicians.

    Who ensures that the data is secure? We in the UK had ZIP encrypted discs containing details of 25 million people (about 2/5 of the UK population) lost by the HRMC recently. http://news.bbc.co.uk/1/hi/uk_politics/7117291.stm [bbc.co.uk]

    One the face of it using an open system for designing a database is a good idea in principle, but it is the people that are responsible for these databases that need to know exactly why they are important and why reliance on such databases is a recipe for disaster if proper considerations are not made. Part of the problem is that many of the people choosing these databases probably don't have a first clue in how a database works, that is the problem we face.

    I did notice that this week the new Australian Prime Minister Kevin Rudd cancelled a National ID card system that was planed by the Howard Administration. This move appears to come from somebody that appears to understand the complex nature of such a system, its cost and its lack of benefit. There are many ways that can be used to determine somebodies identify (bank cards, passport, birth certificate) and having all of them referenced at the same place isn't the most cost effective solution.
  • It's one thing to find out your social security number was stolen. Now add your mental health and STD results to those records.

    Security and theft are not the same as open or not. You can steal my data on closed format, like Word and everybody can see it. You can steal my plaintext gpg files and have no idea what they contain.

    Security must be an extra layer. The main difference mostly between open and closed is that closed formats handles mostly with security through obscurity.

    Use encryption!

  • It's impossible to store in a structured manner health information because it's so complex and individualized. Think about how to store the following.
    1) "My arm hurts right here!" "Show me?" "Here!" "Wait, it's here now" "No no, it's here now"
    2) "It itches sometimes" "when?, where?, duration? during aligment of planets!?"
    3) "You need to take xyz, twice a day for two weeks. Come back in 3 month, and let's do another check up."

    If anyone wants to know how complex it is, try reading the DICOM standard which is just for medical *image* storage and exchange. It's about 3500 pages. The code for medical billing, which the article mentions, is already the size of a dictionary. And all it contains is entries for a simple code and a one or two sentence description.

    Realistically, the best approach may be PDF's and full text search. Anything else is just not going to capture the full extent of the medical history.
    • Whether successful or not, the openEHR [openehr.org] standard discussed in the article attempts to solve this problem by creating a kind of meta-standard where descriptions of data and documents are used in a flexible way. This manner of organizing storage is extremely open ended. There is a graphic overview covering this that can be downloaded from the "Quick links for ... IT professionals" link on the right side of the main page (PDF [openehr.org] HTML [openehr.org]. The design is object oriented and general such that it could be applied to ot

      • DICOM is not constrained by any particular database. It specifies a wire protocol for network exchange and file exchange. It is up to the application to determine where and how the data is stored for internal use, there are implementation that uses dBASE IV. The DICOM standard also does not force a representation. It even says you can use JPEG, jpeg2000, motion jpeg, wave files, pdf, etc. The DICOM standard is designed from the ground up to be object oriented, hierarchical and expandable. There have b
    • by TCook (66808)
      You correctly point out some of the complexity here. But, it is NOT impossible to create systems that use terminologies (like LOINC and SNOMED-CT) that are computable.
      Frankly, NLP just isn't there YET. Even using proximity rules etc. it is just too imprecise to develop a context from natural language from a document (like PDF) that can be used for analysis, decision support, etc.

       
    • "It itches sometimes" "when?, where?, duration? during aligment of planets!?"

      THOSE kind of consultation. Yes, I know and understand, and show all my sympathy.
    • Available via a FOIA request, excepting some showstopping components, of course.

    • by swillden (191260)

      Realistically, the best approach may be PDF's and full text search. Anything else is just not going to capture the full extent of the medical history.

      It's not that bad. Sure, there are cases where symptoms have been reported but no solid diagnostic conclusion reached that can only be stored as text, but there are plenty more cases where a diagnosis can be made, and IDC-9 codes (or whatever -- the lack of standardized coding is a real pain) can easily express the result.

      I've spent some time working with the AAFP group who is developing the Continuity of Care Record [wikipedia.org] (CCR) data format, and while there are some areas in which it can be improved, an inab

      • My understanding is that the first version of CCR was easy to use and wonderfully focused on the needs of clinicians wanting to exchange data for the CURRENT encounter. The second version where they tried to make it as powerful as CDA made it a royal pain in the ass to use.

