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Data for EMR systems

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The use of and case management of EMR information

The use of and case management of EMR information

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  • 1. Electronic HealthRecords DatasetsFrom an MPI to personal recordsMedical information is managed and stored by anarray of people, organizations, and databases.S L Fritz Healthcare LLC5/6/2010
  • 2. Data Residency for EHR systemsContentsPatient Documents .............................................................................................................. 3Provider documents ............................................................................................................ 5Data Residency for the Enterprise ....................................................................................... 7Future Documents and Data .............................................................................................. 11Data Residency Horizon .................................................................................................... 17 1 © 2012 S L Fritz Consulting, LLC
  • 3. Data Residency for EHR systemsBy Steven L FritzThe places where data resides, stored, once a provider enters information, depends largely on theapplications configuration and to a lesser degree the instructions of the middleware – the ExtractTransform Load (ETL) system.All applications have a proprietary database where they put all information they originate or haveownership of. The app has to know about the contents and structure of its own data. Byextension, the app can be instructed to distribute or pole data resident in other databases. Ineither case, data finds it way out of the apps realm and into another.Both the source and target need to be understood as well as the transport systems. Figure 1 - Information Sources, Targets, TransportsPatientsDoctors charts and printed materialsWorkstations, PDA’s, Scanners and remote computers (data entry points)LANs, WANs, Wireless, and VPN transportsServers Web App Clusters and recovery systems ETL, HL7, EDI, BI, DW Print ServersStorage Primary including Local, NAS, Cloud Mirrored and Stripped Backup including data, replication, incremental, and image Transaction packaging and redundant databasesArchival Long term storage and compression 2 © 2012 S L Fritz Consulting, LLC
  • 4. Data Residency for EHR systemsPatient DocumentsThe beginning of the data ownership of medical information begins with the patient and extendsinto the doctor’s office.If we zoom in on the data interaction of the patient and the doctor we’ll see the currentownership and availability of data. Figure 2 - Patient to Provider Information ExchangeI’m a new patient and I arrive at Dr. Smith’s office with prior medical records in tow.Alternately my prior doctor sends the records on my behalf. My provider owns the accessresponsibility of documents in their possession – diagnoses, treatment plans, observations, etc.Conversely I’m responsible for documents in my possession - orders, prescriptions, medicalrecords copies, insurance materials, lab results, bills, information or educational information, etc.Let’s explore how this information does exist today and how it should exist in the distant future.First we need to get through the present and the near future. We end up with four points in time.There is the Past (p), the Present (P or P’), the Near Future (NF), and the Distant Future (DF).All IT initiatives underway today are engaged in taking us from the past to the near future. Ifyou’re shooting for the present, you’re wasting your time. Where I invest a good deal of energyis architecting a system for the near future while keeping my eyes on the distant future.Example; utilizing standard HL7 constructs are preferred over highly customized EDI structures.This helps with scalability, application migration, and future resource skill set availability in themarket place. 3 © 2012 S L Fritz Consulting, LLC
  • 5. Data Residency for EHR systemsSo, in a pre EMR environment, as shown above, data, information, and knowledge is entrusted inpaper and direct personal knowledge. Use of this information is limited to direct interpretationof the documents when developing a healthcare plan by the provider. The key word is limited.Limited by the availability of new technology processes and constructs, not by individualmedical intelligence. My doctor has always been smart. More tools yield better care. Give methat for the time being. Figure 3 - The Paper RecordThe near future is to move the medical records for physical form (at a single repository – theubiquitous color coded manila folders in your doctor’s office) to an electronic (digital) form. Ifwe do only this we have provided greater security, privacy, accessibility, and portability. If weadd the computer’s ability to look at norms for our conditions and remedies, the provider has agreat tool.The distant future will provide the foundation, framework, for me, the patient, to take ownershipof my data, in some electronic form. Let’s not go to chips in my head but rather something like asmart card or thumb drive, or some sort of personal storage device. Secure, indestructible,understandable, and useable by another healthcare profession of my choosing. Let’s thinkworldwide while we’re architecting the standards. Better yet let’s move the data to the cloud.Some computer, somewhere, accessible by the chosen. This includes my data and my doctor’sdata. Now that I think about it, this could become one in the same. 4 © 2012 S L Fritz Consulting, LLC
