Behavior, Content, Money – 3 Things you should never give away for free!!!

BCmoney MobileTV

The Most Meaningful Use of EHR in Health Care

Posted by bryan on March 10, 2013 in E-Business, E-Government with 4 Comments

No Gravatar
EHR Adoption Framework_AD

EHR Adoption Framework (Photo credit: andyde)

I’ve been thinking a lot about ways that Health Care and the medical system in general can be improved through the use of IT. In the United States right now, they’re over 1 year into the so-called “Meaningful Use” guidelines established by the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009.

This means that thousands of doctors, clinics, hospitals and other care facilities are getting beyond the ramping up of Stage 0 & 1 into the next Stages, also called the “Meaningful Use” phase. They will no longer get any government subsidies, grants or assistance simply for basic EHR implementation or “taking old paper patient files digital”. They must now demonstrate “Meaningful Use” of the technology.

Meaningful Use – Core Requirements

  1. Use computerized order entry for medication orders.
  2. Implement drug-drug, drug-allergy checks.
  3. Generate and transmit permissible prescriptions electronically.
  4. Record demographics.
  5. Maintain an up-to-date problem list of current and active diagnoses.
  6. Maintain active medication list.
  7. Maintain active medication allergy list.
  8. Record and chart changes in vital signs.
  9. Record smoking status for patients 13 years old or older.
  10. Implement one clinical decision support rule.
  11. Report ambulatory quality measures to CMS or the States.
  12. Provide patients with an electronic copy of their health information upon request.
  13. Provide clinical summaries to patients for each office visit.
  14. Capability to exchange key clinical information electronically among providers and patient authorized entities.
  15. Protect electronic health information (privacy & security)

These requirements emphasize much more specific use cases of these digital health systems, and offering value-add insights from all this new patient & provider health data that will be generated. However, it seems clear that what the government considers a “meaningful usage” of this new technology may not necessarily be the silver bullet for solving an entire industry’s IT challenges. That said, it seems like a solid enough start, and something Canada and other countries could certainly learn from. Further, there are other nations with more advanced EHR/EMR infrastructure that the US and indeed all countries can learn from, for instance some aspects of Japan’s use of robotics in nursing homes to counter its aging population and robotic surgeons to counter its shrinking workforce double-whamy, China’s use of telemedicine to reach those under-served sprawling rural areas, and France’s continued use of house calls to proactively monitor patient health and progress which costs more up front but improves patient outcomes and may save more long-term.

Next, let’s look at specific menu and display requirements, which get even further into the technical weeds.

Meaningful Use – Menu Requirements

  • Implement drug-formulary checks.
  • Incorporate clinical lab-test results into certified EHR as structured data.
  • Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach.
  • Send reminders to patients per patient preference for preventive/ follow-up care.
  • Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies).
  • Use certified EHR to identify patient-specific education resources and provide to patient if appropriate.
  • Perform medication reconciliation as relevant.
  • Provide summary care record for transitions in care or referrals.
  • Capability to submit electronic data to immunization registries and actual submission.
  • Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission.

The following excellent eHealth overview diagram shows the most popular standards in each touch point of the healthcare ecosystem (from care to billing):
eHealth Overview

Electronic medical records (EMRs) are a digital version of the paper charts in the clinician’s office. An EMR contains the medical and treatment history of the patients in one practice. EMRs have advantages over paper records. For example, EMRs allow clinicians to:

  • Track data over time
  • Easily identify which patients are due for preventive screenings or checkups
  • Check how their patients are doing on certain parameters—such as blood pressure readings or vaccinations
  • Monitor and improve overall quality of care within the practice

But the information in EMRs doesn’t travel easily out of the practice. In fact, the patient’s record might even have to be printed out and delivered by mail to specialists and other members of the care team. In that regard, EMRs are not much better than a paper record.


An Electronic Health Record (EHR) is a comprehensive system that chronicles at least the following minimum information:

  • Patient Information
  • History
  • Allergies
  • Medications
  • Treatments/Procedures
  • Doctors’ Notes on visitations or encounters

An EHR is obviously the lowest minimum requirement to get started targeting further “Meaningful Use” requirements.


DICOM medical imaging standards

Patients may have had any number of previous X-Rays, CT Scans, MRIs, Ultrasound procedures or other advanced 3D Images taken. In this case, a web-based DICOM viewer would provide the instant access needed to make decisions quicker and more reliably.

While decent DICOM software was quite rare and overly expensive/restrictive technology just 5 years ago, the field has now opened up. At this point, you can find some Open Source DICOM viewers that work on the web almost as well as some of the expensive software packages:


OpenECG standard logo


Electro-Cardiograms are machines used for measuring primarily heart beat characteristics such as frequency, strength and regularity, and/or secondary related vital signs such as blood pressure, active .vs. resting heart rate, impact of stimuli, etc.