        In any case, thankfully the powers that be (i.e. the two separate groups making CDA and CCR) came up with a new combined standard called CCD which is essentially the CCR record packaged into a format that the CDA carries.

        I am surprised yo
        • by swillden (191260)

          My understanding is that the first version of CCR was easy to use and wonderfully focused on the needs of clinicians wanting to exchange data for the CURRENT encounter. The second version where they tried to make it as powerful as CDA made it a royal pain in the ass to use.

          You must be thinking of something else. The CCR was never about an encounter, it was always a portable history. Not only that, the second version of the CCR hasn't yet been released.

          In any case, thankfully the powers that be (i.e. the two separate groups making CDA and CCR) came up with a new combined standard called CCD which is essentially the CCR record packaged into a format that the CDA carries.

          There has been an effort to combine CCR and CDA, but it's an abysmal failure. Meanwhile, the CCR workgroup is still active and energetic, working on improving the standard and on getting more real-world systems to support it.

          • Correct, it is not really an encounter, but it is not the entire medical record. CCR was designed as a way for clinicians to share information about a specific incident/episode of care and not the entire medical record. I sort of think of it as a new "medical document" (i.e. just as problem list is another document type), rather than a real data exchange mechanism.

            As for CCD being an abysmal failure, I think you may be incorrect. CCD was just approved by HITSP and is moving forward. From article http://ww [modernhealthcare.com]
      • by blach (25515)
        Is that the actual product?

        I see major problems: chief among them are the medical problems listed under "my problems."

        "Heart disease" is extremely ambiguous. CHF, or coronary disease?
        "Blood pressure, low" ? How about "Blood pressure, high" which is not listed and a far more common problem.
        Kidney disease which is EXTREMELY common is not listed.

        Was this part designed by physicians or computer people?

        Otherwise I think you're doing a fine job.

        • by swillden (191260)

          Is that the actual product?

          It's a demo of one sort of interface that can be used to populate a CCR.

          I see major problems: chief among them are the medical problems listed under "my problems."

          You're just looking at the UI. The CCR format stores diagnoses as ICD-9/SNOMED/etc. codes, so anything that can be coded can be represented, and anything that can't be coded can be described textually.

          Was this part designed by physicians or computer people?

          I have no idea who put together the demo.

    • "My arm hurts right here!" "Show me?" "Here!" "Wait, it's here now" "No no, it's here now"

      The patient's finger is broken.
    • Realistically, the best approach may be PDF's and full text search. Anything else is just not going to capture the full extent of the medical history.

      For the complexities of medical charts and notes you are probably right. However, certain well known and structured information, particularly billing, could definitely benefit from a more integrated database oriented approach to processing. The data set could probably be simplified drastically if, instead of looking to model the structure of ALL medical da
  • Personally, I prefer closed standards instead of the open pursued by government under the lie of being "for your benefit" http://news.bbc.co.uk/1/hi/uk/7158498.stm [bbc.co.uk]

    Or the non-existant opt-out for your confidential medical records being know to millions of bribeable public sector workers... private investigators, crooks etc..
    http://www.nhsconfidentiality.org/?page_id=3 [nhsconfidentiality.org]
  • by XNormal (8617) on Sunday December 30, 2007 @08:12AM (#21855418) Homepage
    You probably know that big IT projects often fail. But for some reason patient record projects tend to fail more than other projects. Administrative systems for setting appointments work. Automation for lab tests works. But projects for actual patient records keep failing.

    I have a friend in the healthcare IT business who claims that they are actively sabotaged. Many more are derailed before they ever get started. Doctors prefer paper records that cannot be efficiently mined for malpractice lawsuits. Paper records that can be conveniently lost.
    • by Rezazur (677119)
      Although it's true that doctors often actively resist the EHR systems, I'm pretty sure this will be the hallmark of the medicine in the 21st century. The possibilities are endless: mining for epidemiological data or adverse events, for instance.
    • I have to call you guys on this whole string. Like a few other respondents, I am an actively practicing surgeon, and a programmer in my spare time, so I know what I am talking about.

