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Tim Mitchell

Tim Mitchell is a business intelligence consultant, author, trainer, and SQL Server MVP with over a decade of experience. Tim is the principal of Tyleris Data Solutions and is a Linchpin People teammate. Tim has spoken at international, regional, and local venues including the SQL PASS Summit, SQLBits, SQL Connections, SQL Saturday events, and various user groups and webcasts. He is a board member at the North Texas SQL Server User Group in the Dallas area. Tim is coauthor of the book SSIS Design Patterns, and is a contributing author on MVP Deep Dives 2. You can visit his website and blog at TimMitchell.net or follow him on Twitter at twitter.com/Tim_Mitchell.

Electronic Health Records – What’s the Big Deal? (Part 3)

In the previous post in this series, I discussed the obstacles to implementing electronic health data systems.  Becausesilos of these obstacles, many providers are resistant to replacing their paper-based “databases” with true EHR systems.  But assuming the best case scenarios, that all healthcare providers and vendors convert from paper (or quasi-paper) to digital, that still  doesn’t fully solve the problem – you’ve still got a lot of electronic data that exists in silos.

Why Integrate?

For maximum benefit to the patient and, in the long run, to the industry as a whole, this information should be visible across every platform and every organization.  Properly authenticated users should be able to access a patient’s health record instantaneously, including even very recent visits to other providers.  Non-clinical decision making personnel should be able to aggregate the same information to analyze disease trends and patient outcomes to help identify the factors that lead to illness and the success/failure rate of different treatment paths.  This information would need to be available in real-time or very close to, in expectation of large scale, rapidly evolving health situations (avian flu, H1N1, etc.).  With this information, front line personnel could quickly make treatment decisions based on previous outcomes and the patient’s own treatment history.  Family physicians could immediately access their patients’ healthcare history from hospitals, specialists, and other caregivers, allowing them to make diagnoses and medication/lifestyle changes based on the big picture of the patient’s health rather than simply addressing acute issues as they emerge.  Insurers and other entities with a financial stake could better plan for anticipated treatment costs, which could become more consistent with the volume of data used for this analysis.  Simply put, the best use of healthcare data would include a large-scale integration plan to insure consistency of treatment and improve patient outcomes.

It’s Not So Easy

Healthcare data integration presents multifaceted challenges, including technical, administrative, and strategic obstacles:

Technical issues include the questions of responsibility and availability: Which entity(ies) will be responsible for insuring the data is always available and is properly protected?  Is the data to be centrally located for common access, and if so, who pays for this storage?  Some initiatives currently underway include RHIOs (regional healthcare information organizations), which seek to share information on a relatively local level.  Properly administered, a national system based on the RHIO model might be a good solution.

Administrative issues include budgeting for data integration, allocating personnel, and integrating the integrated information into the workflow.  It can’t be overstated that healthcare organizations, and especially front-line providers, can ill afford distractions, especially those that don’t result in an immediate payoff.  From the time required of technical staff to handle the nuts-and-bolts of implementation, to providers who have to learn to access and updated the integrated data, and finally the back-office personnel who validate and audit the information, there is an investment in human capital, which always comes with at least a soft cost.

Strategic issues certainly exists – after all, healthcare data integration violates a cardinal rule of business by simply giving away your most sensitive information.  Providers and vendors are under increasing pressure to remain competitive, and sharing patient and treatment information pulls back the curtain a bit, perhaps too much for the comfort of some.  Certainly some safeguards would need to be implemented to allow the sharing of information for everyone’s benefit without unnecessarily harming smaller companies.

Hopefully the picture I’ve painted isn’t a bleak one.  The good news is that there have been strides over the past few years, and we are closer to true healthcare data integration than we were a decade ago.  I think the effort will get a big push with the legislative changes coming down the pike, and while I don’t believe that decisions by Congress will completely address the obstacles, said changes could help establish standards and safeguards to make the process a little less painful for everyone.

Comments

Posted by Steve Jones on 3 December 2009

I think one of the big issues that still exists is one that's in the financial industry as well. How do we fix mistakes? How do we give security to users and ensure that users have some level of both security they control while having recourse if things get mixed up.

The other issue I think really stands out there is discrimination based on your records.

Posted by john.campbell on 8 December 2009

I think that there would be chilling issues to worry about:  My local x-ray dept can never seem to charge the correct account and they go through a whole in-processing procedure, will these mistakes continue, I think so, and how does the patient get them corrected.  Can these records be used in the billing/debt collection process....  they are medical records after all...  Is some government official going to "oversee" this process, and what will be their concerns as to system integrity, orphans, consistency of reporting the same things across the board...

Having my medical records in the hands of "governmental officials" scares the heck out of me..

John.

Posted by crussell on 8 December 2009

I agree that "mistakes" can be a big issue. Does the provider have to verify everything in the history with the patient to make sure there aren't any? On one hand I would want my provider to do that, to make sure the information is all mine and not someone else's. Identity thieves get sick too. On the other hand that slows the process down and heck if I can remember everything that has happened to me. In fact I doubt I even know or understand the kind of notes the doctor may have written about each time I was at the hospital.

