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Are Today’s EMRs Up to the Job?

RS Head Shot 1 This post is a bit different from most of the policy points, institutional cases and reports of technical innovations that I’ve been reading on THCB in the past months. I want to pose the above Question to the readers of this blog, since many of you are uniquely positioned help answer it in your comments. And I have a hope that your responses to this Question will help nuance the technical and policy debate over EMR adoption.

First, let’s unpack the Question:

1. THE JOB. In the past several years, a number of public and private initiatives, most recently ABMS’s Improving Performance in Practice (a project with which I am affiliated) and NCQA’s Patient Centered Medical Home,  have been making fitful progress toward a new post-reform model of primary care:  patient-centered, accessible, care-coordinating, population-focused, prepared, proactive, and the rest. These collaboratives and demonstration projects have all stressed the importance of computerized ‘registry functions’ as the foundation for these progressive capabilities. One, the Health Disparities Collaboratives run by HRSA, went so far as to commission a registry program and provide it free to participating clinics.

A key hope and assumption of many of those leading this work has been that once practices have implemented EMRs, and once they have standardized their protocols and coding sufficiently, they will be able to use their EMRs to fully support the new, population-based model of care. Practices that have attempted to do this have faced daunting challenges. Many practices have ended up using both an EMR and a registry, with all of the duplication and rework that this implies.

2. The EMRs. Fifteen years ago, while working as a QI and informatics trainer, I had occasion to take a first-hand look at the database architecture of one of the popular outpatient EMR programs of that era. (It is still a very popular program, and will here remain nameless.) What I found became a cautionary example for my classes when I explained relational database principles: The database contained a table for patient data, a related table for medication data, and another for patient problems. But, probably for reasons of speed and simplicity, there was no ‘gerund’ table that would link medications to problems. While that data structure worked fine for displaying a list of patients, their problems and medications on a single screen, it was impossible to use the datatbase to answer such population-level queries as ‘which patients are currently prescribed aspirin for CVD prophylaxis?’ And no amount of massaging or exporting or data-warehousing could make it answer such a question – the required relational information was simply missing. Alas, my career path since those days has not put me back in the engine room of that or other EMR systems, so I am unable to say whether this was a fluke, or is now typical of EMR design.The upshot: If these kinds of lacunae still infest the architecture of today’s EMR products, then it would seem that widespread adoption of today’s EMRs will consign much vital clinical data to a kind of ‘black hole’ out of which it will be impossible build the queries and reports that are needed to support the kind of flexible, improvement-oriented, population-based primary care that we increasingly seem to need.

Finally, the question again, refined: “Will the data architecture of any of today’s outpatient EMR programs allow their data to be used – either directly or following transfer to an offline data warehouse, by means either of built-in reports or third-party applications – to support population-based care of the kind described in the PCMH?”

I look forward to your responses and discussion in the days ahead. Since this may be a sensitive subject for some, please mention your affiliations if they are relevant to your response.

Richard Scoville, PhD, is an independent consultant specializing in healthcare quality improvement and performance measurement. He is an Adjunct Professor in the Department of Health Policy and Administration at the University of North Carolina at Chapel Hill where he teaches courses in healthcare quality improvement and informatics. He serves as an improvement advisor to the Institute for Healthcare Improvement, NICHQ, the Cincinnati Children’s Hospital Medical Center, and the Federal Health Resources and Services Administration on a range of collaborative improvement and systems design projects.

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23 replies »

  1. of course like your website however you have to take a look at the spelling on several of your posts. Many of them are rife with spelling problems and I in finding it very bothersome to inform the reality however I will definitely come back again.

  2. However the case, there will be a number of IT healthcare jobs that open up just to deal with all of the bugs that will happen if there is one big shift to EMRs. Most likely it will happen over time, according to each hospital’s budget. Regardless, it’s an exciting time to be an IT professional in the healthcare industry.

  3. The clinicians in England understand…The HIT gear delivered by US companies was “not fit for purpose”. The National Health Service wasted boatloads of money that could otherwise have gone for medication and nurses.
    People would say that it is pathetic that the Obama HIT gurus do not learn from history and the same could be said for the self-interested and self-proclaimed HIT gurus and do-gooders commenting on this blog.

