Virtually Priceless Thoughts

Reflections on Health, Informatics, and Research

Archive for the ‘Health’ tag

The importance of health information

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This is a follow on the last post on health information. I actually started this one before I got the question, so maybe this is a prequel blog post…?

I have been thinking about the challenges that are going to face us in Canada as we move forward and start interconnecting EMRs (Electronic Medical Records) and sharing data. I am wondering:

What happens to health information when the EMRs of today are no longer “islands”(1) unto themselves?

Right now many EMRs are being used in relative digital isolation. Often EMRs have a laboratory results feed in to the practice, but very little comes out of the practice in digital form. Printing of referral letters and consult letters and patient summaries and prescriptions is the norm.

Many clinicians, from what I have observed, still think of their EMRs as “EPRs” – Electronic Paper Records. They use them as legible, remotely accessible paper charts and work around limitations as they would in paper. For example:

  1. Prescription writer or lab form is too complex?
    No problem, write it in free text and use the paper forms still in your office.
  2. EMR have a problem with not putting significant past medical and surgical history on your referral note?
    No problem, just put it in the problem list. The problem list prints on the referral note automatically.
  3. Not able to code procedures correctly (because you are using the problem list as in #2)?
    No problem, do not worry about the code, just pick something close and edit the display name so it is accurate to what you are trying to say.
  4. Do not have a place to document housing issues? No problem, just create a new data element in the problem table for “unstable huosing – living under Main St Brige”(2)
  5. Problem list not specific enough for you?
    No problem, create a new value in your code set that is more specific.
  6. Difficult to write that complex dosing regime of one pill twice a day and two pills at night?
    No problem, put anything in the main field but make sure you use the comments field to say what you really want, the pharmacist will figure it out when she reads the printed prescription.
  7. Want to speed up your new patient visit? No problem, the EMR makes it easy to make your own templates. Just make a new template with tick boxes for “All immunizations up to date”, “NKDA” and others. OR you can just make a text macro that gives you a nicely formatted few paragraphs that you can edit only where you need to.

You can see where things are going, right? All of those are real examples and all of these are uniquely solved in each practice. Oftentimes they are uniquely solved many different ways in one practice.

Now fast forward a few years and start linking up EMRs, through Infoway’s EHR or through a standardized referral system or even through a custom interface from the vendor (it doesn’t really matter) and what happens?

As patients move around, EMR data in each practice becomes a mosaic. Local fixes are copied from one system to another. Each one different, just like the old paper charts. Specialists will have a worse time of it as they will be getting referrals from many sources, each one customized.

Clinical decision support will fall apart — how many people are missing their H1N1 vaccination? Don’t know, some of these records are using this field “immsuptodate” and others code it in the problem list as “053, injection, other” with a display name of “H1N1”, another few have this field called “immunizations_UTD_2009″…

The default approach would be to leave free text alone and only consider coded values, but this does not help when clinicians have co-opted terms for their own use.

This scares me. I do not think we have thought deeply enough yet on how to manage this issue. dreamstimemaximum_766576.png

It is going to be a huge clean up activity to get existing information standards compliant. To be fair to the EMR vendors and clinicians, there is not a supported “right” way to store health information in EMRs yet. We have some standards in Canada, but the bulk of the clinical information has been recorded without those standards in mind. The local “work arounds” were/are required to get the job of providing care done.

What tools should we start seriously considering in order to improve our health information as it moves off the isolated islands? Maybe we just need more duct tape?

Harmonizing our standards and redesigning EMRs to be standards compliant are only part of the process.


1. This is a popular term here in BC and likely elsewhere – a standalone EMR with few electronic connections to the outside world would be an island. Much of the data coming in and out is via paper (printing and scanning). It is an appropriate analogy as information is evolving more rapidly on islands.

2. Typos intentional to prove a point. Note also that there could be no code associated with this if the EMR allowed for codeless terms.

Written by priceless

April 4th, 2010 at 7:49 am

Posted in EMR,Informatics

Tagged with ,

Clinical Architect: Requirements Engineering.

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NOTE: This post is a follow up from the overall post on what does a clinical architect need to know.

A Clinical Architect should be able to design requirements, even though that might not be a day to day activity.

I prefer terms like requirements design or requirements engineering as I don’t think requirements are just out their to be picked off trees. Requirements elicitation, for example, suggests you just have to ask users. I do not think requirements design consists of pulling some people into a room and asking them what they need. Or at least, I do not think that is the only thing required.

While the user is never wrong, the user is not always right. Especially in a meeting room, away from their daily work when they haven’t been trained to think about requirements. You can often get suggestions for solutions (just trying to be helpful!) and a lack of understanding of the needs.

“I need a soft ware for electronic call schedule management”

“I need secure email”

“I need… version 9 of the EMR Cardiology Suite by MegaCorp”

With these statements, one isn’t sure why they need these solutions – what are the solutions addressing? Was it that that EMR Cardiology Suite was seen at a conference? Or were the reasons for secure email really about an integrated electronic solution for referral management?

Complex problems and their “solutions” are intertwined (see Wicked Problems), but it is important to have the context of the problem somewhat understood before exploring solutions (and then re-describing the problems being addressed).

A Clinical Architect’s role here is two-fold. First, to have an understanding of the process used to engineer requirements and be able to articulate it. Second, to ensure that potential solutions are reviewed in the broader context of the organization: how can the solution be reapplied to other settings? how aligned in the solution to other aspects of care delivery? how much patient information is being locked away in an isolated clinical information system that would be useful to other providers or the patient in other settings? These are the types of broader questions that should be explored with the organization’s clinical architect during project scoping and in the more detailed requirements engineering activities.