      The main problem in EHRs is that they are designed by programmers. They are built around databases, and force doctors to change their practice in order to fit the database. ARGH!!! Dumb, DUMB, DUMB!!!

      I have been using a huge, nation-wide EHR for 3 years. From the get-go we found that the input was unusable: we had to type about
      • by blach (25515)
        As a resident physician at a large US teaching hospital, I wholeheartedly concur.

        Many of the systems we're forced to use were clearly designed by programmers (a group of which I include myself) but NOT by physicians (or nurses).
    • "But projects for actual patient records keep failing."

      As a statement of simple fact, this is true. As an emotionally-loaded blanket condemnation of EMR systems, this is bullshit: it fails to mention that projects for actual patient records also keep succeeding.

      I'm a technical guy working in a midsize primary care clinic.

      We've been on EMR since late 2000. Yes, there was resistance to EMR, but not because of the nefarious motivations you postulate. It was more that the older providers had been practicing wit
  • That some kind of solution other than paper records is needed is obvious to anyone. Most existing systems have limitations, but compared to paper records which take up large volumes of space, are highly vulnerable to loss and theft, and can't be easily indexed almost anything is an improvement.

    The main obstacle to adoption pointed out by the article is responsibility. Systems would most likely be put in place by providers who would have the most to loose from the costs and the least to gain from the impr

  • Up until, well, the last year or so, medical software went like this:
    An entire hospital payed over twenty million to one organization. That organization provided an integrated solution for all the hospital's needs. It took five years to get it installed and working, and no part of it worked particularly well. All the staff that might interact with it is also required to attend training sessions for the software. The individual departments have no say in the purchase, and a lot of them refuse to use it.

    And t
  • Didn't RTFA, so you take this with a grain of salt...

    The system created by the Veteran's Administration is public domain software, though it is called VistA, so it can be a bit confusing now. I work for in a department within a medical school and have thought about testing it out, though IIRC it uses Delphi for the database and was created using an obscure scripting/computing language called M. Still, it's used to link all VA hospitals and clinics, so a veteran can go to a clinic across the country and t
  • by MMC Monster (602931) on Sunday December 30, 2007 @09:13AM (#21855644)
    I'm a doctor who joined a small practice a few years ago. The senior partner of the practice created his own EMR system. It's actually quite good and we use it exclusively. Our office isn't paperless, but everything coming into the office is scanned in or phoned into the virtual fax and never printed. We are able to access it from different offices and from the hospitals we go to via a VPN setup, and it significantly improves our efficiency.

    Now the senior partner left. He didn't use a standard database format (but fortunately used Microsoft SQL), and we'll probably have to pay a fortune to have it converted to an open format. Fortunately he's being good about not charging the office for a license for his code, so we have time for the transfer.
    • As for why EMRs haven't spread, there are a couple tidbits:

      1. The security is barely on the radar. Any office that can set up an EMR can do so securely. That's part of the setup costs.

      2. There was an interesting case I heard about recently (I'm not sure if it happened in 2007): A cardiology office in one of the south-eastern states of the U.S. data-mined their patients to find out which ones would benefit from implantation of a defibrillator. (This is a fairly expensive procedure that is covered by ju
  • The article seems hopelessly confused.

    The article seems to suggest that if open standards are used, all of your medical records will be wide open. That does not make any sense at all.

    The openness of the standards has nothing to do with the openness of the records.
    • by TCook (66808)
      Which article are you referring to? My blog post does not suggest those things at all.

  • by DarthBobo (152187) on Sunday December 30, 2007 @10:46AM (#21856212)
    EMRs are a great idea, but the medical world is poorly adapted to build them and integrate them. Its dysfunctional system where billing is becoming increasingly critical, while what you get for is divorced from what you actually do. So we wind up with schizophrenic EMRs that can't decide whether they are generating billing tickets, documenting patient care or preventing a lawsuit.

    1) They are expensive for a small practice - think that a primary care docs office is rolling in cash? Think again. Most of them are barely scraping by, which is why your doc needs to see 30+ patients a day. Otherwise the rent doesn't get paid and he/she can't make payroll. If a new tool doesn't make the office more efficient, it can't be justified. Sound odd? Next time you visit your doc, ask him who determines how much he/she gets paid. Its not you, its not the market and its not actually the insurance companies. Its the federal government when they set payment guidelines for Medicare/Medicaid which the insurers follow. Free market my ass.

