Patient access to their own EMR data

Involving patients as active participants in their own care is an important goal of improving American healthcare. The national priorities called out by the Office of the National Coordinator for Health IT (ONC), as it has elaborated rules for the Meaningful Use of Electronic Health Records (EHRs), cover 5 areas.

The Health Outcomes Policy Priorities, which resulted from a National Healthcare Quality Report by the AHRQ in 2008, are (1) improve quality, safety, efficiency, and reduce health disparities; (2) engage patients and families in their healthcare; (3) improve care coordination; (4) improve population and public health; and (5) ensure adequate privacy and security protections for personal health information.

Clearly, involving the participation of patients in their healthcare is a central theme for Meaningful Use. At a minimum, patients need (1) timely access to their health information (within 4 business days), (2) an electronic copy of their health information upon request, and (3) a clinical summary for each office visit – these are some of the specific Meaningful Use Stage 1 objectives and measures.

Sharing chart information with patients represents a change in the tradition of American healthcare. Chart information, from a legal standpoint, is the property of the person who created it, not the person whom it is about – even though a patient has the right to request a copy of that information. Anecdotal horror stories exist resulting from delayed or problematic access to copies of one’s own healthcare records. These new rules around Meaningful Use add pressure to change that tradition.

But how much is too much? Clinicians keep their records to serve as (1) reminders-to-self for reference during future encounters, (2) information to other clinicians for continuity of care during referrals or transfer of care, and (3) medico-legal documentation used in litigation (either against the clinician, or against other third parties where health records are a part of the argument, e.g. personal injury cases). The audience is therefore technical, clinical and dispassionate, and jargon, technical shorthand, and blunt talk is the norm.

A common concern about disclosing the full content of chart notes to patients (who were not the intended audience when the notes were written) is that unnecessary (and uncompensated) additional time will be required to interpret and explain what is in the note. An additional fear sometimes voiced by clinicians is that routine access to their full chart notes opens the clinician up to potential increased liability exposure from litigious patients “fishing for mistakes.”

To date, this is new territory for American medicine, and fear can fill in the gaps where there is little experience or data. An interesting current research project called Open Notes has enrolled 115 doctors and 25,000 patients at Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Pennsylvania, and Harborview Medical Center in Seattle.

For a year, participants will get an e-mail after each office visit saying their doctor's note is available through a secure online portal. Researchers will track if patients read it and find errors, and how they use it. Doctors' habits are being tracked, too — if they censor themselves or write more patient-friendly notes.

It's not just for the Web-savvy and well-off. Among the Seattle participants are homeless patients who can log in at such places as the public library. The authors described the project, and also include a web survey for physicians not enrolled in the Open Notes study specifically, in the July 22 edition of the Annals of Internal Medicine.

Clearly, the direction toward a fully participatory tradition of medical recordkeeping – involving clinicians as well as patients – is evolving. Meaningful Use requirements take a step in this direction. More complete projects, such as the Open Notes experiment, are also able to gather much-needed experience in order to quell fears and identify the real issues (both positive and negative).

As technologies emerge that can overcome the technical hurdles of sharing information (such as linked EHR-PHR systems), the evolving experience around truly participatory healthcare will move forward. This experience will also shape the kinds of tools that EHR developers create. We live in some very interesting times.


Robert Rowley, MD
Chief Medical Officer
Practice Fusion EMR

Click Here to Read More..

An Update on Practice Fusion's API Challenge

It's been just about three weeks since Practice Fusion announced our participation in the Health 2.0 Developer Challenge. Our plan to open up an API and invite teams to connect patient-driven data to our EHR system in real-time seems to have struck a chord with the health IT community and we've been impressed with the response.

We now have 24 teams competing to connect patient data to our EHR platform.  A few highlights from teams that have posted their entries online:

• Team Razoron, an innovator in medical bar-codes, aims to connect health data from devices and mobile applications to Practice Fusion. 
• Team Stanford Stepper is a student on summer break, also interning on the Chicago stock market, who hopes to create an Android app connected to our EHR.
• Team BodyTrace aims to connect their GSM-enabled scale and weight loss system to Practice Fusion.
• Team Nimbus wants to plug in other PHR and EHR systems to Practice Fusion.
• Team Fusionators (gold star for the name and logo) aims to connect HealthVault and other PHR systems to our EHR platform.

These entries showcase the demand for platforms than can serve as an "iPhone" for the diversity of health 2.0 "apps" that have been built over the past few years. It's something we had long hypothesized at Practice Fusion and nice to see as a reality.