  4. Dear rbar,
    It is worse than that, you forgot the legal system.
    Whatever of the 4 possibilities you pick, you have to deal with Aunt Fleurie who comes in at the last minute and says, “These doctors don’t know what they are doing. They don’t do it like this where I come from. They are doing too much (or too little, you pick) we need to go see the local plaintiffs attorney and sue these docs and this hospital to the max.”
    What part of the final tab is due to “defensive medicine” and making sure that the clinician has “all the bases covered” or the “standardized protocol” has been covered?
    These are not “societal conundrums” but the everyday activities of the people who have chosen to minister to the sick in our society.
    Technology, EMR or something else, is not up “up to the job” and never will be.
    Who do you want to take care of your loved one, the computer delivered, evidence based, “best practice,” insurer mandated, standardized protocol from the ivory tower, or the clinician consulting with the family at the bedside of the patient?
    We all have to make this choice, sometimes over and over again.
    Hug your family today. That is my prescription.
    Evan Earl Dussia, II, MD

  5. Dr. Dussia – I am skeptical re. P4P because I think it is almost impossible to measure best performance with reasonable effort. I think that physicians should be reimbursed mainly with a base salary, and only partially (maybe 30%) with incentives (based on feedback by providers and patients and lastly, productivity in numbers of patients served).
    I gave some thought to your question: “What if your treatment plan had been dictated by an impersonal “evidence based protocol” and decisions were made by a committee based on the fact that “evidence” had determined that you were a “terminal” patient?”
    I think that following an evidence based protocol, even when it determines that someone (or: myself) clearly is a terminal patient, more humane than irrational medical heroism/activism. In most countries incl. developed ones, doctors stop efforts that they realize are futile, some doctors realize futility earlier, some later. Terminal illness and dying are facts of life for all people … except for some (doctors and patients) in the US who believe that they can beat any disease and even death with willpower, expertise and technology. I highly value the “The little engine that could” mentality, but this story has no place in end of life care. In fact, it seems that the unrealistic attitudes rarely come from the sick, but from the family.

  6. Mr. Brammer,
    This is just one of the daily decisions of clinicians. It is what we get paid to do.
    The McGlynn study is typical of institutional studies that try to pick out a plan for care to stamp on a population of patients. This is the typical way we teach. I know, I have been there. It does not reflect what happens at the bedside.
    What if your treatment plan had been dictated by an impersonal “evidence based protocol” and decisions were made by a committee based on the fact that “evidence” had determined that you were a “terminal” patient?
    It is my opinion that medicine is practiced one-on-one at the bedside of sick people. It is hard to find a provider who is not striving for excellence every day. When these slackers are found, their clinical colleagues let them know and offer to retrain them or we kick them off the hospital staff.
    Please consider my 4 different options of care for the 85 year old lady with cancer. Who do you want to make the decision? Which plan should deliver the most compensation for the plan maker? In the P4P, it is anybody’s guess. In the full risk HMO, #4 yields that maximum compensation to the risk taking clinician.
    The providers that you work with, are they focused on compensation when they make their daily decisions? It doesn’t sound like it to me.
    Have a great day.
    Evan Earl Dussia, II, MD

  7. Dr Dussia –
    First off, i have tremendous respect for your work and the challenging situation you present. I don’t think P4P is the mechanism to address such an issue (nor is technology, for that matter). These are clearly societal conundrums -the payment system can only respond to, and reflect, the views of society.
    And from a personal level –as a formerly “terminal” lymphoma patient that finally convinced someone to do a BMT after being rejected from a leading cancer center– i can appreciate the complexity of such a situation.
    Meanwhile, the most frequently cited study in the history of the New England Journal of Medicine showed that patients in ambulatory settings received evidence based care only 55% of the time (McGlynn et al., 2003).
    I work with providers who strive for excellence every day, and far exceed these outrageously low national averages. They exploit technology –including registry functionality– yet, historically, no one even knew that they were better than the rest.
    And, at the end of the day, they probably took home less revenue because they’re buying tech solutions and deploying other strategies to improve care/outcomes that their lower performing peers aren’t even bothering with.
    My point is that this is changing; and i believe (hope) that rationalizing the payment system will help drive demand for better technology solutions with more robust analytic and population management tools.
    tx
    -cb

