Ransomware, Interoperability, Power Outages, Natural Disasters, Oh My!

This blog was initially posted on The Health Care Blog on February 25, 2016. It discusses the pressing need for a patient’s complete medical record to be available at the point of care anytime, anywhere—even in the face of ransomware, simple power outages or natural disasters. And it describes a patient-focused system that achieves that goal today. It is MedKaz®. Extensive comments, some longer than this post,  continued through March 8, 2016.  They are included here because they help clarify the need for interoperability and how we can accomplish it today.

Question: What do ransomware, malware, the lack of medical record interoperability, power outages, floods, hurricanes and tornadoes have in common?

Answer:  They make it impossible for doctors to access their patients’ electronic medical records — which can have disastrous and costly consequences for individual patients, families and our society as a whole.

The irony is that this is an unintended consequence of one of the most successful, albeit forced, programs to quickly move an entire industry from paper records into the modern age of electronic records.  The theory was that when all providers keep electronic records and they are linked together via electronic networks, patient records will be instantly available anytime, anywhere patients require care.  Regrettably, it’s not that simple.

The theory didn’t anticipate the problems that have emerged and, despite the fact that taxpayers spent $31 billion to fund this program and care providers invested perhaps another $150 billion to make it work, it doesn’t.  And it doesn’t appear that we are even close to solving these problems.

We have focused almost exclusively on linking provider record systems to achieve interoperability but aren’t even close to achieving it on a national scale.  Hospital CIOs have attempted to defeat malware by locking their systems but this doesn’t always work and may even block their providers from accessing important patient information.  We are now paying attention to ransomware but have no real solution short of paying a ransom.  And we have all but ignored the effects of natural disasters which are happening with increasing frequency and disastrous consequences.We just accept them.

So where does that leave us?  We can “stay the course” which, I submit, will never ensure that  patients’ records will always be available when they are needed, or we can look for a different approach that does.

Happily, there is an approach that not only solves these problems in one fell swoop but will have highly desirable additional “intended” consequences.  And the best news is that such an approach is readily available today!

The approach is to give patients copies of their records from all their providers that they can conveniently carry with them and give to care providers anytime, anywhere they need care. It’s just that simple!  It is the ultimate “distributed” solution and can work in any unexpected situation as long as an available computer has power or can be recharged.

The “intended consequences” are even better.  Providers can enjoy total interoperability and deliver better, coordinated, lower-cost care.  And patients can participate in their care decisions and save deductibles and copays when mistakes and unnecessary visits, tests and procedures are avoided.
In short, by “giving power to the people” — in this case their medical records — we can overcome the problems that make it impossible today for care providers to access their patients’ medical records and deliver quality care, and everyone benefits!

 

Merle Bushkin is Founder & CEO of Health Record Corporation, creator of MedKaz®, the patient-focused personal health record you carry in your pocket. Prior to entering the world of healthcare IT, he enjoyed an extensive career as an investment banker with Bushkin Associates, specializing in mergers and acquisitions, and earlier as a corporate executive and management consultant. He graduated from Harvard College with an AB in Economics and Harvard Business School with an MBA degree.

Comments

mbushkin
Mar 5, 2016

Just returned from HIMSS16 where I heard endless talk about the need for doctors to be able to share and exchange records and the expectation that such sharing will be possible sometime in the future: some say by 2018, some by 2020, others by 2024.

But the only example of true and total interoperability that is available today was in my pocket where I have copies of all my records from more than 40 providers located in six cities and three states, spanning the past 30+ years, in all formats—from paper to every major and many minor EMR systems; and any provider can search and read them with only to or three clicks—even in natural disasters.

I mention this because it relates directly to the problem highlighted in this blog and the comments that followed. We need a ”better way” to help providers deliver better, coordinated, lower-cost care under any and all conditions — and we should pursue an approach that works rather than one that doesn’t even come close to achieving this objective. Period.

Allan, it’s clear you don’t like the fact that the government mandated the adoption of EMRs and that today’s EMR systems don’t deliver on their promise, but isn’t that water over the dam? Aren’t the issues now: How do we move forward from where we are today? How can we accomplish our unmet objectives?

I have suggested one solution that works and, BTW, it incorporates many suggestions from care providers. Do you have another?

Allan
Mar 6, 2016

Merle, it is not just clear that I don’t like government mandating the adoption of EMR’s, it is clear that the mandate was counterproductive. As I told you earlier, I like electronic records and have experience with them in my own practice almost since their beginning. The difference is who the record is for and how the record should be created, bottom up or top down? What you bring to the table interests me because the patient becomes an important feature.

The top down EMR is not water over the dam rather a continuous drain on society and the benefits of medical care as far as the eye can see. I am not saying put a halt to them, rather put a halt to government’s ability to stop organic growth, by mandates and filling the field with so much money that we create another expensive sector of the medical economy.

“How do we move forward from where we are today? How can we accomplish our unmet objectives?” Good questions. The first thing that needs to be recognized is what are those unmet objectives and how they relate to actual medical care and physicians who are the ones providing medical care. Is there anyone that knows more medicine or the patient better than the treating physician at the bedside?

