Monthly Archive for January, 2008

Health Care Delivery: The Checklist

There was a link in Joel’s recent Five whys post that I found to be a fascinating read: A New Yorker article called The Checklist.

Intensive Care

This got me thinking about how (and if) technology could facilitate the Checklist. The requirements aren’t really very high-tech:

The checklists provided two main benefits, Pronovost observed. First, they helped with memory recall, especially with mundane matters that are easily overlooked in patients undergoing more drastic events. … A second effect was to make explicit the minimum, expected steps in complex processes.

Dr. Pronovost’s efforts were successful because he was able to identify a single well focused process that ended up having a significant ROI. Within the complex workings of an ICU, the checklist ensured minimal compliance.

Point of care computing is ready-made for this type of task, and has many obvious advantages over a paper-based system. As the article points out, even with its dramatic results and minimal cost, adoption is slow. One reason may be:

…where I.C.U. nurses and doctors are in short supply, pressed for time, overwhelmed with patients, and hardly receptive to the idea of filling out yet another piece of paper?

In reality though, the problem isn’t the piece of paper, and technology will also not improve the situation much. I think Dr. Pronovost hits the nail on the head with this statement (my highlight):

The fundamental problem with the quality of American medicine is that we’ve failed to view delivery of health care as a science. The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia.

Well said.

UPDATE (2/11/08):

See: HIStalk Interviews Peter Pronovost MD PhD, Johns Hopkins University.

Dr. Pronovost’s reaction to HSS Office for Human Research Protection deciding that the “list method” was unethical and that the program had to stop: “Shocked.” No duh! Also, the discussion regarding the increased error rates associated with computerized physician order entry (CPOE) is great — yet another call for standardization.

UPDATE (2/29/08):

Just ran across this: The Checklist Saga: Victory! It seems that OHRP had a change of heart after all. It’s great news when common sense (a.k.a. sanity) prevail!

Open Source Medical Software

Free Medical Software appears to be a comprehensive list that’s currently being kept up-to-date (hat tip: LinuxMedNews). The project attributes and annotations make the list quite useful. Nice job Holger!

Patient Command Centers

I read with interest “Art Vandelay’s” (an anonymous Seinfeld fan and HIStalk contributor) comments regarding Patient Command Centers on HIStalk Update 1/21/08. Here’s what the PCC is supposed to do:

It will manage service desks for IT, facilities, clinical engineering, and equipment, as well as clinical alerts and data from medical devices and the computerized patient record for singular issues and trended problems.

Wow! That’s a tall order. Even with advanced tracking systems and AI software trying to make sense of all the activity (events), it seems to me that all these management tasks would require intensive human interaction.

“Art” also raised a question regarding device communications:

SNMP isn’t that complex. What are the chances of getting the medical device vendors to add this to their devices?

IMHO, probably not real good. SNMP was primarily used for the management of network devices (routers, hubs, etc.) and protocols. On the surface, its ability to manage large numbers of enterprise networked devices seems like it would be a good fit for hospitals. Unfortunately, the development and adoption of a unique object identifier (OID) for each medical device seems unlikely. Also, a new OID would require the SNMP manager software to be updated in order to recognize it and properly handle the new data.

As medical devices have become networked, the trend has been to embed an HTTP (Web) server in them. This allows secure remote access and control via any Web browser. Many other commercial networked devices have also taken this route.

Even with my pessimistic view on a couple of the details, I don’t think the vision for a PCC is any worse off than it was before. The concept of a PCC is broad and ambitious. As such, its value to an institution and implementation details need to be continually explored and refined.

Software and Services: A stress reliever?

Here’s a quote from the post: Is this the future of Software and Services?:

…in healthcare these same types of solutions will save lives…as well as reduce stress levels…don’t fear the technology that could some day save your life or the lives of others…

Yes, Software as a Service (SaaS) is a real technology that has a number of pros and cons. All major EMR/EHR software vendors effectively use server-based systems in order to protect data and provide disaster recovery.

The referenced video is essentially a Microsoft advertisement for their Windows Mobile and Surface technologies. This is cool stuff, but I don’t see how it’s going save lives. I also doubt it will reduce the stress levels of clinicians.

