1. Warnings, admissions, and disclaimers

Warnings, admissions, disclaimers without which society will grind to a halt.

This site is primarily an outlet for me (it is my perspective that such is the case for all blogs but I will not generalize).  The blogs represent my personal thoughts and do not necessarily represent those of OZ Systems (I have enough influence with the company that they allow me to post them here).  I reserve the right to post opinions that are nonsensical, inconsistent, and change without notice.  In theory, I may even post opinions that are wrong (just theoretically).

I have imagined that others may read these thoughts and even that reading them might prompt meaningful thoughts they would want to share here.  If a reader should misperceive their thoughts as meaningful (when in my judgment the thoughts are not meaningful) I reserve the right to expunge those entries.  As a heads up, meaningless thoughts will likely include those that are just mean or demeaning to anyone.

If this site should prompt a meaningful dialog that will be a lagniappe.  But the posting reader is warned that I do not promise to respond or participate in the dialog.  That doesn’t mean I don’t find the comments worthy.  A perfectly clear and perfectly correct comment needs no response.  Neither do blatantly confused or erroneous ones.  Sometimes I will just be lazy (or involved with my day job).  If I do not respond the posting reader is free to imagine any one of these reasons applies to their comment.

While I use understatement and sarcasm as “literary” tools I never intend those to be mean or hurtful.  While I do not suffer fools gladly, it is my general assumption that if a reader of my thoughts is not enlightened then I may need to find another way to communicate the thoughts.

I am in my heart a clinician.  Given the choice between patients and providers, I choose patients (Don Quixote is my hero).  Given the choice between patients and society, I choose patients.   Following patients my allegiance priority sequence is society-at-large, providers, with bureaucracies and vendors in a dead heat.

I was a huge fan of the series by James Burke entitled Connections and starting with that approach will often tell stories in a style that emulates his method (imperfectly and with my apologies to Mr. Burke) but augments it by taking poetic license (the literary term for apocryphal).  My stories are not intended to accurately recount the events, their sequence, or even their significance.  They are just fun ways for me to convey my own views.  Names may or may not be changed to protect the innocent or the guilty.  Events may or may not have occurred.  They are just stories of an alternate universe.  I hope you enjoy.

Lastly, this document could not be complete without full disclosure (that is legal talk from our lawyers) so let it be known:

Disclaimer:

• The author has a vested interest in the adoption of the certain principles of healthcare information management.
• The author has a patent awarded dealing with methods of processing of healthcare data to support clinical decision support.
• The author also has a pending patent application related to methods to implement policies for privacy and confidentiality at the data element level enabling data element access services while honoring explicit requests to exclude data from disclosure.
• The author also has a patent submission for a system of distributed information management that includes a “universal exchange language”.
• Lastly, the author is employed by a company that has built software tools and frameworks that embody these methods.

Continue Reading 2 of 3: You hurt those you love the most

2. You hurt those you love the most

You hurt those you love the most

As I approach starting this blog I feel a need to forewarn the reader.  My tone will often sound arrogant.  Lest the reader misunderstand this is virtually always (except for those times where I am truly arrogant) intended to be sarcastic.  Self-deprecating sarcasm is one of my most often used literary instruments (as arrogant as calling what I will write “literary” may be).  The nature of self will sometimes be me as an individual but at times it will be me as a physician. It is in that context that I feel a need to express in advance that the sarcasm that applies to the profession of Hippocrates should be seen against a backdrop of profound respect, admiration, and affection.

As anyone who practices medicine knows, the profession provides a multitude of rewards.  The occasional and dramatic experience of knowing what and how to do something that saves a life is nothing short of intoxicating.  The more frequent, if less dramatic, experience of just making a difference in lives is the liquor that truly addicts the greatest practitioners.  Making it possible for people to live not just longer but better is part of the daily fare as a physician.  Even making personal tragedies and losses, which are the mortal condition, less destructive for the patient and the family is an amazing event to participate in.  These experiences are not just the purview of a physician but they are the fodder that sustains the best physicians.

There are other rewards as well.  Our culture does convey some additional social prestige to physicians as evidenced in our routine of naming them “Doctor Pool”.  It is also undeniable that the profession generally provides an income level that is substantially above the median.  And the list goes on.

However, what is less transparent is the price that my colleagues pay.  It has historically been accepted that the private life of a physician is often subjugated to the immediate needs of the professional demands.  How many movies, dinners, plays, or just quiet evenings at home with family have been sacrificed to the unscheduled medical emergency or often just medical urgency?

The power of being the “Captain of the Ship” (although that approach is less and less in vogue) comes with the pressure to choose wisely.  Each decision always carries that lurking risk that if the choice is wrong that someone will suffer or even die.  Each little decision…  A pediatrician friend once described his day in the office seeing patients with runny noses or runny bottoms.  He admitted that each time he stepped into the exam room he wondered if this runny nose that looked so much like the last 23 runny noses was in fact that one case of meningitis that presents with a runny nose but left untreated could leave the child in that room dead and the parents with a lifetime of grief.  Each and every time he stood with his hand on the knob to enter the exam room he worried that he would miss that case.  It is no surprise that the individuals who are capable of facing that repeated challenge throughout their days have above average ego strength.  That is not intended to justify egotism just to point out that self-selection removes from the profession many who do not have that degree of self-confidence that looks so much like ego.

