Allscripts, the EHR company that was one of the first to enable mobile phones to access EHRs from remote locations continues to gain in popularity, especially in North Carolina.  A recent press release detailing how MedWest Health Systems chose Allscripts shed some light onto the gains Allscript has made in the state of North Carolina:

“Allscripts clearly has superior features and functionality, but what really tipped the scales in their favor was their demonstrated ability to implement and support the technology across a large physician enterprise,” commented Steve Heatherly, Chief Strategy Officer and Vice President of Ambulatory Services for MedWest. “In addition, we’ve always planned to share the electronic health record with our non-employed community doctors as part of our physician integration strategy, and Allscripts has significant experience with similar deployment models.”

MedWest adds to the Allscripts market-leading client footprint in North Carolina, where the company provides solutions to more than 3,300 individual physician practices.

Allscripts allows it’s electronic health record to be accessed off site via the iPhone, Blackberry, and Windows mobile phone. We spoke with Allscripts executives during our coverage of HIMSS – currently we’re still waiting on Android compatibility for the EHR.

Source: Press Release

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Verizon is planning a cloud based services for clinical providers to securely exchange health information. Features will include a clinical dashboard, record locator service, cross-enterprise patient index and clinical messaging.

GigaOm makes the point:

… by delivering what is essentially medical records as a service for hospitals and physicians, Verizon is not only trying to get a chunk of federal money, but also trying to provide the type of cloud service that will fill up its networks.

It is interesting to see established business with scant previous history in health technology enter the rapidly expanding health IT market. With Verizon’s increasingly important ties to Google and its rapidly growing Android mobile operating system, we may even see integration of health exchange information on mobile devices.

Source: CMIO.net;GigaOm

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Kodak and MedCo Data are teaming up to offer a service that will definitely be of need as the push to adopt electronic medical records continues:

Launched in late June at the TechData Technology Solutions Tour, the Patient Chart Scanning Solution uses Kodak Capture Pro Software and Kodak Scanners to capture data from patient charts and transfer it automatically into MedCo Data Vault — a Health Insurance Portability and Accountability Act (HIPAA) compliant product — where the information can be stored and accessed as needed.

The data will be stored in HL7 format, considered the gold standard for interoperability between health records as defined by the “meaningful use” criteria – helping practices qualify for stimulus funding.

Source: Information Week

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One of the newer electronic health records (EHRs) on display at the recent HIMSS conference was by CareCloud. The name “CareCloud” reflects that the application lives in the “cloud” and not on your computer. There is no software to download, and patient records can be accessed from any computer using a web browser.

This web-based application delivery is similar to other EHRs on the market such as the popular & free Practice Fusion, MDLand, Hello Health, and Allscripts (which has both a hosted and client-server option). What differentiates CareCloud is that it is built with some of the same tools and features as consumer websites and that it places high value on graphic design. In particular, it is built with Ruby on Rails – a modern, highly-abstracted programming language well suited for rapid development of web applications – and uses open-source software for infrastructure components, where possible. These strategies allowed the company to build the entire application within 18 months and to continue to add features quickly. The user interface is written using Adobe Flex which outputs to Adobe Flash and allows for a very attractive, fluid interface and, as you can see in the accompanying video, leaves little to be desired in responsiveness when compared to a traditional desktop application.

By carefully engineering the application to keep the user interface separate from the data, the CEO Albert Santalo, told us they are able to easily deliver the same application on multiple platforms, including the iPhone and the soon to be available iPad. In fact, we were advised to stay tuned in this respect given Adobe’s recent announcement of a a Flash to iPhone OS compiler which will allow applications developed for Flash to run natively on the iPhone OS. Having seen the CareCloud application running in a desk-top browser, I can imagine it being quite compelling running in a tablet.