If you’re interested in SaaS topics, here are some good resources:

EHR Visualization: “Google-Earth for the Body”

Check out the IEEE Spectrum article Visualizing Electronic Health Records With “Google-Earth for the Body”.

Image: IBM

The 3-D coordinates in the model are mapped to anatomical concepts, which serve as an index onto the electronic health record. This means that you can retrieve the information by just clicking on the relevant anatomical part. It’s both 3-D navigation and a 3-D indexed map.

Interesting stuff. Especially the general discussion about physician and patient acceptance of EHR systems in the clinic.

Many doctors complain that eHRs have turned them into clerks, while patients say that doctors using these automated systems seem more interested in typing on their computer keyboard than in listening to their health problems.

Also, I wonder how applicable the European experience with exposing patients to this 3D mapping technology would be to US doctors?

Bill Gates CES2008 Keynote

Bill is leaving his full time position at Microsoft this coming July. Even though it’s vainglorious, the video clip from the presentation is pretty funny — the cameo appearances show what money can buy (actually, it makes you wonder…): Bill Gates Last Day CES Clip

The entire keynote is here. The audio is out of sync and intermittent, which seems odd for what’s supposed to be a show-case for next generation consumer products. CES should have consulted YouTube on how to put video on-line.

HIPAA and EMR Design

My last post prompted a comment from Mary Hawking which asked this question:

How does the legal framework in the USA influence the design of US EMRs?

My answer:

The only legal requirements for protecting patient health information in the US is the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA became effective in 2001, with mandatory compliance in 2003-2004. These rules only specify who (“covered entities”) must protect health information and the security standards for electronic transactions. All covered health care institutions in the US must now comply.

How does HIPAA influence EMR design? IMHO: Not a whole lot. Most of the functionality of an EMR system is incorporated in the data presentation and work-flow management within the EMR itself. HIPAA only dictates privacy rules and data protection when health information is being transmitted from one institution to another. Privacy and security measures must certainly be implemented within an EMR, but it is usually a relatively minor component.

I’m talking specifically about the affect HIPAA has on EMR software design though. HIPAA has had a large influence on the behavior of covered health care institutions. Here are some related resources:

EHR System Modeling

I’m a regular Slashdot reader and it’s rare to come across a health care related post. So Arguing For Open Electronic Health Records of course caught my eye. I’m sure it was the open standards aspect that attracted them, but I also wanted to point out why the use of software modeling is so important to the development of EHRs.

The Tim Cook post is interesting in several respects.

The first is the reiteration of the importance of the “lack of true interoperability standards” and its affect on adoption of EMR. I’ve talked about this numerous times.

Another important point is that even though open source licensing may be free, the real costs of implementing any EHR system (i.e. going paperless) are significant.

The importance of understanding and communicating the “semantic context” of patient data is also a key concept.

The goal of the openEHR open-source project is to provide a model and specifications that capture patient data without loss of semantic context. A “two-level modeling” approach is used (from here):

Two-Level Software Engineering
(click on the image to see it at full resolution)

Within this process, IT developers concentrate on generic components such as data management and interoperability, while groups of domain experts work outside the software development process, generating definitions that are used by systems at runtime.

If you’ve done any work with Microsoft’s WPF, this model should look familiar. Separation of responsibilities (designer vs. developer) is one of the fundamental shifts in GUI development that XAML provides. Separating the domain experts from the developers when building a health care IT system is also clearly beneficial.

No matter how good the openEHR model is, it unfortunately has the same adoption problems as many other health care interoperability systems: competing “standards”. For example, HL7 V3 Reference Information Model (RIM) and CEN 13606 have the same goals as openEHR.

Developing software systems based on conceptual models of the real world is not new. For example, the OMG Model-driven Architecture (MDA, also see here):

These platform-independent models document the business functionality and behavior of an application separate from the technology-specific code that implements it, insulating the core of the application from technology and its relentless churn cycle while enabling interoperability both within and across platform boundaries.

These types of systems not only provide separation of responsibilities but are also designed to provide cross-platform interoperability and to minimize the cost of technology changes.

The future of inter-operable EHR systems will depend on choosing a common information/behavior model so that the benefits of these development technologies can be realized. The challenge is to make the use of a framework that implements that model something that all stakeholders find advantageous.



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