You have a suggestion that you say works (no proof and no metrics to create such a proof). Without discussing your idea of patient centrality to the record which I believe is a good idea in what specific ways has it made my treatment of the patient better? We went through some examples earlier that showed something other than you wished those examples to show.

If you can produce something that makes things better you won’t need government revenues or mandates to push physicians in that direction. The fact that the industry needs such help immediately tells us that this new industry isn’t as good as it thinks it is. If it were, the industry would be finding its own money. Be careful about group think especially at those meetings where similar interested parties get together thinking they are at the center of the universe. Remember to a hammer everything looks like a nail.

mbushkin
Mar 6, 2016

Allan,
You asked “Is there anyone that knows more medicine or the patient better than the treating physician at the bedside?”

I suspect your answer is, no. My answer depending upon the illness, is maybe and often might be absolutely. Why? because every doc at a patient’s bedside is not all-knowing about all illnesses or about the care the patient is receiving or has received from other providers. That’s why there are specialists and researchers, and why it is important to be able to access the patient’s complete record to know how other providers are treating her.

I’m not suggesting that a patient’s medical records hold all the answers or treat the patient. But I submit that in a great many cases, especially where the patient has two or more chronic illnesses — and that applies to 50% of adults over 65, having timely access to the patient’s complete record is essential for two very important reasons. One is to help the doc in the exam room or at the bedside to know whether he or she needs input from other docs to avoid mistakes that can harm and even kill the patient. The other, is to reduce the cost of care by avoiding unnecessary visits and redundant tests, studies and procedures.
That’s why I believe it a serious mistake to depend upon any system that is vulnerable to outages if and when another system can make a patient’s complete record available to a care provider even when there is an outage. To me, having the right information when and where you need it counts!

I’m sure you would want any doc treating you or your loved one to have as much information about you/them as possible when they treat you/them. Some records may be relevant to your/their immediate illness and some not. But aren’t you better off having all records available just in case they are needed? I think so. That’s also why I think the examples I cited previously make my point. They “showed” that each patient would be, or have been, better off having all his or her records available anytime, anywhere they needed care.

Allan
Mar 6, 2016

“That’s why there are specialists and researchers, and why it is important to be able to access the patient’s complete record to know how other providers are treating her.”

Merle, I hope you realize that most specialists are physicians at the bedside. Researchers aren’t and don’t generally deal with specific patients. Once again you are talking about the transmission of information and not the information itself. Transmission is not generally a problem. That can occur using a multiplicity of methods. The concern should be the quality of the record and the quality of the care which is dependent upon the physician not the EMR. If the EMR changes the way a physician thinks or takes away time from the examination of the patient that translates into a quality issue.

Of course physicians need to communicate with each other, but that happens with or without the EMR. You have errantly placed the EMR on a higher level than what is being communicated. It appears that some are starting to believe that the most important organ in the human body is the EMR without which neither the heart nor brain can function.

“That’s why I believe it a serious mistake to depend upon any system that is vulnerable to outages”

That is a reason to carry one’s information with them, but that information can be in many forms.

There is such a thing as too much information. Physicians do not study the individual case to the degree you might think. There isn’t enough time. Lawyers do that when they sue a doctor, but they will spend months poring through the information and getting expert opinion. Very frequently the physician has to act in seconds, not enough time to enter the data needed to open a file in the computer. If there is time records can be faxed and they generally are in advance. It would be nice to have the stuff on a computer, but nice isn’t very important in the scope of things we are dealing with. What is much more important is that the record be created for the physician’s benefit in treating a patient, not the benefit of everyone else.

mbushkin
Mar 7, 2016

Allan,
I’m not suggesting that patient records or EMR systems are more important in the care of a patient than the physician. But certainly the more informed a physician is about his patient, the better, lower-cost care he can deliver.

And this is where “transmission,” as you refer to it, does count. If a patient’s records exist but aren’t available at the point of care, they are of no value to physician or patient, and costly mistakes can result. That is why we need a transmission system that works in all situations even during power outages, irrespective of what causes them, and when EMR systems can’t exchange records!

That takes us back to where I started. “[G]ive patients copies of their records from all their providers that they can conveniently carry with them and give to care providers anytime, anywhere they need care.”

Allan
Mar 8, 2016

“the more informed a physician is about his patient, the better, lower-cost care he can deliver.”

Merle, that is true, but there is a benefits vs cost ratio to the EMR created by government and the costs have exceeded the benefits by a mile. When I say costs I mean dollar cost, time cost, quality cost, frustration cost, intellectual cost, security cost and I am sure a host of other costs as well.

I have no problem with new ways of transmitting data as long as it doesn’t negatively impact healthcare like the EMR record seems to be doing because it was created not to satisfy the treating physician’s needs of treating a patient, but to satisfy a lot of other presumed needs that many might be unwilling to pay for.