  • 6. Data Residency for EHR systems Figure 4 – The Cloud RecordAs we add in the other technology components of the picture, the near and distant future willbegin to take shape. As I look at the diagram, my healthcare provider and I appear closer.That’s a good thing.Provider documentsThe next in line of the data ownership of medical information is your health care provider. Thisincludes the staff at the clinicor hospital. They makeappointments, collectpayments, enter notes,immunization statistics, etc.If we look closely at the datautilization of the provider,we’ll see the currentownership and availability ofdata. As you’d expect, all ofthe medical and clericalinformation about the patientis available to the providerand their staff. Everythingfrom insurance to diagnosis Figure 5 - Health Records in the Practiceto prescriptions to treatmentplans. 5 © 2012 S L Fritz Consulting, LLC
  • 7. Data Residency for EHR systemsThe use of technology ranges from a standard desktop computer that is ubiquitous in a modernexam room to high resolution scanners to populate electronic records from hand writtenmaterials and pre-EMR archival documents. In the past (p), as mentioned before, the use of paperrecords were the predominate resource. In a fully implemented EMR environment thesematerials are actually a choke point. You need to have the documents in your hand which meansonly your hand. In the near future, everyone who has permission to view your records can do so.A consultant 1000 miles away.Your doctor doing charting from home using a secure line.A helpdesk nurse taking your call in the middle of the night.For the sake of this discussion, let’s separate the origins of medical information from the use anddissemination of the data. My main reason is that a doctor’s office, big or small, is in thebusiness of collection enough medical information to diagnose and treat its patients. This doesnot necessarily include backing up data, setting up data flows going to insurance companies, ororganizing electronic prescription interfaces with the Walgreens down the street. Think frontoffice and back office.So, as the primary originator of data, the focus becomes the input device and the type of databeing collected. The prize here is to collect searchable data. Scanning an old handwritten note isgood to preserve the document but no good to analyze what it says. The better technologies thatcan be used to help inthis endeavor, the betterthe usability of the data,the better patient care.Putting computers in theexam rooms was a greatleap forward. Use ofvoice recognitionsoftware and digitalmicrophones help withphysicians who don’thave a lot of keyboardtime. Linking emergencyroom informationcollected for pulse,temperature, andblood pressure Figure 6 - Multiple Data Sources and Input Technologiesaddedautomatically to the medical records is very helpful for quality and speed. Providing caregiverssmart phones to make quick decisions help everyone stay informed while on the move.Unlike the paper world, the transport of information within the medical office or hospital, acrosswires or through the air is vulnerable. We don’t even have to open the attack scenario for there tobe a privacy problem. Leaving an exam room with the previous patients’ information open andvisible is a problem. Send an electronic prescription to the pharmacy needs a bullet prooftransport that gets it right every time. Using computers in radiology and attaching an image tothe right patient is critical. 6 © 2012 S L Fritz Consulting, LLC
  • 8. Data Residency for EHR systemsNo matter where the data is coming from, there needs to be an electronic means to collect it andstore it in the EMR files.The distant future provides for any number of collection and storage options with as muchsecurity and privacy as humanly possible. Keeping portability in mine each step of the way will provide for as patient taking their records to whomever they wish to for future care without any lapses or miscommunication of data. The Health Insurance Portability and Accountability Act (HIPAA) was enacted by the U.S. Congress in 1996. It must stay pace with evolving technology landscape. The year 2016 will not look anything like 1996. When my doctor orders a lab test, keeping a tight, closed loop on the data is enormously important. Physical security of these electronic and paper records belongs squarely with the medical office I visit. Storage of the actual bits and bytes may fall to a data center located somewhere on planet earth. My doctor only need to Figure 7 - Movement to the Cloud ensure the transport of my records in and out of this centeris rock solid.For those times when the EMR is unavailable, printing of or access to critical medicalinformation is needed. Storing EMR files locally or on paper puts us back in the past with a 21stcentury twist. Holding the records of next week’s scheduled patients must be hardened withencryption of some sort. Last thing we want is for some person stealing a computer from a clinicloaded with all sorts of private data. Secure the technology. Secure the transportation in-house.Secure the import and export of information to entities outside of the four walls of the facility.Next we’ll travel to the back-end systems that store and organize everybody’s medical records.We will explore how my medical information helps me, the provider, and the multitude ofindustries in the background.Data Residency for the Enterprise 7 © 2012 S L Fritz Consulting, LLC
