TECH: Brief musings on the PHR

Some brief musings on the PHR…given that I gave a talk on it for HIMSS N. Cal yesterday

— Email is unreliable! Not a comment on the PHR but I sent the organizer my talk in both Powerpoint and PDF (one for the talk, one for the web so the secret stuff hidded in the PPT stays hidden). Most of the intellectual property is of course in the fancy “builds” I did in Powerpoint. When I started clicking into my presentation, it became apparent that only the PDF version had gotten tp him, and was the one loaded on the computer. I of course had a copy of the Powerpoint on my thumb drive and this could have been avoided. Motto—always check what’s on the computer you’re presenting from.

— Kaiser Permanente’s PHR is rolling out pretty well, and has decent usage so far. It’s relatively transparent in terms of the views it gives into the patient record (gives full lab results) and links well to Web 1.0 generation content/information therapy.

—One of the points Kate Christensen (from KP) made was that they felt PHRs should be portable. But thus far that means portable within the world of Kaiser. I asked  if a member using KP.org changing plans could move all their data to Palo Alto Medical Foundation (which uses the same basic Epic software and is therefore the easiest imaginable “move”). Kate said that a) no one had asked so far and they didn’t yet have a policy on that yet, b) the data structures were different so it was more complicated than I’d made it seem, and c) they had a technical team working on it, really! Take it as read that this is a major potential future stumbling block and  view all those slides about “portability” and “interoperability” with extremely jaundiced eyes.

—One word baby: Autopopulation

— I didn’t smell sulphur. In fact the entire HealthConnect EMR (clinician part) was basically unmentioned, other than by me saying I didn’t smell sulphur. I think that knocks the conspiracy theory on the head.

This article finally confirms that the just announced Intel/Walmart/BP et al initiative will be using PHR’s developed by JD Kleinke’s Omnimedix Institute. He was keen to point out when I last talked with him that his was a data auto-population and storage, non-profit, trusted 3rd party model, which others could build applications on top of. (i.e. competition for WebMD/Intuit).

— Cleveland Clinic has rolled out its Epic System including the PHR, faster and harder (if that makes sense) than Kaiser. They also have a way that allows referring physicians to get access to their patient’s records when they’re at the Clinic’s hospitals. This is a model for how providers not integrated with insurers or using a “monogamous we hope” (to quote Kate) medical group can roll out EMR and PHR. However, it was very hard work. Holly Miller, the doc in charge of eClevelandClinic, had to buy a lot of pizza. She’s leaving next year to take up the CMIO role at University of Cleveland. I joked that this meant that the Clinic’s docs had succeeded in running her out of their organization, but not yet out of town! Rather more likely, the Univ. Hosp likes her pizza buying/persuasion skills and realizes that the quickest way to catch up with its major cross-town competitor is to steal the talent! (Isn’t that what the Dallas cowboys and the 49ers used to do to each other in the 1990s?)

—Cleveland Clinic is also doing virtual visits into Mexico and Arizona, separating the reading from the diagnosis, and they’re pushing second opinions online as a service. Clearly they see their brand as a major weapon in getting national and international market share. They may be early, but if enough records go online, why does your second opinion need to come from the same city or country? And more importantly why does the patient have to be in the same physical room, when a tech can move the stethoscope or instrument around the patient, and the doc can see it all on screen, or an entire team of experts can be assembled virtually online?

—One reason why is that state laws restrict practice across state lines, and in some states (Holly think Ohio, but it was certainly true till recently in Georgia) even a prescription has to be handwritten and signed by the doctor. So 200 years of trade protection will not go quietly into the night.

—Matthew Guidin from Frost & Sullivan has done some real research on PHRs, which may make my back of the envelope stuff obsolete (or more valuable?). He seems to think that the health plans are talking a good game about interoperability, but have little intention of doing much. He also thinks that CCR (the AAFP-based standard for moving data between EMRs) is being sabotaged by the IHE crowd before its really gets off the ground.

