All Over the Map: Patient Access to Clinical Lab Information

Last September, the Department of Health and Human Services introduced an amendment to the CLIA Program and HIPAA Privacy Rule: Patients’ Access to Test Reports. The rule proposes that patients have unfettered access to clinical lab test reports upon request. While hospitals, clinical labs, and clinicians say they support the proposal, implementation may have its share of problems. Added costs, new processes, privacy protections, and training of lab personnel would be required to comply with the rule.

If the federal rule is adopted, it would override the current model which provides authority to the state health information exchanges who determine accessibility rules. Today, patients’ access to clinical lab information is determined by the states. The rules are, literally, all over the map. I spent the afternoon building a US map in Powerpoint of patient lab data accessibility rules thinking that I would be able to find a rational pattern across the country.

I made a few guesses/presumptions.

• Do states with strong medical lobbies only allow reports to go the the medical provider?
• There are a cluster of states in the Mid-Atlantic (DC, DE, MD, NJ, WV) that already allow patients access to lab data. Has the “open health” movement in DC had any influence on policies in neighboring or nearby states?
• Do states that have large health systems (like Kaiser Permanente in CA, OR, WA, DC, MD, and VA ) with patient portals that share data with patients already have a consistency in policies across states?
• Is there an alignment of data accessibility policies between “blue” states and “red” states?
• Is limited accessibility by patients aligned with strong statewide tort reform and medical malpractice caps?

The answers, for the most part are, “not necessarily.” In politics, it is a mistake to look for rational patterns. Politics aside, looks like the same goes for health care.

Download the map in Powerpoint.

Hot Dog Buns and Health Records

The next time you’re at Costco ogling flat screens and buying a pallet of paper towels, you may also be surprised to learn that Costco members are now eligible to receive incentive pricing on a Costco-branded cloud-based electronic medical record. During my maiden voyage to Costco after arriving in the Bay Area,  I saw a promotion for a Costco-branded EMR, billed as a “Service of the Month.” I was so baffled that I almost crashed into the guy with the cart brimming with hot dog buns. Fortunately, he was more amused than annoyed with me. (When I asked him to pose for this photo, he thought I was crazy.)

I’m not sure if posting marketing materials in Costco’s exit lane is an effective way to target a potential audience of EMR purchasers. However, it demonstrates that EMR marketers will take just about any approach to find a customer.

I picked up the promotional materials on the way out of the store and conducted some research after getting home. I was also surprised to learn that the Costco/EMR partnership was not a first for big-box retailers. Sam’s Club and Dell had a brief affair with another EMR company, eClinicalWorks in 2009, but soon dissolved its partnership due to lack of interest among members.

Given the failed relationship between Dell, Walmart and eClinicalWorks, why is Costco now selling a cloud-based EMR? I asked myself this question. Then I asked this question on Quora and am beginning to collect responses. What’s yours?

 

 

Stick Out Your Tongue!

I am lucky enough to share a co-working space with a woman who recently graduated from the American College of Traditional Chinese Medicine. As a result, I get to be the beneficiary of health advice that lies beyond the parameters of traditional Western approaches. Rather than the anatomic or organ systems approaches I’m accustomed to, TCM’s approach is based on “the ancient Chinese perception of humans as microcosms of the larger, surrounding universe—interconnected with nature and subject to its forces. The human body is regarded as an organic entity in which the various organs, tissues, and other parts have distinct functions but are all interdependent. Health and disease relate to balance of the functions.” Searching for an analogy when reading this translation of the Classic Chinese Medicine text Huángdì Nèijīng, I think of an interactive weather map of the body. Turns out that TCM practices also rely heavily on maps of one kind of another.

One of the diagnostic foundations of Traditional Chinese Medicine (TCM) is tongue evaluation. This practice assesses a patient’s general energetic condition. Because the tongue is positioned somewhere between the interior and exterior of the body, it is particularly well suited to detect imbalances. Different areas of a patient’s tongue correspond to the different channels of the body. The color, texture, shape, and regions of the tongue are mapped and provide clues to diagnosis and therapeutic approach and progress. In addition, the tongue is also particularly well suited for photography in a clinical environment, provided the patient is a willing participant. A series of chronological photographs of the patient’s tongue can also provide a vivid picture of their clinical course and the effectiveness of therapies.

