Month: December 2009

Short Link: http://j.mp/8bsdDO

My parents live on a farm in Illinois (center upper right). That’s the Mississippi River in the lower left and a backwater lake (center) where I fished from my eight-foot flat boat (it’s still in there in the weeds. Imagine three boys and a big ~1950 Johnson outboard motor on such a tiny vehicle. We moved very slowly.). In the winter the lake would freeze and we’d skate, sled, and snowmobile. It was a lot of fun!

Nowadays I spend most of my time in DC or Atlanta. DC can be fun in the winter too.

But my folks now spend their winters in an RV by the ocean in Key West. This is their view! Wow. One of my aunts knitted or darned (or whatever!) that red, gray, and white “throw.” Comfort food for the soul.

 Each morning we have breakfast..

 

…pick up the mail at the post office, which is strangely popular with the famous Key West chickens…

 “Keep track of every little thing with the
EncounterPRO Pediatric EMR Workflow System”

…and go to the beach…

 …while Dad reads the Key West Citizen.

 

Eventually we head to Mallory Square to watch the sunset.

That’s our holiday tradition. I hope you enjoy yours as much!

Again, Merry Christmas and Happy New Year.

–Chuck

PS I moved The Twelve Days of EMR Beta Testing into its own blog post!

Short Link: http://j.mp/64geX6

Originally titled “Traditional EMRs are Problematic, but Let’s Not Throw the Baby Out with the Bath Water,” then “Have Your Cake and Eat it Too: Structured EMR Data AND High Productivity,” I eventually decided that “Mirror, Mirror, On the Wall, Which EMR is Least Traditional of All?” was most clickable. (William Safire said “Avoid cliché’s like the plague”, but while I admired his column in the New York Times I took his advice with a grain of salt.)

The “traditional” EMR is taking it on the chin lately.

I’ve thrown a few punches myself…

…but I’m not the only one. Check it out yourself…

Or take my word for it. I grabbed quotes from the first three pages Google returned and summarized them below by way of paraphrase. I changed vendor and product names to protect the….(innocent? guilty?). Of course, by the time you click the list will have evolved and lengthened (and this post will be on it, how is that for self-reference?).

1. Our EMR implements in much less time than a traditional EMR
2. Our EMR costs much less than an a traditional EMR
3. Our EMR makes physicians more money than traditional EMRs
4. Our EMR requires less change to existing workflows than traditional EMRs
5. Our EMR has fewer security vulnerabilities than traditional EMRs
6. Our EMR helps physicians see more patients than traditional EMRs
7. Our EMR has the 20% of traditional EMR features, 80% of their value, and 200% of their usability
8. Studies have refuted the claims of traditional EMR vendors
9. 30-70 percent of traditional EMR implementations fail
10. Traditional EMRs cause physicians to see fewer patients than pre-EMR implementation
11. Traditional EMRs cause physicians lose revenue relative to pre-EMR implementation
12. Traditional EMRs do not eventually return to pre-EMR implementation productivity levels
13. Traditional EMRs require pointing and clicking that wastes physician time
14. Traditional EMRs distract physicians from focusing on their patients
15. Traditional EMRs implement features mandated by bureaucrats, not physician needs
16. Traditional EMR features are so cumbersome that some are often not even ever used
17. Traditional EMRs are sold by salespeople know their software does not help physicians (harsh!)
18. Traditional EMRs create documents full of cookie-cutter language in which relevant information is hard to find
19. Web-based EMRs are the alternative to traditional EMRs
20. Document imaging-based EMRs are the alternative to traditional EMRs
21. Advertising-supported EMRs are the alternative to traditional EMRs
22. Less-is-more EMRs are the alternative to traditional EMRs
23. Speech recognition-based EMRs are the alternative to traditional EMRs
24. Natural language processing-based EMRs are the alternative to traditional EMRs
25. EMRs that visualize patient data in a different way are the alternative to traditional EMRs
26. Open source EMRs are the alternative to traditional EMRs
27. Mind-controlled EMRs are the alternative to traditional EMRs (just kidding, but cool video)

Pile-On!

