8 ms·

As other comments mention, this project has been going for a while, the central reason it (or something like it) has not been robustly built out and deployed un

by jdhe 10y ago

As other comments mention, this project has been going for a while, the central reason it (or something like it) has not been robustly built out and deployed universally is because of the way congress chose to structure the funding for development of EMRs/EHRs. Rather than trying to find a system that could be universalized, the (idiotic) plan has been to give millions of dollars to multiple corporations to develop systems, then subsidize the purchase cost to providers to encourage adoption. Then, only once everyone has invested in their own proprietary system will they begin trying to universalize the system by developing cross compatibility. This methodology is perfectly in line with the free-market approach that the US has championed for decades. It is also the opposite of how almost every other country has developed and adopted universal EMRs. Sad. Especially because we know that a good, affordable universal EMR would significantly enhance the ability to deliver care for almost all sizes of healthcare providers.

criley2 10y ago
As a programmer for an American EHR firm -- all of the market share already belongs to one of those companies you malign. You could not have had the government sponsor some new software which would eliminate a billion dollar software market. It's a non-starter. All the hospitals already are signed on multi-year contracts with those large providers. Some of the EHR providers began writing medical software for hospitals in the 1960s and 1970s. These companies have multi-decade relationships with the hospitals they service, and decades of patient data stored. What Obama and the Democrats did was to break the "paper cycle". Many hospitals used paper-only system with very little software even into the 2000's and 2010's. The point of investing in each company was to jumpstart their products into meeting the huge new regulations, and the point of giving clients money to buy this new software was to break the paper cycle. There is no "one size fits all" option in the American market. I find it funny that you malign our practice as "(idiotic)" when it is your plan, quite frankly, which is so ignorant to the complicated history and reality of medical providers and their software, that seems idiotic to me. Your opinion sounds to me like "The US Gov should, instead of using MS Windows, pay a company to invent a new operating system, then ban all use of Windows, OSX and Linux to ensure all firms must use the single new solution". We already had so many options that have existed for decades, with so many clients, and so much built-out software infrastructure. There was no "one-size-fits-all" solution unless your solution includes "Destroy the entire industry, and use force of government to destroy a half dozen major software companies in favor of the government mandated and almost assuredly inferior option" The crux you may not realize is how customized every major hospital system expects their EHR software to be. I don't think you realize the sheer level of customization these networks require, due to the size and scope of their businesses. It takes entire teams of my company to service certain major clients. The idea of a one-size-fits-all would have been laughed out of our country.
- mtourne 10y ago
  Not entirely related, but the pain of the "paper cycle" as a "customer" of health-care is real. It seems as if to avoid dealing with hipaa regulation it's all paper, fax machine, and come pick up your x-rays burnt on a cd during your work hours (cd that you have to buy). Having not grown in the states, this type of practices seems very primitive to me. Amongst many other aspects of the American healthcare, but that's another debate.
  - vanattab 10y ago
    I am actually not opposed to the "CD you have to buy" policy. If I was hospital network admin I would not want people just plugging in random usb sticks into my network.
    - cmiles74 10y ago
      I think the expectation is that these organizations should be able to send this data to each other. That they was put the data on a disk and then give that to a patient who the drives it over to another part of town and hands the disk over is a ridiculous waste of everyone's time. It also highlights how far the entrenched vendors and hospitals will go to keep their customers "locked in."
      - nradov 10y ago
        And in most cases they can send that data to each other, at least in the sense that their existing systems are capable of interoperating based on open standards. But to make it work the provider organizations often have to configure and test data interfaces with other organizations. That's an expensive process and no one wants to pay for it.
  - deleted 10y ago
    [deleted]
- Brybry 10y ago
  But most physicians don't work for hospitals. They work at small practices with 10 physicians or fewer (according to the AMA). There was a completely open market, made of the majority of physicians, regardless of existing provider contracts with hospitals. I know I talked to a few physicians (and other healthcare professionals) in the mid-2000s who lamented the paperwork they had to do every day and the lack of available computer automation.
fnovd 10y ago
>affordable universal EMR would significantly enhance the ability to deliver care for almost all sizes of healthcare providers. Additionally, it would open the door for EHR-based research on a massive scale. Getting different hospitals' EMRs to play nice with one another is a huge barrier for large, retrospective cohort studies. Projects like the Million Veteran Program (http://www.research.va.gov/mvp/ http://www.research.va.gov/mvp/) would be just the beginning.
