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

1. 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

2. 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

3. 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?!

4. 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, ...

5. 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

6. 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

7. 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!

8. EMRs in the ‘90s Claim Required usual stuff Gov’t payer EMR

9. EMRs in the ‘00s Claim Required usual stuff ======== Optional comparable stuff Gov’t payer EMR

10. EMRs in the ‘00s $X for “usual stuff” Claim Required usual stuff ======== Optional comparable stuff Gov’t payer EMR

11. EMRs in the ‘00s $X for “usual stuff” Claim Required usual stuff ======== Optional comparable stuff Gov’t payer EMR $ Y = (0.00.. * X) for comparable stuff

12. EMRs in the ‘00s “Railroads” $X for “usual stuff” Claim Required usual stuff ======== Optional comparable stuff Gov’t payer EMR $ Y = (0.00.. * X) for comparable stuff

13. EMRs in the ‘00s “Railroads” $X for “usual stuff” Claim Required usual stuff ======== Optional comparable stuff Gov’t payer EMR “Airlines” $ Y = (0.00.. * X) for comparable stuff

14. EMRs in the ‘00s “Railroads” (Predictably reliable) $X for “usual stuff” Claim Required usual stuff ======== Optional comparable stuff Gov’t payer EMR “Airlines” (Rapidly evolvable) $ Y = (0.00.. * X) for comparable stuff

15. Do the doable with Reimbursement and Claims attachment Pay on the margin for comparable results Assess VALUE of comparability How and when?!

16. Terminology Certain properties Other things Standards for lab values … Comparability requires …

17. 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 Why the gov’t should help($)

18. Terminology providers Comparable description suppliers Description analyzers Competitively satisfy evolving gov’t criteria Gov’t should spread marginal $ among

19. $X for “usual stuff” Claim Required usual stuff ======== Optional comparable stuff Gov’t payer EMR $ Y = (0.00.. * X) for comparable stuff Terminology providers

20. 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 Terminology providers

21. $X for “usual stuff” Claim Required usual stuff ======== Optional comparable stuff Gov’t payer EMR $ Y = (0.00.. * X) for comparable stuff Comparable description providers

22. 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 Comparable description providers

23. Description analyzers $X for “usual stuff” Claim Required usual stuff ======== Optional comparable stuff Gov’t payer EMR $ Y = (0.00.. * X) for comparable stuff

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

25. Define early objectives Budget for seed $ Pre-pays! Define competition Terminology providers Description providers Description analysts A plan …

26. 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)

27. 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 A plan (continued)

28. 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! If you only remember one thing …