Hi Sam,
Yet again, while not wishing to perpetuate the discussion if its unfruitful, I sort of agree!
In both the comments you make the difficulty lies with what you view as "short term". In reality this is extremely (at least in the UK) likely to be anything up to 10 years.
We do have to be explicit about how we achieve some sort of EHR capability in the next couple of years or so - and then how we can migrate toward the nirvana that you describe (and beyond, because we'll have at least two technology, and one modelling, generations in that period).
So I do feel that there is a need to be upfront about these issues while discussing the EHR - or we will lose contact with the mass of the potential user community - simply because they cannot see the connection between the 'now' world and the potential 'future' world. Tedious I know, but that's life...
In mail of Tue, 17 Sep 2002 08:27:24, Sam Heard <sam.heard@bigpond.com> wrote:
Melvin
Once again I agree (mostly!) - and certainly did not want to imply
different levels of medico-legal requirement within any particular
jurisdiction.
The integrated healthcare record is very usefully regarded as a single
repository which contains, either directly or by reference, all the data
that relates to the process of actually clinical care (not the
facilitating aspects of the healthcare infrastructure*) - but upon which
there are appropriate "views" according to the use context. However,
the difficulty I have is with the "throwaway" statements (perhaps just
intended as 'shorthand' but if so not sufficiently specific to be
helpful at this stage of development and email communication) which if
taken literally will result in flawed design:"generally not come from messages - there is no other place for this
data to come from but the GP application"
"generally" and "there is no other place" is the problem here, "often"
would be more accurate because, as an example, the giving of
vaccinations to children in school is not likely to be noted through the
multiple GP systems related to the children - but through a Community
system (of whatever sort) - and then "messaged" back to the EHR as seen
by the GP - so there's clearly an "other place". Similarly Social
history information may well arrive from the Social services system ...There is an issue here about accountability at the point of delivery of the
immunisation system - do they need to take account of all the EHR
requirements? It seems inconceivable to me that they will not want to share
in the information model in the long run - rather than have insular systems.
Unfortunately, because human nature and organisational turf wars are as real in health and social care as in any other sphere, I'm much less sanguine about the "inconceivability" (if that's a word) of not sharing common information models; although I'd concur that agreement is much more likely for community vaccination services than for social services.
The NHS ICRS document makes a (to my mind) naive statement about the irrelevance of organisational boundaries - and in doing so conveniently sidelines the people issues.
If the EHR is predicated upon a perfect organisational world where all organisation leaders and workers are wonderful, co-operative and secure people then regrettably that EHR is doomed to failure. However, if the EHR can explicitly recognise that the world is not like that then it stands a better chance of becoming a reality - albeit accepting that it may not ever achieve its full potential in any particular instance.
In the short term your view is correct. Once there is an EHR model, the
easiest thing is a transpose at the deliverers end to the EHR model and then
send - rather than have to go through the hassle of agreeing a message with
everyone.
I differ from your view that "the easiest thing is a transpose at the deliverers end to the EHR model and then send - rather than have to go through the hassle of agreeing a message with everyone."
Because of the longevity (and to be fair, robust nature) of some of the legacy systems around, and the opacity (at best) or absence (at worst) of the models upon which they are based, then I fear that in many instances its more likely to be "easy" to agree messages than transpositions to EHR model. Not tidy I know...
"instead come through the application / EHR kernel API,"
fine, so long as this means:
"through *an* application *and/or* the kernel API""and create EHR data on the fly."
fine, so long as this means, for example:
"receive (and store) message data,
acknowledge message data if appropriate according to implementation
requirements,
assign message data to EHR as agreed by all users of EHR *or*
reject message data for EHR as agreed by all users of EHR (but in this
case log receipt of message data even if not available for 'default
display')."I do not subscribe to this view in the long term as it is overly complex -
federated data will require this approach in the short term but only until
the agreed EHR model is considered central and the key standard.
To your comment relating my quibbles about "on the fly".
Clearly the centralised EHR model is technically, and in some ways politically, the simplest but, as above, the "short term" has to be recognised as rather long (at least in terms of people working in post doing jobs) at around ten years, and the organisational issues are likely to result in the persistence of federated systems for much longer than even the techno-financial aspects of system replacement dictate.
SAM
Snip
So, summarising, I'm not disagreeing with your vision, but I am more cautious/realistic/ pessimistic (choose your option!) about the chances of that vision ever being achievable in a fully coherent manner - if only because of perpetual organisational change.
Maybe the conclusion from that is that it is safer to view the EHR as being a federation of systems sharing (or at least evolving towards) the same model (and which may be so tightly federated as to be a single system) rather that a single entity that cannot conveniently be federated?