- darkmarmot 10y ago
  I work in this space in the private sector. From my perspective, the greatest impediment in the U.S. relates to our laws regarding PHI. I work on a system with petabytes of medical data -- but researchers can't access it because our laws and regulations don't support it (and thus provide no financial incentive and only risk and lawsuits for the companies holding it.) It's abysmally sad.
  - Eugr 10y ago
    Well, PHI protection (HIPAA) is actually a good thing and doesn't really prevent researchers from accessing data as long as PHI is stripped (de-identified dataset). Now getting that de-identified data is not always easy...
- gmarx 10y ago
  Now you've hit my area of expertise. This might help enable large retrospective cohort studies but would not be sufficient. In order to do that the universal system would need to do several things which are unlikely: 1)Universal clinically meaningful data model 2) Extensive use of standard terminology codes 3) good model of timeline 4) user interface which encourages the entry of discrete data over free text
dragonwriter 10y ago
> Rather than trying to find a system that could be universalized, By "system that can be standardized", do you mean, e.g., defining standard data content, representation, and interchange formats and perhaps funding one or more open source implementations, or creating and mandating a single mandatory software system?
mcphilip 10y ago
>Rather than trying to find a system that could be universalized, the (idiotic) plan has been to give millions of dollars to multiple corporations to develop systems, then subsidize the purchase cost to providers to encourage adoption. Then, only once everyone has invested in their own proprietary system will they begin trying to universalize the system by developing cross compatibility. This is misinformation. Interoperability via HL7 messages has roots in the 80s. The subsidies encouraging provider adoption of EMRs during Obama's administration set constraints on qualifying EMRs including a certain level of support for interoperability. The government sensibly leveraged existing standards produced by those free market forces you decry.
- megiddo 10y ago
  HL7 interop is a joke.
  - angersock 10y ago
    To elaborate for the uninformed: HL7 is literally just a syntax, and one that isn't reliably followed at that. It makes no solid guarantees about the semantic structure of the messages, and so is next to worthless. For a simple analogy, consider that two companies have agreed to write contracts in English--and little else.
- cmiles74 10y ago
  I don't think we will ever see HL7 messages exchanged between organizations. Each product has it's own list of message types that they support, and even then they will vary in terms of which segments have data and in some cases, even what that data will be. Patient identifiers also vary between organizations, making it hard to know which patient goes with which piece of data. Alternative methods for passing data between organizations have been proposed, but the vendors as well as the hospitals have been fighting this tooth and nail. The big EMR vendors are dragging their feet (and cashing government checks) but hospitals aren't pushing for this functionality either. IMHO, hospitals also would prefer to keep patient data to themselves.
  - 10y ago
throwanem 10y ago
> This methodology is perfectly in line with the free-market approach that the US has championed for decades. Not really a libertarian myself, but were I to pretend for a moment that I was, I'd say that this statement of yours could not possibly be less accurate, and that federal interference of this sort is the precise, diametrical antithesis of what is meant by the phrase "free market".
- triangleman 10y ago
  Ah, but then you ignore the many years of deliberate effort by politicians to equate "privatization" and "public/private partnerships" with "free markets", to the point where OP's statement is perfectly reasonable in light of history.
  - throwanem 10y ago
    My undoubtedly imperfect emulation of a libertarian wishes me to note in response that that's just the sort of thing which a statist politician, heavily invested of necessity in the status quo, would say, and that there's no reason why we should lend the claim credence just because it's been around for a while. He suggested following that up with what I believe to be an Upton Sinclair quote, but I'd rather eat my supper than participate in an argument over Mises and Rothbard, so I think it's time I snapshot and terminate the running instance.
clueless123 10y ago
If the government has to get involved, it should be on helping (forcing) to define a flexible/complete vendor agnostic data interchange model that patients can carry along wherever they may go. The rest is just GUI, bells and whistles.
- nradov 10y ago
  The Office of the National Coordinator has been helping on some aspects of that through support of the HL7 Consolidated CDA (C-CDA) initiative. So we do have a vendor agnostic data interchange format. But typically patient records are sent from one provider to another; there's still no good way for patients to "carry" their records.
nradov 10y ago
Your statement is factually incorrect. The US federal government has given little or no money directly to EMR vendors. Instead the HITECH Act grant funding went to providers to reimburse them for purchasing and implementing EMRs. And in order to receive that funding the providers had to demonstrate that they were actually using their EMRs in a meaningful way. Most other countries don't have universal EMRs, and the ones who do aren't necessarily happy with them. One size doesn't fit all.

