Where are we and how did we get here

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• Where are we and how did we get here?
• Dons Detmer and Simborg

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This mornings plan

• First session
• How did we get here?
• Early history Don Simborg
• Recent history Don Detmer
• Discussion
• Break
• Second session
• Where are we?
• Two points of view The Dons
• Discussion

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How did we get here?

• The earliest medical computing
• 1950s research computing, analog computers,
  signal processing
• 1960s early hospital billing systems, patient
  care systems
• Lockheed/Mayo Clinic El Camino TDS
  Eclipsys
• Huff, Barrington, Owens HBOC
  McKesson
• Shared Medical Systems Siemens
• IBM Akron Childrens and Monmouth, NJ, Baxter,
  PCS, et. al.

• The earliest EMRs
• Homer Warner Circa 67 LDS, HELP, coding,
  decision support, 3M
• Octo Barnett Circa 68 MGH community clinic,
  coding, decision support, encounter note
  documentation, COSTAR, NEJ article 1968
• Ed Hammond Circa 70 Duke Univ., coding,
  decision support, encounter note
  documentation, TMR, Commercial version
• Clem McDonald Circa 72 Regenstrief diabetes
  clinic, coding, decision support, NEJ article
  76, SMS

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Features of earliest EMRs

• Coded information
• Decision support
• Encounter note documentation
• Commercialization attempts
• They went beyond order entry and results display
• The vision was clear from the beginning
• Improve clinical decisions and reduce errors

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Other early projects

• VA file manager DiStar SAIC
• TRIMIS
• STOR (summary time-oriented record)
• PROMIS
• Many physician work-station projects

Mid 70s Predictions that paperless systems
and EMRs would be ubiquitous within a
decade 1984 DRG arrived First linkage of
billing to clinical information again led to
predictions of ubiquitous clinical systems The
wave that never breaks
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Evolutionary Themes and Debates

• Mainframes of the 60s 70s
• Minicomputers of 70s and 80s
• Microcomputers of 80s and 90s and
  beyond

• Arrival of the network
• Front-end networks or terminal to host
• Larry Weed, 1975
• TRIMIS, 1976
• Back-end networks or host to host
• UCSF, 1979
• HL7, 1986
• The great debate of the 80s
• Open architecture vs. single vendor
• Distributed systems vs. mainframes
• Best of breed vs. integrated products
• Virtual EMR vs. single database

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Evolutionary Themes and Debates, cont.

• Standards
• Network Levels 1-4
• Message HL7
• Data
• Specialty imaging, lab, drug files, et. al.
• General purpose ICD, CPT, Various billing
• Generalized clinical data
• NLM Metathesaurus
• SNOP leading to SNOMED/Read

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Evolutionary Themes and Debates, cont.

• The struggle for input
• Free text vs. Structured text
• Free text
• Easy, comfortable, familiar
• Fully expressive
• Fast
• No learning curve
• Structured text
• Coded
• Does not require transcription or voice
  recognition
• Takes motivation and practice to become fast
• Promotes consistency, completeness and
  standardization

My biggest fear is that voice recognition will
one day work
and even worse, parsing free text will work.
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Evolutionary Themes and Debates, cont.

• Knowledge vs. Information
• Knowledge
• Caduceus, Jack Meyers
• Problem Knowledge-Coupler, Larry Weed
• MYCIN, Ted Shortliffe
• Information
• Clem McDonald, NEJ article
• HELP, multiple publications
• STOR, information theory study, 1985, JAMA

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Conclusions

• By the end of the 80s, the following was clear
• EMRs improved quality of patient care by
  increasing access to knowledge, increasing
  information flow and availability and reducing
  errors of omission and commission by physicians
  that used them.
• Physicians were not adopting them in large
  numbers.

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Detmer
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Second Session

• Where are we and how did we get here?

Where arent we and why didnt we get there?
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• Point 1 Less that 1 of physicians today are
  using EMR functionality as advanced as what was
  available in the early 1970s.
• Point 2 There has not been a single financially
  significant EMR company in the private commercial
  markets.

Why?
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Possible reasons

• Im using the wrong criteria.
• The vendors.

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Possible reasons

• Im using the wrong criteria.
• The vendors.

Axiom 1 A superb product is not a requirement
for vendor success in areas outside of
EMR.
Axiom 2 A superb product does not guarantee
success of an EMR.
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Possible reasons

• Im using the wrong criteria.
• The vendors.
• The buyers.

• The leadership.

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News Flash!

• Journal, Radiology report about a new radiology
  reporting system.
• Designed by radiologists
• Interactive coded structured text reporting
• Used by all radiologists for all reports
• Reports instantly available to referring
  physician
• Single-blind study No detectable difference in
  quality of report
• Costs lower

• It took the radiologist 12 longer than
  dictation

Wheeler, PS, Simborg, DW, Gitlin, JN, The Johns
Hopkins Radiology Reporting System, Radiology
119315-319, 1976
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Its the Physicians!

• It is NOT
• Quality of care
• Financial return for the hospital or practice
• It IS
• Physician time, convenience, motivation.
• The common denominator for financially successful
  vendors in healthcare is that they dont require
  direct physician input.

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Its the Physicians!

• It is NOT
• Quality of care
• Financial return for the hospital or practice
• It IS
• Physician time, convenience, motivation.
• The common denominator for financially successful
  vendors in healthcare is that they dont require
  direct physician use.

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Its the Physicians!

• It is NOT
• Quality of care
• Financial return for the hospital or practice
• It IS
• Physician time, convenience, motivation.
• The common denominator for financially successful
  vendors in healthcare is that they dont require
  direct physician use.

Overcome