—Everyone I met at the meeting that used to be a client is now a consultant! Who’s doing the hiring these days?

—Whenever a new incredible “innovation”  on their PHR was shown by KP or Cleveland Clinic Phil Chuang (my ex-i-Beacon colleague) and I kept whispering to each other “Didn’t we build a better version than this in 2000?” And we did. Which goes to show that timing, politics and marketing are everything. And technology is largely irrelevant.


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  1. You don’t seem to be the only one with an opinion about the PHR. The week of December 4th must have been PHR week after the Markle Foundation published a nice white paper and Adam Bosworth of Google said that the PHR should be a URL to which health information can be attached.
    Actually, this is not a new idea. Johannes Ernst of NetMesh invented some technology called Lightweight Identity that is exactly this. It is a very powerful concept and leads to some startling conclusions which address the PHR requirements identified in the Markle report.
    It is also a elegant way to unify the PHR as defined by Kaiser/Cleveland at the HIMSS meeting, with the “portable PHR” I might want to carry around in my pocket.
    So, what if my Blackberry stored a URL in it that identified me? This might be an I.C.E.(in case of emergency) entry in the phonebook. Then if say an Emergency Room Physician wanted to find my medical record in a hurry, they could look at my phone, and enter the ICE URL into a browser (perhaps identifying themself by their own URL) and “break-the-glass” to obtain my health records.
    It would not matter where this URL actually pointed to, it might go to Kaiser’s web site, Google’s Web site, or my Blackberry. In any event one place would probably not have all my information, so my personal URL could return a page of URL’s pointing to the rest of my records at other providers. This simple solution obviates the need for a complex health record indexing service that is often talked about.
    Pretty cool. I wonder if this is what Google is planning to do?

  2. I actually used the eCleveland Clinic second opinion back in March. The first step was getting my Urologist to sign the request. If he would not sign the request, no second opinion would be given. Once this was completed and I overnighted them a CD with 3-D Holographic images of my CT Scan, the following emails were sent to me.
    March 3, 2006
    In regards to your eClevelandClinic consult request, ID XXXXX:
    Your medical records are complete and have been forwarded to the appropriate Cleveland Clinic specialist. Your Remote Consult will be ready within 5-7 business days.
    For Remote Second Opinions, it may take longer if radiology and/or pathology review is required. If, for some reason, we cannot process your request within this time frame, we will notify you.
    You will be notified by email once your consultation is completed.
    March 8, 2006
    Your Remote Consult, ID XXXXX, has been completed and is ready for review. Please go to the e-Cleveland Clinic Web site to preview the Remote Consult. You will receive a written copy of this consultation in the mail in approximately one week. If you have sent materials to us, such as films, tapes or CDs, or pathology slides we will return these by mail in approximately 2-3 weeks.
    This was my second opinion:
    Date: 03/08/2006
    Patient Name: SBD
    Physician’s name: Andrew C. Novick, M.D.
    Department: Chairman, Glickman Urological Institute
    Date of Birth:XX/XX/XX
    Patient Address: United States
    Dear SBD:
    It is my sincere pleasure to provide you an e-Cleveland Clinic second opinion consultation. I greatly appreciate the detailed records that were forwarded to the e-Cleveland Clinic for our review.
    Diagnosis / Reason for Consultation: Renal Mass
    SBD is seeking a second opinion regarding the “best surgery” to remove the mass.
    Diagnostic Summary / Treatment Summary:
    It has been recommended that SBD undergo surgery for this mass.
    Second Opinion Recommendations:
    SBD is a 33-year-old otherwise healthy male who was recently found to have a renal mass upon a full body CT scan. Upon reviewing the CT scan, this shows a 3.4 cm solid enhancing mass in the anterior portion of the right kidney. The mass extends centrally into the renal sinus. The mass contains a central scar which may, perhaps, be indicative of a benign oncocytoma. Nevertheless, this radiographic finding is not specific for oncocytoma and there remains a significant possibility/probability that the mass represents a renal cell carcinoma. The CT scan demonstrates a normal left kidney and no other findings. This patient apparently has normal overall renal function.
    The renal mass should be surgically excised due to the possibility/probability that this represents a renal cell carcinoma. Based upon the size and unifocality of the mass, the indicated procedure is a right partial nephrectomy. This technique has been pioneered at the Cleveland Clinic and we have performed over 2,000 of these operations. Our published results indicate equivalent long-term cancer free survival for patients such as this treated with either a partial or total nephrectomy.
    The obvious advantage of a partial nephrectomy is in preserving the function of the involved kidney as added protection against the development of kidney failure later in life. In the case of SBD, based on the central extension of the tumor, I believe that it would be safer to perform a partial nephrectomy through an open surgical incision rather than with laparoscopy. Our experience with laparoscopic partial nephrectomy, while quite favorable, has indicated a higher risk of bleeding when performed for centrally-located renal tumors.
    Thank you for the opportunity to provide you this consultation. I do hope you find it helpful
    Physician Signature:
    Andrew C. Novick, M.D.
    Signed Electronically