by jdhe 10y ago

criley2 10y ago

As a programmer for an American EHR firm -- all of the market share already belongs to one of those companies you malign. You could not have had the government sponsor some new software which would eliminate a billion dollar software market. It's a non-starter. All the hospitals already are signed on multi-year contracts with those large providers. Some of the EHR providers began writing medical software for hospitals in the 1960s and 1970s. These companies have multi-decade relationships with the hospitals they service, and decades of patient data stored. What Obama and the Democrats did was to break the "paper cycle". Many hospitals used paper-only system with very little software even into the 2000's and 2010's. The point of investing in each company was to jumpstart their products into meeting the huge new regulations, and the point of giving clients money to buy this new software was to break the paper cycle. There is no "one size fits all" option in the American market. I find it funny that you malign our practice as "(idiotic)" when it is your plan, quite frankly, which is so ignorant to the complicated history and reality of medical providers and their software, that seems idiotic to me. Your opinion sounds to me like "The US Gov should, instead of using MS Windows, pay a company to invent a new operating system, then ban all use of Windows, OSX and Linux to ensure all firms must use the single new solution". We already had so many options that have existed for decades, with so many clients, and so much built-out software infrastructure. There was no "one-size-fits-all" solution unless your solution includes "Destroy the entire industry, and use force of government to destroy a half dozen major software companies in favor of the government mandated and almost assuredly inferior option" The crux you may not realize is how customized every major hospital system expects their EHR software to be. I don't think you realize the sheer level of customization these networks require, due to the size and scope of their businesses. It takes entire teams of my company to service certain major clients. The idea of a one-size-fits-all would have been laughed out of our country.

mtourne 10y ago
Not entirely related, but the pain of the "paper cycle" as a "customer" of health-care is real. It seems as if to avoid dealing with hipaa regulation it's all paper, fax machine, and come pick up your x-rays burnt on a cd during your work hours (cd that you have to buy). Having not grown in the states, this type of practices seems very primitive to me. Amongst many other aspects of the American healthcare, but that's another debate.
- vanattab 10y ago
  I am actually not opposed to the "CD you have to buy" policy. If I was hospital network admin I would not want people just plugging in random usb sticks into my network.
  - cmiles74 10y ago
    I think the expectation is that these organizations should be able to send this data to each other. That they was put the data on a disk and then give that to a patient who the drives it over to another part of town and hands the disk over is a ridiculous waste of everyone's time. It also highlights how far the entrenched vendors and hospitals will go to keep their customers "locked in."
    - nradov 10y ago
      And in most cases they can send that data to each other, at least in the sense that their existing systems are capable of interoperating based on open standards. But to make it work the provider organizations often have to configure and test data interfaces with other organizations. That's an expensive process and no one wants to pay for it.
- deleted 10y ago
  [deleted]
Brybry 10y ago
But most physicians don't work for hospitals. They work at small practices with 10 physicians or fewer (according to the AMA). There was a completely open market, made of the majority of physicians, regardless of existing provider contracts with hospitals. I know I talked to a few physicians (and other healthcare professionals) in the mid-2000s who lamented the paperwork they had to do every day and the lack of available computer automation.

fnovd 10y ago

>affordable universal EMR would significantly enhance the ability to deliver care for almost all sizes of healthcare providers. Additionally, it would open the door for EHR-based research on a massive scale. Getting different hospitals' EMRs to play nice with one another is a huge barrier for large, retrospective cohort studies. Projects like the Million Veteran Program (http://www.research.va.gov/mvp/ http://www.research.va.gov/mvp/) would be just the beginning.

