Electronic Medical Records

They should be in the cloud but aren't

by Duane Bristow

duane@kyphilom.com

In the early 1980s I began computer consulting and writing business programs for small businesses. In 1983 I wrote a computer system to computerize billing for physicians offices and another to do the same for pharmacies.

Later in that decade when Kentucky Medicaid contracted electronic billing and even later when the Medicare contractor set up electronic billing in Kentucky, I worked with them to test their electronic systems. Both turned to me since I had the only computerized working system in the state which could interface with their systems.

In the early 1990s I computerized a small local hospital as far as patient billing and electronic billing to insurance companies.

My medical systems have been in continuous use in the offices of at least some medical service providers every day they have been open since 1983, a period of 32 years.

I had worked in small business and in medical billing programming for over 30 years when the Affordable Health Act (ACA) was implemented. I was encouraged when the ACA encouraged healthcare providers to record patient information electronically instead of using paper records.

I envisioned a day soon when each person would have a comprehensive detailed record and summary of each patient's medical records which are owned and controlled by the patient available immediately and at all times in the cloud to every medical service provider who interacts with that patient subject to the patient's consent.

My wife was in the hospital for several days in 2015 due to a kidney infection and I was emailed access to what the hospital called a patient portal. "Great!" I thought, "My vision is coming to being." I had also received similar emails from a couple of other health care providers.

However, when I followed up to find what was actually happening I found that there was no central records repository in the cloud but only access to records on the computers of each provider and all the formats and protocols for accessing the information were proprietary to the software used by that provider. This meant that rather than being able to see all relevant medical records at a glance in one place, a provider or a patient would have to access separately the computer systems of every provider which the patient had seen. This seemed to me to be an unreasonable burden since I knew the whole process could be simplified.

For more information see the article, Epic Fail, by Patrick Caldwell.

Since I had time to spend sitting in my wife's hospital room while she was recuperating, I used some of that time planning the way the system I envisioned should work and creating a prototype web site as an example.

Here is the front page of my prototype web site:

As you can see in the picture above full information would be available on each patient with most recent information at the top of the list. Clicking on each link on the main page would open a page with full details.

The demographics for the patient would include full name, sex, birth date and place of birth, address, spouses name, phone number, email address and other contact information.

The other information available would include:

These web pages would be accessed by the patient with use of a user name and password.

A new access code would be generated for the patient to be given to each doctor or facility. The patient could either give complete or restricted access. Example: http://www.medrecords.org/evabristow19476.htm

When the doctor uses the access code the patient is sent a new access code to give to the next health care provider he or she sees. The code is in the form of a URL and in a QR code.

For this system to work all medical software would have to have the ability to create and transmit to the cloud bridge documents in html format which would include the full transcription of medical encounters and such information as:


date
type
        lab
        incidents including icd-10 and cpt codes 
                (icd-10 codes tagged as tentative or confirmed)
        medications
        notes

originating doctor or facility by NPI

Key tags for significant database fields in metadata of the html document.

The provider's medical software should also be able to receive this information by downloading these html pages and incorporate it into their database.

For the initial web site for a patient the patients would give the demographics and medical history and insurance info. Usually this data would be collected and transmitted by the patient's general practice physician and additional data would be added as each visit occurred. The medications lists would come from pharmacies as prescriptions are filled.

The computer should keep track of doctors and dates including speciality by taxonomy code and contact info.

After I had created the web site for my wife's medical records, I asked some of my wife's many doctors to take a look at her information on the web site telling them that all information was easily available at one location.

The responses from the doctors, their nurses and their office personnel amazed me:

Most were not interested in looking at it - They said they could only look at information received by traditional methods by paper, fax or MRI raw data on DVD but not on the internet.

When I offered to email the web page URL to a neurologist his office person said they don't have email.

Some did not think they would be able to view information on a web page.

When I asked at one office for my wife's medical records in electronic format, knowing that everything was available in their computer system I was told that they either do not have the ability to transfer information electronically or were not allowed to do so. The person was unsure which, but they would be glad to print it all on paper and they did so. Quite a number of printed pages which I later scanned to jpgs and put on her web site.

When I showed him the web page on my tablet, one doctor did admit that such information could be useful but his system was not set up to use it.

My son gave his new Osteopath a link to his medical records on the internet. Because my son had had a heart problem with open heart surgery as a baby the doctor ordered an EKG. Later when viewing the EKG results with my son the doctor commented that he "could not tell much from the EKG because he did not have a previous EKG to compare it against." This despite the fact that the medical records on the internet did include the previous EKG. It seems the doctor was unwilling to look at medical records if they were in the cloud.

A similar thing occurred later when my wife's cardiologist said she needed a BNP test. I told her that a walk-in clinic had performed that test a month before when my wife went to them for fluid retention and that I had the report in her medical records on the internet, the URL of which the doctor was holding in her hand. She showed on interest in looking at that report.

In early 2015 my wife's cardiologist's office staff informed us that we would have to be patient with them because they were learning a new computer system and were having problems getting all the data into it.