Once a diagnosis is made, TCM practitioners may use acupuncture to treat imbalances in the body. In acupuncture, small thin needles are placed in points along meridians of the body clear blockages and release “qi,” the body’s energy. Of the over 350 points along 12 major meridians of the body can also be best represented on a map of the human body. For an acupuncturist to track the points that they use in treatment, they typically record the point in a record by number. However, a visual map of a human body be a great addition to an acupuncture record and would likely be a more efficient means of recording and annotating these procedures.

TCM practice, along with a litany of other Western subspecialties can leverage files with annotation. This can be a valuable tool in developing a comprehensive and information-rich medical record. This can also be a valuable tool in the education of patients. DrChrono’s FreeDraw feature provides a seamless way to integrate images and annotate. But it’s up to the practitioner to find creative and efficient ways to use it.

Have you found a way to use FreeDraw that we should know about? Let us know.

Really Touching Data

Opened in 2006, the House of Sweden is a stunning contemporary building that houses both the Swedish and Icelandic Embassies in Washington DC’s Georgetown. The front of the building, comprised of a towering glass facade, provides visitors with a full-scale view of the clean lines of the interior architecture and the workings of the occupants. The four storey building was designed specifically to foster an atmosphere of positive and creative cooperation. The architects envisioned unusual features in an embassy — a combination of openness and transparency.

The building’s architectural elements translate into the technological approaches of Sweden more generally (i.e., their influence in the Open Source movement). Additionally, the spirit of the relationship between technology and medicine is captured beautifully in the Virtual Autopsy Project, an academic-industrial partnership that led to the development of a new commercialized product called the Sectra Visualization Table. In early 2010, the Embassy hosted an exhibit of home-grown technologies that I was lucky enough to see when I was biking around Georgetown and stopped in to check out the exhibit hall.

A dining room table-sized touch screen (basically a giant iPad) obscuring a giant CPU with plywood and tablecloths (this was a prototype) allowed users to interact in with 3-D images generated by CT and MRI scans. Developed at Sweden’s Center for Medical Science and Visualization, the table demonstrated how visualization can serve medical education, screening, and diagnostics.

While a rite of passage for a first-year medical student is a cadaver dissection, the availability of virtual cadavers may enhance opportunities for investigation and thankfully limit the time a student has to withstand the odor of formaldehyde in a dissection lab. The Swedish research team has also demonstrated the potential of touchscreen technologies in clinical care, especially in specialties like cardiology, neurology, surgery, orthopedics, and veterinary medicine. As touchscreen devices reach ubiquity in clinical medicine, there is a world of opportunity for developers of these tools and and expanding toolkits for their users.

Anders Ynnerman, one of the researchers who developed the table, in a recent TED Talk, gives a history of the Virtual Autopsy Table and samples some of the applications.

Coal Miner’s Doctor?

Occupational and Environmental Medicine is a specialty where physicians are responsible for the health of workers. While your average office cubicle dweller doesn’t usually think twice about workplace health hazards, those in mining, manufacturing, and the military have good reason to be concerned.

Typically an occupational health record and a medical record take two completely separate paths, and rarely does a practitioner get the benefit of being able to see both in the same system. As a patient’s work affects their health and vice-versa, this report proposes that an EMR also capture occupational health information. The Institute of Medicine, the Government’s most august body of academic physicians and policymakers just issued a report that examined the rationale and feasibility of incorporating occupational information in patients’ EHRs. Patient records and occupational health records typically exist in separate systems – probably because reimbursement systems differ. To unify these records would give a physician a full picture of the patients’ health, potentially making care more effective and lowering costs.

Though the most obvious place for an occupational health department is a health care setting, occupational health physicians can practice just about anywhere. Judging from a few recent listings on the American College of Occupational Medicine’s website, in addition to the usual suspects like large health systems, occupational health physicians are currently needed at the Harley Davidson Plant in Tomahawk WI, the Social Security Administration in Baltimore, MD, and SeaWorld. It seems that a physician who works at any of these atypical settings would benefit from an EMR that speaks specifically to the needs of these particular sets of patients. A diver at SeaWorld and a line worker at the Harley plant would benefit from a customized OnPatient experience when seeing an occupational health physician. Physicians who work in these environments also need to have their own set of efficiencies built into their workflow given the variety of environments they work in.