The entries also represent a step toward what could be a fairly large change in medicine. Not only can Electronic Health Record systems replace the paper workflow in a medical office, but they also have the power to gather crucial data directly from patients in a way that is usually only seen in a hospital setting. For example: an ambulatory physician "prescribing" a smart phone mood-tracker application to a patient just diagnosed with depression. Then tracking those results real-time in the patient's chart as medications take effect and reviewing with the during their next appointment. What do you think?

It's not too late to form a development team and participate in the Practice Fusion API Challenge. If you enter today, I can send you API access keys this afternoon. There are also established teams looking for additional members - so email healthchallenge@practicefusion.com if you want to join a team.

Emily Peters
Practice Fusion EMR

Click Here to Read More..

The EMR marketplace around hospitals

An interesting market dynamic is emerging around hospitals and Electronic Health Record (EHR) usage. As hospitals begin to EHR-enable themselves, and purchase systems that are geared toward their in-house needs, they attempt to push these systems out towards the local community physicians in their ambulatory offices.

The kinds of systems implemented in hospitals tend to be large, legacy systems built to function within a closed network. Hospitals are in a better position to hire and maintain a health IT staff, and often want to house their own data in-house (with all the attendant security burden, and HIPAA-breach risk involved).

An advantage of this, for the hospitals, is the ability to tie together the disparate systems within their walls, which have historically functioned with internal, local and focused applications – a hospital lab is on one system, the pharmacy runs its own, x-ray/imaging has its own systems, billing is its own world, and medical records has also been a stand-alone (often tied in to a medical dictation and transcription service). Getting all these internal silos to connect into one system has been a monstrous task for hospitals, and an inpatient-oriented EHR is a step in pulling this all together.

When a hospital tries to push its in-house EHR out into the local physician community, the fit might not be the best. Two strategic aspects of this attempt can be seen: (1) hospitals have the well-meaning intent to help their affiliated docs achieve EHR adoption and therefore access to Meaningful Use dollars (and docs might otherwise feel overwhelmed by trying to adopt an EHR on their own); and (2) making their EHR very-low-cost (or sometimes free) to the local docs, the dependence on the local hospital is further cemented.

Of course, the advantage of this is that the community physicians can easily “see” into the local hospital records – labs done there, x-rays carried out there, admission and discharge records can all be accessed seamlessly. What could be better?

Two problems exist with this set-up. (1) Given that a locally-installed enterprise legacy system is what is deployed within the hospital, it still exists as a silo. The ability to connect to the hospital down the street, or with other physicians not affiliated with that hospital, remains as difficult as ever. (2) The kind of EHR system that might work more-or-less well for an inpatient setting may not be the best tool for an ambulatory office. After all, the workflows are different, and the issues are distinct.

This presents a dilemma for the local community physician. “Should I go with the hospital system, even if it is cumbersome and not quite right for my practice, because it is subsidized by the hospital (and maybe free), or should I go-it-alone with something more tooled to my needs and lose some of the connectivity with the local hospital?” Anecdotally, some hospitals have taken a position of “we won’t connect with any one else’s system,” largely based on the belief that it will take a lot of effort (cost) on the hospital side to establish one-on-one connectivity with each and every different system in place in the community. It is also a marketing position, wanting to tightly bind preferred practices to the hospital for all their business. After all, if the hospital owns your EHR, “you can’t take it with you” if you decide to leave.

Free web-based EMRs (like Practice Fusion) have become quite popular among community physicians, especially solo and small group practices. Such systems are focused mainly on functioning as ambulatory EHRs, not inpatient ones. Connecting with hospital systems from the outside (rather than pushing connectivity outbound from within the hospital walls) is more likely to be the path we see in the market. This is especially true with web-based systems, since a single connection will suffice for access to everyone using that web system – unlike locally-installed systems which do require one-on-one connection with each and every hospital/ambulatory pairing.

Connecting to hospital systems will likely not emerge as a “single connection to a hospital” – more likely, the connectivity will be with each hospital function. If a hospital can export its lab results as HL7 v2.3.1 or v2.5.1 files (as is the standard for HHS Certification), then connectivity can be established with outside EHRs. Similar connectivity can be created with x-ray/imaging, medical records, and Computerized Physician Order Entry (CPOE) for ambulatory processes (such as x-ray/imaging ordering, lab ordering, and referrals to hospital-based services such as physical therapy, etc.). The only resistance from hospitals should be from their local political positions around cementing relationships with local docs, and not because of technical connectivity concerns.

The vision of the Office of the National Coordinator for health IT (ONC) is to establish a nationwide platform of connectivity, so that healthcare providers will have the information they need to provide the best possible care. The local, insular mind-set sometimes seen in hospital IT circles needs to be broken, so that an open and willing approach can be taken. The technology is evolving rapidly, and the challenge around connectivity (especially when using web-based technology) is diminishing. It is not as overwhelming a task as previously thought.