  8. Craig Brammer wrote, “Per my earlier post, the authors (providers) are increasingly compensated via payment reform models (e.g., P4P, gain-sharing). Financial incentives, in my view, should be oriented toward improving patient outcomes.
    Here is the case—an 85 year old lady with cancer everywhere. Her entire family has converged at her ICU bed. You are the clinician in charge. Which performance will you get top payment for (P4P):
    1. You call a full-court press. The top of the line bed, top of the line medications, multiple consultations from the very best specialists and the absolute best nursing care to be found anywhere. Let’s say the bed cost is $1,000 per day. The lady passes away after 30 days. Cost: in excess of $30,000—for the last 30 days of her life.
    2. You move the lady out of the ICU. After all she has cancer everywhere. You withdraw all the medications and just give her fluids. Now the bed cost is $500 per day. She passes away in 15 days. Cost: about $15,000.
    3. You send her home. Hospice comes in to give help to her family. Hospice charges $100 per day. She passes away in 7 days. Cost: about $700 total.
    4. You send her home but do not write the order for hospice. She lives 4 more days. Cost: nothing.
    Which clinical performance will you be paid the most for (P4P)? Which is the optimal performance in your eyes? Which is the improved outcome? What does the family think? What do the clinical colleagues think? What does the payer (insurance company or government) think? Who makes the rules? Will the government make the rules? The government is the biggest health insurance provider. How will the government choose? What’s best for the government? What’s best for the people?
    What if you are not the clinician in charge and the lady is your grandmother—who raised you? Which clinical plan do you choose that should get the “additional compensation?”
    Did an EMR help? Was it up to the job?
    Evan Earl Dussia, II, MD

  9. Dr Dussia writes, “The effort should not cost the authors of the clinical information any money. The time and effort are enough. In fact, I believe clinicians should be compensated for use of their DCAs by others with legitimate reasons for access to the author’s work product.”
    Per my earlier post, the authors (providers) are increasingly compensated via payment reform models (e.g., P4P, gain-sharing). Financial incentives, in my view, should be oriented toward improving patient outcomes. Managing data to improve outcomes –and demonstrate it to payers/purchaser– is the cost of business to receive the additional compensation.
    I’m of the opinion that P4P is best viewed not as offering carrots for providers that jump through hoops, but rather as a recognition that improving care requires resources. Performance incentives offset the cost of maintaining a registry, reviewing data with clinical teams, etc.
    Those that want to win in this environment will gravitate toward products that support these aims.
    Tx
    -craig

  10. Dr. Sucher,
    Thanks for responding. I guess I don’t expect much from a surgeon from the South—because I am a surgeon from the South. 🙂
    Nevertheless, just a couple of comments:
    Workflow is critical. Because your work product is a document of clinical activity (DCA), just like mine, any application that collects clinical information should accommodate your creation of the DCA and require no incremental workload. Validity is simple—you signed the DCA.
    The effort should not cost the authors of the clinical information any money. The time and effort are enough. In fact, I believe clinicians should be compensated for use of their DCAs by others with legitimate reasons for access to the author’s work product.
    The patent is there to protect the fact that we are giving the software to those who want to be able to modify the interface between whatever off-the-shelf system they are currently using and the clinical information collector.
    I don’t know what a data cube is, as I said I am a surgeon from the South, but I do know that logical indexing of the DCA can occur with minimal clinician activity. You can see this at http://www.medisyn.com, click on tutorials and then click on the physician tutorial. It takes 12 minutes to learn how to use the system. You publish the DCA to a repository of accessible clinical information shared by all the other clinicians who want access to real time information at the point of service.
    Is that disruptive enough?
    Evan Earl Dussia, II, MD

  11. When designing data models (database tables & relationships) it is good design to think about how the user will use the data and build to make those things easy. (Figure out the majority of your queries in the beginning, and design from there.)
    -Alan

