Interesting that you code using ICD-9. What do you do when you’re testing *for* something, and the diagnosis isn’t present?

Now 4 fields emerge, a friendly description(the clinician’s preferred language), the ICD 9 code, and an additional field comment that is free text with a brief descriptor, and finally room for a longer comment in free text. It is the clinician’s choice which to leave in the record. However if the ICD9 is used it will always appear with a friendly description.

Program Maintainance allows new additions, or editing. Nothing can be removed however since no longer used or inaccurate vocabulary may still be tied to a record and must stand. The onus is put on the clinician to keep documentation accurate, not on the EMR itself.

The system was created to be “held open” until it is complete but once closed(electronically signed) the user has only the same calendar day to change it. After that it can not be changed. Of course there is always the option of inserting a new “Encounter” that corrects any past Encounters. This is the equivalent of putting that neat straight line through the record, dating it, and initializing it as in other legal documents.

Yes there may be some initial extra effort to to customize language to standard vocabularies but the result, once established, is a more accurate documentation process that can be used by its creator and anyone who is a legitimate entitled caregiver to the patient or the patient themselves.

I am, however, a strong believe that any data used outside of the relationship that created it must be corroborated by a new circumstance of a different user and the patient involved. No data not produced by a current user should not be taken for granted. e-patient Dave has already told his story about that one.

You have a great blog. I found your post very interesting to read. We work with the NHS in the UK and have just launched an additional module to interface with the NHS ESR (Electronic Staff Record) system, I think this a step in the right direction that the NHS has the facility to allow third party systems like ours to syncronize with their central database.

We do not deal with Patient records, but my point is the accessability of the data is important. I wonder how long it will take Google to launch Google Health in the UK, as far as I know all my personally health records are still kept on paper.

One of my first medical records projects was in the 90′s and the goal was to communicate the statistics of procedures performed by doctors particularly in the area of the ‘plumbing’. The overwhelming and alarming conclusion of the data was that there were a lot of doctors performing procedures which they were unqualified to perform, based on the results of tests interpreted by personnel unqualified to interpret them after being administered by others untrained and unqualified to carry out such tests.

The experience, which was for a world leader in the field to present at a global conference, left me with a strong and lingering fear of medical treatment. Things haven’t changed. I certainly would like to see improvements in medical services.

Perhaps one good thing about a potential central record data store is that potential patient/victims may at least check whether their doctor is so qualified, and their level of experience in the particular procedure, and whoever trained them, along with the experiences of the patients, even those who perhaps fail to survive the patient experience.

Of course this will open up a big can of worms for lawyers, liability, marketing tactics etc.
Far be it from me to suggest that perhaps that would be as good a place to start as any, if you want to start storing medical records and making them publicly available.

The data on procedures is readily and generally electronically available, is easily sanitised for patient privacy, and would ensure that patients can encourage doctors to be better qualified and educated.

Perhaps this might be a nice project for google to cut it’s teeth on. If google can perform that, with no doubt, much litigation from doctors, then perhaps afterwards they my be given the chance to handle actual patient records.

Our objective is better patient outcomes for fewer dollars isn’t it?

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No kidding – the limits. Six degrees of separation is more like it.

1. The US took a system which was largely created for mortality reporting and made a clinical modification so it would be useful for morbidity too.

2. It is required to be reported for billing.

3. Payment policy is designed around the codes.

4. True use of the codes changes dependent upon the payment policies of the insurance company (not supposed to happen under HIPAA, but check with your billing office).

5. ICD-9 is now over 30 years old because ICD-10 implementation, which would help, was delayed for a decade because the transition would be too hard.

6. Now its supposed to somehow be used for true clinical condition feedback to the patients.

It’s like we are trying to use a PC with 64MB of memory to support the EHR. It just won’t work very well.

I think we’ll be much safer having our health & medical data hosted by Google/Microsoft or whoever ends up being the main provider of cloud-based PHRs than what currently exists.

At least with Google we’ll end up having some way to control the information, unlike today where we are completely at the mercy of a few people who tell great stories at conferences and would make you believe that current EHR can have great positive impact on the quality of care. As with everything else in Medicine we should adopt a strict “Verify and then Trust” policy regarding all statements made about the capabilities of the existing EHRs. It would be nice to get some idea if they are almost pure EBR (I like Dave Electronic Billing Record. Sounds better than Electronic Reimbursement Record) or if they can also be used for more useful purposes.

It is possible that some of the people involved in the design and implementation of EHRs are following our conversations. It would be nice to see them provide some answers.

Like everything else in today’s world, in our post G. Bush time, transparency about hospital EHR should be an absolute requirement. Anything else will just provide great opportunities for investigative journalism. There is just too much that rest on having effective EHRs to keep relying on rational ignorance.