  • 9. Data Residency for EHR systemsThe end of the line for the medical records collected by your doctor is the enterprise database.The eventual storage of your medical information. Small physician offices may have a footprintas small as a minimally configured server. No matter how you look at it, there is a collection ofmedical information held for the convenience of the application that assists in the clinicalpractice. If we look at my original landscape for an EMR, it ends up looking like the followingdiagram. All of the big-practice equipment is consolidated into fewer boxes, in this example,one. Figure 8 - The Enterprise Application at the Data CenterThe use of technology in a small office only requires one computer to run the application, storethe data, and communicate specific data to insurance companies for claims and paymentpurposes.In a larger enterprise, up to the biggest, you do need all of the other systems (servers) partly tospread the work load, and partly to help alleviate a single point of failure causing system wideoutages. 8 © 2012 S L Fritz Consulting, LLC
  • 10. Data Residency for EHR systemsLet’s break down the EMR information, as mentioned previously, into the raw informationcollected and edited by the care giver (input), and the data placed into the system for back officefunctions like claims and insurance (output). Both are electronic (digital) versions of yourhealthcare information. A third type of data is the physical printing of any of your medicalinformation – prescriptions, lab orders, referrals, etc. (print). Figure 9 - Medical Records Transactions In and OutWhen we get to the details of how this information is used, the separation will be clearer.If my doctor was able to provide every medical service I needed without engaging any outsideorganizations, all of my medical information would reside within their walls, and subsequentlyprivate, secure, and complete. Since this is not true, even in tightly coupled HMOs, there willalways be a need to spread information about me to outsiders. This is especially true when theprovider (doctor, care giver) is not the insurer (policy and premium management organization).Most clinics do not house pharmacy departments. This requires some level of communication toyour drug store. A number of clinics do not have in-house laboratory departments. This requiressome level of communication to the lab in the form of an order, and from the lab in the form ofresults. Many organizations are not both the insurer and provider. This requires some level of 9 © 2012 S L Fritz Consulting, LLC
  • 11. Data Residency for EHR systemscommunications to and from the insurance company. All these examples are related directly toyou as a patient.In the illustration above, from the center to the right, are examples of the external interfacesrequired to round out your medical services. Services provided my organizations other than yourprimary physical. The original data, the transportation of that data out, the target system, andround trip, all need to be kept secure, private, identifiable (to you and only you), and accurate.Also in the illustration above, from the center to the left, are the business and accounting aspectsof your records. Information on your insurance company, your dependents, and your amountowed make up this portion of your Master Patient Index (MPI) file.Care on the right and accounting on the left. Let’s add in two other important data residencycomponents. First, your healthcare provider has a business relationship with your insurer. Thisusually encompasses payer contract data - what your physician gets paid for providing a specificservice or performing a procedure. Second is operational data. The types of care being providedby a clinic – immunizations, worker related injuries, and the like. This provides tools to themanagement onstaffing, supplies, andreporting to regulatoryentities. Clinicalinformation may becollected by miningindividual records butin an anonymousfashion. The use ofreporting tools withinthe main applicationor the implementationof businessintelligence systemsaccomplish the datamining task.All medicalinformation should bevalued and protected.Information on howmany patients Figure 11 - Venn diagram of the Three Pillars of EMR Datareceived immunizations for the flu is worth protecting but since it does not implicate anyindividual patient, it is in a different category therefore worthy of different treatment.Finally we’ll look at what all this data and the communication pipes it travels on in the past,Present, Near Future, and Distant Future. Having a roadmap help to guide the conversation, andthe architectural framework needed. 10 © 2012 S L Fritz Consulting, LLC