  12. MUMPS/Cache are “schema-less”. Schema-less models have their place, but I agree with the author that the lack or relational database capability is a component of EHR complexity and degrades EHR fitfulness. MUMPS/Cache are very obscure and have a very limited development community. More modern approaches are needed.
    -Alan
    Twitter:@aviars

  13. Richard –
    Thank you for bringing up registries, which don’t seem to be getting much attention in the ongoing national conversation about healthcare and information technology. This is unfortunate because registries are such an essential tool to improving care and outcomes. I cannot answer your questions about today’s EMRs and registry/population care support. But I’d like to make two points: first, “external” registries (independent of EMRs) are here to stay, and second, EMRs and external registries can interoperate and already are in at least some situations.
    To the first point: external registries are here to stay. EMRs should certainly provide registry capabilities (i.e. views across patients as well as views of one patient). But even if an EMR can do this, there are important reasons for registries as primary data repositories external to EMRs. For example, consider clinicians collaborating on research and/or improvement across sites and health systems; registries allow them to collect and use data unimpeded by the interoperability features of their respective EMRs.
    Registries can also be a more flexible, nimble mechanism for data collection and use, and therefore are more appropriate for research and improvement work even at single sites. Think about clinical data in three “durability” categories. There is the “durable” category: standardized data such as demographics, standard diagnostic data, and NQF endorsed measures. It makes sense for an EMR to accommodate durable data. There is the “semi-durable” category: data elements that might be expected to have a 3-5 year shelf life, such as evidence- or consensus-based quality measures. It may or may not make sense for an EMR to accommodate this category. Finally there is the “ad hoc” or situation-specific category: data relevant to a research question or improvement program that may endure for months or a few years. It is hard to imagine an EMR that is able to accommodate (expand and contract) the dynamic nature of data in this category. But registries can and do.
    To the second point: EMRs and external registries can interoperate. It is possible to configure your EMR to open a registry data capture form, pre-populate common data elements in the registry from the EMR, allow the user to add registry-specific data, close the form, and return to the EMR application. This is possible using something called RFD, Retrieve Form for Data Capture, an integration profile published by CDISC and RFD. Here’s how the IHE Wiki explains it (http://wiki.ihe.net/index.php?title=RFD):
    “Retrieve Form for Data Capture provides a method for gathering data within a user’s current application to meet the requirements of an external system. RFD supports the retrieval of forms from a form source, display and completion of a form, and return of instance data from the display application to the source application.”
    This is a very big deal for several reasons, not the least of which is that it eliminates the dreaded “double data entry” problem. I don’t know how widely RFD is being implemented, but I hope it becomes more popular because it would make it much, much more efficient to conduct research and improvement work in clinical settings with EMRs.
    I also hope that support for registries will be funded with some of the ARRA dollars that everyone is so excited about. If you want shovel-ready programs, registries fit the bill.

  14. Hello Richard –
    Good question, and one that many of us are challenged by -as you know. I’m not an HIT expert but, like you, spend a good bit of time on data aggregation for improvement. If i might, let me briefly try to clarify the problem from my perspective, and then i’ll pitch in two cents about whether and when things might change.
    THE PROBLEM
    Generally speaking, EMRs should do three things: 1) keep records and facilitate communication of those records among relevant providers; 2) pay bills and related admin functions; and, 3) have registry functionality (aka relational database). Vendors focus on the first two –because that’s what providers have asked for– and neglect the third.
    TIMES ARE CHANGING
    Providers we work with are now actively reassessing their current product –or carefully evaluating a new purchase– with a much greater focus on #3, registry functionality. One group that comes to mind just fired their current vendor and is moving to a different EMR largely for this reason. (I hope there are EMR vendors reading this)
    Why are providers doing this? Many are doing so because they’ve come to understand that they need these tools to improve care/outcomes for the broad population of patients they serve. Most, however, get the Payment Reform signals loud and clear… The people who pay for healthcare want to pay for value, not volume. Value = quality / cost.
    Improving quality for a population of patients requires exception reports, point-of-care decision support, performance measures trended over time and relative to peers, etc. P4P, bundled payments, public reporting and the like are causing providers to rethink their tech needs.
    Tx
    -craig