If you believe EMR marketing departments these days, most EMRs are not traditional at all, perhaps an example of the Lake Wobegon Effect (where “all the children are above average”). As my mom used to say, “What in the world is going on here?” (“Nothing Mom!”) What is it about traditional EMRs that have made them so radioactive even traditional EMR vendors are beginning to attack them?

EMR vendors with a-, un-, non- or anti-traditional EMRs (not sure of the correct prefix here) invoke and attack a “traditional” EMR straw man with some or all the following characteristics. A traditional EMR has structured template-driven forms with complicated, inflexible, time-consuming, distracting (from the patient) drop-down menus, check boxes, radio buttons that require massive change to physician workflow. Traditional EMRs have so many features, mandated by so many bureaucrats, that access to the right feature at the right time is effectively impossible, because it is buried. Generated patient notes and letters contain repetitive superfluous cookie-cutter language in which relevant information is hard to find and therefore often ignored.

I think that’s the heart of the traditional EMR stereotype. I refer to them as traditional, hunt-and-peck, clickity-clickity-click-click-click EMRs. 

Traditional “Hunt and Peck” EMRs are not usable for high-productivity data and order entry, nor can they be flexibly adapted to anticipate individual user requirements and preferences. These EMRs are not designed on the process-aware foundations that are required for systematic optimization of clinical performance, workflow efficiency, and user and patient satisfaction.

However, some traditional EMR critics go too far and advocate getting rid of the extraordinarily valuable structured data. I’ve been criticizing “traditional” EMRs for years, publically since September 15, 1999, to be exact. I know the culprit–its flaws and its virtues–and structured data is not the problem.

Generating useful structured data requires the imposition of precise structure and meaning on collected data. Such data are easier to aggregate (important for clinical research such as outcome studies), easier to transport (in the sense of transferring specific data between applications), and more appropriate for driving the automated performance of patient-specific tasks such as alerts and workflows. I published my solution to the need for both structured data and high productivity in 2001, when I wrote:

“In our opinion, the combination of structured data entry, workflow automation, and screens designed for touch screen [today including stylus] interaction optimally reduces inherent tradeoffs between information utility and system usability on one hand, and speed and accuracy of data entry on the other. Successful application of touch screen technology requires that only a few, but necessary, selectable items be presented to the user in each screen. Moreover, workflow, by reducing cognitive work of navigating a complex system, makes such structured data entry more usable.” (also discussed in “The Cognitive Psychology of EMR Usability and Workflow”)

Back then “workflow automation” was accomplished by workflow management systems. Today it is associated with business process management and adaptive case management systems (there’s a interesting and relevant debate between those to “camps”, but I’ll leave that to another post).

[CW: The following pertains a EMR workflow system that won the first three HIMSS Davies Awards. Many of the technologies it pioneered, such as workflow engine and process definitions, are beginning to appear in EMRs today.]

Let’s go through the list of criticisms of “traditional” EMRs one by one.