While the EHR has the usual scheduling and practice management features, one can see throughout the little flourishes of application developers that have one foot in the consumer web space, where usability and integration with other web services are the norm and indeed necessary if a tech startup is going to survive. For example, while confirming a patient appointment, the office front desk can automatically send a Google map of the doctor’s office to the patient’s cell phone. However, the most interesting feature I saw was the built-in communication platform which incorporates a Twitter-like event-stream along with private in-office messaging. The feature is called the “Pulse” and appears as a customizable event stream which shows all the background activity that occurs inside the EHR, such as a patient being scheduled or a patient being taken to an exam room. This means, at a glance, a physician can see what is going on inside her practice, in real time, without having to repeatedly ask the front desk. Also included is a means to send message to other members of the office as well as securely communicating with patients. The patient documentation modules should be live by Q3 of this year.

Also interesting to the physician is that CareCloud’s roots are in “revenue cycle management”, i.e. billing and collection. Mr. Santalo’s last startup was a successful revenue cycle company, also based in Florida, which had grown to 250 employees. This extensive experience has benefited the development of CareCloud which has built-in automated charge submission and detailed collection reporting. Mr. Santalo claims that up to 90% of electronically submitted office charges are paid without complication. Behind the application is a team of collection specialists which will pursue any “stuck” claims on behalf of the physician.

There are two payment options, a flat monthly subscription fee of $350 or payment of a percentage of collections, analogous to a billing company. Thus far, CareCloud has already attracted $2.3m in funding and recently won an invitation to present at the Health IT Venture Fair at this year’s HIMSS, an event to highlight promising growth companies to potential investors.  The product is launching next month with several physician practices already subscribed. For those observers who have noticed that the rapid evolution and attention to usability of the consumer web had yet to make large inroads into health information systems, Care Cloud is a company to keep an eye on.

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This article is part of iMedicalApps HIMSS 2010 Coverage. It includes a brief review of the Allscripts Remote app for the iPhone as well as details of a conversation with Allscripts executives who revealed that they are moving to development of an Android app.

When Allscripts announced the launch of Allscripts Remote last year, an iPhone application for their popular electronic medical record, it was widely touted as a transformational move. Forbes Magazine called this an app “that could change medicine.” Allscripts origins are interesting, shifting from prepackaged medicine to e-prescribing solutions before entering the electronic health record industry. In fact, according to the marketing folks at the Allscripts booth, they are the largest source of e-prescriptions in the United States. And while Epic, Cerner, and Eclypsis may be the players many of us commonly think about, Allscripts definitely definitely is not little – according to their most recent SEC filing, Allscripts had over $500million in revenue for 2009 with a net income of $26million. By comparison, Epic also had $500million in revenue for 2009. So the inclusion of a rich, clinically useful mobile platform with Allscripts Remote has certainly been a big move in the EHR world.

The iPhone App: Frankly, this is the mobile EHR app that clinicians have been waiting for. Imagine being at dinner with your family. The paging service for your practice sends you a text – Mr. Jones called in because he’s got some swelling in his legs.

With the Remote app, you don’t even have to leave your seat (although you probably should for HIPAA reasons). When you open the app you’ve got several frames that you can enter, but you obviously first go into the EHR and look up Mr. Jones. You get a list of all the conditions Mr. Jones has been followed for (oh turns out he has CHF), his current medication list (he takes 20 mg Lasix once daily), and allergies. So you call Mr. Jones back (you also have his contact information) and he says “Doctor I ran out of my Lasix!” Well, the masters of e-prescribing have you covered. You can simply click on the Rx icon at the bottom of the screen to go over to his med list, tap on the “Lasix” to issue a new prescription, and send it to his favorite pharmacy.

Or lets say things are a little more serious – Mr .Jones has shortness of breath also. In that case, you simply touch the ER icon at the bottom of the screen to locate the nearest emergency room and fax a summary of Mr. Jone’s office record to that ER as you tell him to go there. Mr Jones now says “Thank you doctor – I’ll go as soon as I finish this movie and my bucket of popcorn.” You conclude your care of Mr. Jones by going over to the last field, a documentation icon, which allows you to enter a brief note on the call for Mr. Jone’s primary physician, probably with a comment that Mr. Jones may need some help managing his diet.

