Epic Interoperability?
on December 15, 2009
I love being wrong, at least when it comes to how I perceive someone or something like, say, a large organization or company. It's easy to criticize and vilify large entities. I have fun messing with Microsoft employees, or even staff at ONC (Office of the National Coordinator for Health Information Technology). For example, a few months after writing a satirical piece making fun of ONC, I met a couple of ONC staff: Wil Yu and Mary Jo Deering. Wil Yu set me straight on my assumption that ONC would not fund innovative HIT (health information technology) with the federal stimulus money. Mary Jo reminded me that the government was purposefully set up with a comprehensive system of checks and balances. Yes, this bureaucracy slows the government down (almost to the point of absurdity), but it is meant to prevent the abuse of power in government.
Back to my current inaccurate stereotype. This involes Epic (also known as Epic Systems Corporation). I've heard a few stories about Epic's behemoth EMR software and the degree to which it keeps its source code proprietary and "doesn't play well with others." The impression I've gotten is that the last thing they have in mind is what's in the best interest of the patient.
It looks like I might be wrong. I had the opportunity to meet and talk with Robert Kolodner, former head of ONC (what's up with these ONC people showing up in my life?! Did I mention my previous boss just went to work for ONC?). Rob (I think we might be friends already) told me about Lucy, which is Epic's PHR (personal health record). He claims it was designed to give patients access to and control of their data.
This totally goes against my perception of Epic. To be honest, I am a bit shocked. Is it true? What's the catch? Is it possible that Epic isn't as awful as I imagined it to be?
Comments
Technical vs Social Interoperability
Technology under most EMR's - MUMPS
Epic like most of the major EMR vendor, Epic Systems Corporation, EMIS, Partners HealthCare, Meditech, and GE Healthcare is built on a programming language called MUMPS and Rob Kolodner the former director of ONC (and a friend of mine by the way) came via the VA health IT program- VISTA.
Epic which has almost 20% of the US market already allows each customer to customize their application and this makes it challenging to exchange data between two hospital systems even though they are using the same version of Epic in the same city. This explains why you have situations like they do in Palo Alto where Standford, Palo Alto Medical Foundation and Kaiser are all on Epic systems but they still print out paper copies to exchange patient data.
Lucy vs Care Everywhere
Although Lucy ( a free-standing PHR* ) is interesting the more important piece of software is called "Care Anywhere" - "Care Everywhere provides a framework for interoperability, so that wherever the patient goes – between healthcare systems in the same town or across state and national borders – the clinicians providing care can have the information they need.
Information can come from another Epic system, a non-Epic EMR that complies with industry standards, or directly from the patient. When an Epic system is on both sides of the exchange, a richer data set is exchanged and additional connectivity options, such as cross-organization referral management, are available. Regardless of the information source, Care Everywhere connects it to your EpicCare EMR, giving clinicians a more complete clinical record.
PHR vs EHR vs Shard Care Plan
A PHR- personal health record is useless without a clinical record (EHR) to import the data from. It is akin to having quicken or mint when your bank isn't online. The goal should be a shared care plan like they use at Group Health vs an EHR and a PHR but one that goes across all systems. Group Health's EHR which is based on Epic uses a patient portal and consumer centered design principals and has the highest rates of adoption (40% consumers 100% providers) ) of any PHR/EMR by patients (over 580,000 co-op members are on the system). They accomplished this by designing around the patients needs and were told it was impossible but patients were able to "write" to their EHR (via email) before the providers could (they were in read only mode at first).
Electric Pencil or Organizational Change
It is rarely the software that is the challenge but rather the financial incentives and culture surrounding the use of the tool that need to change. It is difficult with M based applications to share information but it is possible and you can exchange clinical data with your competitors if you change the financial incentives. The only way to really put the patient back in the center our healthcare system however is to design the tools and organization around them rather then viewing them as the recipient of care or data. The goal is not simply ensuring that they are able to view the "data" but that they are co-creators of the information that will result in genuine changes in their healthcare. All of healthcare starts with a conversation between a patient and their provider and health IT simply is a tool that allows that conversation to move outside the walls of the exam room. If you simply force providers to adopt a new EHR and fail to change the workflows around staff and patients all you have is an electric pencil in the end.
LUCY
" Lucy is a freestanding Personal Health Record (PHR), not connected to any facility's electronic medical record system. It stays with patients wherever they receive care and allows them to organize their medical information in one place that is readily accessible. Patients can enter health data directly into Lucy, pull in MyChart data or upload standards-compliant Continuity of Care Documents from other facilities.
VA and MUMPS or M
Just as an aside - the VA was an early adopter of MUMPS http://en.wikipedia.org/wiki/MUMPS and has won numerous awards for their system.
Nearly the entire VA hospital system in the United States and the Indian Health Service, as well as major parts of the Department of Defense CHCS hospital system all run systems using MUMPS databases for clinical data tracking.
MUMPS is extremely fast at processing large volumes of data and is also used in the financial services sector- Ameritrade, the largest online trading service in the US with over 12 billion transactions per day, as well as by the Bank of England and Barclays Bank, among others but it is challenging to share data between two data-bases developed on M.