Unconscious in the Emergency Department

As State Health Information Exchanges and Federal efforts (NHIN Connect/NHIN Direct) implement the data sharing technology that will enable all providers in the country to achieve Meaningful Use Stage 1, I’m often asked  “but when will this healthcare information exchange technology be able to retrieve all my records from everywhere when I’m lying unconscious in the Emergency Department and cannot give a history?”

Here are my thoughts about the trajectory we’re on and how it will lead us to supporting the “Unconscious in the ED” use case.

Meaningful Use Stage 1 is about capturing data electronically in EHRs.  Getting healthcare data in electronic form is foundational to any data exchanges.   By 2011 we should have medication lists, problem lists, allergies, and summaries available from EHRs.

The data exchanges in Stage 1 are simple pushes of data from point A to point B – from provider to public health, from provider to provider, and from provider to pharmacy.   There is no master patient index, no record locator service, and no centralized database containing everyone’s lifetime health record.

The Stage 1 data exchanges are the right first step.   Serving as chair for a health information exchange for 12 years, I can tell you that pushing data from point A to point B builds trust and breaks down political barriers to data sharing.   The policy needed to guide  push technology is straightforward, since the parties involved in the exchange are limited – the sender and the receiver.  Consent can be simple.  For a referral, this might be “do you permit me to send your data to a specialist so that your care can be coordinated?”

But how are we going to get to a model that supports the pulling of data by emergency rooms?

There are several engineering approaches.

One is to create a master patient index for a state or region so that the identity of patients seeking care is known.   Once we have a master patient index, we can build a record locator service to keep track of every site the patient visits.   Then, we can build a consent repository so that the patient can control what is shared.  During an emergency department encounter, summaries can be pulled from those sites listed in the record locator service which the patient has agreed to share.

I know that this approach works, because it is what I implemented at the hospitals of CareGroup in 1997 as the focus of my MIT thesis.

However, it does have scalability problems.   Given that there are 500,000 doctors and 5000 acute care hospitals, the engineering complexity to pull data from multiple, disparate sites is significant and it requires that all sites support real time queries 24x7x365, maintaining the necessary security and robustness to enable such interchange.   That’s a tall order.

An alternative, that is simpler from an engineering perspective and achievable with the Stage 1 push technologies looks like this.

What if payers, providers, and private vendors offered something called “the electronic medical home”?  The patient needs to pick some hosting option they trust.  Just as Stage 1 of meaningful use supports push transactions from provider to provider, the same transactions could be pushed to the electronic medical home designated by the patient.    This has the added advantage of providing a means to  support the patient engagement provisions of Stage 1 (deliver summaries of ambulatory encounters within 3 business days, deliver inpatient summaries upon request, deliver lifetime health summaries upon request).   If every producer of data (lab, pharmacy, hospital, eligible professional etc) pushed a copy of the data they generated to the electronic medical home chosen by the patient, then the patient could become steward of their lifetime medical record hosted by the trusted agent of their choice.  Medical home data would be complete and constantly updated by data producers.

Patients could store their electronic medical home designation on a card in their wallet or on a medical alert bracelet.   If patients visited the emergency room of a hospital they had registered at previously, the hospital would have a record of the patient’s electronic medical home selection since the hospital would be one of the medical home data sources.

Ok, but what if the patient arrives in the Emergency Department, naked and unconscious so there is no electronic medical home designation on their body?   I can tell you that in all my years of practicing emergency medicine, I have never treated a naked and unconscious patient, but let’s think about the scenario.

There could be a national or a federated regional database which keeps a record of the designated electronic medical home – an “electronic medical home locator service” that is easy to implement because it only has to point to one place, not to every location which has records about the patient.

When the patient arrives naked and unconscious in the emergency department, assuming someone knows the name/date of birth of the patient, the electronic medical home locator service is queried and once the selection of medical home is known, that one location could be queried to retrieve all of the records.

Finally, just to play out the complete use case to its most absurd, if no one knows the patient identity, then we could suggest the electronic medical home locator service should contain a hash of a fingerprint, so that  a biometric – a scan of the patient’s finger – could be used to identify the electronic medical home designation and then retrieve the  lifetime record summary.


1. In Meaningful Use Phase 1, we implement push transactions by 2011.   Google Health, Microsoft Healthvault, Hospitals, and Payers should create electronic medical home repositories capable of receiving push transactions so that copies of inpatient, outpatient and lifetime summaries can be sent there.   The transport mechanism used to push data to the medical home could be REST, SOAP, or SMTP, just as the NHIN Direct project has suggested.   Ideally electronic medical home providers will issue each patient a Health URL, making it easy for EHRs and  health information exchanges to route data to the correct location.

2. When an electronic medical home designation is elected, a copy of the designation and a hash of the patient’s fingerprint is sent to a regional or national electronic medical home locator service.

3. When the patient arrives unconscious, the name and date of birth  of the patient is used to query the electronic medical home locator service, retrieve the electronic medical home designation and then retrieve the lifetime record summary.

4. If the patient is naked and unconscious, a fingerprint scan could be used to retrieve the electronic medical home designation and their records.