  • 12. Data Residency for EHR systems Future Documents and Data So far we’ve looked at the information the patient provides and brings to the physician. We’ve looked at the way in which the doctor creates information that is added to the master patient index (MPI), the whole of the patient’s medical database. Lastly we looked at how the MPI is blended with other enterprise or practice information to provide the foundation for your provider to give you quality of care using this pool of information / data. This view looks into the future both near and distant. To get the best value out of the current technology we should be guided by our vision of the distant future. If we divorce ourselves from the technology dialog and focus on the expected value to us, the patients, we’ll be positioned to architect the information horizon we want and need. As a patient I want and need;1. The ability to collect medical information needed for discussions and decisions that impact treatment and health plans, using my currently elected provider (the collection of doctors, nurses, practitioners, and need-to-know support staff).2. The ability to continue my care even when my primary physician is away on vacation, leave, busy, retired, and the like.3. The ability to share the aforementioned medical information with other professionals when specialist or second opinions are desired. This should include only the necessity information, not everything about me.4. The ability to utilize foreign or emergency services and have my base medical records be available, and, to have that external service to be properly recorded in my primary MPI.5. The ability to move the aforementioned medical information to a newly elected healthcare provider - change doctors. Maintain a proper continuity of care.6. The ability to keep all of this information secure, private, and correct. Number One There needs to be a centralized collection of electronic medical records that is used to provide the patient care. Simple and hopefully easy to accomplish. The future will dictate the media but for now I’ll pick a form for illustration purposes. I have a smart card in my wallet which holds everything about my medical history. I take my Health Records Card (HRC) to my doctor’s office where they are granted permission to copy it into their own EMR system. Let’s call this the Provider Records System (PRS). As data is created and collected, the PRS will be updated. At some prearranged schedule or event, my HRC will be refreshed so my private copy is kept up-to-date. 11 © 2012 S L Fritz Consulting, LLC
  • 13. Data Residency for EHR systems Figure 13 - Patient Centric EMR Storage and OwnershipThe updated perspective ofthe patient’s relationshipwith his own EMR data isshown below. This satisfiesobjective 1. Somewhere onthe technology horizon, Imight be able to put mysmart card into my homecomputer and see all of myown history. There may beportions that are kept fromme, the patient, but you getthe idea. Everything in oneplace.Number TwoExpanding on the diagramabove will illustrate pointtwo. The main authoritywith permission to thedoctors PRS, is thephysician who provided medirect health services. Toallow for others in themedical office to give meservices we’ll need toexpand on the alternative Figure 12 - Provider Centric EMR Storage and Ownershipproviders, but to providerswithin the same group. Thiscould be a partner in your clinic, or another clinic down the street owned by the same practice.Two, three, or many clinics under one operating umbrella. 12 © 2012 S L Fritz Consulting, LLC
  • 14. Data Residency for EHR systemsIf a group of doctors operate two clinics, one in San Francisco and another in San Jose, theywould all populate and use a singular MPI repository – an Enterprise MPI. There is no technicaldistinction between an MPI and an Enterprise MPI. It only draws a barrier between oneenterprise and another. In the illustration above, each physician has permission to access theirpool of patient data, and as granted, permission to manage other provider’s patients. Thispermission can be temporary or durable depending on how the systems are set up. Another Figure 14 - Multi Provider Data Exchange Methodsdoctor in the same office and another in the office down the street are given permission tomanage patient information. Objective 2 is accomplished with a segregate assignment withoutdispersing or diluting the singular repository of the patient’s data.Number ThreeSharing a patient’s EMR data withpeople outside of the immediateenterprise is rooted on the voice andprinted materials of the primaryphysician. No electronicmechanism (other than pre-screenedfax machines) exist to transportdiagnostic or treatment informationfrom one physician to another.Some technical platform needs to be Figure 15 - Health Records Card Mediabuilding to provide for external(foreign) physicians to enter electronic medical records information which eventually takesresidency in the MPI. This should include any collaborating information sources like images, labresults, and provider treatment and visit notes. 13 © 2012 S L Fritz Consulting, LLC
