1) Instrument Interface with lab information systems (particulalry Point-of-Care instrumentation) is address by NCCLS (1 Nov to be: "Clinical and Laboratory Standards Institutue - CLSI) POCT1A
2) HL7 v2.x standards and CLSI LIS2A and LIS5A which define instrument-computer and computer-computer system data exchanges.
#1 uses message formats from #2 but defines low-lvel protocols similar to LIS1A (the CLSI stds were previously ASTM E-31). The EHR locations of these data (ASTM E-1384) have been mapped to the lab standards and are being related to the newer V3 HL7 standards. VistA has an HL7 messaging module that can deal with these messaging flow how ever the CLSI POCT1A use with respect to lab data flow is in a later state of evolution. Discussions are underway with World VistA about work with the clinical lab specialty societies to address these issues in concert with society educational forums and other meetings. The lab companies below usually have this capability but use of the LOINC vocabulary (present in VistA) within healthcare enterpise business processes is an additional dimension that both lab service and lab information system Suppliers have had difficulty with. Thus this probleme area will require collbaorative work with these healthcare disciplines.
On Tue, 19 Oct 2004, Nancy E. Anthracite wrote:
I suspect by lab interface Kevin is referring to getting lab results back from Lab Corp, Quest and the like and entering the results directly into the EMR. Some years ago, the cost to do that was usually about $5000 collected by the EMR company and another $5000 collected by the lab for an interface for ONE lab. I don't know it that is true any longer, but I strongly suspect it is. Getting labs to make their output compliant with some standard would be a big step forward and one that I think may have to be mandated by the government sooner or later as there will be little incentive to change otherwise. Now if the VA did not do their own lab for the most part, they are big enough to force a standardized interface.
On Tuesday 19 October 2004 02:22 pm, Cameron Schlehuber wrote:I think those are excellent observations!
As for lab results, most lab instruments have electronic interfaces built in. (In my experience, even the oldest equipment had at least a rudimentary electronic output.)
With regard to "upgrading", the VA has been extremely conservative with regard to what kind of equipment the end user needs for access to VistA, as well as the server side hardware and software. Unless you're getting into diagnostic imaging, hardware (and code set license) costs will be in line with support costs (I would guess support costs over a 3 to 5 year upgrade cycle would be nearly the same as the hardware and license fees for the same time period).
Having standard health data interchange standards as ubiquitous as the exchange standards banks use is critical to the VA's and the rest of the world's success at providing a cost saving HER. It's among the VHA's highest priority if not THE highest.
-----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of Kevin Toppenberg Sent: Tuesday, October 19, 2004 5:18 AM To: [EMAIL PROTECTED] Subject: Re: [Hardhats-members] Fwd: Text of Article from Modern Physician
Hello all,
In Tennessee, our medical malpractice company is hosting an EMR conference this December (and why it is them is interesting) . My office manager and I will be attending at the request of my medical group. The group had previously agreed (tenatively) to go with VistA, but they still want me to look at other alternatives. I haven't seen the actual report, but I have heard that AAFP is now "strongly recommending" that physicians get an EMR system. I think this will push many into buying in--perhaps for fear of liability if something happens after such a strong directive is ignored. This will be an business expense, not an investment, because there will be little (and I suspect no) financial return on this expendature.
But frankly, I worry that this will be an expensive wild goose chase. I believe the power of an EMR will not be realized unless there is interoperability. For example, if labs are not obtained in a standard format that could be shared with others, then users will end up scanning the report and storing it as a graphic. This is no better than a paper chart. And while many labs probably have such an interface, I know that my hospital doesn't. And I suspect a majority of small hospitals don't (and remember that MUCH of America's health care is given by small practices working with small hospitals).
So after AAFP and other organizations push doctors into coughing up the $100-200k needed to get a new system up and running, will patient care be better? I'm not convinced it will. I have heard that thought leaders feel that a good EMR could achieve a 20% reduction in health care expendatures. But unless my EMR will somehow let me instantly access a lab/study ordered by another physician in another city, I don't see how this could happen. And now system I have seen addresses this issue. With HIPPA nervousness abounding, no one will release records without a written signature from a patient, and I not heard of any quicker electronic solution to this problem.
I keep a relatively well organized paper chart with tabs etc. It is fast and complete. It easily stores the carbon copies of scripts that I write, letters that patients write me, copies of their advance directives etc etc. All these things would have to be scanned in an EMR, and then possibly lost in a shuffle of filenames (i.e. "image1462"). My charts are portable: they can travel in the car with me, or I can take them to the hospital when admitting a patient. They're flexible: I could have a visit in a patient's home if required (i.e. I don't have to have a computer station set up.) They're "hi-res": Most computer screens have to magnify the image so that a scanned image is readable. Thus a full scanned page often won't fit on a screen and still be legible. So you have to scroll around. Paper doesn't have this problem.
As one who has put in a significant amount of time working with VistA, I don't want to sound like a Luddite anti-technologist. But I am seriously concerned that physicians are being pushed into making a sudden technology change away from a system that has withstood the test of time. I'm also concerned about a "lock-in" issue. I suspect that none of us use the same word processor that we did 10 years ago, but rather technology has progressed and we regularly purchase the latest and greatest. But will physicians be willing to purchase system after system the way we do computers now? I doubt it. If our group buys a non-VistA EMR, I imagine we will keep it at least 10 years. We'll be locked into 2004 technology until 2014. (Our current system is 1980's technology)
So what do I think the solution is to all this? Well, VistA goes a long way. First, it is easily conceivable that VistA could be established in an office for ~$10-20k, one-tenth the cost of a commercial system. (And my goal is to make the cost much less than this). This will make it much less painful for small practices, and still quite attractive for vendors (multiply the "272,428 practices" below by $10,000 makes for a nice retirement plan.) And if we have a critical mass of physicians on the same system, we have more chance of interoperability.
