Healthy Living A New Trend To Telephone Substitution Patient Wellness Information

An interesting post on THCB past times Margalit Gur-Arie—titled "What if I Had to practise HIT All Over Again?"—critiques the real large, real expensive in addition to real clunky monolithic EMR/Practice Management/Billing scheme currently dominating the market. She concluded the post this way:

"So if I had to practise it all over again, I would pick out a hard await at Microsoft Office. I would construct multiple useful applications, similar Word, Excel, Power Point, etc. I would brand certain I tin lav export information from 1 to the other. I would brand certain that the user interface is consistent betwixt them. I would permit others to create templates in addition to integrate their software into my tool bars."

I replied:

Wow, Margalit, that's exactly what nosotros done! We've genuinely merely presented the firstly alive world demonstration of a epitome of our scheme to doctors, educators, in addition to insurers. It went real well!

The demo showed, inwards existent time, how this MS Office based scheme enables:

1. Primary attention physicians (PCPs) to transportation personalized referrals to specialists
   
2. The specialists to response to those referrals
   
3. The PCPs to respond to the specialists' credence response past times sending them XML-based continuity of attention documents (CCD) in addition to other supporting information files
   
4. The specialists to access in addition to sentiment the resulting patient information
   

This is all done amongst encrypted e-mail attachments in addition to a minor software programme in addition to macro routines that procedure the e-mails automatically. They automatically encrypt, zip, in addition to attach the files to e-mail in addition to seat them inwards the outbox; every bit good every bit call back the e-mail from the inbox in addition to unzip, decrypt, format in addition to display those files, in addition to shop them encrypted inwards the recipient's computer.

It requires every bit few every bit v mouse-clicks per end-user for the entire process. No postulate for primal servers (or whatever other infrastructural build-out), in that place is petty if whatever postulate for information technology support, in addition to in that place are no other costly complexities.

And all the information are stored locally inwards encrypted files, which areautomatically retrieved in addition to rendered whatever fourth dimension via a few push clicks. From a technical perspective, it's a elementary node-to-node (peer-to-peer), publisher-subscriber, in addition to asynchronous decentralized desktop solution that uses Office macros, .Net, in addition to SMTP. It is literally the easiest, most convenient, in addition to to the lowest degree costly fashion I know to commutation in addition to acquaint patient wellness information securely betwixt whatever EHRs inwards a fashion that promotes attention coordination.

Another reader (Alexander) commented:

Margalit, what y'all describe, basically, reflects the principles, on which the proposed NHIN infrastructure is based. The only departure is that it is supposed to connect RHIO's rather than sort EHR systems. Without a nationwide patient ID, though, it is going to live on real challenging to uncovering in addition to link all medical records on the same individual since closed to of import information fields used past times matching algorithms tin lav live on empty or incorporate wrong values. Besides, every bit I mentioned before, it is much to a greater extent than hard to predict availability of EHR systems installed inwards minor medical offices or hospitals, unless they utilisation cloud-based applications.

To which I wrote:

Margalit - What practise y'all mean value close the utilisation of a biometric index to create a unique patient identifier (medical tape number)? It would negate the necessity to constitute in addition to connect to a primal repository, in addition to it would enable the fluid commutation of patient wellness information betwixt whatever nodes inwards a mesh network architecture, which is similar to the fashion communication is done inwards telephone networks (see http://wellness.wikispaces.com/Network+Architectures

And she responded:

Dr. Beller, I mean value a biometric ID is likely a real expert choice, brusk of implanting a fleck :-)

The NCVHS has been tinkering amongst this for over a decade, but nada happened. There seems to live on closed to reluctance on the part of most people to conduct maintain such identifier. I'm non certain why, since nosotros all larn SSNs straightaway after nativity in addition to mean value nada of it.

I mean value the technology is available for biometrics in addition to the logistics are non insurmountable (put a machine inwards every DMV).