Robert Rowley, MD
Chief Medical Officer
Practice Fusion EMR

Click Here to Read More..

Healthcare Providers on Twitter and Facebook: What You Need to Know

The following post is a reprint from The Health Express:

When you use social networking such as Twitter and Facebook, the very use of those tools implies that you want to connect socially with friends and business partners through social media platforms. But, how can you keep the worlds of business and socializing separate, especially if you work in the healthcare field? While these platforms can promote services as well as connect with patients, how far can healthcare workers take these platforms, and what do they need to know?

How Employers See Social Media

One way to define how to use social media is to learn how employers view these tools. Jobvite published a report this year that shows how recruiting professional use social media to find and vet candidates for jobs. This report reveals two things: That social media has become a viable resource for finding candidates and jobs, and that how you use social media could affect your ability to obtain or keep a job.

Recruiters, it is shown, are using social networking sites far more today than they are using traditional methods for hiring. The social media sites that are important to them include the following:

1. LinkedIn: 78 percent
2. Facebook: 55 percent
3. Twitter: 45 percent
4. Blog: 19 percent
5. YouTube: 14 percent
6. MySpace: 5 percent
7. Other (None): 14 percent

This report might simplify the social networking maze than any other tool, as it points to LinkedIn as the professional networking tool and to MySpace as almost irrevelent for professional networking.
This report does not answer the question as to whether Facebook is professional or social (as in friends and family), but any Facebook user knows that there are two ways to present yourself in that medium — as a social user with friends and family and as a professional through Facebook Pages.

How Mayo Clinic Uses Social Media

While many patient privacy issues are addressed with HIPAA (Health Insurance Portability and Accountability Act), it appears this legislation has not extended to how medical students use social media. Age is a concern here, as many medical students and young healthcare professionals are far more in tune with social networking than their elders. Still, a recent study shows that 60 percent of U.S. medical students post unprofessional content online.

In a professional situation, the Mayo Clinic provides one example of how to use social networking tools. Lee Aase is the clinic’s manager for syndication and social media, and they began their campaign with a podcast in September 2005. From there, the Mayo Clinic began to build blogs addressing various topics and uses Twitter as a means of broadcasting new content on their blogs and video pages.

The Mayo Clinic is concerned about HIPAA, but patients are legally entitled to post information on their own conditions. To safeguard their credibility, legal stance and the patients’ privacies, the clinic needs to get a consent form for interviews with patients about their stories. To protect patients, the Mayo Clinic reserves the right to remove personal contact information from any interaction on their social media platforms.

While a professional healthcare institution with a manager for syndication and social media – and probably an attorney who is schooled in privacy issues in the wings – might show the way on how to use social media responsibly, how should an individual use social networking in a personal situation or in a smaller healthcare routine?

Some Tips on Using Social Media for Healthcare

If you plan to use social media, or if you already use Twitter, LinkedIn, Facebook and YouTube, you might heed some of the following tips for your own credibility and job insurance:

• Learn the platforms: Learn how to use each social media tool to your advantage, which means learning how to use privacy controls and other customizations.
• Keep professional and social relationships separate: By dividing social and business lives, a healthcare professional can maintain a professional demeanor on one hand and socialize with friends and family on the other. It is not appropriate to “friend” patients on Facebook or to follow them on Twitter.
• Watch your associations: You may want to connect with a patient on a blog, but you may not want to connect with that patient on Facebook or LinkedIn. On the other hand, you don’t want a friend with an offensive user name to appear on your list of people you follow on Twitter, unless you Tweet anonymously (possible by not revealing your real name, but a user name when registering).
• Keep politics and religion quiet: Unless you plan to be a journalist or an activist, it is best to keep those two topics in the personal realm, rather than the business realm. Activism, however, is up to you — if you, as a healthcare professional — want to campaign for clean water, then use your professionalism to temper your activism.
• Use social networking to say “Thank you” and to set up meetings in person: This Mashable article explains that social networking provides the perfect medium to extend your hand in business situations appropriately.
• Keep comments civil and don’t use social media while under the influence: The article about medical students explains succinctly how these comments can lead to expulsion from school — and in professional situations may lead to job loss or loss of clients.

Conclusion

If you want to connect professionally, used LinkedIn to find your peers and to network among other health professionals. If you want to socialize, use what your friends and family members use. Facebook seems more popular than MySpace, but in both cases you need to watch privacy issues and check your home page constantly while logged out to make sure you are not revealing any information you want to keep confidential.