I’m not sure how your system works when power outages occur, but it sounds like you have the patient carrying the information. That is fine as long as you don’t define by law the information that must be carried.

Allan
Mar 2, 2016

mbushkin,
People can draw all sorts of conclusions desired, but the one thing lawyers always want is the medical records. They would gladly cull through any records presented to them in order to look for a cause of action. I can’t prove this one way or the other, but neither can he. The difference is I am the one that ultimately gets sued. He might say that he is in the same position, but maybe the way he writes his notes changes his risks. Do we now debate who writes better notes?

“ yearning for the good old days ” No, that is just a way people talk to make it seem that the other person’s position is shaky. It isn’t. The good old days one is yearning for may not be better than the new days you are promoting or worse. No one knows. The ACA was supposed to cure our problems because they represented the new days to come. How has that turned out?

“ taking those same approaches today often adds greatly to the cost of care. ” Actually the cost of care has spiraled precisely because of those wanting the new instead of the old, not because there is proof that the new is better, only that the new offers CHANGE. How is that working out?

“Sure, you could see a patient today, have a talk with his other providers tomorrow or the next day, request a faxed record, and see the patient again the next week.”

But, none of that is true. There are many ways of transmitting data timely and efficiently. That is what this is all about, the transmission of data. Today we can use air delivery or ground which is slower, but we only spend the money where there is benefit. I see the benefits, but certainly not the way they are being perceived as benefits by those that are interested more in the technology than in the patient. Such transmission of data that you seem to be referring to requires a one size shoe fits all attitude where bottom up is bypassed and top down control forced. That is not a good idea and is counterproductive.

“I agree that the focus on installing and having to use EMRs has placed a big burden on docs and distorted the doctor/patient relationship.”

That is known as big damage with little to see for it. I don’t disregard the benefits of EMR and support its development, but not its mandates. Don’t forget I was already using a form of EMR in the mid 80’s and wanted to expand that use, but government interfered. Now they are getting rid of some of the laws they created as stumbling blocks and closing their eyes to the problems they had magnified years before making those problems many times worse today.

We estimate that the time taken from the physician office practice is about 15% because of the present EMR. That is a lot of wasted time and money. My advice once again is to move slower with a bottom up approach rather than the top down approach we see today. It might be slower, but it meets the needs better and provides greater innovation. It also prevents stagnation that we see from government programs.

(Just for your edifications, some of my consultants used speech to text more than a decade or so ago. When their consultation with the patient was done I had the type written note within a minute. That was long before EMR’s. I guarantee you that the note he wrote then would not be as cogent or informative as the note he would be forced to write today. But even the speech to text advance has its problems as some of the notes I received in that fashion deteriorated from prior years.)

Allan
Feb 29, 2016

mbushkin, I believe we have basic agreement as to the centrality of the patient regarding his records. I hope we agree that the release of his information should require his informed consent. The records should only be used by those given that consent and only for the time frame necessary to complete the task for which the consent was given.

Where I think we have disagreement is in our perceptions of how physicians actually utilize records that are available. Firstly we both agree that it is a good thing to have records available in the easiest way possible. They can be made available in many ways, but each way carries a cost. Any record can be faxed. We also probably agree an electronic transmission of records might be the most efficient way to store and transport them though there are significant dangers and problems with the method.

Dealing predominantly with the physician patient interaction we have two types of need; emergency and other. We seem to differ as to what a physician requires and how best that need be fulfilled. I believe the needs will vary from practice to practice, but having practiced for decades I think that some of your perceptions about medial care might be a bit overblown.

1) “patient access to their complete records might fuel litigation, but there is little evidence to support it.”

Medical records are greatly involved in the litigation process. Just like there is little direct evidence supporting the above statement (there is indirect evidence) there is no evidence proving it doesn’t exist. Thus the statement by itself is meaningless.

I agree with Dr. Palmer’s assertion that these things can adversely affect the ways physicians act. We have seen this from litigation, Medicare audits etc. I have seen this occur in real time. This does not mean the patient doesn’t have a right to his records, he does.

2) You discussed the rapid need for records. Most of the time records are not needed so rapidly and can be obtained over a longer time frame without problem so the speed offered by the electronic medical record mostly is not needed. Having dealt with a very sick population I found that the emergency data needed in an emergency could be written on a small card.

I looked at your examples and they did not require instantaneous records. Your first example demonstrates an inadequate history and acquisition of the needed information. Electronic records don’t guarantee they will be read or the needed information found.

The second example involved research. The diagnosis wasn’t made because of electronic records rather someone actually read the data. Likely, at least some of her doctors though her symptoms weren’t real. Her last doctor recognized that such a varied group of symptoms could be due to certain diseases and did a relatively simple and inexpensive blood test for Lupus making the diagnosis. He probably tested for Lupus with a bunch of other tests because her insurer permitted such testing to be done. Maybe an earlier doctor thought of Lupus, but the test didn’t yet turn positive. Maybe others noted the negative test for Lupus and didn’t repeat it when it would have made the diagnosis.