1. Our EMR implements in much less time than a traditional EMR
   • You’ll be “Live in Five” (back to pre-EMR implementation patients-per-day in five days). Since automated workflows do so much without requiring human intervention, and since tasks are pushed to the right users without them having to perform laborious navigation, learning curves are ultra short.
2. Our EMR costs much less than an a traditional EMR
   • Our total cost of ownership is substantially less than traditional EMRs because the largest single expense to owning an EMR is the time it takes for you to learn and use it. And if you never do, well, that is the biggest expense of all.
3. Our EMR makes physicians more money than traditional EMRs
   • Pediatricians using the an EMR Workflow System can more than double patient volume, billings, and revenue.
4. Our EMR requires less change to existing workflows than traditional EMRs
   • “Using EHRs that are easily molded to existing physician workflows, which can then be systematically improved while respecting normal human tolerance for change, is the key to EHR adoption” (quote from  “Automate Your EMR Cow Paths *and* Reengineer Them Too!” )
5. Our EMR has fewer security vulnerabilities than traditional EMRs
   • Workflow management systems have an additional layer of security due to role-based task execution permissions and detailed workflow audit trails. Workflow management systems represent individual tasks at a higher degree of granularity than non-workflow management systems. Workflow engines execute process definitions that contain these tasks. The workflow engine consults a role-based permission system to decide whether or not a user has the right to initiate or complete each task. As a result, a workflow management system can enforce controls over what can and can’t be done before hand, and provide a more detailed audit trail afterwards.
6. Our EMR helps physicians see more patients than traditional EMRs
   • See response to claim 3
7. Our EMR has the 20% of traditional EMR features, 80% of their value, and 200% of their usability
   • See post about “EMR Featuritis”
8. Studies have refuted the claims of traditional EMR vendors
   • Three primary care physicians–two pediatricians and one obstetrics/gynecology and family medicine physician–submitted detailed documentation, hosted site visits, and won the first three HIMSS Davies Awards for ambulatory care excellence.
9. 30-70 percent of traditional EMR implementations fail
   • “The basic problem is that implementing *most* EHRs is an act of reengineering, and reengineering is a high risk endeavor.” (Source) Implementing an EMR Workflow System is not an act of reengineering, resulting in a virtual 100% rate of successful implementation.
10. Traditional EMRs cause physicians to see fewer patients than pre-EMR implementation
    • See 3
11. Traditional EMRs cause physicians lose revenue relative to pre-EMR implementation
    • See 3
12. Traditional EMRs do not eventually return to pre-EMR implementation productivity levels
    • See 3
13. Traditional EMRs require pointing and clicking that wastes physician time
    • Done right, pointing-and-clicking is much faster than all the alternatives (except perhaps mental telepathy, but that technology hasn’t been perfected yet). See “The Cognitive Psychology of EMR Usability and Workflow” for explanation.
14. Traditional EMRs distract physicians from focusing on their patients
    • One Georgia pediatrician, a winner of the HIMSS Davies Ambulatory Care Award of Excellence for his use of an EHR workflow system, shows his attentiveness using one hand to steady an energetic child and the other hand to enter data and orders out of the corner of his eye, facilitated by large colorful buttons. A workflow engine pushes screens in preprogrammed sequences so he is not distracted by screen-to-screen navigation. His focus remains uninterrupted and attentive to the concerned parent. (Article: “What Makes a Great Pediatric EHR?”)
    • A Chicago pediatrician, who also won the HIMSS Davies Ambulatory Care Award using an EHR workflow system, notes that its customizable workflow has made his office so much more efficient that he can see more patients and spend more time with each patient. Efficiency allows more time to be available to parents and patients.  (Article: “What Makes a Great Pediatric EHR?”)
15. Traditional EMRs implement features mandated by bureaucrats, not physician needs
    • Short anecdote: I presented to an audience of health professionals almost all of whom worked for various government agencies. An animated question-and-answer period ensued. Many of the questions where “Have you thought of…?”, “Why don’t you add…?” To which I answered “Yes”, “Yes”, and “Yes” and “Our sales people aren’t being asked for it,” and  “It hasn’t lost us any sales.” There was a moment of befuddled silence, and finally someone from the audience commented “That’s a really stupid reason for not doing something!”
16. Traditional EMR features are so cumbersome that some are often not even ever used
    • “Since 1994 we’ve been adding pediatric-specific features to the first Windows-based pediatric EMR (and workflow system), however its completely customizable workflows “anticipate” what you need and where you want to go, unlike “hunt-and-peck” EMRs that force you to click your way through cluttered screens and lengthy picklists. Our philosophy is to optimize, not maximize, pediatric EMR features. With an EMR workflow system you can have your features and use them too.”
17. Traditional EMRs are sold by salespeople know their software does not help physicians (harsh!)
    • Our sales folk sleep very well at night! I do too. I believe EMR workflow systems will be transformational at healthcare industry, organizational, professional and personal levels.
18. Traditional EMRs create documents full of cookie-cutter language in which relevant information is hard to find
    • I took two courses on natural language generation in graduate school and even presented a paper at a workshop on the topic. Automating the writing of fluent, appropriate, and natural language is difficult. However, getting rid of structured medical data and databases is akin to throwing the baby out with the bath water. The issues are complicated, interesting, and reflect well on EMR workflow systems.
19. Web-based EMRs are the alternative to traditional EMRs
    • Many workflow management systems and business process management suites are web-based. It’s only a matter of time before EMR workflow systems are delivered in this manner too.
20. Document imaging-based EMRs are the alternative to traditional EMRs
    • Ironically, many of the first commercial workflow systems (such as FileNet’s WorkFlo system back in the 80s) were document scanning/imaging solutions. Why ironic? I am arguing that EMR Workflow Systems are the next step in EMR/EHR evolution (see my recent white paper on this topic), but workflow systems (and the underlying workflow management systems that create and manage them) are decades old. Healthcare is that far behind other industries in adopting workflow technology.
21. Advertising-supported EMRs are the alternative to traditional EMRs
    • This is an alternative business model, not EMR model. And in the immortal words of the solo family medicine physician, “I don’t care if you give it to me free and then bribe me to use it, if it slows me down I won’t!”
22. Less-is-more EMRs are the alternative to traditional EMRs
    • See 7
23. Speech recognition-based EMRs are the alternative to traditional EMRs
    • I worked on a speech recognition project in graduate school (writing natural language syntax grammars for the Pilot’s Associate project) so I know a bit about the topic. The Holy Grail is large-vocabulary, speaker-independent, continuous speech recognition. I’m a fan. But it is not an “alternative” to structured data EMRs, any more than scanning/imaging. [3/3/12 update: This is changing!]
24. Natural language processing-based EMRs are the alternative to traditional EMRs
    • However words get digitized, whether through speech recognition or optical character recognition (or physician fingers), they need to be combined into phrases and sentences and meaning derived. There’s been some interesting work in this area. But it’s not ready to replace structured data entry. [3/3/12 update: This is changing!]
25. EMRs that visualize patient data in a different way are the alternative to traditional EMRs
    • New ways to view data result in more decisions to make about which view is appropriate at each workflow step. However, the way in which data is presented at a particular step can be determined automatically by the workflow engine. New ways to view data increase the need for EMR workflow automation, not diminish it.
    • EMR workflow systems also generate a lot of new workflow-related data that will need to be visualized. Increasingly, as patients begin to interact with EMR workflow systems via Web portals, their activities (infotherapy, supplying information, documenting compliance) will become part of the EMR record proper, and therefore need to be visualized too.
    • Both are examples of a complimentary relationship between new ways to look at patient data and the larger EMR system within which this data is viewed.
26. Open source EMRs are the alternative to traditional EMRs
    • There are some excellent open source workflow management systems out there. I’d like to see some pressed into service within health care. In fact, if you’ve read any of my posts about how to solve the pediatric medical home care coordination problem, the more EMR workflow systems the better!
27. Mind-controlled are the alternative to traditional EMRs (just kidding, but cool video)
    • I look forward to mind-controlled EMR workflow systems! I suspect that even in the “mind’s eye” Fitts and Hicks Laws will hold true.

