Re: Medical Record Location(s) was: Virtual Privacy Machine - reprise
will ross wrote: We agree about shared access to the ultimate EHR repository, which is not like private access to an individual email box. That wasn't my point, which was poorly made, for which I apologise. I should have said that while the EHR repository itself is not like a private email account, the workflow queue of incoming EHR content (or action items) resembles a shared email inbox. I was speaking about the way an email *inbox* (as a gateway to a respository) organises inbound EHR content from various sources (both human and bot), not about the way an email account controls user access to the *content* of the inbox. It occurred to me because I'm working on a clinical messaging middleware project which uses an email paradigm to provide practice level access (as opposed to individual clinician access) to queued EHR content one step before it flows into the EHR, or in the case of some EHRs, as workflow events to be viewed from within the EHR. Will, your analogy makes more sense to me now. However I would still contend that an even better analogy is a configuration management system server receiving incoming flows from multiple simultaneous modifiers/creators (of its contents), and knows not only how to sort them chronologically, but how to merge the incoming new or changed items with the existing repository. And it can always tell you a) the current state of the repository, which is what any clinician has as his/her evidence basis at that moment, and b) any previous state of the repository, which any clinician (or a court) can use as proof of evidence used for some past decision (or a medical error). In your project, are you saying that the email EHR Inbox is a place where practice physicians vet content before it goes in? I think this is a sound approach, and one which I would like to see implemented in systems which have as their repository architecture the aforementioned version/configuration management paradigm under the hood. - thomas beale
Re: Medical Record Location(s) was: Virtual Privacy Machine - reprise
Original Message From: Tim Cook [EMAIL PROTECTED] To: OpenHealth List [EMAIL PROTECTED] Date: Fri, Oct-22-2004 10:39 AM Subject: Medical Record Location(s) was: Virtual Privacy Machine - reprise Thanks to Tim Churches for doing a great analysis of this issue and then following it up with real world testing and a report on his results. These things (see Tim Flewelling's article reference as well) can be very important if you have information that is very private and you want to keep it to yourself. In the real world though my medical record needs to be accessed fairly often when I'm not there. One example is when lab test results come back to the ordering physician. These results could sit and wait in an electronic holding bin until I come back in with my record in hand but they are relatively useless from a clinical standpoint without the context of the complete (or significant parts) medical record. So if I carry it around with me I may have to come in to see if the doctor needs to see me again..There might be a workflow issue or two with this scenario. g I agree. The ability to have the medical record carried with the patient doesn't change the fact that it must be available in other locations at other times, too. This simply indicates that the record to be carried around needs to be reconciled with a higher level medical record. In the DoD case, they would care basic information in the portable medical record as well as triage results associated with some medical event, the results of which would be reconciled at the higher level at a later time. I still contend that my primary health record should be at my primary care provider's location where ancillary data can be pushed into it. Be this a radiology report, lab report, hospital discharge letter or cardiologist results. Using this approach there is no need for huge MPI's (that invariably contain errors) and there are no socio-political concerns about unique patient identifiers and their abuse. I disagree. Your medical record can be created over a variety of locations each of which may have its own id. This can occur even within a single hospital system. Thus an MPI of some sort is required to stitch the medical record together. At any one point in time I have a unique patient identifier. Because my records are on file in Dr. Smith's office on Broadway in MyTown and the file number is 12345 I can have any pertinent information sent to my record. When I decide to switch to Dr. Jones on Main Street in AnotherTown I can do so and still have a unique patient (record) identifier.just not the same one I had before. Exactly, but the records from both locations may need to be combined. Thus the need for an MPI. Dave Cheers, Tim
Re: Medical Record Location(s) was: Virtual Privacy Machine - reprise