The third is an example where an integrated system would help, but there are many ways to insure that all the records are available to all the treating physicians. The electronic method is a method of transmission and filing such information, but the same could be done in many different ways. The electronic element is not a treatment or diagnostic mechanism.

I like your last example because I believe all patients should be knowledgeable of their diseases and have access to their records. This is one of the reasons I like your patient centric type of approach and one of the reasons my sickest and most complex patients were encouraged to carry certain information with them.

3) The medical record and physician discussion: My oldest sickest patients could have paper records six inches or more in height. Those same records today likely if placed in paper form would be many feet in height. Too much information. I’ve gone through all varieties of records and it seems the more the computer is involved the more available reading there is for the physician. It is counter productive and eventually unreadable and even on the computer unsearchable in the time available.

On these complex patients a 2 minute discussion physician to physician can answer a lot of questions and permit doctors to get on the same page. Not only that, but that two minutes can be like a lecture adding knowledge to both parties for future use in other patients.

4) Electronic searches: Can be helpful and might not be helpful at all. A negative search doesn’t mean the needed information doesn’t exist or even that one can conclude an important detail.

5) Errors: The people in power have demanded so much from the physician in order to be paid that it is impossible for the physician to do a good job in each and every entry. Therefore canned notes are used as shortcuts and inadvertently important information can be left out. If not enough time exists for the needed entry of all the data necessary a physician copies the data of another physician and copies all the errors.

6) $1,000 vs $49 actually deals with other inefficiencies than the electronic medical record. The electronic medical record is a small tool in a vast industry loaded with information filled physicians along with expensive complex tools that might require several people to operate.

I am not for or against any of the things you or anyone else might suggest, but we should recognize that our focus on electronic records and transmission has been far greater than deserved. My advice is to move slower with a bottom up approach rather than the top down approach we see today. The physician is the epicenter of the sick patient and everything else extends outward from that point.

mbushkin
Mar 2, 2016

Allan,
WRT informed consent: we agree and in our system when the patient enters his or her password allowing a provider to access his or her records, that is informed consent. And if the provider wants to download a copy of another doctor’s record(s), the patient must enter his or her password before the record can be downloaded.

WRT to litigation: Just heard a presentation today at HIMSS16 by a doc from Oregon affiliated with the OpenNotes program. He stated that their experience has been exactly opposite of what you and Dr. Palmer suggest—the amount of litigation has actually declined!

As I read your other comments they come across as a yearning for the good old days when everything was simpler and moved more slowly. Unfortunately, those days are gone and taking those same approaches today often adds greatly to the cost of care. Sure, you could see a patient today, have a talk with his other providers tomorrow or the next day, request a faxed record, and see the patient again the next week. But you have taken the time of other docs and required the patient to return for another visit. All that time and related cost could be avoided by the patient’s doc being able to access the other docs’ notes during the first visit.

I agree that the focus on installing and having to use EMRs has placed a big burden on docs and distorted the doctor/patient relationship. But I submit that the remedy is not to disregard the benefits that EMRs can provide. Rather, it is to take advantage of the good that EMRs make possible and come up with other approaches, such as I have described, that achieve interoperability and overcome the negatives of today’s systems.

Paul @ Pivot ConsultingLLC
Feb 29, 2016

The concept for this is fantastic…..patient controlled as well as extraordinarily inexpensive to implement. Likely, it is too simple, too inexpensive and too patient-centered to gain traction as the powers that be prefer massively expensive top-down, mandated solutions that can be rolled out system-wide with little or no evidence they work to control costs or improve quality…and end up damaging cost control and quality of care…. (ACO, EHR etc.).

William Palmer MD
Feb 27, 2016

I think I understand your idea now. The patient is the only vault for this aggregated data. Otherwise it resides in a particulate form with each provider who generated it.

If this is correct, what do you think will happen to the rate of litigation if patients have all this data at home and they marinate and soak in it whilst communicating in normal social interactions with nurses and docs and attorneys and other knowledgeable folks and friends in health care? Aren’t they or their friends bound to say: ” Hey, Charlie, they should have tested you for B-12 deficiency, your MCV was a little high at 96.” Et al, ad infinitum.

Do you or do we or does anyone really want to have professional records sitting around patients’ homes? Dentist records? Attorney? Chiropractor? Psychotherapist? Docs? I bet that professionals would gradually learn how to generate bland inforamation-poor records if this happens.

mbushkin
Feb 28, 2016

Dr. Palmer,
You’ve got it! Each provider has his or her records for each patient, and each patient has copies of all their records from each provider which are aggregated in only one place: on a device the patient carries in their pocket—not on web or Internet-accessible servers.

I understand your concern about how patient access to their complete records might fuel litigation, but there is little evidence to support it. In fact, there is evidence to the contrary.
HIPAA and subsequent legislation requires that providers electronically deliver copies of a patient records to the patient, so the question about whether to do so is moot. That’s why providers have adopted portals that make summaries of their notes available to their patients.