I knew that Allscripts Remote could do all of this when I walked in, but I was still amazed. The UI was cool and intuitive, with features like a touch-to-call feature in the patient’s individual record that show you that the folks at Allscripts thought of the little things that make a clinicians life easier.

The Android App: The Androids among us should get excited – I heard at the Allscripts booth that they are currently developing their Remote app for Android with hopes of release in the near future. More on that as we hear it! Remote is already available for Blackberry and Windows Mobile, but not with all the features available on the iPhone – I suspect its with Android that we’ll see the same level of functionality on a competing platform.

Allscripts EHR offerings are pretty diverse, including software-as-a-service solution for as little as $300, geared to the smaller practices that aren’t looking to make a huge investment in an in-house EHR. These kinds of offerings will be crucial for companies like Allscripts to capture the small-practice market, where a 70% of healthcare is delivered according to some studies. These practices, of which up to 80% may be looking at EHR adoption now based on a 2003 survey, may find particular appeal in the web-based EHR’s that we have discussed previously. However, Allscripts Remote is likely to challenge the mobility argument for web-based EHR’s in that this app is designed with an intuitive UI and rich features that clearly fit the clinician’s workflow – it will be interesting to see whether the web-based EHR vendors can develop, at least in the near future, a similarly rich, intuitive mobile interface for their products. As Mr. Hollis from MacPractice -another EHR vendor with a pretty cool iPhone interface – pointed out, there may be much richer possibilities with local apps and software than with a web-based platform.

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This article is part of our HIMSS 2010 coverage. It includes an overview of the MacPractice EHR and its iPhone interface as well as a conversation with Mark Hollis, CEO of MacPractice.

One of the key’s to Apple’s success has been the reliable, simple, and fun UI it has designed for every one of its products. Part of the reason that this feature has stood out is because the Microsoft-based PC world has become known for essentially the opposite. The same is true for many electronic health record platforms built for Windows, where the same security vulnerabilities, networking complexity, and famed “blue screen of death” plague the slightly-less-than-tech-savvy average physician. For this reason, Mark Hollis – CEO of MacPractice – offers a system that runs entirely on the Mac. I had the opportunity to check out the iPhone platform tied to this EHR and also to chat with Mr. Hollis about his vision for this platform and some of the challenges it faces.

The iPhone Platform – From the start, the interface looks pretty slick. There are a number of different functions built in including a calendar of appointments, patient contact information (with a simple touch allowing you to call or email them), charge capture, patient prescription history, and referral management.

The appointment calendar (pictured here with the Rx history) basically consists of the patient’s name, appointment time, and picture. This last feature, a simple picture, is great for two reasons – it could help jog your memory so you remember who this person is (rather than just the diseases they need followed up) and it does wonders for morale (its a lot harder to be unhappy with a packed afternoon schedule when you have those smiling faces looking at you). Honestly though, I was underwhelmed with the remainder of the features. I expected more in terms of ability to view a problem list, recent notes or labs, or other information that would be useful in caring for a patient. This app, at least at this stage, seems to be geared more toward the administrative side of a physician – planning a day, getting all the charges in, etc. I hope that future versions of the iPhone interface improve on the clinical utility of this app.

In addition to this iPhone platform, there are a number of other features that make the MacPractice EHR pretty cool. Among them are the UI which Mr. Hollis noted was designed so that pretty much any office personnel can be up and running with minimal training. It can also be used by patients via a special interface to make appointments, send messages, and so on. For the tech-wary among us, it runs on networked MacBooks/iMacs without a server, which means a far simpler system to manage – according to Mr. Hollis, its not uncommon for a practice to go years without ever needing corrective service of any kind. And if they do, its often fixed with a trip to the Apple Store, thus leveraging Apple’s customer service infrastructure. Finally, its a highly customizable system – this is a particularly useful feature for small specialist practices who often require very different kinds of patient records. In fact, the basic system has been customized for dentists and optometrists as well.