  15. Answer: No. Reality is that the vendors of the 1990s that survived into the 2000s had no intention of creating such relationships. In fact, even if they did, who would have taken such time to enter the information? We continue to completely overlook a key overlooked issue. That is 1. workflow, 2. who will enter the data and how and at what cost? and 3. who will ensure the validity of the data?
    Regardless of the database, the current products are woefully designed, with hardly a thought for human-factors or cognitive workload. This has lead to increased workload on the clinician (or stated another way.. the clinician is serving the data more than the data is serving the clinician).
    It almost appears as if the industry has not only stagnated in its desire to improve the usability of their systems but also in their ability to make the the systems actually useful to the practicing clinician (there is still more focus on the business of medicine and not the practice). I believe there are a number of reasons. First, cost. Second, industry fragmentation of where the information must come from (interoperability). Third, lack of implementing a standard (there are more than enough standards, just that no-one is implementing them – back to fragmentation.).
    In response the Google search returns “results in 0.55 seconds”. In fact you did hit a database or rather a data-cube that is rebuilt at intervals (of which I don’t recall … maybe every day now). But in the health care arena we need real-time information… and therefore the cube wouldn’t work for our needs (at least not for the day to day stuff).
    In response to “Standardizing protocols just institutionalizes mediocrity”. I completely disagree. This is only true if your protocols are mediocre. Otherwise what it can allow is for the uniformity of excellent care that can then be measured, analyzed, and improved on. Implementing standards appropriately can help advance practice of care faster with more efficiency. This in in contrast to the ongoing chaotic, ‘do whatever you want to do because you’re a smart doctor’ attitude that (at times) allow for worse than mediocrity.. bad, ineffective and sometimes downright negligent “care”. We need to dispel this belief that protocols are somehow inherently bad and lack the ability to allow for the nuances of individual patients. The fact is we all practice protocol based driven branching algorithms. That’s how we learned medicine. But in fact, too many times we choose which branch to take without any true logic thus reducing the clarity of when our therapies are truly effective and when they are not.
    In response to patent # …. I’ve seen this patent. Please tell me your point. I do not see anything noteworthy in the patent that was not already done by software designers for years and continues to be done everyday already. It appears to me to be generic enough for you to claim that every vendor is now infringing on your patent. Can you tell us what is novel and unique and how implementation of this system will be better than what is already out there?
    The bottom line to me is that the issue which we must focus on is communication. This is not a novel idea, but at least one that I have spoken about since 1997. Documentation is supposed to be about communication. If done properly it should help us care for the patient. It should help us understand if we are doing what we think we are doing. It should help us improve processes and efficiency of care leading to lower costs due to better utilization of resources.
    The only thing that will save this industry is a disruptive advancement that will change the game entirely. Having doctors and hospital spend literally billions of dollars every year on these systems that continue to fail on delivering on the promise of improved care, work flow and data analysis is abhorrent.
    JFS

  16. There is no simple answer to the question posed here.
    Generalizations, like “all EMRs are inadequate” or vice versa are bound to be incorrect. Like everything else in life, the answer is… “depends”.
    Some EMRs provide the technology to enable registries and data mining. Some do not. Some EMRs are more usable then others, making it more convenient to collect data. Some are so clunky and convoluted that users are not particularly willing to put in the effort. Some users take full advantage of the technology and collect the data elements necessary. Some do not.
    There isn’t much uniformity across the software products sold today under the EMR/EHR label.
    Also, physicians’ objectives when purchasing and using EMRs are not as far reaching as data mining in the distant future. The clinical portion of the software is used as a replacement for the paper chart in the hope that it will automate manual tasks and provide a certain level of efficiency in maintaining the medical record. And the medical record, as noted by several commenters above, is the physician medical record – a tool for the physician in his daily work. It is not a “consumer” tool, and it is not a bio surveillance tool.
    If someone (the government or “consumers”) wish to have tools for their own purposes, then the same someone needs to somehow compensate the physician for the data collection and translation of his/her proprietary documentation. Not much different in principle than the paper chart, but probably much easier to accomplish with electronic medical records.