Perhaps more important to your question, the OpenNotes project funded by the Robert Wood Johnson Foundation disproves the fears many providers had expressed about patients having access to complete progress notes. Virtually all 20,000 patients and 100 providers who participated found patient access to their records very helpful, and the providers found that their fears about how patients might use them were unfounded.

Allan
Feb 27, 2016

mbushkin, thanks for your reply. From the medical perspective I don’t think all this data collection is that meaningful even though it would be nice to have such access. The problem among other things is the cost and disruption. As I mentioned earlier I had the ability to get certain information from my computer via telephone in the mid 80’s. Almost all the information I needed from my personal records (Internist treating mostly an aged and very ill population) amounted to less than this response. Before I computerized some of my sickest patients carried a license sized picture of their EKG plus all the most urgent information on the other side. Though I think the technology is there for greater access and I support it, it is not the panacea many might believe.

Along with the downsides that are apparent physicians should be encouraged to speak to one another. This overemphasis on computer data likely causes quite the opposite. Additionally the records are unwieldily. Too much can be as bad or even worse than too little since too much will not be read. There also can be an over reliance upon the data in the chart where errors are duplicated over and over.

The examples you provide are true, but limited because the real information needed almost requires customization. For example one reason for the discharge summary from a hospital is to help the nursing home or PCP to take over care. That is what is useful to them. The reams of electronic paper are not. Testing is east to obtain and a lot of the repeats often mentioned are necessary.

You say: “ it can facilitate the restructuring of our healthcare delivery system to make it more effective, efficient and less costly.”

That I don’t think is true except perhaps from the bookkeeping end of the problem or research. From the medical end it is starting from the backend and forcing the back end to run the brain. I understand where you are coming from and perhaps you have a better way than we have seen, but I think the desire to overkill by leading from top down has been so great that we are creating another Rube Goldberg machine.

If you think anything I have said is wrong or you think the need is greater than what I believe please point me in the right direction by providing your best real life examples for discussion.

mbushkin
Feb 28, 2016

Allan,
You raise several important points. I like your idea of doctors talking to one another, but in today’s world where a PCP typically has 7 to 12 minutes with a patient, that’s unrealistic. That’s why it is so important for the doc to have quick, easy access to their patient’s complete record — including complete progress notes not just summaries — when they are with their patient.

Your concern about “unwieldy” records is certainly valid. Progress notes today can run 20 or 30 pages, and no doc has time to rummage through them. The solution to this problem, in my opinion, is to make it easy for the doc to electronically search the patient’s aggregated notes, highlighting in each encounter note the specific reference he or she is looking for and enabling them to rapidly click through from note to note until they find the record they need. (That’s what we do in our system.)

There is a simple solution to your point that charts may contain errors “duplicated over and over”: enable both the doc and patient to attach addenda to correct erroneous notes. That’s precisely what the OurNotes project seeks to do. It enables patients to add comments and corrections to provider notes that are displayed in their portals. (We do that in our system, and when a patient creates an addendum, we send a copy to his or her provider so the provider can add it to his or her records.)

WRT restructuring our delivery system, what I mean goes way beyond bookkeeping. Once a patient’s complete record is untethered from his or her providers, it becomes possible to split huge care delivery complexes into more economic units that require less capital and match costs with revenues. It also enables a patient to have copies of his or her records sent to other parties concerned with their health, such as their children and other care providers.

One example. When a patient goes to the ER for a sore throat or other relatively common ailments, the cost can run $1,000 or more. But if they go to outpatient care centers such as Minute Clinic or Urgent Care, the same treatment may cost only $49 — reflecting the lower capital requirement of outfitting the facility and lower operating costs.
Another example. Healthcare facilities can reduce their capital requirements and costs by supporting one another. Each can offer a specialized service that the others refer their patients to — thereby relieving the everyone from offering the same service. A good example of this is where a small, acute care rural hospital offers post-operative rehab care to patients of all other hospitals in the geographic area, including one major teaching hospital and four or five other hospitals.

Finally, you asked for real life examples where a provider having immediate access to a patient’s complete record made a difference in both care and costs. I’ll cite some. I’m sure you can cite many others. Please forgive my terminology; I’m not clinically trained.

In one case, a 70 year old woman had two open heart operations because her first surgeon didn’t know she had had rheumatic fever as a child and didn’t replace a damaged valve. A second surgeon asked if she had ever had any prior heart issues. She told him about her rheumatic fever but that it had no lasting consequences. When asked if the other surgeon knew that, she said he hadn’t asked. If the first surgeon had had access to her complete medical record, he would have known, and the second operation would have been unnecessary.

A second is a 35 year old woman who had been seriously ill from the age of 15. During those 20 years she saw many doctors but none diagnosed her problem. They prescribed various treatments including serious psychiatric care but nothing helped. Finally, at 35, one doctor assembled all her records from her other providers and diagnosed her problem as Lupus. She believes if others had had access to her complete record they would have diagnosed her problem years earlier and saved her from painful, inappropriate treatments and extensive costs.