Twitter is an amazing tool for broadcasting, but it takes time to build up a following. If you want to vet who to follow on Twitter, use Listorious, or use search: site:twitter.com/*/keyword to search for Twitter Lists containing your keyword on Google Search. You can also search for multiple words by putting a hyphen between them, such as site:twitter.com/*/healthcare-pediatrics. Be sure to avoid any spaces in your search (via Tweetsmarter).

Although social media is not conducted as a regular class in most medical or healthcare courses, plenty of information is available online on how to use social media tools in a professional manner. Read blogs such as Mashable or ones focused on healthcare such as Social Hospital to learn more about content management. If you apply HIPAA to those constructs, you may find that social media can provide a wonderful extension to your healthcare services, much like positive word-of-mouth testimonies.

Click Here to Read More..

EHR Engineers: Behind the Scenes at Practice Fusion

We often talk about our business in terms of the Practice Fusion "Community". It's more than just a nice phrase: with 43,000 medical professionals registered on our system, plus student users, plus business partners, plus the larger health IT sector, plus our social media networks, plus the Certified Consultant Network...it really does feel like a giant village most days.

Left to Right: Lyubov Kassianik (QA Engineer),
Nicolas Louis (Junior Software Engineer), Scott Halfon (Senior
Software, Engineer), Robert Ryan (Software Architect),
Roman Klyuyev (Senior Technical Analyst) 
Not pictured: Matthew O'Meara (UI Architect)

Our team of almost 50 employees here in San Francisco interacts with these various community groups on a daily basis.  We're constantly getting questions, feedback, ideas, suggestions, new business deals and reporter queries.

At the heart of this massive, whirling EHR community is our engineering team. They're the core of our business - the group that makes everything else we do possible.  They created the Electronic Health Record system and the Personal Health Record system, Patient Fusion. With incredible speed and quality, they turn the influx of new ideas into real systems that are used daily by doctors and patients.

If you're not a Practice Fusion user yourself, you may not be familiar with just how much the engineering team here produces. We release enhancements and product features to our EHR system every 3-5 weeks.  As a web-based system, each release goes live instantly across every account (usually at 2 or 3 in the morning to minimize disruption). Each release includes upwards of 30 user suggestions along with larger new functionality.

"We intensely focus on the needs of the doctor and the patient, and by doing this we are building the best health community in the world," said Robert Ryan, Software Architect.  "We all enjoy building new features for our users, but never forget how critical our system is.  Every prescription dose must be conveyed perfectly to each pharmacy, and every lab result must be correctly displayed to the doctor.  And with the sensitive nature of healthcare data our system must be secure.  These are the things that drive us during the day and keep us up at night."

Matthew Douglass, VP of Product Development, works
with Gary Gray, Senior Software Engineer.

As we get closer to Meaningful Use, the engineering team is working long hours to make sure that each of the final 25 EHR incentive criteria are ready for use. That's they key to Practice Fusion being HHS-certified and they key to our users qualifying for $44,000 in EHR incentives.

The engineering team has some amazing new features and systems coming very soon. There's no external engineering team at Practice Fusion; every single piece comes straight from our San Francisco tech team.  And we're in the process of hiring more engineers to add to group so we can deliver even more. If you know an enthusiastic engineer in San Francisco looking for a job - let us know!


Emily Peters
Director of Communications
Practice Fusion EMR

Click Here to Read More..

How does HL7 fit into EMR interoperability?

Modern healthcare technology needs to communicate and share information with others. That seems like an obvious statement. However, this has not been the legacy of the health IT industry – historically, Electronic Health Records (EHR) have been built as large, all-inclusive enterprise systems designed to function within a closed network environment.

In this setting, interoperability was not a key priority – after all, “everything you’d ever need” was already within the product. If anything, exchanging data with others was like “making nice with the competition.”

However, the national health IT policy as articulated by the Office of the National Coordinator (ONC) is focused on building a nationwide electronic health information infrastructure, in order to avoid medical errors, measurably improve clinical performance, improve patient access to their own health information, and reduce disparities in healthcare. And interoperability of health data is a key part of that.

So how should health data be communicated? There actually is a divergence of opinion about that – perhaps dubbed a “legacy approach” and a “web approach.”

The legacy approach
Given that legacy systems function behind the closed walls of their networks, it is not feasible for them to look into each other’s systems in any easy way. Instead, what legacy systems have to rely on is packaging up different pieces of data into (basically) a text file, and transmitting it securely to someone else. The main content-standard for these files has been HL7.

