Health Care IT Community Discussion
Gerald D. Neale
http://chlug.org/exclusive/CHLUGhealthcareIT_discussion.pdf
Below is the text for the web:
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Group Submission for Health Care Community Discussion
Hosted By The
Cherry Hill Linux User's Group
Submitted to
Senator Tom Daschle- Incoming Secretary of Department of Health and Human Services
Event date & time:
December 30, 2008
7:00PM – 9:00PM
Summary
This evening we focused on Health Care IT, referred to in many debates as the magic bullet that will make health care affordable again. We agree that IT can and must play a major role in Health Care Reform, but could be a major hindrance if we make the wrong choices.
The Federal Government through the Department of Health and Human Services (DHHS) should:
• Maintain a fully free and open source electronic medical record (EMR) system.
• Mandate the EMR be taught in all medical and nursing schools.
• Mandate an open and freely implementable EMR communication standard.
• Mandate a national medical identification number and prohibit the use of, and storage of, Social Security Numbers in any health care system.
Complete Report
This event was organized in a very short period of time by the members of the Cherry Hill Linux User's Group (CHLUG). We are a community based technical enthusiast group in Southern New Jersey meeting consistently once each month for the last 10 years. The event was attended to by 12 members of the local community. It will be considered January 2009 meeting of CHLUG. Our focus has always been to spread the concept of openness in computing, embodied in the Linux operating system, to our local community. Naturally, many of us are also concerned about the lowly and degrading state of health care in our country. Specifically concerning to us is the popular notion that information technology (IT) should be the main tool implementing change. As the following
report will illustrate, in a general sense, we feel that IT can provide much needed support, but not without the Department of Health and Human Services (DHHS) thoroughly embracing the concept of openness. In fact, embracing “closed“ medical information systems goes against the basic fiber of peer review and scientific validation of our
successful medical history and could actually further degrade an already ailing system.
One major problem that we see with the current state of IT in American medicine is the presence of too many prominent incompatible proprietary vendors. Standards' bodies like Certification Committee of Healthcare
Information Technologies (CCHIT) offer a good start helping to ensure a compatible back-end for technicians to support, but do not go far enough ensuring a compatible front-end for medical practitioners to use. The result is that doctors and nurses must be expensively trained and retrained on non-standard interfaces multiple times over their
careers.
We discussed at length this waste. There are 2.4 million registered nurses in the US [1]. Each makes roughly $30/hour. There are more than a dozen fully functional and unique electronic medical record (EMR) programs utilized in the US. Each new IT system takes RNs 8 hours minimally to train, which becomes time away from direct patient care.
That is $576 million dollars to minimally train nurses. Waste is introduced by repayment each time a nurse changes jobs using another incompatible, non-standard system. Previous training is useless for the nurse's long term practice because it is so vendor specific. Additionally, nursing schools do not require learning any EMR yet. In our meeting room, we had three nurses present, including myself, and a nursing student validating this notion. We talked about cost escalation when considering the 850,000 American physicians [2] making about $100/hour on average, given 8 hours training per new system. That is another $680 million dollars incurred every time physicians rotate,
presumably several times during their careers. It is also a fact that nurses and doctors resist learning new IT systems. Could it be that practitioners instinctively know it's a waste of precious health care resources? Additionally, the truly unforgivable waste in the current system is that at the end of training, many practitioners are still not proficient. As a result, the IT systems themselves introduce a new opportunity for unsafe practice. Someone in the room cited a study
entitled “Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors”[3] Koppel et al published in 2005 supporting this notion. It was noted that this well known study was conducted at a local academic medical center, Hospital of the University of Pennsylvania.
We briefly talked about the similar dollar waste and risk incurred by training other medical professionals in this way: pharmacists, dietitians, social workers, medical assistants, clerks, and the entire dental field must be trained to use vendor specific medical IT systems again, again, and again.
Our solution to this problem is to federally mandate the training of all medical and nursing students using the open, freely available, and highly regarded Veterans health Information Systems and Technology Architecture (VistA). This kind of academic course work could be done before actually practicing in the field and can be incorporated into all medical and nursing school curriculum. It can be accomplished using remote access to the VistA EMR system itself over the internet without any cost to individual institutions. It would cost the tax payers a
negligible amount of money to support, and what they would get in return, over time, is a renewed medical community knowing better how to perform their role using a standard EMR system. The dollar value is realized by less training costs, but the true health care value is safer practice because now a base level EMR proficiency would be presumed by state licensure. Other opportunities to use VistA and other open projects can be encouraged as applicable, i.e. continuing education credits, and technical certifications.