A third is a 17 year old woman with “broken bone” disease. She is treated by four different institutions: for simple problems by a rural local hospital; for more complex problems, by a nearby major teaching medical center; for specialized care, by St. Judes Children’s Hospital; for other specialized care, by a children’s hospital in Pennsylvania. None have her complete record so they cannot coordinate her care and often repeat tests, studies and procedures.

Finally, a 75 year old man had an Iridotomy to avoid Glaucoma. When he returned for a checkup, he spent an hour and a half with supporting clinicians who put various drops in his eyes, took measurements and tested his eyes. When the doc came in, he said he had to reschedule the appointment. His EMR system’s computer was down and he had no pre-surgery measurements to refer to. The patient had his prior records on our system’s device. The doc opened the device on his laptop, accessed the earlier records and completed the examination. This saved another visit and all the necessary preparation and extra time which, in total, would have cost almost $300.

William Palmer MD
Feb 27, 2016

I agree with Allan. In fact, it might be better from a qaly-improvement standpoint to have all providers NOT communicating with one another and have them all approach the patient in a fresh de novo way. Of course, the costs, you say…think of costs. But If we extrapolate and hypothetically say that all lab and imaging is free, then why wouldn’t this anti-operability be the best way to go? The only objection here might be that you desire the ideas and histories of those providers who came before you to be widely heard. And it is not pleasant for the patient to have to repeat too many lab tests and imaging studies. How important is this? Maybe a some or a bit. I do feel that the wisdom of crowds is important in finding correct diagnoses and intervention, so I do agree that some interoperability is nice to have, but it seems vastly overdrawn in importance in our present faddish concern for it. Lab work does need to be repeated. Other folks can get important new slants on the patient’s history. It has got to be a truism that if you make it easy for all providers to get all of the record, it makes it easier for all hackers too. How can it be otherwise? And all this leaky patient data could be the fatal bete noir of the entire EHR effort.

It is another so-called improvement in health care that was not thought up by docs and nurses in trenches.

mbushkin
Feb 27, 2016

Dr. Palmer,
Don’t throw out the baby with the bath water. You clearly see value in providers sharing records so don’t trash the idea just because it’s hard to do. Instead look for a better way.

If you connect all providers via an electronic network, the approach the country has been pursuing unsuccessfully for years, your “truism” that you make it “easier for all hackers” to breach the network, is certainly true. And they surely will, to show they can and/or to make money.

But if each provider instead gives his/her patients copies of their records, the only place they are aggregated from all providers is with the patient. This is far less attractive to hackers. The challenge isn’t as great and they would need a band of pickpockets, a la Fagan in Oliver Twist, to assemble enough patient records to make any money.

BobbyGvegas
Feb 27, 2016

“If you connect all providers via an electronic network, the approach the country has been pursuing unsuccessfully for years, your “truism” that you make it “easier for all hackers” to breach the network, is certainly true.”
__
Straw man. That’s not what’s being proposed. Both APIs and “standard data” (my preference) assume the continuation of (mostly incumbent) heterogeneous end-point platforms.

mbushkin
Feb 27, 2016

Allan,
Thanks for asking the most critical, important question of all: What is the “value” of interoperability? My answer is that it enables care providers to deliver better, coordinated, lower-cost care in virtually every care setting, not simply emergencies. In my opinion, its benefits are so enormous that we can’t afford to wait one extra minute. We need total interoperability now. Waiting until 2024 is not acceptable! I’m sure anyone with a serious health issue agrees, whether they have cancer, a serious heart condition, diabetes, or other chronic illnesses.

PCPs need to know the care their patients are receiving or have received from all other providers who are treating or have treated their patients, including the reasons their patients saw the other providers and the other providers’ diagnoses, assessments and prescribed treatments and meds.

Similarly, specialists need access to a patient’s records relating to their ongoing and past issues and treatments so they understand how their patients’ current issue(s) impact or are impacted by their overall health.

And access to other providers’ records is especially critical when a patient transitions from one provider or care setting to another, such as from a nursing home to a hospital or vice versa; from the active military to civilian life or the VA; changes doctors or moves to a new community; or sees providers in their ACO who have disparate EMR systems.

If done right, interoperability can benefit everyone: patients, providers, employer, insurers and government—both in terms of care and financially. First, patients get better, lower-cost care and save money. Second, it can save care providers’ time and help them avoid mistakes that can trigger enormous suffering, even death, and financial costs. (Our system also increases their income.) And it can avoid unnecessary or redundant visits, tests, studies and procedures that are partially to blame for our high healthcare costs in the US. And third, employers/insurers/government can all enjoy lower health insurance costs.

Lastly, over the longer term it can facilitate the restructuring of our healthcare delivery system to make it more effective, efficient and less costly. This by the way is probably why established many vendors, providers and large care facilities pay lip service to the need for interoperability but fail to support it aggressively.