  3. Thanks for sticking up for *genuine* portability!
    As for email – Kaiser delayed giving me the email portion of medical record for months (I participated in an email test run for Oakland), and at first they said that it wasn’t accessible. When I finally got my records, I was given the explanation that it had taken my primary physician that long to figure out the system. Portions, notably the email I most wanted, were missing – Kaiser is counting on faded memory so they can select which portions of your medical record to turn over.
    Also, when I tried to question Kaiser about this, my questions were directed to the wrong physicians. When I complained about this (to the DMHC), I was told I could only file a complaint with the medical board at that point. (To get my email medical record? WTF???) I went back to the DMHC, and they sent me the “not our Knox-Keene bailiwick” letter). Also, the call back number where people could leave messages with the DMHC was long distance.
    As the capper, the DMHC promised to look back into this as part of their “settlement” with me. The DMHC did not follow through on this.

  4. Switching costs, Tom, switching costs. But come time for the upgrade to Vista, well then who knows…
    TLP (nice TLA there)–you may well be right. I like the idea of recordings and transcripts anyway–especially for health records and revisiting what the doctor said in that once every 3 months interaction. And of course lots of other uses. How far away from searchable video/audio are we?

  5. I think it will be even more drastic than this.
    Certainly, radiology is easiest to identify as soon to change (or outsource, your choice.)
    But it seems to me obvious that very soon all patient interviews/examinations will be videotaped.
    First, the cost of storing all these recordings is going down to almost zero. consider that Google stores all emails, pictures, caches of ever webpage, ever search you’ve ever performed, all Adsense data (including who visited the page, from where, and where they went next (even without clicking on an Adsense ad). It is therefore (going to be) a very small cost to install cameras in every room, on every doctor, etc.
    Secondly, doing this is not just for liability, but adds value. There was no point in taping such exams in the past because there was no way to “get at” the info– you had to watch the exam yourself and decide what you wanted to see. The most you could do is label your video.
    But imagine a search system that allows you to ask for specific info throughout your archives. For example, “Patient coughing AND wife disagreeing with his story; select patients with family history of bipolar NOT smokers, must have BLUE PANTS.” This requires no preparation or labeling of the videos in advance; the exam is the label. (Think of how GMail works, or Technorati (for a lesser example.)
    Let me point out that soldiers and police officers already tape many of their interactions– but they can’t be searched because they’re tape, not digital. So they can’t be searched this way. But wait for it.

  6. Your comments were very insightful and left me feeling that the other speakers really did not “get it.” Maybe this was because your quirky English presentation style (Eric Cantona, indeed) went straight over their heads, but more likely because the conclusions support a threat to the establishment.
    A consumer-driven market for health care, facilitated by third-party consumer information intermediaries (read Google, Yahoo, MySpace …) upends the provider medical guilds.
    Web front-ends to a provider’s store of patient electronic medical records, dressed up as a PHR, is a lame response to the competetive threat posed by a real PHR.