I don’t propose starting with the hardest task first, merely improving the processes where we can without forcing people to learn new things or do more than they do now. Perhaps relieve them of some of the load and they can put some time into arriving at a common language for both treatment and billing. I am not sure that coding is going to be the easiest place to gain efficiencies or improved outcomes in treatment.

I do agree that there has to be some form of common language for billing, but a common language is not the easiest way to make improvements in health care, and I would seek to pursue the easiest gains first.

Perhaps I see the priority as who, what, when, why, who paid. The billers obviously see it from another angle. Google Health sees it from the view of how do they get their hands on all that valuable data, and get it into their system so you have to visit them to see it, and see the advertisers ads.
That’s the real world of health records, but not a doctor or patient priority.
The doctors and patients want their accurate records available for treatment, not marketing or research primarily.
Who is the patient? the doctor? google health has neither the correct diagnosis nor the prescription to satisfy the primary concerns of either.

I put it to you, just because we have a super modern warehouse with all the data in it doesn’t mean that patient outcomes will be better. It has little effect on the personnel and patients in the real world. To improve patient care we must seek to improve the processes that those personnel participate in, and where the information is stored is of little relevance when you are staring at a screen, what is relevant is whether they are the right records for the right person and that you have the right to access them. If that can be properly established, all else follows. Providers will be able to compete to provide records storage services and if it is easier and more efficient then customers will use their services, but it makes little difference where the records are if the mechanism to share them is in place.
Everyone is in danger of being distracted. Electronic records make sense, provided they are safely stored and adequately backed up and google may one day provide a better service than their competitors, but until all the newly created records and the old ones are digitised (impossible) there will be gaps, errors and ommissions. Simply tipping all the records into a barrel, albeit a sophisticated search enabled one, will not suffice.
While no-one can argue that e-records can improve efficiencies, they can also degrade services in the short term unless properly conceived and executed.
That means we need to improve our current processes so that whatever we build upon is a solid foundation for achieving our real goals, better outcomes and lower costs.
While others herd the cats, I’ll streamline their processes so they have a little time to listen to your message and learn new things.

Yeah, I first heard GIGO several (ahem) decades ago. :–) You should go back and read my previous post, where I twisted GIGO to “Garbage out [of the old system], garbage in” [to the new one].

Gilles, you are one step ahead of me. Just this weekend as I thought about this post I was reflecting on “Wait a minute, if this vocabulary was developed for disease statistics, why on earth is it being used for billing??” And indeed, one major missing factor is that the vocabulary has no way to encode “testing for this condition” vs “has this condition” or “suspect he might have this condition.” That would be a pretty fundamental thing to build into something that was designed for accurate billing.

Dean, what are you talking about with “ad-supported”? I don’t recall seeing ads in Google Health, but besides, I have no difficulty ignoring ads that I don’t care about. Besides, Google’s not the point here. The point is the accuracy of my medical records. (And yours of course.)

There are many issues with what google proposes, the chief one being why would you need to give them your records, or create any other copy of them, merely to share them with someone you have authorised to treat you?

Security is a serious issue, not effectively addressed by google or any other proposer of a central storage system.

A central ‘permission system’ is what is required, as part of a medical system which automatically provides only those with a need and your permission, to access your records, wherever they are. This might include insurance, VA, government, employer, doctor, doctor’s receptionist,medical researcher, all with different levels of access, but provided through a central ‘permission system’ with your knowledge and permission.

The core function of the permission system would be authenticating the participants and providing the path to the information, without ever holding the information. It’s fairly obvious that a doctor isn’t interested in the patients billing information, rather the clinical information.
Role based authentication would make it easier, more efficient and minimise confusion by not drawing conclusions from codes, or bills, and providing less distraction for the particular user.

Moving everyone’s medical data to a central ‘warehouse’ will not improve patient care.

The primary area where we can effect an improvement in treatment is correctly identifying the patient, then we can locate the required records, provide better accountability for treatment costs, reduce fraud and generally provide better outcomes.

Reduction of costs through efficiencies in billing and fraud control will improve patient outcomes. Streamlining and securing payment and claims processes and reducing paperwork for medical personnel will improve patient care.

These are the areas we should be focusing on, not a google-type ad supported medical records warehouse which provides little improvements in patient care whilst significantly increasing the risk of error, loss of data and privacy and additional costs for heathcare providers and consumers.

By all means leave your records where they are, and of course upgrade doctors to electronic systems, but teaching every medical practitioner to speak in codes is a gross waste of education brainpower and resources.
They already speak a language perfectly adequate to provide treatment. Make the system fit them, not the other way around.
Best regards.

DR Procter
deanprocter@transinteract.com