So in summary, I support getting EMRs into physicians offices, but I think we need to have realistic goals. We need to provide inexpensive solutions, and plan for gradual transitions. And VistA has a great potential meeting some of these goals.
Hope to see you all at the WorldVistA conference.
Kevin
--- Joseph Conn <[EMAIL PROTECTED]> wrote:Re: market size
According to an AMA survey from 2001, 33% of what it calls "patient care physicians" are in solo practice, another 11% are in practice in two-physician offices, 8.5% in three-physician offices. These exclude government and military docs. That 52.5% is in practices so small most EMR vendors I've spoken with don't want to bother with them because the sales costs excede the returns.
The vendors' interests might change some if an Oklahoma gold rush mentality develops to get an EMR, and say a salesman's batting average rises to one hit for every three times up to bat, as opposed to one hit in 10, but while physicians are much more receptive to the idea of buying an EMR today than just four years ago, price is still the No. 1 barrier to EMR purchase, as cited by the recent MGMA survey and the Modern Physician IT survey last year.
The AMA says there is no direct number of "patient care physicians" to multiply these percentages against, because they are for a sample, not a total count, but that said, there are about 514,016 docs in what the AMA calls "office-based physicians in patient care,"which is not exactly the same as patient care physicians, I'm told, but it is probably close enough for handgrenades and this estimate.
So, doing the math, that's 171,167 in solo practice, 57,570 in dual-practice, 43,691 in trio-practice, and 272,428 in those three combined. That's the market that's being underserved right now and where EMR penetration rates are lowest (10%) according to the latest MGMA survey.
Joseph Conn Online Editor Modern Physician ModernPhysician.com Modern Physician STAT Heatlh IT Strategist 312-649-5395 [EMAIL PROTECTED]
Check out the NEW ModernPhysician.com, and register now for MP Stat and MP Point of Care
[EMAIL PROTECTED] 10/15/04 01:07PM >>>
May I suggest shifting the frame of reference to the global context which is where open source really matters. In this context the numbers of potential adopters for VistA, whether for clinics or hospitals becomes staggering. Not one of any of the current vendors of any system has the capacity or business model to ramp up the way a well designed open source application with an effective community behind it can.
VistA is a classic example of a disruptive technology...stay tuned we are just at the beginning of the ride.
Joseph
On Fri, 2004-10-15 at 17:03, Michael Ginsburg wrote:Bill,
Let's not confuse ourselves. As far as I know,
there are no commercial
vendors planning to release their products as Open
Source or to put
them in the public domain. If I'm wrong, please
let us know! If I'm
right, than the VistA community, regardless of the
actual number, is
larger than a non-existent (fill in the blank)
community. So worrying
about something that doesn't exist isn't going to
help us.
Having said that, the size of the VistA community
will be important as
we move forward. It's the law of Small Numbers. 1%
market penetration
is 4000! That's a lot of potential customers for
any business. These
are customers that will need help implementing
their systems, training
their users and fixing problems when they arise.
They will also be
constantly demanding upgrades and improvements.
Figuring out how to
provide all that to the same standard set by the
best non-VistA
vendors is the challenge for the VistA community.
And I say community
because references and credibility are the keys to
product acceptance.
If a VistA site crashes and burns it will reflect
badly and impede the
efforts of everyone. You are right, the community
needs to get
serious.
As for documentation, I can assure you that
VistA-Office EHR will be a
high quality product in all respects, including
good documentation. As
for M, I see that as being a big plus since it's
the only technology
that I know of that is purpose-built to handle
medical information.
But that's just my opinion.
Mike
[EMAIL PROTECTED] 10/15/2004 4:17:15 PM
Hi Michael, ----- Original Message ----- From: Michael Ginsburg To: [EMAIL PROTECTED] Sent: Friday, October 15, 2004 1:18 PM Subject: Re: [Hardhats-members] Fwd: Text
of Article from
Modern Physician
In my opinion, (and, as always, I speak
only for myself) I
would agree that in a head to head
competition with "Open
Logician" that VistA-Office EHR would
lose. That is if all you
were comparing was functionality. As a
system for the
physician's office, Logician is a more
mature offering, no
question. VistA-Office EHR is only in the
embryonic stage.
However, if you were to compare them in
"open source"
market and all that implies and entails,
VistA-Office EHR
would be the clear winner. To the best of
my knowledge,
Logician does not have a rabid (and I mean
that only in the
nicest sense!), international community of
developers or an
organized community of cooperating vendors
who can supply
professional services, with all working in
concert to promote,
support and enhance the application.
This community you speak of... how big is
it exactly?
Compared to the one the exists that could
and would sign up to
support Open Logician. See my comments
re: this topic in my
response to Mark.
On the topic of 'rabid' ... I've never
seen that included in a
recommended list of selection criteria.
Reliable,
yes. References, yes. Responsive, yes.
Cost effective, yes.
Frankly, I'm not sure that VistA has all
that yet either and
therein lies the challenge and the
opportunity! Yes, the
serious discussions have to start, but,
the VistA community
doesn't need a survival strategy, it needs
a growth strategy.
We don't disagree on this. It's
perspective, I guess. Growth
vs. Survival. My background in business
has
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-- Nancy Anthracite
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