Hi Thomas, Comments in text.
----- Original Message ----- From: "Thomas Beale" <[email protected]> To: <openehr-technical at openehr.org> Sent: Saturday, August 02, 2003 4:33 PM Subject: Re: certification and verification of OpenEHR > > Hi Thomas, > > lakewood at copper.net wrote: > > >Hi All, > > > >Been off looking at some operational considerations associated with > >supporting, maintaining and updating global EHRs. > > > What was your study to do with? Our analysis of possible EHR users is > that most people would use regional EHRs, i.e. EHRs which are embedded > in the healthcare network in which they normally live. Issues of > consent, privacy, security, as well as technical and clinical issues can > be determined in advance on a regional basis, and set up with > appropriate contracts. When such patients have a health problem outside > this jurisdiction, e.g on holiday overseas, and ad hoc request for > health data needs to be possible - where there will be no advance > contracts, security clearances etc. > STUDY: -several counties in California and Nevada ranging from agriculture to forestry and their current healthcare systems -current budgetary constraints and potential for new funding -can they develop county-wide and state-wide healthcare systems that incorporate an OpenEHR-based system -can they get support from the federal government -how are they handling HIPAA -can they integrate individual and small groups of Practitioners -can they handle current levels of care for current populations -are their open-source solutions currently available that could be used by county personnel to introduce and maintain a EHR/EMR system NOTE: -restricted to individual counties and counties that have an established inter-county organization -homeless and transient healthcare a major problem and remains so. -within each county there are major disconnects between different departments and services -county healthcare services are over-burdened, under-funded, under-staffed and in constant danger of closure -governments seem to make matters worse -charities and welfare agencies are unable to participate for a long list of reasons -in-place IT Departments are over-loaded > However, some patients are always on the move. Military, aid workers, > elite athletes, conference speakers, entertainers, airline staff and so > on. THey can routinely have a problem anywhere in the world. So their > EHR needs to be set up in a different way - probably served from a > secure webportal which the network of carers for that kind of person > will have secure access, also set up in advance. But these people can > also need medical help outside their routiine care network, and > communications of part of the EHR will again devolve to ad hoc requests > and replies, where security and privacy have to be worked out on the spot. > > >The following types of > >users were considered: > >1)CREATORS > >-individual, groups or organizations that must, or want to, generate new or > >updated EHRs > >2)REVIEWERS > >-overseers, peers and formal reviewers > > > can you define this role in more detail to do with EHRs? Do you mean > senior medical staff? CREATORS The bulk of Patients are handled by staff, some untrained, e.g., admitting. They (admitting, etc) require automatic, form-based software applications and lots of it. RNs and LVNs carry the load; fewer numbers of doctors do the major work, senior medical staff, where present, and chasing funding and performing administrative duties. A local county hospital can admit a Patient and setup billing but does not know how long a Patient is resident or when they actually leave. The floor nurse has to check the beds and report on who is in and who is out. Certainly better than nothing but needing considerably more. The hospital Administrator was just involved in a serious controversy because of a budget item for an ABSOLUTE BOTTOM-LINE Catscan system (first in the county). There will be no computer system connection. This has been added to show that there are many Practitioners and staff that SHOULD be CREATORS but cannot be because of UNAVAILABILITY. A local county resident can travel globally with the assurance than NO medical record could be accessed by any regional, national or foreign Practitioner. This can be contrasted with another county in which a private hospital is situated and Practitioners even have hand-held computers and staff do reports on a computer system. Unfortunately there are many machines that have no connection to a computer system (reason unknown). POSITION: Practitioners and staff should be connected at all times on-site, and some off-site and should have full access to an OpenEHR application on a suitable computing system. > > >3)ADMINISTRATORS > >-Data management/processing Experience has taught that Administrators have to be connected. Ordering a procedure is a natural for inclusion in an EHR. What is tacked onto the procedure by the facility is often amusing and upsetting. I have reviewed more than one hospital bill and have had the opportunity to discuss certain entries. Turns out that when my Mother was in the ICU prior to her death the bill reported entries in sufficient quantity to have filled the room up with equipment and placed her in the