The central issue is whether we can have EMRs with high productivity data entry *and* that can produce structured data.

Productivity is the quality and quantify of output divided by cost of input needed to cause the output. The value of data is what you can do with it and you can do many more valuable things with structured, than unstructured, data. The most important input costs are the time and effort of the physician user to master and use an EMR. Reducing these costs is requires improving EMR usability. Improving EMR usability requires improving workflow. The most effective and efficient way to improve EMR workflow is with an EMR workflow system (AKA EMR business process management/BPM system).

EMR workflow systems are compatible with, and can strategically combine all of, the “alternatives” offered by critics of traditional EMRs. In the main, these alternatives are input modalities, delivery platforms, or business models, all of which are needed. But none of them directly addresses the contradictory need for both structured data and high productivity (except perhaps for natural language processing, which is not yet a sufficiently mature technology).

In the long run, it’s not whether you speak into it or write on it, whether you get if for free or have to pay for it (as long as it’s worth it), or whether the code executes in front of you, down the hall, or across the country. It’s whether EMR effectiveness, efficiency, and usability can be systematically improved to achieve well understood, consistently executed, adaptively resilient workflow. Doing so will require both structured data and high productivity. The best, most obvious, most comprehensive, most mature means to achieve these goals are business process management techniques applied to process-aware EMR workflow systems.

So “Mirror, mirror on the wall, which EMR is least traditional of all?”

Good question!

