Even with electronic health records systems widely adopted by the nation’s healthcare providers, limitations of current technology is putting health IT vendors on the spot to innovate across a range of technology.
The development is being prodded by customers who want ever more sources of data to be available in their EHRs, from Fitbit data to many-slice MRI studies at DICOM-quality diagnostic definition, says Aaron Miri, CIO of Walnut Hill Medical Center, Dallas.
For example, at Hennepin County Medical Center in Minneapolis, health IT executives see a forthcoming expansion beyond its installed Epic EHR platform, and “as Epic gets better at some of these other modalities, we will consider that as it makes sense,” says Matthew Werder, chief technology officer. “You talk about unstructured data and it’s endless in healthcare, everything from drawings and handwritten notes to voice dictation and text messages you might want to put into it. So it just comes from every angle, and we’re looking to our EHR to help us with that.”
At Avera Health, Sioux Falls, S.D., which is a long-time Meditech customer for clinical IT systems, a web-based re-engineering of its EHR architecture is in full swing, which will bring fast functioning of multimodal data call-up as well as a user display that can be tapped, swiped and finger-scrolled at will.
The conversion of a traditional, rigid EHR platform to new technology and different assumptions about computer architecture will be tricky, but attempts to morph older EHR software into contemporary products are under way.
McKesson is moving away from MUMPS and going to .Net technologies and tiered architectural approaches, which provide the flexibility to accommodate new application requirements and build them to a large scale, says Ron Dobes, vice president of infrastructure and architecture for McKesson Enterprise Information Solutions. Dobes is chief architect of EHRs that are designed to use newer technologies.
Separating the three layers of functionality—the user interface, the business logic in the middle and the data access and storage on the back end—is enabling faster and more focused efforts to add or improve features at any level, while preserving the others as they are, Dobes explains.
As demand rises for mobility and web enablement, McKesson’s efforts to make its Paragon EHR application available on mobile devices at the interface level won’t involve the business logic or database logic. At the database level, work in progress to build a virtual data store to house all multimodal applications together instead of as separate outside calls is being developed without having to also touch the rest of the product, Dobes says. Even if MUMPS architecture could accommodate some of the new technology developments such as web-enablement, the entire application would have to be rewritten.
Basically, McKesson’s modernizing strategy “is predicated on that nimble architectural framework that can change with changing business needs without always having to go back and start over and over and over,” Dobes says.
Meditech’s EHR reinvention is based on the latest web technology iteration, HTML5, which has the power to replace the traditional relational database and can be summoned by any web browser to tablets and phones as well as laptops and desktops, says Melissa Swanfeldt, associate vice president of marketing.
The technology helps handle calls to nontext databases quickly and display them natively in the Meditech EHR view, says Andrew Burchett, DO, Avera’s medical information officer. For example, he says, he can tap in and tap out of a radiology PACS to view anything of interest stored there, without ever leaving what he was doing at the moment—reviewing, documenting, e-prescribing, ordering. The same goes for electrocardiograms, wave forms from the cardiology image storage and so on.
The summoned information sources retain their functionality within the EHR, Burchett adds. “You’re not losing anything by launching from Meditech, because you are going to a PACS system, and then you have all the tools within that system, whatever that might be.”
Lag time is further reduced by pushing information into a position of readiness depending on what the physician has been asking the EHR to do, says Swanfeldt. It anticipates that the next task might be to query for immunization or medication history, for instance, and queues the data so it’s available more quickly if the patient’s immunization or medication file is opened.
Ambitions of the federal Precision Medicine Initiative to employ genomics in clinical decisions lays yet another nontraditional demand over EHRs engineered decades before the human genome was figured out.
It adds both a storage and a network burden, says Miri, possibly hundreds of gigabytes per patient genomic record and the performance challenge of doing sequencing tasks. Miri knows of a children’s hospital that had to lay down private fiber-optic cable between multiple sites of care, separate from the rest of the IT network, just to keep up with its genomics activities.
A report published by an AMIA task force last year on the status and future direction of EHRs touched on the need for more innovation to support patients’ molecular profiling data for person-centered care delivery. IT vendors face not only the known computer burden but also being able to support yet-unknown factors, says Thomas Payne, MD, board chair of AMIA and chair of the task force.
“Our understanding of that genomic information is changing, and we don’t necessarily know today as much as we’ll know in five years, and about what parts of that sequence might mean for our future health,” says Payne, medical director of IT services for UW Medicine at the University of Washington. “So you can’t just digest it and understand it once; you need to go back and apply new discoveries to information that you have stored previously.”
A variant in a genome of uncertain significance today can be better understood in time, and researchers and providers need to be able to search for it a second time and bring new findings to the attention of the patient and other clinicians, Payne says. “It is a lot of information, and what we learn from it changes over time. And we need to be prepared for that.”
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