darkmarmot 10y ago
I work in this space in the private sector. From my perspective, the greatest impediment in the U.S. relates to our laws regarding PHI. I work on a system with petabytes of medical data -- but researchers can't access it because our laws and regulations don't support it (and thus provide no financial incentive and only risk and lawsuits for the companies holding it.) It's abysmally sad.
- Eugr 10y ago
  Well, PHI protection (HIPAA) is actually a good thing and doesn't really prevent researchers from accessing data as long as PHI is stripped (de-identified dataset). Now getting that de-identified data is not always easy...
gmarx 10y ago
Now you've hit my area of expertise. This might help enable large retrospective cohort studies but would not be sufficient. In order to do that the universal system would need to do several things which are unlikely: 1)Universal clinically meaningful data model 2) Extensive use of standard terminology codes 3) good model of timeline 4) user interface which encourages the entry of discrete data over free text

dragonwriter 10y ago

> Rather than trying to find a system that could be universalized, By "system that can be standardized", do you mean, e.g., defining standard data content, representation, and interchange formats and perhaps funding one or more open source implementations, or creating and mandating a single mandatory software system?

mcphilip 10y ago

>Rather than trying to find a system that could be universalized, the (idiotic) plan has been to give millions of dollars to multiple corporations to develop systems, then subsidize the purchase cost to providers to encourage adoption. Then, only once everyone has invested in their own proprietary system will they begin trying to universalize the system by developing cross compatibility. This is misinformation. Interoperability via HL7 messages has roots in the 80s. The subsidies encouraging provider adoption of EMRs during Obama's administration set constraints on qualifying EMRs including a certain level of support for interoperability. The government sensibly leveraged existing standards produced by those free market forces you decry.

megiddo 10y ago
HL7 interop is a joke.
- angersock 10y ago
  To elaborate for the uninformed: HL7 is literally just a syntax, and one that isn't reliably followed at that. It makes no solid guarantees about the semantic structure of the messages, and so is next to worthless. For a simple analogy, consider that two companies have agreed to write contracts in English--and little else.
cmiles74 10y ago
I don't think we will ever see HL7 messages exchanged between organizations. Each product has it's own list of message types that they support, and even then they will vary in terms of which segments have data and in some cases, even what that data will be. Patient identifiers also vary between organizations, making it hard to know which patient goes with which piece of data. Alternative methods for passing data between organizations have been proposed, but the vendors as well as the hospitals have been fighting this tooth and nail. The big EMR vendors are dragging their feet (and cashing government checks) but hospitals aren't pushing for this functionality either. IMHO, hospitals also would prefer to keep patient data to themselves.
- 10y ago

throwanem 10y ago

> This methodology is perfectly in line with the free-market approach that the US has championed for decades. Not really a libertarian myself, but were I to pretend for a moment that I was, I'd say that this statement of yours could not possibly be less accurate, and that federal interference of this sort is the precise, diametrical antithesis of what is meant by the phrase "free market".

triangleman 10y ago
Ah, but then you ignore the many years of deliberate effort by politicians to equate "privatization" and "public/private partnerships" with "free markets", to the point where OP's statement is perfectly reasonable in light of history.
- throwanem 10y ago
  My undoubtedly imperfect emulation of a libertarian wishes me to note in response that that's just the sort of thing which a statist politician, heavily invested of necessity in the status quo, would say, and that there's no reason why we should lend the claim credence just because it's been around for a while. He suggested following that up with what I believe to be an Upton Sinclair quote, but I'd rather eat my supper than participate in an argument over Mises and Rothbard, so I think it's time I snapshot and terminate the running instance.

clueless123 10y ago

If the government has to get involved, it should be on helping (forcing) to define a flexible/complete vendor agnostic data interchange model that patients can carry along wherever they may go. The rest is just GUI, bells and whistles.

nradov 10y ago
The Office of the National Coordinator has been helping on some aspects of that through support of the HL7 Consolidated CDA (C-CDA) initiative. So we do have a vendor agnostic data interchange format. But typically patient records are sent from one provider to another; there's still no good way for patients to "carry" their records.

nradov 10y ago

Your statement is factually incorrect. The US federal government has given little or no money directly to EMR vendors. Instead the HITECH Act grant funding went to providers to reimburse them for purchasing and implementing EMRs. And in order to receive that funding the providers had to demonstrate that they were actually using their EMRs in a meaningful way. Most other countries don't have universal EMRs, and the ones who do aren't necessarily happy with them. One size doesn't fit all.