Allan
Feb 27, 2016

Reading this discussion makes me think of an over engineered Rube Goldberg machine that makes getting a ball from point A to point B very complicated. I asked, where is the value? There was no response. We are left with a Ruble Goldberg apparatus costing billions and making a mess of the physician’s working atmosphere. Since the patient travels the short path of A to B it sounds quite ingenious to me that the patient be the carrier of necessary information.

BobbyGvegas
Feb 27, 2016

You have a point. Margalit is also on record as characterizing “interoperability” as perhaps a chronic case of “Tail Wags Dog.”

Adrian Gropper, MD
Feb 25, 2016

The risks of a monoculture on something as critical and dynamic as one’s health records are immense. We need to be careful to design standards that are simple enough to be relatively secure and distributed in the sense that a vulnerability affects only one or a few thousand patients. We also need to design redundancy into the system. The principles of sound privacy and security design are not a mystery.

One principle however is core to the security and interoperability of critical infrastructure. It’s open source software. Much of the problem with how the HITECH stimulus was spent and much of the reason interoperability and security are lagging is that today’s health records software is secret and inaccessible to peer review. I can’t think of a single major piece of Internet security software that’s not open source. Can you?

mbushkin
Feb 25, 2016

Adrian,
I can’t agree that redundancy is the solution to interoperability first, because we don’t have anything close to total interoperability now and having redundancy still won’t solve the problem and, second, because redundant facilities are uneconomic. Even Netflix and other major sites were shut down for as much as 24 hours when Amazon’s Web Services failed.

A simpler approach is to give the patient his or her records. That way they can be available under any and all conditions, and the risk of a security or privacy breach is limited to a single individual — assuming a hacker finds it worthwhile to bother hacking into a single individual’s record.

John Irvine
Feb 25, 2016

I get the point you’re trying to make and I think it has to do with your own solution.
But this is actually an argument for interoperability. Not against it.
Am I missing something?

The internet was originally conceived to prevent these kinds of data blackouts by making it possible to share information during moments of crisis.
We’ve had the technology for thirty years.

mbushkin
Feb 25, 2016

John,
We didn’t design a solution to the problem of medical record accessibility and interoperability in a vacuum or as an added feature to a system designed for billing and other purposes. We started from scratch, looked at the need today that I think everyone agrees isn’t being met whether in daily use, simple power outages, natural disasters (and now shutdowns for ransom), analyzed why and formulated a very different kind of solution that does work.

Frankly, the fact that it is an out-of-the-box solution makes it hard to grasp for those focused on the conventional approach.

The fact is that in the daily delivery of care as well as in “moments of crisis,” we do NOT have interoperability! Like it or not, the approach being pursued — whether FHIR-based, CommonWell, Carepoint, or others — do not and will not provide total interoperability. They don’t come close to solving the many problems this approach creates. Unless you have received all your care from providers in one small network, none of your providers can access your complete medical record.

In contrast, the approach I am advocating —which admittedly is “different” and some call revolutionary — makes it possible for any provider anytime, anywhere to access and instantly search their patient’s complete medical record. That’s total interoperability!

In my own case, any provider I see, at home or away, in or out of my providers’ networks, can access and electronically search — even without Internet access — all my records for the past 30+years on a device I carry in my pocket, from more than 40 providers located in six cities and three states, using paper and more than 14 EMR systems. If your life or the life of a loved one depended on access to your/their records being available, would you prefer the approach the industry is following or ours?

BobbyGvegas
Feb 25, 2016
Where’s the “SPONSORED POST” tagline here? 

John Irvine
Feb 25, 2016

It’s not sponsored. But he is advocating for his product.

There’s nothing wrong with that, mind you. If you’ve developed a technology and you believe in your product, why wouldn’t you? I’d rather have people be upfront about their biases and let me decide.

On the other hand, I don’t think the solution works.

I’m going to take some convincing.

mbushkin
Feb 25, 2016

John,
Hope my response above starts you down the path of becoming a believer that there really is a better way!

BobbyGvegas
Feb 25, 2016

Just snark, man… But, when I see your “Sponsored Content” posts, I simply won’t read them. That advertorial stuff is starting to infiltrate most online media.

William Palmer MD
Feb 25, 2016

I don’t understand. Do you want the EHR to be a legal document? or not? If the patient has ownership of his record or Read and Write privileges, he is going to be motivated to remove evidence of his own contributory negligence isn’t he? (E.g. I forgot to take my warfarin). If you want both provider and the patient to have read and write privileges, then you have to kill the lawyers. :-) .

mbushkin
Feb 25, 2016

Dr. Palmer,
I’m NOT advocating that providers do away with their records. What I am advocating is that every provider give his or her patients copies of their records which can be stored on a device the patient owns and carries with him or her and gives to any provider they see — so the provider can understand their issues and coordinate their care. (In the system our company has designed, the doctor, hospital, ACO or other provider is paid for doing so thereby giving them a substantial new source of revenue.)

This way, you as a provider have your records for your patients and they have copies. They certainly can’t change or delete your records. They can create addenda to add comments or correct their copies of your records but they can’t change them on their device. (In our system, they can’t even delete a record.)