While there a lot of cool features here, MacPractice also faces a big challenge from web-based EHR’s. These systems provide similar benefits – minimal setup and maintenance for example – with very low price points (as low as free). And they too are directed at small-medium sized practices that don’t want or need a complicated, in-house EHR. Mr. Hollis raised a number of very interesting points as to why he believes web-based EHR’s will join the same market space that MacPractice occupies rather than dominate it.

First, most web-based EHR’s come prepackaged, and that packaging is largely defined by the “meaningful use” criteria that will allow clinicians to get stimulus funding. However, those criteria are basically geared to primary care – specialists could be left out on this one. That’s an opportunity for customizable, simple EHR’s like MacPractice.

Second, Mr. Hollis notes that the development possibilities are far more rich using Apple’s XCode, giving him opportunities he wouldn’t have with a purely online platform. Finally, there’s the issue of reliability – what happens if your internet goes down? Clinicians who adopt web-based EHR’s will not only need high-speed connectivity, but they may also need some sort of redundancy and managing that could be a headache.

All that being said, Mr. Hollis doesn’t dismiss cloud functionality as unimportant – in fact, its likely to be essential to meet meaningful use criteria. MacPractice is exploring ways to bring data in aggregate onto the cloud for analysis and take that essential step to contributing to population health management. Additionally, they have been engaged in the development of the Stage 1 criteria, being released in June, and plan to be certified as well. I certainly look forward to seeing how this EHR evolves in the coming months.

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1. Triage and Treat Patients From Anywhere with Allscripts Remote iPhone App- An Electronic Health Record and ePrescribing Tool (upcoming Android support)
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3. Epocrates’s recently announced Electronic Health Record will utilize many iPhone features

We’re live here in Atlanta, Georgia, at the HIMSS conference.  This week we’ll be bringing relevant posts and interviews related to the conference in breaking news fashion.

The 2010 HIMSS (Healthcare Information and Management Systems Society) conference is now underway in Atlanta in what promises to be a signal year in the world of health IT. The reasons seems to be the confluence of a year long public discussion on health care reform and, very important, the provision in the American Recovery and Reinvestment Act (ARRA), also known as the stimulus bill, that rewards physicians for meaningful adoption of a qualified electronic health record (EHR).

The reward can equal as much as $44,000 over 5 years and is creating a frenzy of vendors asserting that their EHR is certified, meanwhile the community at large is breathlessly awaiting to hear what the government regards as “meaningful use”. The final rules on meaningful use are expected later this year. Partially, as a result this, HIMSS found in its annual survey of its leadership:

“… [these]  incentives and a rebounding economy, nearly three quarters (72 percent) of respondents said they expect their IT operating budgets to increase, bringing that response back to the levels of two years ago.”

In the meantime, the non-profit organization which certifies EHRs (CCHIT or Certification Commission for Health Information Technology) continues to develop deeper and broader specifications on what it means to be a “certified” EHR.

These are interesting developments for physicians in a few ways. Most obvious is the financial incentive to adopt an EHR in one’s practice. As the table below shows, the financial incentive decreases the longer one waits to adopt.

Perhaps the most compelling reason for adoption of EHR standardization is to make interoperability the norm rather than the exception. Currently, if you have adopted one EHR for your practice, the burden of changing to another system quickly becomes the fear and difficulty of transferring your medical records electronically. Therefore, innovation can often be dampened by the fact that physician consumers are mostly locked into whatever purchase decisions they have made.

EHR certification and thus partial standardization also opens the door to new business opportunities. I had the pleasure to meet with Dr.James O’Connor, the CEO of a startup named MDcohort LLC, which is developing tools that enhance the entry and maintenance of data by physicians into EHRs with the goal of having better data available for research.