  17. ravi says:
    > The EMRs are a technical produt that
    > being forced fit to the need.
    I say EMRs are technical products being implemented to meet undefined needs. Most docs seem to want to solve what I call “the location problem” — the patient’s jacket can be read in more than one place at the same time. Dr. Scoville and ravi evidently want to solve many, many more problems. Nobody asks a paper chart to be error-proof, for example.
    t

  18. Richard,
    In an absolute term, the answer would be NO. And it does not seem that in the near future, that will change.
    The EMRs are a technical produt that being forced fit to the need. There has been a sufficient lack in trying to understand the need, benchmark the operational flow, and to large extent the disciplined product development approach.
    If some of these were done to start with, one would have a better adaptation already.
    I heard in one of the interviews here, someone telling ( and I already have made this comment earlier) that the EMRs are working at some places…so it is probably not the EMR but the implementation and the customer competence/training etc to be blamed.
    That is the silliest arguement I have ever heard. It working at some places is not a testimony to EMRs quality but the ability of thoese implementing. A good product works most of the time even under distressed conditions. It has to be designed for sufficient robustness and error proofing. Now if you continue with the same mindset that EMRs are good and others are to be blamed, the solution is going to come in long time.
    What we need is a recognition by the developers that they need to spend some effort upfront, look at the system level need asnd then rewrite/update/modify the code to fit the need.
    Make it CUSTOMER CETRIC. Right now the attiture is more of a sellers market and government is pouring money to fix the EMRs to those who have messed up in the first place.
    Now, I want to be clear that I am not questioning the intellect of the people involved, I am questioning the experience or desire to follow a step by step process. The EMRs may be the greatest tool technically…I am talking about its practicality or usefullness not the technological geniusness.
    rgds
    ravi
    blogs.biproinc.com/healthcare
    http://www.biproinc.com

  19. Dr. Dussia is reiterating Dr. Virgil Slee’s main point about the medical record. Dr. Slee says the medical record is the doctor’s notes. All the coding (ICD9, CPT, whatever) are abstracts of the “real” medical record. Many abstracts of this record are possible, and might be made for different reasons: I have mentioned two, but you might imagine a third kind of abstract for epidemiology. More are certainly possible. And the abstracts may have varying quality levels too. Look here for a condensed version of Slee’s argument (and proposal for dealing with it) http://www.ncmedicaljournal.com/sept-oct-05/Slee.pdf
    Dr. Scoville asks:
    “Will the data architecture of any of today’s outpatient EMR programs allow their data to be used […] to support population-based care of the kind described in the PCMH?”
    I’d say “yes, but not directly”. If a system does not record a link between a particular Dx and Rx (for example) one might be inferred “using their data” about Dx and Rx associated with a patient. Of course, this is a little speculative and keep in mind these records will be quite incomplete.
    > probably for reasons of speed and simplicity,
    > there was no ‘gerund’ table that would link
    > medications to problems.
    Speed and simplicity of what? Certainly not the computer software! I think your gerund relation was omitted because this simply wasn’t a use-case for the system: it was for reasons of speed and simplicity of data input! Nobody wanted to take the time to document the relationships, and in the prophylaxis example, what exactly is the “problem”?
    It sounds to me like Dr. Scoville is asking for a lot more documentation in electronic form than EVER existed on paper. And so indeed “what is the job”? Replace the little 4 X 6″ note cards filled with their own private shorthand docs used to keep on their patients? Or something more? Or something else?
    t

