Tag Archives: ehr

Health IT Ontology

2 weeks ago I solicited help to put together this Health IT Ontology (see Components of HIT…a start). This post is the result of 6 rounds of edits. The new name, I think, better represents the goal of defining all the entities and relationships within the domain of health IT. Click on the image below to see it full size.

Health IT Ontology

Following are the top-level categories:

  • Health Information Technology
    • Clinical Information System
    • Hospital/Clinic Management
    • Consumer-Oriented Technologies
    • Public Health & Biosurveillance
    • Reference
    • Research
    • Regional & System-Level HIS

The initial motivation behind this was to determine where ART-focused EMRs sat in the scope of HIT, but what I expected to be a trivial exercise quickly became a difficult task. Health IT is an extremely complex and expansive domain and every item in this heirarchy could be broken down into even smaller pieces (similar to EMR/EHR). My goal for this diagram was to cover the breadth of health IT more than the depth. It is certainly possible that there are some oversights, in which case I would love to hear from you.

I welcome your thoughts, criticisms, and suggestions on the HIT Onthology. Using social media (esp. Twitter and Aardvark) was so successful this time around that I plan to pursue more online collaborative projects in the future.

Many thanks to everyone who contributed, and a special shout out to Jacob Sattelmair, Janette Heung, blog commenters, Richard Thall and Eddie from Aardvark, and the score of Twitterers who provided very valuable feedback!


How Kaiser Permanente Went Paperless

A great article in Business Week from April 7, 2009: How Kaiser Permanente Went Paperless. Describes Kaiser’s $2 billion electronic health record implementation and the resulting benefits. The major conclusions:

  • Return on investment is a wash at best, although quality improves in some areas
  • Implementation isn’t transferrable to small providers

A sustainable business model for health information exchange

Personal Health Records (PHRs) have received a lot of attention lately with the release of Google Health and Microsoft HealthVault. PHRs allow individuals to securely organize their own health information and to control who has access. PHRs allow users to import data from many large repositories, including insurers, pharmacies, and laboratories, but mostly do not connect to care providers, excepting a few integrated delivery networks such as Kaiser and Beth Israel in Boston.

RHIOs are less well known but have been around much longer. RHIOs exist at the community level to facilitate the exchange of health information between care providers (e.g. doctor notes), though some also aggregate data from insurers, pharmacies, and labs. The primary audience here is care providers, rather than consumers. In theory, a network of RHIOs could form together to create a National Health Information Network (NHIN), but this is unlikely to occur without significant federal funding. More than 140 RHIOs exist today, but only a handful are considered sustainable (look at the Regenstrief Institute and MA-SHARE). Interoperability between EHR systems is complex and expensive, and though it will improve quality of care, there will be a negative return on investment until a significant proportion of providers is sharing data in a standardized way. Read The State Of Regional Health Information Organizations: Current Activities And Financing by Julia Adler-Milstein, et al for a better understanding of the current RHIO landscape.

Given the similar goals of PHRs and RHIOs, I have speculated that these ideas may eventually end up merging. John Halamka, CIO of Harvard Medical School, commented on Google Health’s new sharing and auditing features in his Cool Technology of the Week update:

I’ve already invited my primary care doctor, my family, and a few of my clinical systems colleagues who built the BIDMC-Google interface. Thus, in one morning I’ve become my own regional health information organization, sharing medical records across multiple organizations with perfect privacy controls.

However, Dr. John Glaser, CIO of Partners Healthcare, estimates that only 1 out of 10 American’s with access to an electronic health record will access it, meaning that consumers are unlikely to drive the healthcare industry’s to adoption of EHR and HIE (see Glaser’s interview with Information Weekly).

Though PHRs do not have a huge chunk of the health consumer market, 6 million users (10% of the estimated 60 million American’s with electronic health records) is large enough to give Google, Microsoft, Dossia and Revolution Health some leverage with data furnishers. PHRs also capture a monetizable audience (consumers) whether through advertising or sales of health applications. RHIOs, on the other hand, make participating providers pay to use their service, but are not large enough to offer providers significant incentives for involvement. Most rely on government funding to stay afloat. I am of the opinion that unless government steps in to fund a largescale network, PHRs have settled on a more sustainable business model and could more easily extend their data aggregation efforts into doctors notes and other administrative data handled by RHIOs. In this case, both providers and consumers would be the primary audience of the platform. By using the PHR for both consumer and clinical needs, the record becomes immensely more useful, assuming that audit trails, quality control, and security measures are in place.

What is an EHR?

There is actually a lot of discussion still taking place about what an electronic health record (EHR) actually is. Earlier this decade, a survey taken at a convention of EHR vendors and hospitals estimated EHR adoption at 60%. This information was used by the Bush administration in 2004 to justify formation of the Office of the National Coordinator for Health IT (ONC) and to set the goal of 90% of Americans having electronic health records by 2014. One decade seemed reasonable given the 60% adoption rate. We now know that the adoption rate among hospitals is closer to 10%, with 10-25% currently in planning or implementation stages.

Part of the problem is in the definition. The survey simply asked if care providers had electronic records. But that could mean patient information, a billing and claims system, electronic order entry, or any number of things. The Institute of Medicine released a report in 2003, Key Capabilities of an Electronic Health Record System, that attempted to solve this, and identified the following core functionalities of EHR:

  1. Health information and data
  2. Results management
  3. Order entry/order management
  4. Decision support
  5. Electronic communication and connectivity
  6. Patient support
  7. Administrative processes
  8. Reporting and population health management

The 4 in bold might be considered the bare minimum. Administrative processes are certainly important to the operations of a hospital, but these are historically separate systems focused on billing and insurance claims. Oddly enough, evidence has shown that providers that initially adopt electronic billing systems are no more likely to adopt EHR than those without it. Treating electronic billing as a first step, then, doesn’t work.