Short Link: http://j.mp/727OEr

Many thanks to the Technology Association of Georgia for publishing one of my white papers on EHR Workflow Management Systems.

TAG has many excellent resources on their web site, and I had them in mind when I recently wrote:

“Atlanta is a sophisticated medical and information technology market….To do well in Georgia, whether you are a pediatrician or develop and market a pediatric EMR, is to do well in a state that does a lot of things rather well. We are both a beneficiary of, and contributor to, Atlanta and Georgia’s unique workforce, infrastructure, and business climate:

Best Managed State in the Southeast

No. 1 in U.S. for Workforce Training

Most Inexpensive U.S. City to Do Business

Second Fastest Growing City in America

Fastest–growing Port in the US (that’s sea, not internet, port!)

To which I’d like to modestly add:

Home of the Best (and Only) Pediatric EMR Workflow System”

Most of our product website focuses on EMRs for pediatrics and related primary care specialties. This blog is more opinionated and predictive about where I think healthcare is going (application of business process management to process-aware EMRs). The white paper states the more general (not pediatric-specific) case for EMR/EHR workflow management systems while maintaining focus on more immediate benefits.

Below is the beginning and end of the white paper. If you want to fill in the gap (“…”) you can download the complete document here.

Electronic Health Record Workflow Management Systems:
The Next Step in EHR Evolution

Nov 1, 2009

Charles Webster, MD, MSIE, MSIS
Chief Medical Informatics Officer
EncounterPRO Healthcare Resources, Inc.
Atlanta, Georgia

Implementing an Efficient Electronic Health Record

Electronic Health Records (EHRs) are becoming more than just electronic patient documentation systems; they are evolving into tools that assist physicians in managing the patient care tasks they perform for major types of patients they see. These systems allow providers to analyze, manage and optimize the work that has to be performed, as well as to direct and to delegate it to others. EHRs based on a Workflow Management System (WfMS) accomplish this by offering a way for the user to customize workflow to practice specialty, to local clinical and administrative processes and to user preferences. If an EHR can be instructed to do tasks in a customized sequence – automatically – based on who the patient is, why they came to the office, what care needs to be provided, when and where care needs to be provided, and how it best fits the office staffing, the EHR is not just a patient documentation system, it is an EHR Workflow Management System.

Workflow Management versus Mere Workflow

Most EHRs have basic task management functionality, yet very few are built upon a user-controllable WfMS “engine.” “Workflow systems” and “Workflow Management Systems” are frequently confused and poorly differentiated, yet there is an important distinction. This distinction is particularly important to know if a physician is planning to automate his or her office and is in the market for an EHR. A Workflow Management System is a software application that stores and executes workflow (or process) definitions to create and manage workflow processes by facilitating interactions among users and applications. Users usually interact with workflow systems, not the WfMSs used to implement them. It is the underlying WfMS that allows a workflow system to be flexibly tailored to local processes and user preferences, and to be easily monitored and maintained by the user, not the computer software vendor. The less a user is dependent upon their EHR software vendor, the faster changes can be made and the less maintenance cost there will be.

…

Conclusion

The earliest EHR systems were developed primarily to automate patient charting functions. If an EHR cannot chart patient data, then it scarcely seems to qualify as an EHR at all. Next, additional functions and capabilities were added in a drive to eliminate paper (except for that which must be scanned in from the outside world or printed in order to communicate). However, even when the paperless office is achieved, this does not mean that the paperless office is efficient. The availability of WfMS-based EHRs brings us to that next step in the evolution of the EHR development, in which we have not only gotten rid of paper but inefficiencies as well. EHR WfMSs have already begun to impact the EHR market. Each of the first three Health Information Management and Systems Society’s Davies Awards (2003, 2004 and 2005) included physicians who relied on a WfMS-based EHR (the EncounterPRO EHR) to achieve remarkable improvements in volume, billing, cost, and convenience – for themselves and their patients.

When looking at an EHR, one may wonder whether or not it is an EHR WfMS; simply ask this question: Who or what is the workflow engine? If the answer is “who”, this is bad, because “who” is a person; a potentially expensive professional who should not be wasting their time pursuing non-value-added EHR activities. If the answer is “what”, this is good, because “what” is a much less expensive inanimate object; the computer. If the computer can accomplish non-value-added activities and help coordinate value-added activities, then workflow is likely being automated by a true Electronic Health Record Workflow Management System.