hallway. Common objection from HMOs and Medicare, i.e., erroneous billing. Administrative records have to be 'tight'. They need inclusion in the records systems and they need 'tight' monitoring and control. > >4)CERTIFIERS > >-Handles tasks associated with correctness, e.g., prior to use or archiving > > CERTIFIERS Medical errors alone cause substantial harm. In many cases the error is just plain stupid. Lost a neighbor because in a 'simple' operation she was treated in POST-OP for high rather than low blood pressure because a paper record was misread and not double-checked. Mistake made and continued resulting in death. Of course there was a case at the same hospitable where the wrong leg was taken because of a mistake on what was the proper way to identify which was which. Everything in an operating room has to be checked. A certifier for the records is necessary as is a certifier of ongoing operations, e.g., where are we in this procedure. One must be able to rely upon electronic records and all other types, hence certification is required. Patients should be able to order certifications of their own records. For example, a large HMO had a Doctor that seemed to like telling people they needed a bypass operation. Some Patients opted for second opinions and opted-out when they came back against the operation; some took it on faith and are now on a downhill slide. I would like to see a CERTIFIED capable of reviewing my records, history, ancestry, whatever to determine if a particular procedure is necessary and where my health is headed. Reminds me of the time I took my daughter to the Doctor and he made a mistake on the prescription. The Chemist questioned me about the symptoms, contacted the Doctor and got a modification downward in the dosage. Electronic prescription has a bright future due to the continuing over-abundance of prescription-related errors. CERTIFY AS MUCH AS POSSIBLE > also this role > > >There has to be user toolkits, possibly with custom components, available > >for the EHRs, and perhaps many different implementations of EHRs. There must > >also be administrative (e.g., configuration management), > > > you will see that the basic of configuration management are in the > COmmon RM (http //www.openehr.org/Doc_html/Model/Reference/common_rm.htm) > > >QA (e.g., does it > >work), evaluation (e.g., workflow) > > > clinical workflow is a big area, and will most likely have its own > services, but very closely bound in with the EHR > > > and performance (e.g., does it take less > >time to perform a task using pen and paper?) tools to address related > >operations (note that the supporting networks and systems have been left > >out). > > > I think all of what you are saying relates to IT / software engineering > quality assurance measures? > Make that Information Architecture and Engineering. IT can go nowhere by itself since it employs tools to implement applications. > >What kind of tools? > >SUGGESTION: graphical, possibly remote access and possibly wireless enabled. > > > >WHY? Not everyone loves computers, scripting and software plus is willing to > >dedicate the time and energy to get some script to play right. > > > >OPINION: Would like to see a tool that can access/breakdown different types > >of EHRs, support information transfer and synthesis of additional records, > >even a modified EHR. > > > there are two approaches to this. One is where the source "EHR" systems > are legacy databases, and don't obey any models. THere are approaches to > getting data using archetypes to model it, but of course they are not > completely simple - most legacy databases have different, annoying > schemas....you have to extract the raw data, match columns and rows to > target structures, synthesis missing bits etc etc. > > The other approach is when we are talking about moving information > from/to EHR systems which obey openEHR or some other accepted standard > for which we can write interoperability software much more easily. Then > interoperability is largely a matter of archetypes. > > - thomas > Legacy databases store information. How about applications that extract the information, note deficiencies, merge other data and build compatible records. Sounds similar to extracting data from an ancient tape-based database, updating the information and storing it on a disc jukebox. An information transformation and integration. Example given to satisfy an IT problem. Another IT example that keeps popping to mind is that of a frame-based Fibre Channel network. It does, or can, interface to a wide variety of technologies. As a frame-based information transfer system you decide what goes in the frame. Some modifications serve storage-related tasks; other serve data communications- related tasks. Impose any structure you wish on the content, standard or otherwise, e.g., streaming data. Very much multi-purpose. Send a digitally-formatted sequence of picture embedded in a collection of healthcare records. The sender and receiver care about the content. Part standard/part unique. > > - > If you have any questions about using this list, > please send a message to d.lloyd at openehr.org Thanks for the great response! -Thomas Clark - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