  • RR interval The interval between an R wave and the next R wave. Normal resting heart rate is between 60 and 100 bpm 0.6 to 1.2s
  • P wave During normal atrial depolarization, the main electrical vector is directed from the SA node towards the AV node, and spreads from the right atrium to the left atrium. This turns into the P wave on the ECG. 80ms
  • PR interval The PR interval is measured from the beginning of the P wave to the beginning of the QRS complex. The PR interval reflects the time the electrical impulse takes to travel from the sinus node through the AV node and entering the ventricles. The PR interval is therefore a good estimate of AV node function. 120 to 200ms
  • PR segment The PR segment connects the P wave and the QRS complex. The impulse vector is from the AV node to the bundle of His to the bundle branches and then to the Purkinje Fibers. This electrical activity does not produce a contraction directly and is merely traveling down towards the ventricles and this shows up flat on the ECG. The PR interval is more clinically relevant. 50 to 120ms
  • QRS complex The QRS complex reflects the rapid depolarization of the right and left ventricles. They have a large muscle mass compared to the atria and so the QRS complex usually has a much larger amplitude than the P-wave. 80 to 120ms
  • J-point The point at which the QRS complex finishes and the ST segment begins. Used to measure the degree of ST elevation or depression present.
  • ST segment The ST segment connects the QRS complex and the T wave. The ST segment represents the period when the ventricles are depolarized. It is isoelectric. 80 to 120ms
  • T wave The T wave represents the repolarization (or recovery) of the ventricles. The interval from the beginning of the QRS complex to the apex of the T wave is referred to as the absolute refractory period. The last half of the T wave is referred to as the relative refractory period (or vulnerable period). 160ms
  • ST interval The ST interval is measured from the J point to the end of the T wave. 320ms
  • QT interval The QT interval is measured from the beginning of the QRS complex to the end of the T wave. A prolonged QT interval is a risk factor for ventricular tachyarrhythmias and sudden death. It varies with heart rate and for clinical relevance requires a correction for this, giving the QTc. Up to 420ms in heart rate of 60 bpm. See diagram at right for other heart rates.
  • U wave The U wave is hypothesized to be caused by the repolarization of the interventricular septum. They normally have a low amplitude, and even more often completely absent. They always follow the T wave and also follow the same direction in amplitude. If they are too prominent we suspect hypokalemia, hypercalcemia or hyperthyroidism usually.
  • J wave The J wave, elevated J-Point or Osborn Wave appears as a late delta wave following the QRS or as a small secondary R wave . It is considered pathognomonic of hypothermia or hypocalcemia.

There are other rival standards to OpenECG’s SCP-ECG, the main one being HL7 aECG. I’ve included ECG’s as they along with standalone Blood Pressure and/or full Bloodwork (lab analysis) are the most commonly paired external system for an EHR, as per #8, #10 and #14 in partcular from the “Meaningful Use” standard.




A standardized Messaging format is required to send Patient data between offices, which is where Health Level Seven (HL7) comes into the picture. Why is the standard called HL7? This is an important question with a relatively straightforward answer, but it requires a quick trip into Computer Science history. The number seven in HL7 refers to the top level of the seven-layer International Standards Organization’s (ISO) communications model for Open Systems Interconnection (OSI) – the application layer. The application level addresses definition of the data to be exchanged, the timing of the interchange, and the communication of certain errors to the application. The infamous OSI Model for network communications is listed in descending order with Application layer on top, as follows:
7. Application
6. Presentation
5. Session
4. Transport
3. Network
2. Data Link
1. Physical

The seventh level at which HL7 was implemented also supports important functions such as security checks, participant identification, availability checks, exchange mechanism negotiations and, most importantly, data exchange structuring. HL7 focuses on the interface requirements of the entire health care organization, while most other efforts focus on the requirements of a particular department such as Radiology or Critical Care. HL7 undertakes ongoing development of protocols on the fastest possible track that is both responsive and responsible to its members. The group addresses unique requirements of the already installed hospital and departmental systems all over the world in over 40 countries, some of which use mature or legacy technologies (via HL7 version 2), and others of which use more cutting-edge systems (that support both the older and less expressive version 2 and the XML-based version 3 of the HL7 messaging standard).

The following is an example of the original version of HL7 version 2:

PID|||56782445^^^UAReg^PI||KLEINSAMPLE^BARRY^Q^JR||19620910|M||2028-9^^HL70005^RA99113^^XYZ|260 GOODWIN CREST DRIVE^^BIRMINGHAM^AL^35 209^^M~NICKELL’S PICKLES^10000 W 100TH AVE^BIRMINGHAM^AL^35200^^O |||||||0105I30001^^^99DEF^AN
PV1||I|W^389^1^UABH^^^^3||||12345^MORGAN^REX^J^^^MD^0010^UAMC^L||678 90^GRAINGER^LUCY^X^^^MD^0010^UAMC^L|MED|||||A0||13579^POTTER^SHER MAN^T^^^MD^0010^UAMC^L|||||||||||||||||||||||||||200605290900
OBX|1|NM|^Body Height||1.80|m^Meter^ISO+|||||F
OBX|2|NM|^Body Weight||79|kg^Kilogram^ISO+|||||F

The HAPI Test Panel is an HL7 v2.x test tool that should come in handy for testing purposes on older v 2.x messages.