This could make it easier to enroll patients into FDA clinical trials while empowering physicians in negotiations with parties potentially interested in the data, such as the pharmaceutical industry. It also enhances data collection by integrating research tools, such as disability indexes in the initial data capture. Dr. O’Connor says the specialty societies are key to understanding the needs of physicians in each specialty.

There is much more to learn in this sprawling conference where the energy is palpable. The role of informatics in healthcare will only continue to increase and become more diverse. Physician entrepreneurs like Dr. O’Connor will hopefully continue to make sure it works for the maximum advantage of physicians and patients.

Above table from Chilmark Research

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When I was handed my first pager, I was stunned. It looked like the beeper that Will Smith used to flash on the Fresh Prince of Bel Air (and not even the later seasons, I’m talking about the early, crazy outfit seasons!). So I asked why I couldn’t simply use my phone or, for that matter, why we didn’t all use phones. The answer was simple – reliability. The paging system, of which this rather archaic looking item was part, was very reliable. But was that enough? No. The hospital also maintains it overhead paging system just in case. And if that goes down – yep, there’s a back up there too. In health information technology, reliability is everything. And for the iPad, that could prove to be a major barrier to adoption in the medical community as it faces off with other medical tablets, at least if the FCC’s recently voiced concerns prove to be true.

We all know that AT&T has been having issues with their telecommunications network since the inception of the iPhone.  The NY Times did a great piece on the 3G woes and how the public finger pointing between AT&T and Apple has exposed some serious problems with their partnership – the funny thing is, the article is 2 years old yet still holds true today.  It seems AT&T was not prepared for the surge in usage brought by the iPhone, a phone that guzzles data and network resources much like a Humvee uses gasoline.  So its wasn’t surprising that the reaction was less than warm when Steve Jobs announced AT&T had once again won exclusive rights to the data plans for an Apple product, this time the iPad [it was the only time during his presentation when the audience actually jeered him].

And now, the FCC is expressing concerns the iPad, of which there could be millions on the AT&T network, could overwhelm the existing infrastructure. Two high profile FCC officials, Phil Bellaria, Director of Scenario Planning, and John Leibovitz, Deputy Chief of the Wireless Telecommunications Bureau had the following to say on their blog:

Widespread use of smartphones, 3G-enabled netbooks, and now, perhaps, the iPad and its competitors demonstrate that wireless broadband will be a hugely important part of the broadband ecosystem as we move ahead….With the iPad pointing to even greater demand for mobile broadband on the horizon, we must ensure that network congestion doesn’t choke off a service that consumers clearly find so appealing or frustrate mobile broadband’s ability to keep us competitive in the global broadband economy.

This isn’t necessarily a deal-breaker for every healthcare provider. Hospitals and health systems, for example, generally rely on local Wi-Fi networks through which a mobile device could access an EMR. The providers for whom this is more likely to be an issue are the private physicians and physician extenders (physician assistants and nurse practitioners) who work in multiple hospitals, surgery centers, nursing homes, and so on. These providers are more likely to rely on a commercial data network to access their own clinic’s EMR when, say, doing a bronchoscopy on a patient at an outpatient surgery center or on-call for a nursing home. For them, slow or absent connectivity even 1% of the time is unacceptable.

This issue is certainly not intrinsic to the iPad – it’s an effect of Apple’s relationship with AT&T. And AT&T has recognized this problem and is moving to improve its infrastructure. But time is not on Apple’s side. Lenovo, HP, and numerous other vendors are releasing new tablets at a dizzying pace with a range of features and prices. And the healthcare community is certainly looking closely at tablets right now, as various EMRs are being adopted by healthcare providers across the country. So now is the time for tablet vendors to reach out to the medical community. And carrying the baggage of an unreliable data network is certainly going to be a strike against any tablet hoping to gain traction in the medical community.

