EMR Adoption and PHRs

Chilmark Research published a "PHR Market Report, Analysis and Trends" - the Executive Summary is available for free (with sharing of your details). In their blog commentary they make an relevant point

PHRs simply won’t go anywhere without data and arguably the best source of data is a physician EMR system. Unfortunately, the adoption of EMR is abysmal across the care continuum of providers sitting at somewhere around 15-20% depending on how you count it/who you believe.

And even if you believe the 15-20% penetration of this, the vast majority of the information in these systems comes from dictation and transcription and is stored as blobs of text. There is certainly some potential for the personal health records/systems to help drive the capture of more shareable data. There are problems of security and confidentiality but as they suggest I think the benefits will outweigh the risks in the near future, especially given the entry of Microsoft, Google, Intuit and Dossia (there is a piece of my British Heritage that feels this is not the best name choice - see here).

For both PHR's and EHR's to succeed the data has to be shareable.....easily. It has to be as easy as clicking on a link or plugging in a USB stick and selecting import. To see what this needs to look like you need look no further than Facebook which has rapid user adoption. Facebook has exploded onto the social networking scene by offering simple ways for sharing applications, data and tools between all the users.

The HL7 approved CDA format represents the way forward and the potential to bridge the divide between structured and unstructured content. CDA4CDT commenced the process in 2007 and has defined the formats for 4 document types so far and there are more to come. There are several presentations available here. With shareable formats data can be made available from PHRs to EHRs and vice versa. This will drive adoption in both systems.

The Medical Transcriptionist - Knowledge Based Workers Setting Clinical Data Free

Sitting in the Medical Transcription Industry Association Board meeting recently the group spent some time discussing the future of the industry and the changes we need to demonstrate the key value that our members and their organizations bring to the healthcare setting.

The Medical Transcription Industry is transforming and will become increasingly important to the successful implementation of electronic medical records to meet the burgeoning need for better more cost effective healthcare.

Clinical information is critical to the systems that are necessary to support our increasingly complex healthcare delivery. Clinical information comes from the patient via the clinician, the vast majority of whom are dictating that information for a medical transcriptionist to transcribe. Years ago this was done with tapes or even wax drums and type writers..... we have moved on from this paper based communication to digital information and sharing of data like every other part of society as detailed in a report The Digital Workplace and the Information Worker:

...the nurse who enters patients' vital signs into a patient-tracking system on a wireless PDA
...the pilot who uses a laptop to download flight manuals and who calculates flight plans based on weight and balance inputs

and in our personal lives as well.... I am sure many can relate to my experiences with my own 81 year old mother who is digitally connected despite distance and time to me and my family. I am grateful to receive regular e-mails and text messages and we both know what is going on in each others lives and schedule. This connection has morphed from traditional (snail) mail and letters, through telephone calls, faxes into full digital connectivity and near instantaneous updates.

Medical Transcription and the medical transcriptionist have moved on too and the transcriptionist, like everyone else, has become a knowledge based worker and increasingly applies technology to assist in producing accurate, timely clinical documents. And it is this production of documents that remains a barrier to the growth. 60% of the current inputs to the EMR are clinical documents that have been dictated and transcribed. It is hard given the length of time we have depended on documents and in particular paper to leave that paradigm behind but to grow into the value added profession that clinical documentation specialists/medical editor/medical transcriptionist needs to become, it is imperative to move away from two dimensional documents and start to think about clinical data that has been locked away in these documents and needs to be set free.

Those in the profession already know the extensive clinical knowledge stored by those in the industry. This was brought home to me some years ago when I discovered that a favorite past time amongst transcriptionist's was to guess the final diagnosis for the patient as they transcribed a dictation - before reaching that point in the dictation. That's a tremendous amount of clinical knowledge available to be applied and will make this transition to knowledge based worker a breeze!

And the technology is heading that way too - documents are so version 1.0. Structured encoded clinical data in semantically interoperable form is available today in the HL7 Clinical Document Architecture and the CDA4CDT format is available and implementable and brings the value of structured clinical data moving away from v1.0 documents to v2.0 clinical data container (I don't like this term either but I'd be interested in suggestions for another term that doesn't use "document" and captures the idea of data and knowledge)

We are all knowledge based workers. Knowledge and in particular clinical data is one of the key ingredients necessary to help automate clinical care and provide safer more cost effective care. Dictated documents contain clinical data and knowledge that is locked in a proprietary format that is human readable but not machine readable. Clinical documentation specialists/medical editor/medical transcriptionist provide the key to unlocking this data and placing that data into a CDA computer readable format.

Consumerism and Clinical Knowledge

Providing the population with the right information at the right time to help them navigate the murky waters of health care delivery, insurance, hospitals, payors, denials, quality indicators and pay for performance statistics is going to be a key facet to the success or failure of any consumer driven revolution in health care.

The recent study by McKinsey “What Consumers Want in Health Care“ - summary here

Faced with health care decisions, consumers are concerned, confused, and unprepared. They rely heavily on personal recommendations and brand recognition, according to a recent McKinsey study

No big surprise here but if this is to change and the consumer is really to become informed and help drive change in health care delivery they need to have access to the right information

...48 percent report being prepared for common medical problems but only 15 percent for more disruptive medical scenarios...

To help satisfy this need consumers are already turning to the web in increasing numbers and estimates range from 50% to as high as 75/80% of patients use the web before and after visiting their physician. But much of the information available comes from a range of sources some less qualified than others. By providing structured data output as part of the clinical documentation process and delivering documents in a standard form that can be read but also imported into computer systems it should be possible to support this burgeoning need for clinical data as a natural part of the process - this is exactly what Clinical Document Architecture for Clinical
Clinical Documentation Architecture for Common Document Types (CDA4CDT) is intended to provide directly from dictation.

You can read more about the process and the concept in these articles
Guidelines Will Standardize Dictated Documents
HL7's first ballot in expected series under way
HL7 CDA: The Missing Link in Healthcare IT

As the McKinsey study revealed

Most people need additional guidance, education, and advice to make decisions
Innovative, cross-industry products that assist with the complex decision making will be highly valued by an influx of consumers eager for options but unsure where to turn

That's going to be difficult until we can standardize the clinical information coming out of clinicians offices and hospitals and make it available in machine readable form to consumers to aid their voyage of discovery in the new health care world of consumer driven choice