- Discrete: the type of data that is easily queried, has understood distinct and discrete values, is coded, etc

- Free-text: Generally what doctors use, that is – notes, pathology reports, radiology reports, etc

Being a computer scientist (and budding biomedical informaticist) my feeling is “well just make the EHR collect all information discretely” but there are many problems with this approach. It is insufficiently holistic with regard to actually speaking about a patient’s health, it is not how doctors usually “think” about patient information, it is MUCH harder (prohibitively) to collect, and the field of medicine changes so quickly that it is very difficult to keep your “library” of variables up to date. And thus, unfortunately, shall it always be.

Hence the dichotomy between the discrete (read: insurance billing) and the free-text (read: patient care) types of data. The key here is that I suspect the folks DESIGNING the google systems are some mix of MDs and Strict Computer Scientists, whereas they really should have bioinformatics people designing it.

In response to your specific questions raised:

1) Billing data is discrete, hence it cannot by definition explain fully patient conditions. Unless and until there is a perfect mapping between free-text entry and discretely defined patient data, coded billing data will always be “confusing” if viewed as diagnoses.

2) My feeling is that this is GOOGLE’s fault (see my point above about who is working on the google product). Doctors typically use PATIENT CHARTS and have absolutely no interaction with billing codes.

3) Because without using complicated programming like natural language processing (NLP, which is always only partially successful in representing free-text), billing data is often the only discrete data available. My guess is that nobody is using billing data for disease management. :)

4) This is a VERY interesting question. It would only be posed by auditors. They would look at your scenario and see that you received what you thought was ONLY your own data and looked at it in good faith. My feeling is that the results of this audit would say “correct your systems so that patient data is associated with the correct patient.” In other words an IT compliance problem and not a patient or doctor behavior problem.

5) Good question, harkens back to 4. I work in medical IT and one of the biggest barriers to a real cross-institution EHR are complex and scary privacy laws which cause us to ask questions like the one you pose above. There is of course still the challenge of GETTING patient charts (read: the free-text stuff) into an electronic format (as opposed to billing information, which already is for the most part).