In late 2016 she was once again referred to that cardiologist. When I asked about getting a copy of her medical records from her tests performed in the previous year I was told that they did not have records before March of 2016 in their system because they had once again replaced their computer system and their old records were stored by a company from which they could request those records and they would do so. A few days later they had paper printouts of her 2015 records. From numerous stories heard in the offices of several of her doctors I conclude that doctors probably replace their whole computer system on an average of every two years incurring huge expenses and lost productivity while learning new systems as well as the fact that, since such systems are proprietary, most records can not be electronically transferred from the old system to the new system. They could be by means of a crossover program but that would require that the old software company would have to make their file structure available to the new company and none will do that. There is no standard file structure in the industry.

A week after the above incident in mid-December my wife was referred to a new doctor who was a member of a women's health group. The first thing I saw at the receptionist's desk when we visited his office was a sign asking patient to please be patient with the office staff because they were learning a new computer system and as a result they did not have access on their computers to any records before September which was four months before.

There are two kinds of records kept in medical offices. One type is financial records used for billing and the other is patient's medical records such as diagnoses, treatments, lab results etc. The billing system I wrote for use by physicians in 1983 was still in use by those physicians who had not retired during that time period 33 years later. The one exception to this was a doctor who let a software salesman tell him that their system was better than mine because it cost 4 times as much and that they were a company that he could trust to remain in business and I might quit or die. That was in 1985. Ten years later he returned to use of my system because the two or three software systems he had tried in those ten years had either lost his data or the companies had gone out of business. I am sure that he lost at least $150,000 or more in billings and lost productivity during those ten years due to changes in computer systems.

So, I found that there are many obstacles to efficient use of modern computers and cloud based data systems in the field of medicine. Much of it seems to be caused by lack of knowledge, lack of imagination, and tendency of software systems used by medical providers to be insular.

Later on I realized that some doctors could feel threatened by the idea of their patients having complete records of the medical care they had received and were receiving. This, as well as a luddite attitude toward electronic records, could explain their reluctance to use such systems.


Electronic medical records in the cloud.
Duane Bristow

12/9/15

This is a copy of an email I sent to a doctor:

These are my thoughts after our discussion yesterday about medical records in 
the cloud. 

create an organization for all medical service providers
purpose - to set standards for medical service software.

All medical service software must be capable of two way communication with a 
cloud based database server set up by above organization. 

Organization supported by membership fees from medical service providers?

Organization certifies medical service software to their standards.

The purpose of the organization is to make a comprehensive detailed record and 
summary of each patient's medical records which are owned and controlled by 
the patient available immediately and at all times in the cloud to every 
medical service provider who interacts with that patient subject to the 
patient's consent. 

To get such an organization off the ground form an exploratory committee
composed of five to ten medical service providers, each from a different field 
and two to five medical software programmers. 

Committee starts with two meetings.

In the first meeting, I propose a tentative outline of how such a database
would work.

In the second meeting the committee discusses and creates the final version of 
a plan for implementing such a system including the preliminary standards for 
the database. 

If this makes sense I will begin work on the tentative outline.

You will begin work on forming such a committee.

'If you have built castles in the air, your work need not be lost; that is
where they should be. Now put the foundations under them.'

Henry David Thoreau

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There is a similar organization for the pharmacy industry already:

 Multi-stakeholder, Problem-solving Forum for Healthcare

NCPDP is a not-for-profit, multi-stakeholder forum for developing and
promoting industry standards and business solutions that improve patient
safety and health outcomes, while also decreasing costs. The work of the
organization is accomplished through its members who bring high-level
expertise and diverse perspectives to the forum.

Standards for Electronic Exchange of Information

As an ANSI-accredited Standards Development Organization (SDO), NCPDP uses a 
consensus-building process to create national standards for real-time, 
electronic exchange of healthcare information. Our primary focus is on 
information exchange for prescribing, dispensing, monitoring, managing and 
paying for medications and pharmacy services crucial to quality healthcare. 

For more than 30 years, NCPDP has led a transformation in the pharmacy 
services sector by creating and promoting standards for electronic healthcare 
transactions. Our collaborative, consensus-building process has produced 
operational efficiencies that save $30 billion annually in healthcare costs, 
while increasing the safety and quality of patient care. 

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Notes on outline for database:

URL: http://www.kyphilom.com/www/med/eva19647.htm
web page by Duane Bristow
A prototype patient web page for the database.

A web site - say medrecords.org

in which each patient would have identity information including full name,
birth date, and place of birth & full demographics
 
accessed by user name and password.

a new access code would be generated for patient and given to each doctor or 
facility. either giving complete or restricted access. example: 

http://www.medrecords.org/evabristow19476.htm

when doctor uses access code patient is sent new access code for next doctor.  
code is in form of URL and in QR code. 


Bridge documents

date
type
        lab
        incidents including icd-10 and cpt codes
                (icd-10 codes tagged as tentative or confirmed)
        medications
        notes

originating doctor or facility by NPI

entire html documents

Key tags for significant database fields in metadata.

Patients fills in demographics and medical history and insurance info. & 
general practice doctor to coordinate. medications list comes from pharmacies  
as prescriptions filled. 

computer keeps track of doctors and dates including speciality by taxonomy 
code and contact info 



********************************************
Duane Bristow        

Albany, Kentucky     

(606) 387-5884       

duane@kyphilom.com

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