Just for reference:

BABOK 2.0 is now available free on Google Books. To be shared with BAs, absolutely, but also adapted to the organization so that there is local expertise in a subset of approaches. (They also speak of requirements elicitation…)

Written by priceless

March 14th, 2010 at 8:18 am

Clinical Architect: General Enterprise Architecture

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NOTE: This post is a follow up from the overall post on what does a clinical architect need to know.

Being able to consider the full scope of design is, I think, an important piece for someone who – as an organization’s Clinical Architect – is leading the decision making around how the clinical systems fit together (or consciously do not fit together) to meet the organization’s goals.

While clinical leaders often think of systems from a care perspective, they often have not had training in the areas of information systems. With the complex CISs in play in many large organizations today, this kind of structured thinking is key.

Enterprise Architecture is the logic, processes, and products that connects the organization’s operations to its ICT infrastructure design.

This architecture should span the organization, not just IM/IT.

National Institutes for Health have their description of Enterprise Architecture.


There are many approaches to Enterprise Architecture. For organizations that are developing their architecture capabilities, it does not make sense to go too heavy, nor invest in a proprietary approach when there are good, published, open approaches. TOGAF, for example, is a good, open standard to enterprise architecture. It can be tailored to be light enough for early use and can the grow with organizations as they are ready to grow. Version 9 is available online. The figure on the side is a nice cyclical approach to EA management from TOGAF.

The Zachman Framework (wikipedia link) was developed in the 1980s at IBM and has been adopted, adapted, and revised since then. The Enterprise Architecture Center of Excellence now is its home. There are several tools to members (I am not a member). I have always thought of the Zachman Framework as something that is heavier to implement than other frameworks, such as TOGAF. I do like how the Zachman Framework ensures goals are explicit in the modelling processes.

I think what is important to keep in mind, for me, is that this level of architecture is much more socio-technical in its approach than simply a technical architecture.

There are others, certainly, but I thought I would list two. Please suggest others that you think are applicable to healthcare.

Written by priceless

February 28th, 2010 at 8:15 pm

Clay Christensen at Mayo’s Transform 2009 Conference

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Here is an interesting conference on line from Mayo. I’ve just watched Clay Christensen’s keynote on disruptive technologies and healthcare.

He spends time comparing business and healthcare and does it quite well.

An interesting piece at about 21 minutes, where he talks about non-disruptive competition leading to increased prices. He gives examples in the Boston-area and others where head on competition results in increased prices. Competing groups tend compete on features, driving up costs.

He argues that disruptive technologies come in that are simpler and cheaper. They enter the marker in a related, but more decentralized market that could not afford the incumbent’s full product but could use some features (his big example was the mainframe computer being disrupted by the minicomputer being disrupted by the personal computer). Each one was increasingly cheaper, less powerful, and more widely available – they were increasingly decentralized and thus were able to provide value in markets that where the others could not / would not compete and then provided more over time.

In healthcare this means enabling outpatient services and primary care to do many of the things that hospitals do. IV antibiotics, for example, could be given at my clinic much cheaper than they could in the Emergency Department, with all of its overhead, skills and equipment that are there, designed to manage acute traumas and heart attacks.

Today, our nurse practitioners and nurses in my clinic do many of the things I might have done in my private office (or might still be done in a typical family physician office without nursing support).

This decentralization ultimately would extend out far beyond the walls of hospitals directly to patients, providing them with the technology for self management.

Three Enablers for disruption to be successful:

  • Simplifying Technology – that can maintain quality
  • Business Model allows for innovation
  • New Value Ecosystem that can consume the disruptive technology

At around 39 minutes, he makes a statement that general hospitals are not a viable business model and spends some time talking about types of business models and how general hospitals are really a mush of all three major types of models. No wonder that hospitals and the flows of patients through hospitals are so complex.

He ends with an interesting piece on where chronic disease management is best situated, in terms of motivation. While I have concerns about heavily engaging employers in patient care, I found his mapping of motivation and requirements for behavioural change something that resonating both my clinical experience and my work on PHRs at the National Research Council.

Here’s a version of his chart from my notes:


(click for larger version)

I found this an hour well spent – thanks KL for the link to this excellent talk.

Written by priceless

December 9th, 2009 at 6:18 am

Posted in Uncategorized

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Palm Prevention Lives – Sort of.

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Nine years ago I started a little research / development project on the palm PDA called Palm Prevention. This was my resident research project in family medicine and I eventually did a “pilot” study (forgive the pun) and was published. In the nineties I was very interested in PDAs in healthcare and had several projects looking at clinical education, decision making, access to reference materials, and creating tools that took simple context into account.

Palm Prevention was a quick, patient specific screening tool that essentially took 50 or so evidence-based clinical practice guidelines and presented them to the user, filtered based on a few key criteria that fit on a single palm OS screen. Here are a couple of screen shots. The first screen is the start screen where the user provided a few key elements of patient history. The second is the filtered list of guidelines ranked in order based on evidence level (A being the strongest for). From there, tapping on any line brought you details of that guideline.

Palm Prevention1.png Palm Prevention2.png

I released it free on the Internet (now deunct, but had several of my projects on it)

Today, I was on the AHRQ site and rediscovered their ePSS. Using the USPSTF guidelines, that have a similar approach and a tool that is available on multiple platforms, including the iPhone:

IMG_0003.png IMG_0004.png

More slick GUI thanks to the more advanced platform, but similar approach to what I was working on nine years ago. I do not have anything to do with the AHRQ or their tool, but I am happy to see that the idea is still alive and people are finding it useful enough to have a very similar design 9 years later.

Written by priceless

June 14th, 2009 at 10:26 am