I have long marveled at how much equanimity my colleagues bring to another price they pay.  When a patient doesn’t do well and especially when they die (which they do at times no matter what we do) the family will grieve.  It should come as no surprise that the physician feels grief as well. As we grieve we often look for solace in our bond with others who grieve.  However, as pop-psychology has taught us, one of the “stages of grief” is anger.  I have often watched physicians stand as the target for that anger (often when they could easily have deflected or redirected it) because the alternative targets (such as other family members) might leave scars in relationships and those other relationships are far more intertwined than those with the physician.   The physician often accepts not only the anger but forgoes the solace of sharing grief.  A long unwritten book of my earlier years was entitled “The Physician Grieves Alone” that had it been written would have chronicled how I had seen physicians respond, adapt, and cope.  Some of them were inspiring.  Some were disappointing.  Some were strengthened by it and some were worn down by it.  But one and all pay the price.  Grief is part of the daily fare for those who choose this profession.

I could, and perhaps on quiet “news days” will, indulge in more stories from the road about these women and men I admire so much.  But most days I will present us in less than favorable light because we have a special responsibility.  I believe we should be, and are, up to the task if it is clear what that should be.   So let the games begin and let the reader beware.

Continue Reading 3 of 3: PCAST – What it means to me

3. PCAST – What it means to me

PCAST – What it means to me

I have found amusing the “elevator” impressions of the PCAST report from people in the healthcare IT community.  It has been called  “Microsoft’s PCAST” and “Google’s search for healthcare.”   Other comments include:

• Just what we need a new language
• They don’t know about SNOMED
• It’s basically a CDA so we’re on the right track
• Interesting idea but we have too much data to think about changing
• Bunch of people who don’t know healthcare

In all likelihood my own “elevator” impressions will end up in someone else’s list but here it goes.

I read PCAST to be a simple elegant approach to healthcare information management;  dead center where information management in general is heading.  Is it incomplete?  Yes.  Are there devils in the details?  Yes.

Is it Microsoft’s?  No.  They clearly contributed but this is not a prescription to use Microsoft.  Will they propose using new or existing Microsoft products to follow this path forward?  Of course they will.  Healthcare is too big to ignore.

Are there influences of Google’s approach to locating and organizing distributed data?  Yes.  If you have a big hammer a lot of problems look like nails.  Will that hammer work for this problem?  My personal opinion is that it will not.  Will that experience be useful in this distributed world?  Yes.

I will not walk through all of the examples.  Instead, let me describe what I think this report  means.  The core concept is that we need architecture that is robust in the face of change at all levels.  Implicitly it acknowledges that change (progress) will occur and describes an architecture that can accommodate change with little or no change to the architecture itself.

To achieve this (and other benefits) the report essentially recommends the creation of a singular logical patient medical record.  It spends some time addressing how the data are stored in a distributed world; how the individual elements of that medical record might be linked to one another; and how searching for data might be different from how the individual elements might be retrieved.  But the big point is that at the end there is a singular logical patient medical record.

Stated another way, the report guides us to utilize a contributory model of a patient’s medical record rather than the old custodial model.  In the custodial model, a provider has his or her (hereafter her)  copy of a patient’s medical record and  acts as the custodian of her part /copy of the record.  Other providers can request a copy of the copy.  There never is a patient’s medical record and changes to the part held by one custodian are not implicitly shared.  In the contributory model, there is, external to the provider, a patient medical record.  When the provider has information to add (or modify) she contributes that change to the record.  The provider is  not responsible for the record.  Providers  are responsible for contributing their information to the record.  Lest the reader get distracted by a devil, this approach does beg the question of how/who/where that record is persisted but that detail can be addressed and will be a topic I will post ruminations about soon.

So the first big message of PCAST is transition to a distributed and linked logical medical record wherein providers contribute to that record.  This effectively decouples the application from the data persistence.  In PCAST this is the “Data Element Access Service”.  It is this approach that logically leads to the conclusion that we need to transition from EHR systems to this new path.  To my read that is really a call to transition to a contributory model of medical records wherein applications and data persistence are decoupled.

If that is the first big message of PCAST there must be a second.  Yes there is.  From my perspective they choose unfortunate wording for their “Universal Exchange Language”.  My simple minded interpretation of this is that we should create an electronic container that can be used to move data around in a distributed world.  That container should be generic enough to hold any kind of data.  But being generic is not enough.  It needs to be interpretable (yes, I just endorsed the idea of language) by a system that receives the data.  They have suggested a technology (XML) that allows us to put virtually anything in it and allows the system generating the message (does sound more and more like a language doesn’t it) to describe what the data are (tags).

PCAST did not attempt to tackle how the tags are established.  That will require the use of vocabularies and ontologies.  There are undoubtedly going to be several dialects and as with other languages used by people they will evolve.  There may be places for dictionaries and translators (where is my Stedman’s).  Some applications will be multilingual.  Just as the Brits and the Americans both started with a common language there will no doubt be divergences that lead to problems in communication.

So the second big message is that the structure of the message should be decoupled from the applications and the data persistence and that the contents of the message should allow for a “language” of exchange without prescribing the vocabulary or ontology of that language.

While there are lots of details and devils, these two powerful points characterize the path forward I see on the map that is PCAST.