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Having had the opportunity to visit nearly a dozen academic medical centers in the past few weeks, I saw quite the spectrum of IT systems – from simple order entry to fully-integrated decision support systems. And for programs with the former, that revelation was quickly followed by the timeline for the coming upgrade. But what’s next for the most IT-savvy institutions? Well, Steve Jobs thinks he has an answer. Rumors abound that Apple is already pitching the iPad in LA-area hospitals as the replacement for the old physician clipboard. For outpatient practices already running a Mac-based EMR, MacPractice has already announced development plans for an iPad interface. According to their press release, they plan to develop apps that will allow patients to fill out registration, medical history, and other forms on the iPad. For physicians, it will integrate with the MacPractice EMR to manage schedules, view patient records, and even enter clinical notes. So could the iPad become the new best friend of healthcare providers? Well, there are a few challenges that need to be overcome first but the opportunities are exciting.

First, it has to be useful enough that I’m going to want to carry it around and that usefulness largely rests on the ability to write on the iPad. As we’ve discussed previously, handwriting functionality does appear to be coming to the iPad. But just having it isn’t enough. It has to really good. As experience with previous tablets has shown us, most of us can type faster than we can write on a tablet screen. So for me to carry around an iPad, that handwriting functionality has to be good enough that, at the minimum, I don’t get slowed down by using it. Either that, or the dictation apps have to learn words like “heliotrope” and “sulfasalazine.” Granted, order-entry can probably work well without this functionality (all you need is a good user interface with an excellent search for medications and tests). But if the iPad is going to be my sidekick, it needs to relieve me of the chore of finding a computer to enter orders and write my daily progress notes.

Second, even if the functionality is all there, the fact that the vast majority of EMR’s run on a Windows OS is another challenge. While Citrix has released an app that enables the iPad to run Windows 7 remotely, which would conceivably allow one to access any Windows-based resource, we would then lose the user interface that made us want an iPad in the first place (having to spend a lot more money to do it). That being said, the Epic-Apple partnership clearly found a way to make it all work with Epic now having released Haiku, the fruits of their pilot at Stanford. That on the iPad plus the functionality I just talked about – then we’ve got something.

The day is probably not far of where a tablet like iPad becomes a healthcare provider’s primary portal into the their health IT system. Issues like battery life (I suspect 10 hours will be a stretch), infection control, multitasking, and ports for peripherals – these can all be improved in the coming iterations of the iPad. One thing worth remembering though – Apple’s Windows-based competitors will not be as far behind this time (see number 9).

[Side note: Now you may wonder “what’s the clipboard for if you work somewhere with an electronic medical record?” Well, the fact is most providers don’t like running to computer every time they need to check what dose of antibiotic their patient is on or what type of COPD they have. So we carry printouts with that information. I, for example, carried my patient’s admission notes (which generally detailed their past medical history) and an EMR-provided daily summary of their medical condition(s) and medications/doses. The advantage with paper though, I found, was that I could ditch the clipboard with a few folds and an empty pocket.]

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3. Apple squashes any hopes of flash based electronic health records on the iPhone or iPad

Now that Apple’s bombshell has finally been dropped and the world has met the iPad, its finally time to begin separating fact from fiction. Will the iPad boast the same outstanding user interface as the iPhone and iPod Touch? Yes. Will the iPad solve world hunger? Probably not. Will the iPad be a useful tool in medicine, perhaps even transform the way healthcare is delivered or electronic medical records organized? The jury is still out on that one but, admittedly, I am skeptical. Here are a few of the reasons why.

1) For a healthcare provider’s day-to-day use, the iPad doesn’t do anything better than an iPhone or a laptop/desktop.