Health Level 7 (HL7) is an organization created by many large institutional players in over 55 countries, which try to agree on a standard format for all sorts of data exchange. HL7 has created Messaging Standards (version 2.3.1 and 2.5.1 are specifically mentioned in HHS Certification specs), as well as standards for Continuity of Care Documents (CCD), and Clinical Document Architecture (CDA) files. These standards describe structured data put together into a text file, and are how lab results are reported, immunization registry data is exchanged, public health events are reported, and legacy EHRs exchange clinical summary data with each other.

Other approaches to data exchange seen elsewhere also follow a method very similar to HL7 – the NCPDP standard for transmitting prescription information to the prescription clearinghouse (Surescripts) is a file structure very reminiscent of HL7.

In short? Legacy systems need to have agreed-upon file formats on which to write health data, so everyone knows what-goes-where and can report and consume such files. The transport of these encoded files can take place a number of ways – from FTP downloads, to secure web transport, to even modem-based bulletin-board BBS posting-and-download (Kermit protocol). So, legacy systems need to agree on (1) content of structured text files, and (2) secure transport methods.

Web approach
Internet technologies are built differently. To begin with, a web application is intended to be shared widely, not behind a closed wall. Security and permissions are therefore key for a web application – a good example is web-based personal banking. Web applications make use of “web services,” which expose selected functions and features to authorized requestors. For instance, a credit-card payment piece of an e-commerce web site is typically a web service that is external to the e-commerce vendor, but functions seamlessly together for a unified end-user experience.

Web-based health IT is an emerging technology. Recognizing this, the department of Health and Human Services (HHS), along with Health 2.0, has launched a Developer Challenge to encourage web-application developers to come up with innovative solutions. Think “an App Store for health IT.”

These kinds of web-based solutions use web services to communicate with each other. They do not use HL7, or other legacy methods. It is true that such apps must be able to use HL7 documents (generate them and import them) in order to remain backwardly-compatible with large, legacy systems. But that is not necessarily the way of the future. Or at least, not the only way of the future.

Over the next 6 or 12 months, some very exciting collaborations are sure to emerge within the web-based sphere of health IT (so-called “Health 2.0 companies”). They will be based on sharing data using web-services, and not HL7. But – to be fair – as long as large systems, such as laboratories and prescription clearinghouses, remain as important centers for health information needing to be exchanged, then backwards-compatibility with their methods will need to be maintained. But future growth will be in a web-based direction. These will be exciting times!

Robert Rowley, MD
Chief Medical Officer
Practice Fusion EMR

Click Here to Read More..

Homo EHRectus

In what could be the most significant archaeological discovery of the millennium, four teenage boys and a dog named Trax have discovered the remains of an ancient predecessor of modern man. The hominid, who probably walked with a slouch and stood 5 feet tall in wingtips, apparently died while trying to use an equally ancient, legacy electronic health record that was discovered nearby by the same group.

The boys also found a rusted server and a 750-page, water-logged training manual in a nearby ditch.

Archaeologists quickly descended on the site, which is near Montignac, a town in the Dordogne region of France. The region is already famous for its proximity to the caves of Lascaux, which are adorned with paintings dating back 17,000 years to the Upper Paleolithic period.

Early observations by the archaeologists suggest the decomposed body is a remarkably intact specimen of Homo EHRectus. If these observations are confirmed, it would roil existing theories about the evolution of man. Prior to the discovery, experts believed that Homo EHRectus existed only in hospital-like cave dwellings…at least before they died, apparently due to toxic frustration and historic floods of error messages.

There are no hospital-like cave dwellings near Montignac. For this reason, the scientists will want to determine the caveman’s cause of death, since this could help prove that ancient, legacy EHR systems were incapable of supporting care in ambulatory settings.

The finding could also help explain one of the great mysteries surrounding the Lascaux cave paintings. Whereas most of these paintings depict realistic images of large animals known to have lived in the area at the time, a set of abstract symbols and geometric figures in one of the caves had defied explanation until now.

The carved symbols were previously assumed to have astronomical significance, or to reflect visions experienced during ritualistic trance-dancing. But the discovery of a legacy EHR near the remains of the prehistoric man makes it likely that they reflect work-around protocols that Homo EHRectus used to circumvent insanely poor system design, as well as help-line numbers that the cavemen could have used when their systems crashed.

One of the boys involved in the discovery, Pierre Foufou, was amazed by the primitive architecture associated with the EHR he discovered. “I’m studying to be a doctor,” Foufou told Paris Match. “I don’t know how those little men could have gotten their work done with something so old-school. Web-based EHRs sure did change everything, didn’t they?”

Glenn Laffel, MD, PhD
Sr. VP Clinical Affairs
Practice Fusion EMR

Click Here to Read More..