On Fri, 22 Oct 2004 09:35:44 -0700, Tim Cook [EMAIL PROTECTED] wrote: ... In the real world though my medical record needs to be accessed fairly often when I'm not there. One example is when lab test results come back to the ordering physician. Tim, I agree. However, also having a portable copy of your records in your pocket (in addition) can still be useful. These results could sit and wait in an electronic holding bin until I come back in with my record in hand but they are relatively useless from a clinical standpoint without the context of the complete (or significant parts) medical record. So if I carry it around with me I may have to come in to see if the doctor needs to see me again..There might be a workflow issue or two with this scenario. g The portable copy can be synchronized with the doctor's-office-copy in various ways: at the next office visit, from home via Internet, etc. I still contend that my primary health record should be at my primary care provider's location where ancillary data can be pushed into it. Be this a radiology report, lab report, hospital discharge letter or cardiologist results. Using this approach there is no need for huge MPI's (that invariably contain errors) and there are no socio-political concerns about unique patient identifiers and their abuse. Right - of course, we still need a reliable way to transfer/synchronize records between different doctors' offices, hospitals, etc. MPI is exactly designed to serve that function - but there are other ways to do it. At any one point in time I have a unique patient identifier. Because my records are on file in Dr. Smith's office on Broadway in MyTown and the file number is 12345 I can have any pertinent information sent to my record. When I decide to switch to Dr. Jones on Main Street in AnotherTown I can do so and still have a unique patient (record) identifier.just not the same one I had before. What ends up happening in the absence of a master patient index (MPI) is that we use record-location, date of birth, SSN, + name to serve the record matching function. This is the current state of the field. It has advantages and disadvantages - but adopting electronic medical records systems (EMR) does not mean we have to adopt MPI. Best regards, Andrew -- Andrew P. Ho, M.D. OIO: Open Infrastructure for Outcomes www.TxOutcome.Org
Re: Medical Record Location(s) was: Virtual Privacy Machine - reprise
Hi David, How did I *know* I would hear from you on this subject? vbg (BTW: we still need to write that paper) On Fri, 2004-10-22 at 10:12, David Forslund wrote: I disagree. Your medical record can be created over a variety of locations each of which may have its own id. This can occur even within a single hospital system. Thus an MPI of some sort is required to stitch the medical record together. Allow me to add a bit more context here. MPI's are required where you have disparate applications within a facility. I fully agree with those type of enterprise wide MPI's. It is very true that parts of my health record are created in various places. For example; my family doctor recommends I go see a cardiologist and she will send him a summary of the information he needs. My cardiologist (if I had one) does what cardiologists do and collects lots of data about my condition. At this point my family doctor doesn't need or want all that data. She wants a summary of my condition and the treatment plan. If for some reason she needs more information she knows where to get it. The same applies to hospital discharge summaries. This process / workflow remains the same irregardless the information transfer media. It is appropriate, certain and efficient. The federated approach means you have to be able to guarantee that I will have a unique identifier or trusted mapping between identifiers, between my family doctor and any number of potential specialists that I might be referred. Either of those two solutions is all the same just the latter has an extra layer for errors to creep into and the former is an impossible administrative task. The federated approach also means you must supply five nines or better connectivity. My recommended approach means I can send data and if it fails, retry later. There are still many many places in North America where you can't guarantee connectivity across town much less between towns. At any one point in time I have a unique patient identifier. Because my records are on file in Dr. Smith's office on Broadway in MyTown and the file number is 12345 I can have any pertinent information sent to my record. When I decide to switch to Dr. Jones on Main Street in AnotherTown I can do so and still have a unique patient (record) identifier.just not the same one I had before. Exactly, but the records from both locations may need to be combined. Thus the need for an MPI. No, they don't need to be combined. My original record can be moved/copied or not, as I choose and whether the applications provide a suitable means of import/export. The scenario above says I am changing PRIMARY care physiciansmeaning there will still only be one primary care record. If a patient chooses to visit more than one primary (more than one 'primary'?) care physician at a time then they are controlling the quality of their medical record in a negative manner and simply should be advised as such. The potential still exists for one physician to send summary data to the other record if the patient wants. The technology exists to make large scale MPI implementations work. What doesn't exist are the social, administrative and financial capabilities. Regards, Tim
Re: Medical Record Location(s) was: Virtual Privacy Machine - reprise
On Fri, 2004-10-22 at 10:17, Andrew Ho wrote: Right - of course, we still need a reliable way to transfer/synchronize records between different doctors' offices, hospitals, etc. MPI is exactly designed to serve that function - but there are other ways to do it. MPI's are designed to uniquely identify patients. They have nothing to do with record transfer/synchronization. The latter is a separate issue no matter which approach is used. The CCR in the US is supposed to solve that problem but they chose not to base it on any established standards (e.g. an HL7 CDA). The vendors I spoke to that have implemented it, said that even though it was adopted as an ASTM standard it is still rapidly changing and is impossible to keep up with at this point. Maybe the ASTM and HL7 will get together with a consensus standard for transferring patient summary data. The approaches are somewhat different at this point. The likely hood of full EMR transfer is isn't very good (IMHO)) and may not even be desired. Dr. Forslund has published in this area before. For those that haven't read this from four years ago: http://www.wma.net/e/publications/pdf/2000/forslund.pdf Later, Tim