In considering whether to invest in an iPad, my question is simple – how does this device help me do my job better? The iPhone answered this question by enabling me to put a wealth of medical resources into a small mobile format. In certain health systems, I can even check on new labs or radiology reports from anywhere in the hospital via my iPhone. I’m less convinced the iPad offers similar benefits, at least beyond the iPhone or iPod Touch. Improved graphics or a higher resolution screen don’t really matter much for reading text or looking at numbers. And when it comes to looking at CT, MRI, Echo, or other kinds of imaging where resolution does matter, I’m going to use the 25’’ high-resolution monitors that are available in the hospital. While I agree that this would all be much “cooler” on the iPad (it’d be fun to scroll through a high resolution CT on a larger screen in the cafeteria), the fact is that specialists, such as radiologists, are the ones who really degree of resolution and their screens are already better than the iPad. The iPad certainly does it all, but I have yet to see how it’s a significant improvement over the iPhone in this type of day to day use.

2) Big hurdles face development of peripherals for more advanced healthcare functions

The mobility of the iPad certainly offers some opportunities for the more procedural tasks of hospital care. For example, there would certainly be value to a peripheral that measured blood pressure, heart rate, and other vital signs and then uploaded them to the inpatient electronic medical record. Or for a peripheral adapter that allowed connection to fiber optic cameras or ultrasounds, allowing me to view or record the images from my iPad to the electronic medical record. These are all intriguing possibilities. However, the big obstacle here are the entrenched powers currently in control. Medical devices are a big money game, and companies like Stryker, who make a number of such devices, including fiberoptic cameras, will likely not want to cede the user interface of their platforms to Apple, let alone standardize connectivity options with other device manufacturers.

3) Safety

I mean this in two ways. First, patient safety. Infection control is a paramount concern in hospitals today. You don’t want to know the number of protective layers I had to wear at the height of H1N1 (or the cost of this extra protection). If the iPad is going to do more than be an EMR portal for writing patients notes and reading their records, then it has to be strong enough to withstand disinfection procedures. Second, property safety. Desktops are hard to steal, laptops are easier, and an iPad would be a breeze. If patient information is stored or accessible on the iPad, the hospital’s lawyers will demand a pretty high level of security.

With that said, Apple has had discussions with with Epic, a major electronic medical record developer, on iPhone OS integration. I’m sure the parties involved in these discussions have thought about the potential the iPad has for EMR use. And I do think there is potential in healthcare, particularly in niches where tablets are already used (such as emergency medical services). There is a case to be made that this is the first tablet that’s easy and fun to use and it will succeed where prior tablets have failed. And while we at iMedicalApps have some differing opinions about the possibilities of the iPad, we’re excited to see what happens once developers start making medical apps for the iPad.

And by the way, while the iPad is certainly the coolest kid on the block, at least one competitor (Freescale) may offer customized tablets running open-source operating systems like Android for as little as $200.

Related Posts:

1. Apple iPad and Electronic Medical Records – Could it Replace the Physician’s Clipboard?
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3. iPad 3G Arrives: Should the Medical World Care? Yes!

The march is on across the American healthcare landscape to implement electronic health records that  also function as decision-support systems. These “advanced” electronic health records will both provide centralized records and assist providers in making care decisions such as implementing therapy and utilizing evidence-based practice on the individual patient level. And anyone that has had the opportunity to work with some of the systems out there knows that they can be pretty impressive, doing everything from risk stratification for embolic events to calculating weight-based drug dosages. While this technology continues to reshape the way medicine is practiced in the United States, it is worth making note of some interesting tactics that corporations are using with regards to risk-management. Because, inevitably, these systems are designed and used by regular people and mistakes will be made. And as often occurs in medicine, the first question will be where the liability for the mistake falls.

Health IT (HIT) companies basically use two principles that protect them when patient harm results from a failure of their IT systems. The first is the principle of the “learned intermediary,” which basically refers to healthcare providers who, because of their specialized training, are making individualized decisions based on risk/benefit profiles. As a Koppel et al (JAMA, 2005) explain,

HIT vendors thereby claim that, because they cannot practice medicine and are merely creating a software tool, clinicians are in much stronger positions to identify those errors resulting from faulty software or hardware.