Short Link: http://j.mp/6J0J2e

[4/19/12 update: I renamed this post from “Why Pediatricians Need Pediatric EMRs That Understand More Than Pediatrics” because its argument applies to any specialty-specific EMR intended to communicate and coordinate with other EMRs. Substitute your specialty for “pediatrics.” Specialty-specific EMRs need to know about more than just their own specialty to coordinate care across networks of EMRs. Workflow technology such as business process management and case management software will be essential to creating EMRs and EHRs that can adapt to medical specialty workflow.]

This post is fourth in a series about EMR workflow systems and the high performance medical home model. The first post presented 12 key quotes. The second post introduced coordinated workflows among pediatric, subspecialty, and other primary care practices. The third stressed creation of well understood, consistently executed, adaptively resilient, and systematically improvable workflow within and between practices. This post discusses how to select a future proof pediatric EMR.

I took a short virtual tour of just a few websites of pediatricians. I read their staff bios and mission statements. Guess what? Many pediatricians practice with subspecialists in such areas as cardiology, neurology, gastroenterology, endocrinology, nephrology, allergy/immunology, emergency medicine, and developmental-behavioral pediatrics (and that was just a sampling). Many pediatricians also practice with other primary care physicians in family medicine, general internal medicine, and obstetrics & gynecology. Some pediatricians are double (or even triple) board certified.

Communication of Shared Meaning across Specialty Boundaries

If you are a pediatrician, reflect on how much you know about the other medical specialties that you call on when you refer a patient. Throughout your career, starting in medical school, you’ve been exposed to much more than pediatric medicine and you use this knowledge to better coordinate your patients’ care. Consider how you communicate with a physician from another different specialty. Each of you share a common foundation of basic medical knowledge, plus you both understand enough about the other specialty in order to communicate. You use words to mean the same thing.

Soon your EMR will need to be like you, and know enough about other specialties in order to coordinate care with other EMRs. They need to mean the same things.

Meaning

is shared between two systems (human or computer) when the following occurs:

1. An external real world entity (drug, diagnosis) is referred to by an internal concept
2. The internal concept is encoded as symbol (word, number, ICD-9 code)
3. The symbol is transmitted across a channel (air, paper, TCP/IP, string)
4. The symbol is decoded to an internal concept
5. The internal concept refers to the same external real world entity (drug, diagnosis)

Two systems that can do this are “semantically interoperable.”

Of course, it is more complicated than I make it seem. For example, meaning is usually composed smaller bits of meaning (AKA “words'” as in my “Chuck likes workflow”  sentence diagram). However, my simplified portrayal is sufficient for the main point I will make below.

General-purpose versus Specialty-specific EMRs

You may be aware of a recurring debate about so-called general-purpose EMRs versus specialty-specific EMRs. Applied to pediatrics it goes like this: general-purpose EMRs were designed for adult medicine and lack pediatric-specific functionality (screens, picklists, and workflow). As a result they cannot do what a pediatrician needs quickly and easily. Homegrown pediatric-specific EMRs on the other hand started with pediatric-specific functionality, carry out stereotypic pediatric workflows, and don’t try to be anything besides a pediatric EMR.

Sounds like a slam-dunk for the pediatric-specific EMR, right? The problem with this debate is that only makes sense for traditional EMRs that lack customizable workflow. An EMR workflow, or BPM, system can support multiple specialties (including general adult medicine) working off the same patient database and make is seem to each specialist (or generalist) as if they are using their own specialty-specific EMR. That was the point of quotes 6 and 8 in the post that kicked off this series on the relevance of EMR workflow systems to the medical home.

Think about the implications for coordinating workflow between pediatricians, subspecialists, and other primary care physicians to achieve the high performance medical home. Some multi-specialty practices already market themselves this way:

“When your family physician or your child’s pediatrician determines you or your child should see a specialist that usually means a trip down the hall. Don’t worry about carting your records. Our modern electronic medical record system makes sure you have the best care from each specialist under the watchful eye of your personal physician. And when your child grows up, transition is seamless to a family medicine physician who will also coordinate the best care possible”

These practices are taking advantage of a multi-specialty capable EMR to implement a version of the medical home, by taking advantage of the default “semantic interoperability” gained from sharing the same EMR database.