  20. Dr. Scoville, thank you for your question. It has a problem. It contains a category mistake. Let me explain.
    Dr. David Kibbe has done an admirable job in pointing out, on this blog, that EMR no longer means anything. It was supposed to be defined by the output of an application—electronic medical records. It has come to mean—whatever my commercial off-the-shelf (COTS) package gives you.
    These COTS packages have delivered a variety of things: verification of coverage, accounts receivable reports, scheduling, appointments, bills, claim forms and reminders. These all represent front and back office activities in medical offices and hospitals and are important. But this is the business realm. A realm because many individuals can take responsibility here and make the rules. Short training courses are needed. No clinician is required. (Incidentally, we clinicians don’t want to operate here, or clean the rooms either).
    What I call my job, the clinician’s job, is something all together different.
    With all the changes that have occurred in the enterprise of medicine in the past 100 years, there “remains a single common title to distinguish a doctor who treats sick people: he is a clinician.” This is from Dr. Alvan R. Feinstein’s seminal work, Clinical Judgment, published in 1967.
    Dr. Feinstein goes on to point out that the word clinician comes from the Greek κλίνη, which means bed. The word patient comes from the Latin pati, which means to suffer. “The clinician is the doctor at the sufferer’s bedside, the doctor who accepts responsibility for the life entrusted to him by the patient, the doctor who plans the strategy and executes the tactics of therapeutic care.”
    And I will add, that the doctor is the individual on the care team responsible for creating the document of clinical activity (DCA) so that all members of the team, consultants, nurses and other medical professionals, will “know what he is thinking.” The DCA contains the processed data—now called clinical information. (More on the difference between data and information later.) The DCA represents 100% of the information that the clinician deems important.
    This activity does not occur in the business realm, but rather in the clinical domain. There is your category mistake. Only clinicians have the expertise to operate in the clinical domain. It takes years to acquire and hone this expertise. It is why residency training isn’t a weekend seminar.
    Creating an effective DCA is the key element learned and refined during training. It is what other clinicians use to measure your clinical value to the collaborative effort of caring for the sick—the ultimate activity in the medical enterprise today.
    Electrifying the DCA has defied programmers’ attempts to use relational databases because of the nature of the DCA. (This is not an impossible task. I just Googled “Britney Spears video” and got 67,200,000 hits in 0.55 seconds—no relational database required.)
    Clinicians observe and accumulate at least three types of data: the type that describes a disease, the type that describes a host and the type that describes the illness that occurs in the interaction between the disease and its environmental host. This is Dr. Feinstein again. For a complete explanation and why he determined that computers are lacking—read his book. Suffice it to say that he is still right.
    The key to this dilemma is keeping your eye on the clinical domain. (It is not standardizing protocols—that just institutionalizes mediocrity.) In the clinical domain, dedicated clinicians are working diligently to diagnose and treat their sick patients. For example, maybe the “best” therapy is practiced in a one doctor office in an inner city. If that clinician uses an EMR that is available today, the “best” therapy will remain hidden just as effectively as if it were printed on a page, placed in a manila folder and filed away.
    I am the designer of a clinical information management instrument and process for which I received US Patent 7,464,043. My team will be making this instrument available as a open source resource in the near future. Use your COTS or not—it makes no difference. Practicing clinicians will have access to their collaborating colleagues’ DCAs through a secure, credentialed channel at the point of service—an office, an ER, an ambulance or the patient’s bedside in their home.
    When the community of clinical colleagues has a FOSS clinical instrument to channel the power of the information pathways that exist today, lives will be saved, time will be saved and we can see another sick patient or go home and hug the grandchildren.

  21. According to my data base wizard friends at Kasier is can be a real challenge to extract data from any MUMPS/Cache based EMRs (like the largest private EMR vendor with 150,000 providers and 22% of all patients) but “has a sophisticated electronic medical records system that links medical record data to its registries.”
    The best overview of an example (including a data registry map) is The Kaiser Permanente National Total Joint Replacement Registry http://xnet.kp.org/permanentejournal/sum08/joint-replacement.html that contains over 68,000 total hip replacement surgeries.
    It might have changed but the very thing that makes the data quick on a patient level requires laborious searches to create a registry in MUMPS based EMRs. But I will defer to the actual IT guys vs those of us in policy, strategy, organizational development and provider / patient / payer engagement.

  22. I am confused about a number of things, including what “population-based care” exactly means. Health care is directed towards the individual patient (of course based on evidence gained in research- or obsevation populations). Based on the ASA/CV disease example, is the question maybe: does any of today’s EMR allow data mining in order to improve individual care, as well us surveillance of best practice parameters?
    “of the kind described in the PCMH?”
    I assume that PCMH means patient-centered medical home (and not Pitt County Memorial Hospital), but who described what where? Maybe I am listening in on an insider discussion of EMR afiicionados. But as a physician, I do work with them and know several.

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