  • 15. Data Residency for EHR systems Figure 16 - Health Records, Patient, Multiple Providers, and the CloudThe media can take the form of links to data that resides on the individual providers EMR system(assuming secure transports and timely accessible), or as information that resides directly in thepatients MPI just as if the primary physician has entered it themselves. If the latter, keeping thetwo synchronized is not as important because one must be promotes to the position of ‘Data ofRecord’ status. This represents the one authoritative record.In the distant future, an exchange needs to be built to provide for the transportation of an HRC-light packet. Enough data to enable the alternate physician to provide the requested servicesincluding the return trip requirements. If the data is kept secure then the transport does notmatter (email, secure server, cloud, interface, VPN). If the transport is kept secure then the datadoes not matter. I recommend both.Number FourThe ability to utilize foreign or emergency services and have my base medical records beavailable, and, to have that external service to be properly recorded in my primary MPI.Key to the near future is the ability to give the patient their own electronic medical records viathe HRC. The alternative is to have access via old technologies to share conversations betweenproviders. This is impractical considering these are mainly non-scheduled visit. No advancewarning or preparation. The distant future should provide for an exchange where the data isavailable to be pulled on demand. As mentioned earlier, the treatment and notes need to bepushed back into the patients MPI. Security is the pivotal success factor for both the healthrecord card in the hands of the individual, and for the package of similar data that travels through 14 © 2012 S L Fritz Consulting, LLC
  • 16. Data Residency for EHR systemsthe cloud. Objective 4 is accomplished on paper. The job is to build the systems andtechnologies needed to enable it.Number FiveMoving from one provider to another is a very common event in the United States. There are anumber of reasons why a person would change doctors. Considering the linkage betweenemployment and healthcare insurance coverage, we will continue to require a smooth, complete,secure, and accurate movement of the contents of the MPI.The solution is the same for a permanent migration of the data as it is with a temporary use of thedata. The near future is the first stop. The distant future should be close behind – 2 years.Number SixFinally is the requirement tokeep the information secure,accurate, accessible, andprivate.When the information is heldwholly within the wall of myprovider, access is sufficientto keep my records secure.When that data moves to asemi-private platform suchas is required when I visithealthcare outside of thenetwork. This could be as Figure 17 - Health Records Transfers; Provider to Providersimple as prescriptions goingto the local drug store. It can be as complex as a review of an MPI by a consulting radiologist.Three layers of protection can be employed. First is encryption. Scrambling the data unless acipher is knows. Second is the transportation that will move the EMR data. Virtual PrivateNetworks (VPN’s) are a common and effective tool. Third is encoding. The removal of anyinformation that would identify the individual patient in question. The use of Medical RecordNumbers (MRN’s) may not be sufficient as this information is too readily discovered. Somesecondary coding is required, similar to the coding implemented for people seeking AIDStesting.There is nothing that prevents the use of all three simultaneously. I recommend it if performanceis not adversely impacted.When the data is housed, even for a short period of time, on a public platform, protection is mostneeded. What I mean by public is the placement of the data on the outside of the enterprises 15 © 2012 S L Fritz Consulting, LLC
  • 17. Data Residency for EHR systemsfirewall. There are any number of commercial solutions like those used by the credit cardindustry.Access and audit logs can be implemented at every level of access – additions, modifications,edits, and deletion. Deletion is actually a flag indicating the data is no longer part of normalreview of the file. The data is not actually deleted to provide for loss recovery and resurrection.Encrypt the data, control access via passwords, network security certificates and authentications,coding, and good old fashion physical security.Summary1) Transformation from current to future; i) Move EMR data to portable devices: (a) Secure, accurate, complete – Health Record Card HRC (b) Create synchronization systems to ensure timely updates between HRC and PRS (c) The cloud could be used but security is paramount2) Creation of new solutions; i) Build a MPI – EMR exchange infrastructure using encryption and coding: (a) In the form of on-line, linkable, pull systems - I come and pull data off {Good} …or… (b) In the form of on-line push systems - I push data to your secure system {Better} …or… (c) In the form of clearing houses where data is placed there for: Designated users, periods of time, with return reply required {Best} ii) Build extensions to records interfaces to accommodate transactions based vendors (a) Electronic prescriptions from the provider to the pharmacy, and back (b) Electronic lab orders from the provider to the lab, and back (c) Electronic referrals to external healthcare providers, and back (d) Electronic orders to durable medical equipment suppliers, w/supplies, and back (e) Electronic notifications to governmental, reporting, and regulatory agencies, and back 16 © 2012 S L Fritz Consulting, LLC
