A New Vogue To Telephone Commutation Patient Wellness Information
An interesting post on THCB past times Margalit Gur-Arie—titled "What if I Had to practise HIT All Over Again?"—critiques the really large, really expensive as well as really clunky monolithic EMR/Practice Management/Billing scheme currently dominating the market. She concluded the post this way:
"So if I had to practise it all over again, I would choose a hard await at Microsoft Office. I would construct multiple useful applications, similar Word, Excel, Power Point, etc. I would brand certain I tin export information from 1 to the other. I would brand certain that the user interface is consistent betwixt them. I would permit others to create templates as well as integrate their software into my tool bars."I replied:
Wow, Margalit, that's exactly what nosotros done! We've genuinely but presented the firstly alive world demonstration of a paradigm of our scheme to doctors, educators, as well as insurers. It went really well!
The demo showed, inward existent time, how this MS Office based scheme enables:
- Primary attention physicians (PCPs) to ship personalized referrals to specialists
- The specialists to respond to those referrals
- The PCPs to respond to the specialists' credence respond past times sending them XML-based continuity of attention documents (CCD) as well as other supporting information files
- The specialists to access as well as stance the resulting patient information
This is all done amongst encrypted e-mail attachments as well as a pocket-sized software computer program as well as macro routines that procedure the e-mails automatically. They automatically encrypt, zip, as well as attach the files to e-mail as well as lay them inward the outbox; every bit good every bit call upwardly the electronic mail from the inbox as well as unzip, decrypt, format as well as display those files, as well as shop them encrypted inward the recipient's computer.
It requires every bit few every bit five mouse-clicks per end-user for the entire process. No necessitate for primal servers (or whatever other infrastructural build-out), at that topographic point is lilliputian if whatever necessitate for information technology support, as well as at that topographic point are no other costly complexities.
And all the information are stored locally inward encrypted files, which areautomatically retrieved as well as rendered whatever fourth dimension via a few push clitoris clicks. From a technical perspective, it's a uncomplicated node-to-node (peer-to-peer), publisher-subscriber, as well as asynchronous decentralized desktop solution that uses Office macros, .Net, as well as SMTP. It is literally the easiest, most convenient, as well as to the lowest degree costly fashion I know to commutation as well as acquaint patient wellness information securely betwixt whatever EHRs inward a fashion that promotes attention coordination.Another reader (Alexander) commented:
Margalit, what y'all describe, basically, reflects the principles, on which the proposed NHIN infrastructure is based. The only divergence is that it is supposed to connect RHIO's rather than sort EHR systems. Without a nationwide patient ID, though, it is going to live really challenging to uncovering as well as link all medical records on the same individual since about of import information fields used past times matching algorithms tin live empty or incorporate wrong values. Besides, every bit I mentioned before, it is much to a greater extent than hard to predict availability of EHR systems installed inward pocket-sized medical offices or hospitals, unless they occupation cloud-based applications.To which I wrote:
Margalit - What practise y'all intend close the occupation of a biometric index to create a unique patient identifier (medical tape number)? It would negate the necessity to constitute as well as connect to a primal repository, as well as it would enable the fluid commutation of patient wellness information betwixt whatever nodes inward a mesh network architecture, which is similar to the fashion communication is done inward telephone networks (see http://wellness.wikispaces.com/Network+ArchitecturesAnd she responded:
Dr. Beller, I intend a biometric ID is likely a really skillful choice, brusk of implanting a flake :-)
The NCVHS has been tinkering amongst this for over a decade, but zippo happened. There seems to live about reluctance on the constituent of most people to own got such identifier. I'm non certain why, since nosotros all larn SSNs at nowadays after nativity as well as intend zippo of it.
I intend the technology scientific discipline is available for biometrics as well as the logistics are non insurmountable (put a machine inward every DMV).