Re: Medical Record Location(s) was: Virtual Privacy Machine - reprise
Original Message From: Andrew Ho [EMAIL PROTECTED] To: [EMAIL PROTECTED] Cc: OpenHealth List [EMAIL PROTECTED] Date: Fri, Oct-22-2004 11:18 AM Subject: Re: Medical Record Location(s) was: Virtual Privacy Machine - reprise On Fri, 22 Oct 2004 09:35:44 -0700, Tim Cook [EMAIL PROTECTED] wrote: ... In the real world though my medical record needs to be accessed fairly often when I'm not there. One example is when lab test results come back to the ordering physician. Tim, I agree. However, also having a portable copy of your records in your pocket (in addition) can still be useful. Absolutely. These results could sit and wait in an electronic holding bin until I come back in with my record in hand but they are relatively useless from a clinical standpoint without the context of the complete (or significant parts) medical record. So if I carry it around with me I may have to come in to see if the doctor needs to see me again..There might be a workflow issue or two with this scenario. g The portable copy can be synchronized with the doctor's-office-copy in various ways: at the next office visit, from home via Internet, etc. I agree. I still contend that my primary health record should be at my primary care provider's location where ancillary data can be pushed into it. Be this a radiology report, lab report, hospital discharge letter or cardiologist results. Using this approach there is no need for huge MPI's (that invariably contain errors) and there are no socio-political concerns about unique patient identifiers and their abuse. Right - of course, we still need a reliable way to transfer/synchronize records between different doctors' offices, hospitals, etc. MPI is exactly designed to serve that function - but there are other ways to do it. More than an MPI is needed. Tags as to the origin of the data need to be provided in some way so that data duplicates can be handled. These are distinct from the process of identifying the patient. At any one point in time I have a unique patient identifier. Because my records are on file in Dr. Smith's office on Broadway in MyTown and the file number is 12345 I can have any pertinent information sent to my record. When I decide to switch to Dr. Jones on Main Street in AnotherTown I can do so and still have a unique patient (record) identifier.just not the same one I had before. What ends up happening in the absence of a master patient index (MPI) is that we use record-location, date of birth, SSN, + name to serve the record matching function. This is the current state of the field. It has advantages and disadvantages - but adopting electronic medical records systems (EMR) does not mean we have to adopt MPI. Well if every location or system uses a different identification mechanism it makes the patient identification even harder, in my opinion. You are effectively adopting an MPI process. Having a relatively more uniform process and separating out the service explicitly would make it all much easier. Dave Best regards, Andrew -- Andrew P. Ho, M.D. OIO: Open Infrastructure for Outcomes www.TxOutcome.Org
Re: Medical Record Location(s) was: Virtual Privacy Machine - reprise
On Fri, 22 Oct 2004 12:22:10 -0600, David Forslund [EMAIL PROTECTED] wrote: ... Right - of course, we still need a reliable way to transfer/synchronize records between different doctors' offices, hospitals, etc. MPI is exactly designed to serve that function - but there are other ways to do it. More than an MPI is needed. Tags as to the origin of the data need to be provided in some way so that data duplicates can be handled. These are distinct from the process of identifying the patient. David, Good point! It seems to me that we really must get together and work on this. Maybe via the hxp effort? http://hxp.sourceforge.net/ ... What ends up happening in the absence of a master patient index (MPI) is that we use record-location, date of birth, SSN, + name to serve the record matching function. This is the current state of the field. It has advantages and disadvantages - but adopting electronic medical records systems (EMR) does not mean we have to adopt MPI. Well if every location or system uses a different identification mechanism it makes the patient identification even harder, in my opinion. You are effectively adopting an MPI process. Having a relatively more uniform process and separating out the service explicitly would make it all much easier. I agree. Maybe we can work out a sufficiently uniform process and implement it in our respective software packages? Best regards, Andrew -- Andrew P. Ho, M.D. OIO: Open Infrastructure for Outcomes www.TxOutcome.Org
Re: Medical Record Location(s) was: Virtual Privacy Machine - reprise
Hi Tim , you got it. Its not the technology. The obstacles are somewhere else. Elpidio On Friday 22 October 2004 10:47, Tim Cook wrote: The technology exists to make large scale MPI implementations work. What doesn't exist are the social, administrative and financial capabilities.