Another avoidable problem present in health care today that we discussed this evening is rampant greed plaguing what should be an endeavor of the greater good, not that of individual interest. An example of this can
easily be found in the many fraudulent medical law suits and mounting pressure for tort reform addressing them. More to the point of CHLUG's concern is the recent overuse of patent law in health care for seemingly obvious technical accomplishments. For example, the U.S. Patent Office recently granted Janus Health patent number 7,249,036 B2 addressing virtually all forms of digital data transfers emanating from a physician housecall [4].
CHLUG believes that large companies wielding vague patents like this stifle individual innovators from enhancing our medical information systems in necessary ways. As a resolution, we believe that if the concepts of openness are adequately embraced, then exemption from
liability in law suits stemming from patent infringements should be provided. For example, if VistA is successfully programmed to do “a physician housecall” and the source code is given back to the public domain, then the programmers who developed it should not be fair game in a law suit stemming from Janus Health Patent 7,249,036
B2. Our leadership can easily legislate protection for individuals giving to the greater good in this way.
Another concern that universally affects all IT systems is balancing the ability to identify people in a ubiquitous electronic system without exposing them to unwarranted privacy exposure risk. It is a given that a unique identifier for each individual is the absolute base for any successful EMR. This is because without it there is no context to a health care encounter beyond what can be derived by the patient's physical appearance and interview.
Participants in our discussion pointed out that all recently born children in the State of New Jersey, and other states (i.e. Arizona), have an immunization number issued early on in life that is unique to them. This number could serve as a national medical identifier without posing additional risk to financial ruin as does using one's social security number, for example. It was proposed to have immunization numbers placed on driver's licenses, or other wallet sized cards, so that unconscious victims could have their EMR easily accessed in case of emergency.
Also concerning to us is the notion of a singular monolithic EMR system for the entire nation as is the case in some foreign nations. On the surface it would seem that one master EMR is most efficient for utilization and support, however the decision to choose one vendor over all others is too hazardous to us given the entrenched interests of
closed, proprietary vendor systems already in the American market. We ask DHHS to look to our friends in England for an example of what not to do. Their esteemed National Health System (NHS) originally rewarded one major American proprietary EMR vendor over all others, then suddenly dropped them to chose another. This process continues to be ruinously expensive for the English tax payers and does not seem to benefit anyone, even the proprietary vendors themselves, oddly enough. A better example to look at for guidance is the one implemented by our Canadian friends which seems like it will be much more successful over the long run. This is because much of the underlying architecture of the system was developed openly and locally to suit Canadian patient needs. One major
component developed in-house is something sometimes referred to as "HL7 2.3.1 Enhanced". The Canadians took an open standard communication protocol called HL7 2.3.1 and greatly enriched the potential of it for connecting EMRs, while satisfactorily protecting entrenched vendor interests, and protecting patient privacy. The Canadians, in the true
spirit of medical advancement, fed their enhancements back to HL7.org thereby keeping their improvements open to anyone for peer review, validation, utilization, or enhancement. Also, this keeps all future enhancements compatible with their own system. Much like in scientific discovery this type of behavior contributes to an infinite positive
feedback loop.
A final recommendation came from one participant in the room who said we should create a federally funded contest using reward money of $10 million dollars encouraging the development of open source projects for
medicine.
“For example,” this citizen said, “we could reward the first team porting the Canadian HL7 2.3.1 Enhanced to the
American EMR VistA.” CHLUG believes that a contest like this, though emblematic of the enthusiasm in the room, is not necessary because the forces of the open source community will eventually accomplish this on their own anyway. It will probably be done by tech savvy medical practitioners using various open systems every day for their work and
“scratching their own itch” by tinkering and combining them. That is the nature of openness in computing. The question is, how long can do we want to wait for it to happen on its own?
Respectfully submitted by,
Gerald Neale, RN
University of Medicine and Dentistry of New Jersey SOM - Clinical Analyst
Cherry Hill Linux User's Group- Organizer
Bryan Quigley
Community Organizer
Brian Green
Healthcare IT Professional
[1] http://www.census.gov/Press-Release/www/releases/archives/facts_for_features_special_editions/004491.html
[2] https://catalog.ama-assn.org/Catalog/product/product_detail.jsp?productId=prod10002?checkXwho=done
[3] http://jama.ama-assn.org/cgi/content/abstract/293/10/1197
[4] http://www.janushealth.com/about/patentinfo.html