Posted by Simon Taylor on 8 December 2009

Having recently traversed the medical system for two eye surgeries, using a provider over 1,000 miles from home (services not locally available), I think it's important to add a dimension to this discussion regarding "repeated data collection".  Some folks see EHR as an "end to filling out forms", but this notion is at least partly mistaken.

The provider we were dealing with had complete electronic medical records, but still repeatedly collected the data, especially at hand-offs between different units/offices.  At first I was frustrated to see what seemed like a habit born of a pre-EHR era.  Then, after going through the process several times, I realized there was a very key data quality assurance activity occurring.  Medical technicians and professionals, like everyone else, make mistakes (we encountered several examples) in documenting the health data.  Additionally, sometimes physicians do make changes to medication regimines in the middle of the night that do not make it into the system (yes, the changes should, but I do not see this problem going away)By repeatedly collecting and verifying the data, the doctor and patient (my wife) were able to ensure at each step along the way that critical information was corrected and understood by each treating physician.

I agree with your point, Tim, that the real benefit of EHR is cross provider information sharing and trend analysis.  Due to the nature of EHR, data quality assurance methods need to be built-in to the data collection methodology.

Posted by JackBIWA on 8 December 2009

There is already a working production system here in the US that really works. It is the VA's system. Too bad everybody wants to build their own. How can it be worse to have the government holding your health records than giving access to the insurance companies?

Posted by vickiy on 8 December 2009

scares the crap out of me, also.  I have a very generic name.  I'd rather my info be my info since I have some life-n-death allergies.  Putting my ssn, birthdate, etc., out there does not make me feel better.  It makes me feel vulnerable.  

I believe the VA had a data access infraction?  People that want at data will get at data.  Mistakes will be made and the patient will pay the price:  "Well, sorry, Mrs. Generic, it says here that you owe $2 million, so you must owe $2 million - my computer is never wrong."   ack!

I want to opt out of having my records digitized!

Posted by Dream Weaver on 9 December 2009

There's another type of data quality problem, a big one, that hasn't been mentioned:

Anyone who's worked in a large corporation and tried to use the "enterprise tools" for case management, bug tracking, systems inventory and configuration--any "enterprise" tool--knows that they are incredibly flexible but also incredibly complex.  

Inevitably some important types of information don't get into the system at all because they are "round pegs that don't fit into the square hole".  Whether it's a software issue or training issue isn't relevant; it's not likely to be fixed within a year even if reported.  

So the vital information never hits the system...with luck it gets passed from person to person through informal channels since there's no other way to do it--email, IM, face-to-face, paper documents (or electronic ones outside the system), etc.

EHR is so complex that this problem is certain to arise, frequently.

People who don't understand this will just trust that all relevant information is present in the system and is correct.  I would personally hope that anyone billing me, let alone making medical decisions or diagnoses on my behalf, doesn't trust the system to be entirely accurate.  

But having a system perceived as untrustworthy opens a whole new can of worms!

Posted by jcrawf02 on 10 December 2009

@dream weaver: But end users have no recourse but to depend on the data in the system, that's a separate discussion around how the data integrity should be audited/protected. The fact that data gets screwed up all the time should not be a deterrent to moving to an EHR format.

@crussell: mistakes happen in paper formats too. one doc asked someone I know how the medicine regimine was going, when she wasn't on it. His copy of her chart was wrong. Had all the records been synched, a comparison could be done between what he thinks he prescribed and the actual pharmacy records having been dispensed, etc.

@vickiy: similar response to above, these mixups happen now too. I know someone else who received three other people's radiology scans on cd because their names were similar. We can't let existing problems like this stop us from moving forward, we need to fix the problems, but it's not a new one.

Tim - great series, thanks for spelling it all out so neatly!

Posted by Tom.Thomson on 2 February 2010

In the UK just now medical records and sharing them are a hot topic of discussion in security circles and in human rights circles as well as in medical circles.  There are several different views.  First the view of the big IT supply companies, and of the government currently in power (who have swallowed everything the salesmen have told them): that's that getting universally shared medical records into a vast centralized database is essential for the health of the nation, and that access should be available not just to those with clinical need but to everyone who wants to do any kind of medical research too.  Second the view of most medical professionals (this doesn't include the non-medical managers in the NHS) which is that this information would not actually be very useful and that the damage that its inevitable insecurity would do to the doctor-patient relationship would far outweigh the very limited benefits. Thirdly the view of most security experts, which is that anyone who believes that putting together such a massive database of commercially valuable sensitive personal data without it being misused and provided to people who should not have it is possible has no idea at all of how difficult security is.

I agree with the third camp, and also with the view that the clinical value of such a system is usually greatly exaggerated by those with a massive IT system and lost of "consultancy" to sell. You don't even have to think about the technical problems of securing such a thing, or the administrative problems of determining who needs access to what, you just have to look at the numbers who will inevitably have access - every ward sister, nurse, house physician, medical registrar, medical consultant, general practitionar, district nurse, and so on in the country - in 2005 (the last year for which I have numbers) that amounted to more than 126000 people. Is the data secure if 126000 people have access?

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