The second risk-management principle that HIT companies use is  non-disclosure clauses, which basically state that healthcare providers are forbidden from sharing software faults with anyone but the vendor. While this may be a norm of the IT industry, it clearly goes against the principles of beneficence that healthcare providers ascribe to. For example, if a patient were to be harmed  due to  a faulty dosage calculator embedded in the software, not only is all liability shifted squarely onto the provider but the providers is not allowed to share that information with the medical community.

While these contractual provisions may seem like absolute nonsense to most healthcare providers, it is worth pausing and looking at it from the vendors point of view. Another study published by Koppel et al in JAMA (2005) looked at errors related to CPOE (computerize physician order entry) at a large academic medical center. Errors they identified fell into two major categories – human-machine interface flaws and information errors related to poor multi-system integration.  In English, the former boils down to poor functional design (think Windows Mobile) and the latter is a failure to make different systems work together (think roll-out of Vista).

Errors resulting from entering orders on the wrong patient because of a poor display design, accidentally ordering a medication for tomorrow instead of today because of preset dose timings, and so on – these are errors that result from how we use it. No software company is liable for mistakes made while using their software, sort of along the lines of the “buyer beware” that underlies our whole economic system. Integration errors, such as incorrect drug dosages resulting from usage of a hospital’s pharmacy warehousing and purchasing databases instead of clinical guidelines, often result from the customization that occurs when rolling out these systems at a hospital or other venue.

That being said, its hard to see how absolving a HIT vendor from all liability for any error related to its software and then keeping that error a secret is consistent with basic ethical principles of healthcare. And the letter sent by Senator Chuck Grassley (R-Iowa) to Cerner Corporation, who own the popular Eclipsys system among other things, seeking information on these practices suggests that there may be some movement on the regulatory side to reshape the relationship of HIT vendors with the healthcare system in general. In the meantime, healthcare providers need to leverage our negotiating power with the several HIT vendors out there and push for change that both creates a more open system for managing the inevitable errors that will result from this technology while giving HIT vendors more incentive to protect patients from harm.

Also contributing: Iltifat Husain

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2. Apple iPad and Electronic Medical Records – Could it Replace the Physician’s Clipboard?
3. Why Apps are the Future of Mobile Health
 and Electronic Health Records

The Wall Street Journal has a great article mentioning most of the current mobile electronic personal health records for the iPhone and how they are being used. The article talks about the usefulness of these mobile records and also tells of some of their pitfalls.

One of the biggest pitfalls mentioned is how users have to input their own medical data manually.  Currently some insurance companies and hospitals offer tethered systems, where they will automatically update your personal health records.  Once this becomes more common there should be a greater usage of these mobile platforms.  Although they are improving, these tethered systems often do not communicate well with each other.  This is a topic we’ll discuss on this site in the future since it’s a personal interest of mine.

Polka, TheCarrot.com and Ringful are among a number of new services that allow consumers to input their medical information and track their conditions using a smart phone. Particularly for the small but growing number of people who use electronic health records, phone applications are appealing because they can allow mobile access to personal information.

The market is nascent, however. Currently, only about 3% of U.S. consumers put their medical information online in personal-health records, according to Forrester Research. It’s mainly up to consumers to accurately log their own health data…..

…..With AllOne Health’s application called AllOne Mobile, users can view their medial history on the go, see prescription history and pharmacy information and receive alerts on medical appointments. It gives mobile access to existing personal-health records maintained by participating health plans and for users of Microsoft’s HealthVault program. But right now the application is view-only; users can make changes to their health records using the health plans’ Web interfaces, but not directly from the phone. (The company says it plans on adding this feature next year.)

Related Posts:

1. Wall Street Journal Chronicles Recent Mobile Platform Proliferation into Healthcare
2. Google shows how mobile health care apps can sync with their personal health record
3. Epic developing iPad app to complement popular iPhone electronic health record app