5. All of this is empowered by Stage 1 of Meaningful Use as currently written.   All that needs to happen is that providers, payers and vendors need to offer a place to push transactions on behalf of the patient.

Some have suggested that we should abandon the NHIN Connect, NHIN Direct, and Stage 1 push exchanges in favor of an engineering optimal solution of creating one large database of all electronic health records in the cloud.

Sometimes the engineering optimal solution is not the social/policy optimal solution.

The idea of creating a voluntary, opt-in electronic medical home supported by many hosts – payers, providers, vendors etc.  is achievable and appealing.

In the US, we are wary of any top down, government mandate.   We  are suspicious of centralizing anything.  Maintaining patient control of healthcare data and letting the market provide multiple hosting options seems like an achievable architecture that builds upon what we have already implemented and the meaningful use regulations already in place.

John Halamka is the CIO at Beth Israel Deconess Medical Center and the author of the popular Life as a Healthcare CIO blog, where he writes about technology, the business of healthcare and the issues he faces as the leader of the IT department of a major hospital system. He is a frequent contributor to THCB.

9 replies »

  1. Margalit,
    Thanks for the clarification. I understand and agree that a PCMH team is better for the management of health than trying to do it myself. In a perfect world this would be my original family doctor expanded to a PCMH which would follow me everywhere for my entire life. The problem is that I have moved many times and I have had many doctors with medical records scattered all over the world.
    Wherever I am, I need to get my current “care team” up to date on my history and I think that this means having access to and control of all of my health data. I can’t rely on prior PCMH teams to pass the ball to my new team.
    So I think it does boil down to me have access to and control of all of my health data so that I can give my PCMH team the information they need.

  2. Are you kidding me???
    “3. When the patient arrives unconscious, the name and date of birth of the patient is used to query the electronic medical home locator service, retrieve the electronic medical home designation and then retrieve the lifetime record summary.”
    You guys keep relying on the unconscious patient in the ER to make the case spending billions $ on equipment not fit for purpose.
    In the UK, the NHS had a film about some poor old lady who collapsed unconscious in the street and the handy dandy EMR opened by the Ambo Team gave them all sorts of useless information to sell the country what turned out to be a pig in a poke.
    This is nauseating.

  3. If you are unconscious in the ED I do not need your medical record to get you conscious again, if that is even possible.
    If you are unconscious I will not know your identity.
    Your record would help if you had advanced directives and did not wish to be resuscitated. But you can have that tattooed on your chest.
    Your Medic-Alert necklace would be more immediate than a computer file I might access after myriad security screens.
    While it is hardly likely yoou will be unconscious in the ED we certainly should spend 10’s of billions of $$$ just in case.

  4. Mark,
    The difference between a commercial PHR and a Medical Home portal, IMHO, is that the former requires the patient’s active maintenance and involvement, while the latter is maintained by the Medical Home team. The other difference is that, hopefully, the PCMH team does something clinically useful with that information. I don’t feel qualified to do as much and most patients are probably like me.
    I think this boils down to a philosophical question of whether health should be managed on one’s own, with clinicians brought in on an ad hoc basis, or alternatively, health should be managed by means of a long lasting relationship with a primary care physician and supporting medical team.
    I think the latter has been repeatedly shown to have better cost effective outcomes.
    As to control of the records, I’m all for the blue button. People move, change providers or just want to do something else with their records. I just don’t see the blue button as a means to care management.

  5. Margalit,
    I am not clear on the distinction you are drawing between a “commercial PHR” and a “true medical home”. It seems that both of these as currently implemented are commercial software and it is not clear to me that the PCMH “patient portals” give patients much control of their information.
    I do think a core issue is patient “ownership” and control of their information. This can be done through a Google or Microsoft PHR or some other public information infrastructure or it even could be done with a true patient owned and controlled individual application with local (to the patient) data storage and backup.
    The key is the “Blue Button” which should be mandatory for everyone who creates patient information.

  6. I am happy to see John proposing the medical home solution for electronic medical records. This would be my first choice as well, but I would personally prefer a true version of a medical home instead of a commercial PHR and here is why (this is from April and some things may have changed since):
    Patient Centered Medical Home for Your PHR
    I believe the origin of the term “medical home” was indeed a medical records repository, and more…

  7. I agree that a patient-controlled “medical home” is probably the best solution. This does not need to contain all of the patient information but could be just a series of pointers to data that is stored with the creator of the data. However, most people would probably want to have something like the continuity of care record summary pushed to their medical home.
    This leaves the question of “Should we build the Stage 1 data exchanges?” While I agree that they are a start on getting people used to sharing data they are not a good design since they rely on the cumbersome process of setting up multiple peer to peer relationships. I think it would be much better to just have everyone who creates data make it available to a medical home such as Google Health or Microsoft Healthvault or similar. This would involve only a few (already standardized) data links. Giving individuals direct control of and access to their data rather than institutional control would be very powerful. I don’t think data exchanges are necessary or even useful in the short or long term. It is very difficult to get institutions to give up access to “their” (actually, the patient’s) data. Giving it to another institution and not to the patient doesn’t solve the problem of patient access to their own data.
    “Just give me my damn data!”