# Presentation: 325185

## The Electronic Medical Record (EMR)can be the “Air Mail” of the ‘00s

- Mark S. Tuttle
- Chief Technology Officer
- Lexical Technology, Inc.
- tuttle@lexical.com
- www.lexical.com

## Problems ...

- ‘20s - Air travel primitive, disorganized, chaotic
- 1926, Charles Lindberg flew mail from St. Louis to Chicago
- ‘00s - EMRs primitive, disorganized, chaotic
- Harvard Beth Israel, Kaiser NW, et al., have Electronic Filing Cabinets (EFCs)
- Few standards
- Limited economies of scale
- Public poorly served

## Solutions ...

- Gov’t paid for “Air Mail” on the MARGIN
- Gov’t pays for EMR RESULTS on the MARGIN
- Public gets Air Travel and EMRs
- How?!
- When?!

## 1999 Background

- Most EMRs ever built failed
- Some EFCs flourish
- Def’n - An EFC can retrieve patient information by patient ID, and little else
- Information arranged by date, category
- 24  X 7 available
- Accessible from anywhere
- Embraced by users
- But, ...

## 1999 Background (continued)

- EFC data not comparable, mostly
- Comparability ...
- not sustainable
- not scalable
- EFCs highly idiosyncratic
- Few opportunities for economies of scale
- Existing opportunities not exploited
- Public poorly served

## Air travel in 1920s ...

- Local efforts sustained through airmail contracts
- Gov’t did NOT pay for
- Planes
- Airports
- Pilot training
- Passengers
- ...
- Competition, standards, regulation was incremental and reactive
- “Loss leader” for Post Office

## Air travel in 1920s (continued)

- In summary, ...
- Gov’t paid for RESULTS on the MARGIN
- Regulated what COULD be airmail
- Preserved privacy
- Adapted rapidly
- Gov’t did NOT cancel railroad contracts!

## EMRs in the ‘90s

- EMR

- Required usual stuff

- Gov’t payer

- Claim

## EMRs in the ‘00s

- EMR

- Required usual stuff
- ========
- Optional comparable stuff

- Gov’t payer

- Claim

## EMRs in the ‘00s

- EMR

- Required usual stuff
- ========
- Optional comparable stuff

- Gov’t payer

- Claim

- $X for “usual stuff”

## EMRs in the ‘00s

- EMR

- Required usual stuff
- ========
- Optional comparable stuff

- Gov’t payer

- Claim

- $X for “usual stuff”

- $ Y = (0.00.. * X) for comparable stuff

## EMRs in the ‘00s

- EMR

- Required usual stuff
- ========
- Optional comparable stuff

- Gov’t payer

- Claim

- $X for “usual stuff”

- $ Y = (0.00.. * X) for comparable stuff

- “Railroads”

## EMRs in the ‘00s

- EMR

- Required usual stuff
- ========
- Optional comparable stuff

- Gov’t payer

- Claim

- $X for “usual stuff”

- $ Y = (0.00.. * X) for comparable stuff

- “Railroads”

- “Airlines”

## EMRs in the ‘00s

- EMR

- Required usual stuff
- ========
- Optional comparable stuff

- Gov’t payer

- Claim

- $X for “usual stuff”

- $ Y = (0.00.. * X) for comparable stuff

- “Railroads”
- (Predictably reliable)

- “Airlines”
- (Rapidly evolvable)

## How and when?!

- Do the doable with
- Reimbursement and
- Claims attachment
- Pay on the margin for comparable results
- Assess VALUE of comparability

## Comparability requires ...

- Terminology
- Certain properties
- Other things
- Standards for lab values
- ...

## Why the gov’t should help($)

- We know what to do, sorta
- We’re stuck
- Like air travel in 20’s
- Marginal subsidies would “level the field”
- More comparability will benefit the public
- We don’t know how much, and we’d like to know

## Gov’t should spread marginal $ among

- Terminology providers
- Comparable description suppliers
- Description analyzers
- Competitively satisfy evolving gov’t criteria

## Terminology providers

## Terminology providers

- To qualify for $ ...
- Terminology server
- Optionally mirrored for gov’t
- Authoritative archive of versions
- On Web for all “licensees”
- Support class-based queries
- All changes supplied as XML transactions
- Support longitudinal queries

## Comparable description providers

## Comparable description providers

- To qualify for $ ...
- Description server
- Highly secure!
- Optionally mirrored for gov’t
- Patient normalization
- Support class-based queries
- Support longitudinal queries
- Current with relevant terminology servers
- Sustained across all relevant terminology versions

## Description analyzers

- EMR

- Required usual stuff
- ========
- Optional comparable stuff

- Gov’t payer

- Claim

- $X for “usual stuff”

- $ Y = (0.00.. * X) for comparable stuff

## Description analyzers

- To qualify for $ ...
- Web scale
- Do the doable
- Optionally mirror for gov’t
- Help gov’t focus opportunities/needs for incremental improvements
- Quantify value

## A plan ...

- Define early objectives
- Budget for seed $
- Pre-pays!
- Define competition
- Terminology providers
- Description providers
- Description analysts

## A plan (continued)

- Charge Bill Braithwaite, MD, PhD with implementation
- Make evaluation ongoing
- Accelerate feedback and evolution
- Communication
- Standards
- Focus
- Pluralism
- A GIANT clinical trial

## A plan (continued)

- Budget ...
- “Seed” industrial-strength servers
- “Pre-pay” at $500,000 each, up to fixed upper limit
- Award on merit
- Sustain on margin
- Adjust on value
- Sunset provision
- Hypothesis - Benefit many times the investment

## If you only remember one thing ...

- Marginally,
- subsidize existing and emerging efforts
- to achieve economies of scale
- on public’s behalf.
- Help get us unstuck!
- In 10 years, “optional part” will dominate!

## Slide 29