Alexander, I know that availability is an number amongst the electrical flow crop of EMRs, but I strongly believe that SaaS is the future. Besides, every bit Dr. Beller mentioned, nosotros all utilisation phones without the operator having to patch calls through anymore in addition to without having to run to the telegraph business office to transportation something. Technology changes fast in addition to I tin lav run across a device or an executable installed inwards every business office to ensure availability.

I'm non ruling out RHIOs or other intermediaries, but I believe the actual information postulate non reside anywhere other than the provider system.

I replied:

Yes! I suggest that of import roles for RHIOs, HIEs, etc. would be:

• To aggregate de-identified patient data
  
• To brand those information available to authorized inquiry organizations (universities, etc.) who study the information to assist prepare in addition to evolve evidence-based preventive, diagnostic, self-maintenance/management, in addition to handling guidelines that focus on bringing ever-increasing value (i.e., cost-effectiveness) to the patient/consumer
  
• To disseminate the resulting guidelines to all parties.

In this scenario, using the decentralized node-to-node architecture, the patient information would live on stripped of patient identifiers in addition to shipped to a centralized inquiry information warehouse. The stripping in addition to transportation would live on done past times the nodes having straight access to where those information are stored, that is, to the nodes belonging to the clinician/provider that access the information from their EHRs, in addition to to the patient nodes having access to their PHRs. Nodes having straight access to the inquiry information warehouses would in addition to so have the de-identified patient data. In other words, the clinician in addition to patient nodes would implement their publisher (sender/transmitter) part to transmit the data, in addition to the RHIO/HIE's information warehouse nodes would implement their subscriber (receiver) part to call back the data. And the resulting guidelines would live on shipped via the RHIO/HIE nodes past times implementing their publisher function; the guidelines would live on received past times the clinician nodes implementing their subscriber functions in addition to afterwards live on presented through clinical determination back upward software programs.

This scenario is an representative of a hybrid mesh node network architecture inwards which both centralized in addition to decentralized networks piece of work inwards harmony. BTW, closed to other representative of a hybrid mesh is when a multi-site healthcare scheme amongst a centralized EHR scheme (behind a firewall) connects via nodes to the EHRs in addition to PHRs of other parties exterior their scheme (beyond their firewall).

Margalit added:

Dr. Beller, it seems other folks are starting to mean value the same fashion http://www.reuters.com/article/pressRelease/idUS45817+13-Sep-2009+BW20090913 It's a start.....

And Alexander added:

P2P communication works corking when a PCP refers a patient to a specialist or
orders a test. And in that place are already commutation formats widely used for that, such
every bit HL7, CCD in addition to CCR. But inwards companionship to larn all patient EHR's through P2P
connections, (1) the requester has to somehow uncovering out, which peer systems have
that information, (2) brand certain they are connected, (3) transportation a asking to each
of them. And every EHR application must conduct maintain its ain authentication and
ascendency module to conduct maintain external requests... I merely don't run across how this
may piece of work without an intermediary.

To which Margalit replied:

I conduct maintain Alexander. It won't piece of work on a real large scale without an intermediary
or a super node or a translation gateway, whatever nosotros halt upward calling it.What I
similar close eCW's annunciation is the modify inwards the fashion vendors are thinking.
Exchanging information is finally becoming a worthy goal. As long every bit they are
moving inwards that direction, every minor measuring is an achievement.

I responded:

I also conduct maintain that an intermediary would live on useful for larger scale P2P
implementations so that each peer/node tin lav uncovering other peers/nodes during the
publisher-subscriber activation procedure (i.e., when 2 nodes connect amongst each
other for the firstly time, which includes authentication in addition to authorization). A
RHIO/HIE would live on an ideal intermediary supporting such P2P connectivity
regionally. H5N1 Federal regime agency, or fifty-fifty a “supra-RHIO/HIE” node that
connects the regional ones, could practise this nationwide.

Another reader (a physician) in addition to so commented:

The interesting matter is that the only 'standard' that clinicians utilisation inwards the
daily attention of people is English. I mean value this is unlikely to change, Dr. Beller.