Alexander, I know that availability is an number amongst the electrical flow crop of EMRs, but I strongly believe that SaaS is the future. Besides, every bit Dr. Beller mentioned, nosotros all occupation phones without the operator having to patch calls through anymore as well as without having to run to the telegraph business office to ship something. Technology changes fast as well as I tin run into a device or an executable installed inward every business office to ensure availability.
I'm non ruling out RHIOs or other intermediaries, but I believe the actual information necessitate non reside anywhere other than the provider system.I replied:
Yes! I suggest that of import roles for RHIOs, HIEs, etc. would be:
- To aggregate de-identified patient data
- To brand those information available to authorized query organizations (universities, etc.) who study the information to aid prepare as well as evolve evidence-based preventive, diagnostic, self-maintenance/management, as well as handling guidelines that focus on bringing ever-increasing value (i.e., cost-effectiveness) to the patient/consumer
- To disseminate the resulting guidelines to all parties.
In this scenario, using the decentralized node-to-node architecture, the patient information would live stripped of patient identifiers as well as shipped to a centralized query information warehouse. The stripping as well as transportation would live done past times the nodes having directly access to where those information are stored, that is, to the nodes belonging to the clinician/provider that access the information from their EHRs, as well as to the patient nodes having access to their PHRs. Nodes having directly access to the query information warehouses would as well as so have the de-identified patient data. In other words, the clinician as well as patient nodes would implement their publisher (sender/transmitter) constituent to transmit the data, as well as the RHIO/HIE's information warehouse nodes would implement their subscriber (receiver) constituent to call upwardly the data. And the resulting guidelines would live shipped via the RHIO/HIE nodes past times implementing their publisher function; the guidelines would live received past times the clinician nodes implementing their subscriber functions as well as afterward live presented through clinical determination back upwardly software programs.
This scenario is an instance of a hybrid mesh node network architecture inward which both centralized as well as decentralized networks piece of work inward harmony. BTW, about other instance of a hybrid mesh is when a multi-site healthcare organisation amongst a centralized EHR scheme (behind a firewall) connects via nodes to the EHRs as well as PHRs of other parties exterior their organisation (beyond their firewall).Margalit added:
Dr. Beller, it seems other folks are starting to intend the same fashion http://www.reuters.com/article/pressRelease/idUS45817+13-Sep-2009+BW20090913 It's a start.....And Alexander added:
P2P communication works non bad when a PCP refers a patient to a specialist orTo which Margalit replied:
orders a test. And at that topographic point are already commutation formats widely used for that, such
every bit HL7, CCD as well as CCR. But inward social club to larn all patient EHR's through P2P
connections, (1) the requester has to somehow uncovering out, which peer systems have
that information, (2) brand certain they are connected, (3) ship a asking to each
of them. And every EHR application must own got its ain authentication and
ascendance module to grip external requests... I but don't run into how this
may piece of work without an intermediary.
I concord Alexander. It won't piece of work on a really large scale without an intermediaryI responded:
or a super node or a translation gateway, whatever nosotros destination upwardly calling it.What I
similar close eCW's proclamation is the alter inward the fashion vendors are thinking.
Exchanging information is finally becoming a worthy goal. As long every bit they are
moving inward that direction, every pocket-sized mensuration is an achievement.
I also concord that an intermediary would live useful for larger scale P2PAnother reader (a physician) as well as so commented:
implementations so that each peer/node tin uncovering other peers/nodes during the
publisher-subscriber activation procedure (i.e., when 2 nodes connect amongst each
other for the firstly time, which includes authentication as well as authorization). A
RHIO/HIE would live an ideal intermediary supporting such P2P connectivity
regionally. Influenza A virus subtype H5N1 Federal regime agency, or fifty-fifty a “supra-RHIO/HIE” node that
connects the regional ones, could practise this nationwide.
The interesting affair is that the only 'standard' that clinicians occupation inward theAnd I replied:
daily attention of people is English. I intend this is unlikely to change, Dr. Beller.
