Electronic Health Record (EHR) II draft

It is easier for a doctor, not connected with a major institution, to obtain government secrets than to access current medical information. The funding for electronic health records (EHR) affords an opportunity to advance education and channel that, difficult to obtain medical information, to the medical student, the practicing doctor and the point of patient care.

Translational medicine makes an issue of researching and implementing new knowledge into clinically applicable substance. That substance has little merit until it becomes a part of clinical practice. The flood of new bio-medical information overwhelms the process of translating and delivering relevant advances to the clinician. Many EMR proposals contain substantial decision support capabilities, but neglect to feed current and changing medical information.

Vender centric programs meet the economic needs of the client and the vender. Government centric strategies stress avoiding errors, reducing cost, meeting fixed quality criteria[1] and quantifying the benefit. Drug centric solutions attempt to aid in selection of medical treatment and prevent adverse drug reactions. Hospital centric EHRs must deal with pooled data with other institutions, confidentiality, their own institutional review boards (IRB) and somehow collate data from divergent sources.[2] Hospitals and insurance companies seek control of the data as an administrative and economic strategy. Drug companies have a similar motive.

Make patient needs the first priority by centering the EMR in the computer of the individual provider while linking that database with a secure cloud database. Supply the provider with total access to total medical information. Include the decision and support capabilities. Generate a continuous differential diagnosis. Include a self-correcting statistical element. Compare and analyze the relationship between patient data and outcome.

Impediments in developing meaningful EMRs

·         Battle over final ownership of the data

·         Divergent priorities in function and goal of the EMR

·         Colossal challenge in meeting every bodies demands

Proposing that these electronic patient records (EPR) belong jointly to the patient and the primary care provider resolves a number of the impediments and problems.

·         Eliminates incompatible database problems among various institutions

·         Individual providers work with off the shelf database linked to major database provider.

·         Clinician can modify the reports and add criteria at will without upsetting the core software schema.

·         Medical school and institutional researchers can access accumulated patient data anonymously.

·         Patient genetic data correlates with clinical pathology in real-time

·         Enhances medical student education by learning the database in clinical years

·         Gains acceptance among private practice physicians by its sponsorship in the medical school and by its use among graduating physicians

·         Puts the medical school in control of the patient database

·         Puts a regional and environmental spin on the relevance of medical information

·         Promotes competition between medical schools in developing the best medical information database and operating system

·         Frees the decision support function and diagnosis from the distortion created by arbitrary regulation and economic motivation

·         Maintains political neutrality

·         Data accessible:

o   1. because in standard and widely used database program  

o   2. Because all information recorded as specific data entries and thus retrievable  

·         Informed consent no longer an issue for cohort studies

·         Use and cooperation become ubiquitous – spreads voluntarily

·         Free use provides an unwitting contract to use the information wisely

·         Errors and misdirection become immediately transparent to the medical school and a pointed direction for CME

·         Gives medical students much more of a vision of the totality of medical knowledge and a more organized way to store it.

Requirements

·         Open source and free to all providers

·         All patents and copyright in the  public domain

·         A database purchase from Major database provider, probably Oracle or IBM, unlimited users

·         Medical information in database form provided by medical school, free of copyright and cost! As an educational and CME function

·         Enough federal and state financial support

·         Initial programming of the database schema and the statistical relational rules

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[1] J Am Med Inform Assoc. 2009 Sep–Oct; 16(5): 637–644 Decision Support Capabilities

[2] J Am Med Inform Assoc. 2009 Sep–Oct; 16(5): 624–630 The Shared Health Research Information Network (SHRINE)

Bio Medical Database

I need to tell you what I am excited about. It involves the patient record, the human genome, medical information, statistics and a database program.

Scope “In April, the Department of Health and Human Services awarded a second round of grants totaling $267 million to create 28 new centers to assist health-care providers in implementing health information technology. The funds were part of the $20 billion allocated in the American Recovery and Reinvestment Act of 2009 to help doctors and hospitals make the switch from paper to electronic records.”

This is an opportunity to channel biomedical information into the hands of students and graduates and correlate that information with the patient record. 

From MIT’s Technology Review, “Electronic medical records provide vast amounts of medical information that can be combed automatically and used to ask questions…

...Scientists and physicians are now scouring the growing number of electronic medical records and genomic databases to figure out how to use this vast medical resource…”

More to the point of medical education, students and graduates alike experience a continuing need to reference current medical information. Current information is not easy to come by. It is expensive, closely held and often inaccessible. U of Michigan took a great stride in recording the lectures for students to review on their computers. Bravo, but the data is not indexed and it’s slow to access for a specific reference. In addition, there remain the student’s patient contacts and a need to correlate patient information with medical knowledge to develop a differential diagnosis.

Lists are hard to remember, but a modern user-friendly database program can retrieve a relevant list. The database’s – pardon the analogy -- left-brain contains the patient information, recorded as data points, whilst the database’s right-brain contains all available medical knowledge also as data points. The relational features of the database can easily match patient variables with diagnostic criteria, providing a differential diagnosis or list. Filing information in a database obviously compresses the data in that it eliminates repetition.

Other electronic medical records (EMR) applications stress “best evidence” treatments. While including up to date treatment options, this proposal stresses differential diagnosis.

Furthermore, a built in statistical application offers probabilities for the differential. Intriguingly, a more developed statistical attachment will correct itself in real-time based on outcome; this is the important aspect of the matter.

Everything I have read suggests great difficulty in analyzing the data -- data mining -- and that may be so on a central server, but on the student’s computer with a current state of the art database, the real-time statistical analysis should give an accurate picture of the outcome in relation to the clinical data, including the genomic information if available. As this data accumulates in the medical school server, over the professional life of the student, analysis should be much easier.  

I had some operational experience with an old Borland database while I was in practice. I got some of this schema done, but at that time, it was slow and limited. Today the computers are fast and there is virtually no limit to scalability.

It will take a couple of high-level database persons, a couple of statisticians and a couple of medical people who can pull together the full range of medical information in a database format, genetic data included. Students should be able to write the data fields for the patient record.

The resulting product should be open source and available to all clinicians willing to link to the medical school server. Both patient and medical information would flow both ways. Researchers can extract patient data anonymously. New bio-medical information can flow back the other way providing the clinician with continuous access and update of biomedical information.

 The educational advantages speak for themselves. Health and Human Services has the money. I believe that Medical Schools represent the only trusted vehicle for such a program.