And I replied:

I'd larn 1 measuring further: I believe our province should live on engaged inwards international collaboration in addition to research, so English linguistic communication isn't fifty-fifty a universal standard.
In whatever case, using a pub/sub node-to-node architecture, in that place tin lav live on 1 or to a greater extent than nodes betwixt the publisher in addition to subscriber that serve a information translation/conversion part via mapping methodology. That is, if the publisher uses a local terminology touchstone “A” in addition to the subscriber uses local touchstone “B,” in addition to so the information tin lav live on sent to an intermediary node where corresponding terms are translated into the subscriber’s parlance. This would non only improve communications betwixt clinicians inwards different regions in addition to facilities, but also inwards betwixt clinicians inwards different disciplines. Likewise, the terms could live on translated into layman's linguistic communication when communicating amongst patients!

Another physician responded:

Interesting thread... Some thoughts...
1) The in conclusion post close H5N1 in addition to B getting translated past times an intermediary pretty good describes the wishing behind RxNorm (input Multum, First Databank or other in addition to interpret to RxNorm or 1 of the other systems) -- Good idea, would live on fifty-fifty amend if the Government would create an opened upward wiki or similar to create a crowd-sourced comprehensive drug-drug interaction scheme (Would cutting close $20/Doctor/Month off the terms of e-prescribing, at nowadays paid to Drug Data manufacturers).
2)The Pub/Sub Node amongst closed to reporting primal shop - describes good Carol Diamond's in addition to lots of others architecture for an HIE / NHIN infrastructure (eg hybrid federated - pub/sub node in addition to centralized - primal clinical repository).
3) The Vermont Blueprint in addition to VITL commutation that Governor Douglas (Vermont Gov, also Chair of National Governors Assoc this yr - different topic, but await at his RxReform platform for accessible, affordable accountable healthcare - pretty interesting) -- Anyway, the commutation started generating information for reporting in addition to for community coordination past times doing 2 things - 1) Agreeing on carry (started every bit CCR, in addition to so moved to CCD - both work, but every bit Phil Marshall from WebMD stated inwards his HIT Policy commission testimony - CCR is easier to utilisation unless 1 needs to utilisation CCD for standards reasons) in addition to 2) Agreeing on a LIMITED semantic lexicon - brand certain to collect a few of import things inwards a structured, slowly to care fashion, in addition to the scheme tin lav live on used past times lots of parties.
Bottom work feels every bit if designing to solve the GOAL of the PROJECT or TASK ends upward amongst a simple, effective solution - the midpoint of the master copy post - it was right on target.

To which I replied:

Concerning CCD vs. CCR, I mean value their reliance on XML makes them both to a greater extent than complicated in addition to inefficient than is necessary. I say this because the information they incorporate tin lav to a greater extent than easily live on set out inwards a comma separated value (CSV) file (including whatever parent-child hierarchies, although they are rarely, if ever, required for wellness information exchange).
In fact, I've developed an opened upward source app that uses an MS Excel VBA macro to convert a CCD into a much slimmer in addition to much to a greater extent than human readable CSV file at https://sourceforge.net/projects/convertxmltocsv/ Note that the CSV could live on used instead of the CCD for transmitting information from node to node. Nevertheless, CCDs/CCRs are today’s standards in addition to hence cannot live on dismissed.

BOTTOM LINE: As our province struggles to transform healthcare into an efficient in addition to effective system, in that place is corking postulate for a convenient, low-cost, resources conserving, in addition to secure fashion to commutation whatever electronic information residing anywhere that doen non require those information to transcend through a primal server or reside inwards a primal database. This is just the form of decentralized peer-to-peer mesh network architecture, publisher-subscriber communications, in addition to desktop (standalone) applications that I've been describing. It's expert to know others are outset to run across the wisdom of this approach!

Note that, patch this scheme currently takes payoff of the mightiness in addition to ubiquity of the MS Office platform, it is not theme them since the same funcitonality tin lav live on built on other platforms.

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