    2) They are slower than paper - few docs can type as fast as they can dictate or write. Most of us can take notes on a piece of paper while interviewing a patient - no one I know can talk to a patient and type into a form.

    3) Many are designed to maximize billing, not care - we get paid based on how many indicators of complex care we hit. How many "systems" asked about, how many organs examined etc etc - not by our time or skill. So in order to bill we have to document all of these. Some EMRs are designed to force the MDs to check many boxes for billing and audit purposes. Unpleasant and slow.

    4) Many are slow and perform poorly - my hospital switched recently from a physician designed an written EMR from the 80s that was text/terminal based and blindingly fast, to a web-based system. The new system is slow, and doesn't really do much that the old system did. The difference was that the first system was built by MDs who ate their own dog-food, the second by teams of very smart, very committed programmers who don't practice medicine.

    5) They are the camel's nose under the tent - my hospital based practice was recently instructed to begin doing "medication reconciliation" on all outpatients. That means at the start of the visit I have to type in all of a patient's medications into the EMR. Sounds fine for you, right? Now imagine your grandmother. As a sub-specialty consultant I see most of my patients once to twice a year and they are on 20+ medications, over the counters, vitamins and herbal supplements. It can take 6-7 minutes out of an already short 30 minute visit. Sure its great for safety, but it means we are running an additional 45 minutes late at the end of the day. Not so great for you if you have a late afternoon appointment.
  • for centralized medical records: reducing fraud. Unless you have some central repository of records that doctars can connect to - there is nothing stopping Joe Schmoe from going to 5 doctors and getting perscriptions at 5 pharmacies. The fucked up way billing works is he could bill some to his insurance company, some to medicade, some to medicare, and never pay a dime - none would even know about it. The cost of fraud is a HUGE percentage of healthcare costs - far more than malpractice insurance.

    Then there
  • Ideal situation is when the treating medic has the patient's details in hand and *can* readily read them. Put them on USB pen round the patient's neck 24/7 in a truly open format - then 90% is achieved.
    The other 10% - like external exams and reports - need the network up and running and the interoperable database world. Backup could be on any encrypted cloud disk.

    Come on guys this isn't rocket science, its human lives, "stupid".
  • This was predicted in 1995.

    "The Net" with Sandra Bullock

    A socially retarded software engineer cannot tolerate intrusion.

    http://www.imdb.com/title/tt0113957/ [imdb.com]

    She fought back!

  • Electronic health records will be a privacy disaster. It isn't about open standards, it is about the ease of access that will be created and the fact that security is *ALWAYS* an afterthought or cut/put off to "get an initial release out, but we'll fix it later". What we'll have is a hodgepodge of poorly implemented systems with a TON of security holes and NO ONE'S privacy will be safe.

    What is needed is an initial focus on the security of the systems, access rules defined, complete auditing of all actions
  • There are two standards called DICOM and HL7. DICOM handles binary data, and HL7 handles more of the process and is the primary integration point with EMR.

    With these a PACS (Picture Archive Communication System) forms the "database" of data. The PACS is actually more work-flow based which then stores the actual data on some type of highly-reliable data storage system.

    These two protocols make up the totality of your health care experience at a hospital. Your hospital certainly uses these two protocols, so wh
    • by tg2k (895772)
      DICOM and HL7 are great for communication. As for opening the actual DB schemas...

      I work for a medical company and our EMR schema takes a lot of work to design. To open it up would be to tell our competitors "hey, just use our schema and all the thought that went into it!" Not the best idea if you want to remain competitive. (Well, not unless open source is something that the customers start to demand.)

      Also, opening it up means that our competitors (and customers) will want to write custom apps directly
  • EHR systems come online across the country, what do we have to fear from proprietary databases? It's one thing to find out your social security number was stolen. Now add your mental health and STD results to those records.

    The above is an argument for proprietary databases — they are harder to steal from. Well, harder for a layman. And a disclosure by an adverse-minded layman is what the vast majority of people need to fear. Unless you are a prominent politician or a businessmen, you need not fear a

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