Wait it minute, you say. You could stipulate that a multispecialty EHR database is an an ideal vehicle for implementing a high performance pediatric medical home *if* everyone uses the same database. However you are a solo pediatrician. Why should you care?

I wish I could say “Simple!…” but I can’t. Some answers deserve to be complicated, and this is one of them.

(That said, click here to skip the complicated stuff anyway and get to my point.)

Of Data Models and Medical Ontologies

Reconsider steps 1-5 to transmission of shared meaning and achieving semantic interoperability. In step 2 a concept refers to a real world entity and is encoded as a symbol. In step 4 a concept refers back to the real world entity. If either source or target EMR lacks the right concept, meaning is not successfully shared. Where do these EMR “concepts” come from?

They come from each EMR’s conceptual data model, which is:

“…a map of concepts and their relationships. This describes the semantics of an organization and represents a series of assertions about its nature. Specifically, it describes the things of significance to an organization (entity classes), about which it is inclined to collect information, and characteristics of (attributes) and associations between pairs of those things of significance (relationships).”

Let’s see if I can make use of my word substitution technique to make the above quote more relevant:

…a map of pediatric, subspecialty, and primary care concepts and their relationships. This describes pediatric or primary care practice clinical knowledge and operational workflow. Specifically, it describes the things of significance to an organization (patients, body parts, diseases, treatments, specialties etc.) , about which it is inclined to collect information, and characteristics of (such as size, weight, duration, etc.) and associations between pairs of those things of significance (such as has-assessment(Tom Smith, asthma), is-prescribed (Tom Smith, Albuterol), is-specialty(Dr. Jones, pediatric neurology), common-assessment(epilepsy, pediatric neurology)).

Data models are closely related to ontologies, increasingly proposed to provide semantic interoperability between EMRs.

“An ontology defines a set of representational primitives with which to model a domain of knowledge or discourse.  The representational primitives are typically classes (or sets), attributes (or properties), and relationships (or relations among class members)….The key role of ontologies with respect to database systems is to specify a data modeling representation at a level of abstraction above specific database designs (logical or physical), so that data can be exported, translated, queried, and unified across independently developed systems and services.” (Tom Gruber, Ontology, Encyclopedia of Database Systems, Ling Liu and M. Tamer Özsu, Eds., Springer-Verlag, 2008, retrieved 12/2/09)

(Ah yes…takes me back to my Knowledge Representation course in Intelligent Systems at Pitt.)

I could substitute in words from the pediatric and primary care domain as I did before, but you get the idea. A medical ontology or data model is the set of things, stuff, objects, entities, individuals, etc. (for examples, patients, body parts, diseases, treatments, specialties etc.) about which a community of medical agents can think and communicate. These entities have properties (such as size, weight, duration, etc.) and relationships (has-assessment, is-prescribed, is-specialty, common-assessment, and so on). And an EMR can only do things and communicate about them consistent with its domain model.

Again I simplify, as was the case when I described the five steps to successful transmission of shared meaning. It’s still sufficient to make my main point (which is…).

What’s my point? Intelligent systems (you, or increasingly, EMRs) cannot communicate about concepts they cannot represent. Specialty-specific EHR databases need to “know” a lot more than just their specialty focus, if they are to participate in creation of virtual medical home enterprises.

“I am a solo pediatrician, why should I care about multi-specialty EMRs?”

To future proof your practice.

• You may eventually add a pediatric subspecialty or other primary care specialty to your list of board certifications.
• Your practice may add a subspecialist or non-pediatric primary care partner—specialty-specific workflows will allow you and your partners to “Have It Your Way” while not stepping on each other’s toes.
• Or you may need to communicate and coordinate with other general-purpose or specialty-specific EMRs as part of a high performance virtual medical home.

If you think any of these events may happen in your future, please consider getting a pediatric EMR that can do more than pediatrics.