After coming back from the HiMSS conference and having just attended the Health-e conference it cemented a few things in my head

  1. We are a long way off from being efficient health care nation
  2. Any EMR (electronic medical record) in existance in the present form is sorely lacking in acceptance.

In 2004,President Bush declared that every American should have a “personal electronic medical record” within 10 years – by 2014. With computerized records, he said, “we can avoid dangerous medical mistakes, reduce costs and improve care.” I am politically neutral, but in the course the computer industry, thinking back 10 years from today, the world was still primarily using Windows 95, now we (or at least someof us)are using Windows Vista, this is just to show you the progress of theindustry.Not only is this ridiculous, it is completely an emtpy promise, as it is two elections away, there is no guarantee that then next president, or possibly even the president after will continue the vision!

The U.S. spends 16 percent of gross domestic product (GDP) on health care, compared with 8 to 10 percent in most major industrialized nations. The Centers for Medicare and Medicaid Services (CMS) projects that growth in health spending will continue to outpace GDP over the next 10 years. U.S. health care spending weighed in at $2.1 trillion last year. By 2016, the figure is projected to jump to $4.1 trillion, according to a government report published in Health Affairs. This is in contrast the annual military spending budget of $500 million. The graph shows the amount of spending.

We actually could fund 4 wars this year, and even more in the years to come. I am also not making any statement about my views of war, I just wanted to make a comparison the amount of spending in relative terms.

Now to talk about resolutions, coming from one major healthcare conference and the state meeting, there is the personal heath record (PHR) and the electronic medical record (EMR) that has been touted as the answer.

Yes, having a PHR and the clinition having access to the EMR will greatly reduce the costs in the healthcare industry. The problem is that at the HiMSS conference I visited an entire conference center full of EMR companies displaying their EMR systems. Doing a search on Google, the result was: Results 1100 of about 107,000 for EMR vendor in production.

So we are looking at roughlyone hundredthousand different EMR systems that are in production! I like to be in an enviornment where my skills are needed, and I know that Microsoft loves to tout the capabilities of BizTalk, but the sheer number of different EMR products make it impossible to integrate them all together!

So, if you have got this far, you are probably asking yourself, “where are you going Ericwith this rambling?” I have been very involved in the health information exchange (HIE) and regional healthcare information organization (RHIO) movement. These organizations have good intenetions, but profit centers are hard to come by, and some of them are already disappearing. Also, RHIO’s as good as they are, as profitable as some of them are, they still do not account for the fact that I do not spend my entire time here in one region. Hence the name regional does not account for the fact that I, along with a lot of people do not live in the same region all of the time. (Visit the lines at the airport.)

Since I am a gadget geek, after reading this article that this not only applies to the mobile phone industry, but also to healthcare.

What we really need is a National Health Record. We need a way for doctors to be able to access medical records anywhere, anytime, regardless what region.

Going down this path, there are a few questions that are raised:

  • How is it going to be stored, where, and by whom?
  • How are we going to make it secure?
  • How do I opt in/opt out?
  • How is the clinitian going to view my data/how is the data going to be delivered?
  • Who is going to pay for it?

Well, this is where it gets fun, I will answer each of these questions in turn.

How is it going to be stored, where, and by whom? XBox Live is a perfect example of an EMR without the medical part (well… in some cases there is some medical information about your alias is stored). Let’s say that three big internet service providers gather (Google,Microsoft, and Yahoo) and and come up with a standard (schema)to store EMR information. Where would they start? Yes it would need to be updated, but the VA is a perfect example of a NHIO (National Healthcare Information Organization). A schema would be presented and mandated by the Federal Government. The data would be stored in any one of the ISPs. Who would be those companies, well to insure that the data is maintained, any company would have to present $1,000,000,000 cash so that it is a reputable company, so a mom and pop shop would not be hosting your EMR. Now with companies like Google, Microsoft, and Yahoo having 99.999% up time, you arepractically guaranteed access to your EMR at anytime, anywhere. Your EMR is stored in secure locations throughout the companies infrastructure. Yes, I admit, I don’t know where Microsoft stores XBox Live alias profile informaiton.