  • 18. Data Residency for EHR systemsData Residency HorizonTo close the loop on where and how data is stored for EMR systems, we’ll revisit the beginningillustration, and morph it to what the technology horizon will look like. A reachable horizonwithin the coming ten years. Figure 18 - Data Ownership; Patient, Provider, EnterpriseWhen I partitioned up the first data illustration, we saw that there are three distinct owners. ThePatient, the Physician, and the Enterprise. Let me rotate the diagram and illustrate it as layers ofclouds. The movement from one cloud layer to another is managed by the technology andsecurity parameters. The population of theEMR data is managed by the EMR application.If we morph one more time concerning theEMR application, the program that collectsand displays the appropriate data, we caneliminate it by putting it in the cloud as well.Web based application build on a .NETframework (browser based) provideseverything required.A browser based application is available forme, as the patient, to see my ‘charts’ and addnotes as I see fit. As a parent I would holdresponsibility to safeguard my children’s data.My doctor has a more powerfully configuredbrowser based application. His partners within Figure 19 - EHR Data Possessionhis network have another. Lastly the healthcare 17 © 2012 S L Fritz Consulting, LLC
  • 19. Data Residency for EHR systemsprovider community at large has yet another browser based application to view and/or managethe data.The final question left to answer is where does the formal record of my health live? It resides atmy physician’s office where is has always been. The difference is the availability of technologiesto make copies and transport that data to where it is required to give me the quality of care Idesire. If my Health Record Card gets destroyed, I only need to visit my local clinic and get anew one. If I change doctors, I only need request the transportation of my data to my physician’soffice. If a consulting physician needs my records, he only needs to dip into or get sent my data.The data residency eventually ends up in the cloud. The application resides next to it in thecloud. 18 © 2012 S L Fritz Consulting, LLC
  • 20. Data Residency for EHR systemsTable of FiguresFigure 1 - Information Sources, Targets, Transports .................................................................................... 2Figure 2 - Patient to Provider Information Exchange ................................................................................... 3Figure 3 - The Paper Record .......................................................................................................................... 4Figure 4 – The Cloud Record ......................................................................................................................... 5Figure 5 - Health Records in the Practice ...................................................................................................... 5Figure 6 - Multiple Data Sources and Input Technologies ............................................................................ 6Figure 7 - Movement to the Cloud................................................................................................................ 7Figure 8 - The Enterprise Application at the Data Center ............................................................................. 8Figure 9 - Medical Records Transactions In and Out .................................................................................... 9Figure 10 - The Constellation of Medical Information for a Patient ............................................................. 9Figure 11 - Venn diagram of the Three Pillars of EMR Data ....................................................................... 10Figure 12 - Provider Centric EMR Storage and Ownership ......................................................................... 12Figure 13 - Patient Centric EMR Storage and Ownership ........................................................................... 12Figure 14 - Multi Provider Data Exchange Methods ................................................................................... 13Figure 15 - Health Records Card Media ...................................................................................................... 13Figure 16 - Health Records, Patient, Multiple Providers, and the Cloud .................................................... 14Figure 17 - Health Records Transfers; Provider to Provider ....................................................................... 15Figure 18 - Data Ownership; Patient, Provider, Enterprise ........................................................................ 17Figure 19 - EHR Data Possession ................................................................................................................. 17 19 © 2012 S L Fritz Consulting, LLC