Here is the equivalent message in the new Reference Information Model (RIM) for HL7 version 3 (which is now an XML-based, more machine-readable format):

 <?xml version="1.0" encoding="UTF-8"?>
 <PRPA_IN101001UV01 ITSVersion="XML_1.0" xmlns="urn:hl7-org:v3" 
   <id extension="3948375" root="2.16.840.1.113883.19.10.700363.2288"/>
   <creationTime value="20060501140010"/>
   <versionCode code="NE2006"/>
   <!-- Interaction is a notification of a person registration -->
   <interactionId extension="PRPA_IN101001UV01" root="2.16.840.1.113883.1.6"/>
   <processingCode code="P"/>
   <processingModeCode code="T"/>
   <acceptAckCode code="ER"/>
     <id extension="922" root="2.16.840.1.113883.19.9"/>
     <name>Master MPI</name>
           <id extension="1002003" root="2.16.840.1.113883.19.200"/>
           <name>Alpha Hospital</name>
       <id extension="1" root="2.16.840.1.113883.19.9"/>
   <controlActProcess moodCode="EVN">
     <code code="PRPA_TE101001UV01" codeSystem="2.16.840.1.113883.1.18"/>
     <effectiveTime value="20060501140008"/>
     <authorOrPerformer typeCode="AUT">
         <id extension="000338475" root="2.16.840.1.113883.19.201"/>
           <name use="L">
           <id extension="1002777" root="2.16.840.1.113883.19.200"/>
           <name>Regional Person Registry</name>

     <!-- registration event has been removed
          see next section of this whitepaper-->


From the developer perspective, its a fairly notoriously ugly/painful format to work with, but it’s reached such wide usage and is a welcome improvement on the myriad of custom CSV, TSV, XML, RDF, JSON, etc formats that have been used prior to “Meaningful Use” across EHR/EMR systems. The following two links can help as a quick intro to the format:

As the book offers, billing is one of the most complicated parts of the healthcare industry. It can provide multiple Beneficiaries (Non-Profit Organizations & Individuals), Payers (Insurers & Government bodies), Providers (Hospitals & Clinics) and potentially if drugs or procedures are involved, Prescribers (Doctors & Nurses). Due to the nature and urgency of medical care, billing is often done after-the-fact to recoup costs of the procedure, but planned or “elective” care procedures are almost always carefully calculated and accounted for before service is provided.

The leading billing standard is X12 and billing “transactions” are carried out based on specific procedure or billing codes, usually ICD-9 (however, by 2014 the required standard for coding will be ICD-10).


For scheduling, there are no clear “de facto” standards across the Healthcare industry but iCalendar and CalDAV (extension to WebDAV) are dominant in email-interfacing segments of EHR/EMR scheduling software due to their support in Microsoft Exchange and other major email servers and providers. These options, however, do not take into account the unique needs of the Medical community which may require secure transfer of patient information between clinics, labs, major hospitals, insurance providers, 2nd-party payers, government and banking institutions. In addition, health facilities need to coordinate staff, rooms and medical equipment around a given visitation or procedure being scheduled. All things that are nearly impossible to get right using simple calendaring extensions to existing email and filing software.

The ability for a patient to be able to access and potentially edit their own electronic health record is key to any successful and meaningful implementation of an EHR system.

Systematized Nomenclature of Medicine for Clinical Terms (SNOMED-CT) helps realize shareabilty goals by using common terminology for medical conditions, diseases, viruses, bacteria, treatments, medication codes, etc.

Speech Recognition
Although not called out specifically, I believe Nuance’s Dragon Medical, and similar offerings from Speech Recognition software providers should be high up on the list of meaningful use. These Speech-To-Text (STT) & Text-To-Speech (TTS) tools can free the healthcare provider from staring at a screen and typing into forms rather than interacting with the patient, which helps prevent the entire healthcare experience from feeling cold/robotic or lacking that critical word “care”. They can also help to bridge some accessibility gaps between healthcare providers and their patients.


So what is the most meaningful use of EHR in Health Care? Well, it really depends on your unique setting and needs, but the most unobtrusive combination of well-tested and popularly employed standards is surely at its core.

Healthcare providers and their tooling partners need to continue to find ways to innovate; and consumers, whom are being asked to give up unprecedented levels of personal information for long-term storage/reference, need to be able to obtain more value from such, otherwise the whole thing would end up nothing more than a glorified exercise in cleaning out the filing cabinets and dumping paper into hard drives.