How are we going to make it secure? How secure is your email, how many of you log into your online bank account to check your balance? Security definately is not something to gloss over, but I am bewildered by the amount of security that is put in place for electronic health information. At the HiMSS conference a doctor was relaying a story of an individual who had doubts about the doctor as soon as he walked in the examination room. This was surprising for the fact that most patients are doubtful after the visit. Inquisitive as to why the patient was not comfortable with the doctor, the doctor inquired as to why. The patient stated that she was not comfortable with her medical information being stored in a computer. The doctor told her that it was fine, that he could refer her to another clinitian who would write down her medical information and the cleaning crew at night can rifle through the information.

How do I opt in/opt out? In my profile on the MVP site I have the ability to select a few different views, what I see, what Microsoft sees, what other MVPs see, and what the public see. This same logic can be applied, what I see, what a clinitian sees, what an employer sees, and the list can go on. What this implies is that you can create profiles and show each part of your EHR based on a profile, one for your family, one for your employer, the list goes on.You as the individual controls who sees what. This also allows for the break the glass situationso that a ER Doctor can immediately look at your information.

How is the clinitian going to view my data/how is the data going to be delivered? If the clinitian does not have an EMR, there would always be the web login that would be a default view. With the standard schema defined, any EMR product on the market will be able to integrate withthe schema, the delivery method is really inconsequential, web service, MLLP, etc… Think of it like the web interface to your bank account, yes it is convient, but sometimes not as practical as configuring MS Money to pull the data in and see it in the format I like to see the data in. If there is a standard schema, I can go see my doctor and helogs into hisEMR that he is familiar with and my data looks likethis:

Whereas when I fly to Florida, and get bitten by a shark, the doctor that loads my EMR into her system sees it like this:

The way that this is possible is that the underlying schema is the same, so that the particular system that the clinitian purchased will display the data a certain way that the medical professional is used to.

Of course, I probably need to mention it again, for the smaller practices, a web interface into the data would be a way that the data can be accessed.

Who is going to pay for it? Now we come to closure on the money problem I started with. Lets just say that it costs $2 per month per person to host the information. If there are 300,000,000 individuals in the USyou are looking at $1,200,000,000 in ‘hosting fees’ per month. $14,400,000,000 per year. Now that does seem likea lotof money, but look at this years cost of healthcare:

$2,100,000,000,000 annual health care costs

$14,400,000,000 for nationally hosted EMR

Bill Gates could write a check for this!

If calculations are correct that is 0.69% of the total cost the nation pays. (For every$2,100 $14.40 would go to the EMR, for every$100spent 69%u00a2 would be spent)In this situation, the ROI would be immediate.

So where would the money come from: taxes! $24 per person per year. Eventually it all comes from us as tax payers, yes it might be disguised as grants, but that grant money has to come from somewhere. The government is not in business to make money, it is there to collect taxes and give it back, so however you wrap this up, it comes from us, we pay it one way or another, so I am not going to disguise it in any way.

More expanded vision

Why can’t this be a global EMR? Not only is this world not staying in a region as long as used to, but more and more are flying to different countries. There are very few places that I can’t access Google, Microsoft, or Yahoo across the world. How many international flights leave/come to the US, is anyone concerned with SARS, we are becominga smaller world.

Next steps, so where do we go from here?

This has to be a mandate on the national level to be accepted, but it needs to be run by the private sector (how many pork projects can you name?). This needs to be addressed in a standards commitee, not the WEDI/SNIP or HL7 committee, but something similar. In order for this to be successful it needs to use already proven infrastructure. The schema can be modeled after the VA system and will definately need to be enhanced. I would imagine that there would be at least 3 levels of the schema, level 1 is the basic information, level 2 would be all clinical data, level 3 would include how often my daughter excercies a week, number of hang nails, etc.

If we don’t come up with a standard, the number of proprietary EMR vendors will continue to grow (they will grow regardless actually), howeverwith no congruent measurable improvement of care.

There is always going to be nay-sayers, but we live by a majority, all we need is 51% to accept it. Yes, there will be the people that don’t want their information stored electronically, but your electronic profile is already being stored, so also is your profile being stored in the hands of the three credit agencies.

Here we are not really talking any technology, technology is never the issue, if XBox Live can go up in a few months, so also can anational EMR. There are a lot of smart people out there that can get this up, regardless of the technology. We, the United States, cannot sustain the cost of healthcare in the foreseeable future. If the fedrally mandated EMR is accepted, we can be the leaders muchlike the CDC is respected globally, so also we can be the pilots to be able to connect the world in a way that benefits everyone.

I want to thank KevinDolan for the enlightening conversation that was the catalyst of most of the information on this post. Hope to hear your thoughts on this.