I'd larn 1 mensuration further: I believe our terra firma should live engaged inward international collaboration as well as research, so English linguistic communication isn't fifty-fifty a universal standard.Another physician responded:
In whatever case, using a pub/sub node-to-node architecture, at that topographic point tin live 1 or to a greater extent than nodes betwixt the publisher as well as subscriber that serve a information translation/conversion constituent via mapping methodology. That is, if the publisher uses a local terminology criterion “A” as well as the subscriber uses local criterion “B,” as well as so the information tin live sent to an intermediary node where corresponding price are translated into the subscriber’s parlance. This would non only improve communications betwixt clinicians inward different regions as well as facilities, but also inward betwixt clinicians inward different disciplines. Likewise, the price could live translated into layman's linguistic communication when communicating amongst patients!
Interesting thread... Some thoughts...To which I replied:
1) The lastly post close Influenza A virus subtype H5N1 as well as B getting translated past times an intermediary pretty good describes the wish behind RxNorm (input Multum, First Databank or other as well as interpret to RxNorm or 1 of the other systems) -- Good idea, would live fifty-fifty ameliorate if the Government would create an opened upwardly wiki or similar to create a crowd-sourced comprehensive drug-drug interaction scheme (Would cutting close $20/Doctor/Month off the toll of e-prescribing, at nowadays paid to Drug Data manufacturers).
2)The Pub/Sub Node amongst about reporting primal shop - describes good Carol Diamond's as well as lots of others architecture for an HIE / NHIN infrastructure (eg hybrid federated - pub/sub node as well as centralized - primal clinical repository).
3) The Vermont Blueprint as well as VITL commutation that Governor Douglas (Vermont Gov, also Chair of National Governors Assoc this twelvemonth - different topic, but await at his RxReform platform for accessible, affordable accountable healthcare - pretty interesting) -- Anyway, the commutation started generating information for reporting as well as for community coordination past times doing 2 things - 1) Agreeing on carry (started every bit CCR, as well as so moved to CCD - both work, but every bit Phil Marshall from WebMD stated inward his HIT Policy commission testimony - CCR is easier to occupation unless 1 needs to occupation CCD for standards reasons) as well as 2) Agreeing on a LIMITED semantic lexicon - brand certain to collect a few of import things inward a structured, tardily to care fashion, as well as the scheme tin live used past times lots of parties.
Bottom business feels every bit if designing to solve the GOAL of the PROJECT or TASK ends upwardly amongst a simple, effective solution - the middle of the master copy post - it was right on target.
Concerning CCD vs. CCR, I intend their reliance on XML makes them both to a greater extent than complicated as well as inefficient than is necessary. I say this because the information they incorporate tin to a greater extent than easily live set out inward a comma separated value (CSV) file (including whatever parent-child hierarchies, although they are rarely, if ever, required for wellness information exchange).BOTTOM LINE: As our terra firma struggles to transform healthcare into an efficient as well as effective system, at that topographic point is non bad necessitate for a convenient, low-cost, resources conserving, as well as secure fashion to commutation whatever electronic information residing anywhere that doen non require those information to transcend through a primal server or reside inward a primal database. This is exactly the form of decentralized peer-to-peer mesh network architecture, publisher-subscriber communications, as well as desktop (standalone) applications that I've been describing. It's skillful to know others are get-go to run into the wisdom of this approach!
In fact, I've developed an opened upwardly source app that uses an MS Excel VBA macro to convert a CCD into a much slimmer as well as much to a greater extent than human readable CSV file at https://sourceforge.net/projects/convertxmltocsv/ Note that the CSV could live used instead of the CCD for transmitting information from node to node. Nevertheless, CCDs/CCRs are today’s standards as well as hence cannot live dismissed.
Note that, patch this scheme currently takes wages of the might as well as ubiquity of the MS Office platform, it is not theme them since the same funcitonality tin live built on other platforms.