The Super Silo

I wanted to republish a post that I made to emrupdate here.

This was in response to a person who wants to help a doctor with what amounts to a super-simple note-keeping system for her nursing home patients. I should note that I think the mashups of technology that this person is suggesting is pretty clever. This is obviously a bright guy who is responding to a doctors sense of the record keeping problem. This is the dangerous first step of healthcare informatics, where a geek feels like he understands the requirements, but really has only scratched the surface. What feels like a good idea to this pair will create problems later that neither of them could effectively handle.

Here is the summary of theĀ  original proposal:

Essentially I am using File Explorer (and optionally, Launchy) as the EMR system, and Notepad (with its .LOG function) as the note-taking application. Since she is the only physician in her practice and nobody else needs access to these files, I see no need to complicate things further. This system should also be extremely small in size, and trivial to back-up.

Is this sufficient, and is it HIPAA-compliant?

My response (which references more of the message)

> Is this sufficient?

No. For the love of all that is good. No.

What you are talking about is a system that is designed to make -your- doctor more effective, at the express cost of the ability to have information sent to or from other healthcare providers. The notion that this is acceptable is tragic. Your doctor is simply considering rendering her note into a format that would have maximal use for herself, at minimal cost, both in dollars and effort. Because she has so few patients, there will never be enough financial incentive to justify porting this data into a form that can be merged with other patient data. In short, you are considering creating a kind of super-silo.What happens to this data when your doctor retires? What happens to this data if you are not around to support the solution? Neither of you has thought this through, or even taken the time to consider that you to not even have the needed tools to properly think it through. I would encourage you to play a long game of “what-if” sprinkled with some “what-happens-when?” so that you can fully appreciate that you have not thought this through.

In twenty years people will talk about projects like this in the same terms as people do now about doctors participating in blood-letting and refusing to wash their hands because they were “gentlemen”. Your doctor is considering excusing herself from the responsibility to participate in Science and you are enabling her. The informatics community does not have that much figured out (sadly) but we know enough to say that this plan is a bad one.

Do not feel too bad. Yours is just an especially bad version of the bad decision that most doctors are making to use any proprietary EHR system. The problems that you will face will happen to most doctors in America, just a little later.

Please reconsider going down this path. I would recommend ClearHealth or OpenMRS as other simple and cheap EHR systems that you can use in your environment. But really you should look into VistA, either Astronaut or OpenVistA (which both have good licenses and OK installers) b/c the VA runs many nursing homes and VistA has a reputation of handling that use-case well.

4 thoughts on “The Super Silo”

  1. I stumbled across this blog and thought I would offer a couple of comments on this. As an incessant “problem solver” I have tried over many years, addressing some of the same shortcomings in EMR software/industry that you describe. I have had numerous discussions on GPL EMR but don’t see a particularly good solution out there, YET. I would be most interested in better understanding your MM product.

    I agree wholeheartedly that the proposed solution is inadequate for the doctor. The described Explorer/Notepad solution is even less functional than dictation with either voice recognition or transcription and indexed storage. There is nothing wrong with this approach any moreso than keeping paper charts – except perhaps that it is greener than paper. Still, filling out paper and scanning would probably be an improvement. If you don’t have structured data then keeping notes as text is no better than keeping them as indexed images.

    I am no fan of government certifications but they often address real needs and problems. I think we should all try to be as HIPAA compliant as possible when it comes to patient privacy, security and backup whether or not there is any certification. Keeping patient records as text files on a doctors laptop strikes me as irresponsible without clearly identified programatic, process and human resources to help the doc protect and secure it. Otherwise it is again no different than doctors keeping paper charts in the trunks of their cars.

    I loudly applaud creative thinking for simpler, less expensive solutions for doctors. They deserve a lot more help than either the industry or government is giving them (HITECT and PQRI incentives notwithstanding). But, I think you do the doctor a disservice to limit your recommendation only to open source options. As many faults as the proprietary vendors have, there are at least a few proprietary products that actually do the the job for the doctor. I do like your recommendation that “if you can wait for a great open source emr, do so.

    But what makes you think that the open source community is even capable of designing and creating such a solution. The industry, with its tight relationships with large numbers of providers providing input and combined with organized and well funded development staffs have been mediocre at best in coming up with that.

  2. I think the community is capable of it, because we have already done it with VistA and we are doing it again with other projects. Would recommend “the best care anywhere” as a book that give evidence of this…

  3. Umm, yeah, right.

    I installed both Astronaut WorldVistA and OpenVistA. I’m pretty knowledgeable about Linux and systems in general, but not so much about GT.M/MUMPS.

    When I went to the VistA community (e.g. N.A.), they merely respond : “hire someone.”

    As if I have the money in my small practice to hire an installation and support company.

    The open source community is not really that much more helpful than proprietary companies…l

  4. What you are describing here is the “smooth wall” that VistA has presented for years. Outsiders have great difficulty getting inside and insiders often expect to be paid to help. Astronaut has been focused on fixing this problem for quite some time, and there are others. But you are making a criticism of VistA and trying to make it stick against Open Source EHRs generally.

    Hire someone is generally good advice if you cannot get the tech that makes something go, but I understand that given your level of expertise in software you justifiably feel that you should be able to self support. I would recommend looking into OpenEMR, Tolven, ClearHealth and OpenMRS all of which would be easier for someone with general Linux skills to support.

    -FT

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