The concept here is very simple. It’s impossible today and for the foreseeable future for all doctors to directly access your EMR records for any of your patients. That’s as it should be. But it is possible for them to access your records if your patient has copies of them in a format that they (or you) can easily access, search and read. And that is completely doable today!

Looked at differently, it is somewhat like Facebook. Individuals can’t share their posts directly with other individuals but they can by posting them on Facebook. In the system I am proposing, the patient becomes the third party — with a very strong vested interest — who makes it possible for two other parties to indirectly share confidential, personal information even when their systems are incompatible.

BobbyGvegas
Feb 25, 2016

Looking for the “like” button again…

BobbyGvegas
Feb 25, 2016

“Providers can enjoy total interoperability”
__
Assumes that a patient’s data can and will autopopulate any given EHR. Otherwise, it’s not “interoperability,” and no amount of intoning the word will make it so. The inconvenient IEEE definition clause “without special effort on the part of the user” always gets lopped off in these “data exchange” discussions.

mbushkin
Feb 25, 2016

Bobby,
In the patient-centric system I propose, any provider (with their patient’s OK) can download another provider’s record or records from the patient’s device and import them into their own EMR system. All it takes is an API interface or, if the provider’s EMR vendor won’t provide an interface, it can be downloaded as a PDF and uploaded into the provider’s system just as is done today when a patient brings a paper record to a provider.

WRT definitions of interoperability, the only one that counts for me is not at all technical. If any provider can electronically access a patient’s complete medical record from all their providers anytime, anywhere, we have total interoperability. Anything less doesn’t count.

BobbyGvegas
Feb 26, 2016

“it can be downloaded as a PDF and uploaded into the provider’s system just as is done today when a patient brings a paper record to a provider”
__
Seriously? You call that “interoperability”? MEGO.

“All it takes is an API interface” ALL it takes? Seriously? So, which vendors have provided your product with APIs? Do they map to all of the variables in the source EHR’s data dictionary? Again, if it’s “plug & play” so that the data will autopopulate a destination EHR, then you can argue you’ve met the definition of “interoperability.” Short of that you’re still stuck with the clunky, expensive data transcription problem. e.g., screen-scraping variables off a PDF for cut & paste destination EHR input is not “interoperability.”
Standards definitions matter.

Allan
Feb 26, 2016

Bobby, I am not a computer junky so bear with me. To me interoperability is extremely risky from a security point of view as interoperability makes it easier and more desirable for large scale theft to occur.

Why must patient records provide more than the generic text data and graphics data that can be placed on a thumb drive or something else? From the physician’s vantage point not much data is truly helpful. In the 80’s I communicated to my office computer and was able to get the small bit of information I thought was needed in an emergency and I could have had a lot more information if I wanted it. I hear talk about duplication of tests, but most common blood tests are very inexpensive needing to be repeated anyway in most circumstances and CT’s and MRI’s have been provided to patients on discs for years.

Member
BobbyGvegas
Feb 26, 2016

“interoperability is extremely risky from a security point of view as interoperability makes it easier and more desirable for large scale theft to occur.”
__
Perhaps an interesting point, but,

you still have to breach a given system. The metadata RDBMS “typing” of the patient data within a given system is not material to the hacking expertise required to penetrate the compiled source code of the system itself.

Medical data thieves, in the aggregate, don’t give a flip about, say, your vitals or lab values or active meds list or PMH, or ROS data, etc. They want financial-related stuff, just like data thieves do in general. Name, address, DoB, phone#, HIC#, credit card#, bank acct#. Stuff with “social engineering” utility and outright financial theft leverage.

My latest rant on “interoperabbable.” http://regionalextensioncenter.blogspot.com/2016/02/syntactic-and-semantic-interoperababble.html

Member
Allan
Feb 26, 2016

Bobby, I understand your defense of interoperability, though there is a lot more than the things you mention that one should be worried about. The health status of certain individuals is extremely valuable and apparently made very easy to get when all in one place.

My question is where is the value? I thought the main value was supposed to be to help the patient especially in an emergency, but as I have said the amount of information actually needed, if any, is quite small.

Why are we so all consumed about interoperability? Is it for the patient or not?

mbushkin
Feb 26, 2016

Bobby,
We seem to have different objectives, define interoperability very differently, and look to a different standard to achieve our objective.

Our objective is to enable any care provider to access a patient’s complete medical record at the point of care anytime, anywhere. When we can do that by whatever approach, we will have achieved total interoperability — perhaps not by your standard but by the standard of care providers and patients.

The patient-focused system I’ve described does that in spades and does so today. It works because it focuses on how records are managed, not on how they are kept, and thereby avoids the many intractable problems the conventional approach you are following create and are expected to take another eight years to solve.

Our unconventional approach relies on an internationally accepted standard designed specifically to manage highly disparate documents. It is used probably billions of times everyday. It turns every record into a pdf document which then can be read in a browser irrespective how they were created or stored!

The additional “magic” we provide in the system our company has created is that we make each pdf searchable, and can deliver its contents as structured data as well.

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