Insight into IT – the top five issues

Dr. John Halamka offers EHM’s Rebecca Goozee his insight into the top 5 issues and innovations in IT.

Four main challenges

Halamka believes there are four major challenges currently facing the healthcare IT industry at a national level, the first is a need to ensure that there is just one set of interoperable data standards for medications, laboratories, demographics, labs, radiology images, quality measurement and personal health records. Standards are the first step, but the US also requires a nationwide foundation to exchange data once these standards are in place. This foundation is most likely to be peer-to-peer and coordinated rather than centralized. Accenture, IBM, CSC and Northrup Grumman have developed pilot foundations as part of the Nationwide Health Information Network (NHIN) project and in 2007 these pilot schemes will be put into production regionally. Thirdly, Halamka goes on to say that privacy and security is imperative to the first and second challenges. However, the Health Information Security and Privacy Collaboration (HISPC) is to complete the inventory of privacy policies and security requirements for the US states and territories and should be naming the standards necessary to protect privacy by October 2007.

Finally, Halamka states that the fourth challenge facing healthcare IT at the moment, is namely, certification of vendor products that comply with standards, architecture and privacy which, “is key to ensuring adoption of appropriate software by clinicians.” He goes on to point out that the Certification Commission on Health Information Technology (CCHIT) is working closely with HITSP to ensure that interoperable standards are included in certified vendor products.

Chippy

Rather than having a chip on his shoulder Halamka has opted for a chip in his shoulder. Halamka has an RFID (Radio Frequency Identification) chip inserted into his upper right arm and which can be read by a RFID scanner that will tell any authorized healthcare worker his medical identifier, a 16-digit number, and the name of his primary care physician who can provide medical history details. The chip does not contain any demographic or medical data.

Halamka recalls the process as “virtually painless”, with a few milliliters of local anesthesia the chip, about the size of a grain of rice, was inserted into his upper arm. In the days after the implantation there were no horrific side effects – no pain, no infection and no restriction of activities, and months after living with the device Halamka is yet to experience any other side effects even after exposing himself to extremes of temperature, wind and water. He even has the option to ‘upgrade’, which will only require minor surgery. The chip is expected to last at least 10 years although in the future it is hoped the chips will last as long as the human life span.

The main concern about RFID chips is privacy. The main reason being that the chips approved for implantation in humans are not encrypted yet and can therefore be read by many radiofrequency readers. However, while Halamka’s chip does contain healthcare information, unauthorized reading would only reveal his medical identifier which would not be very useful to a hacker. Although future chips are predicted to contain cryptographic identifiers it is widely thought that hackers’ technology will only get better too.

There are some major reasons why RFID chips could be beneficial in the future, (identifying bodies, patients with Alzheimer’s and so on). Halamka has remarked in the past that friends and acquaintances find the notion ‘dehumanizing’, however, Halamka himself states, “I was chipped in order to evaluate the technologic, privacy-related, and medical issues as they affect the provision of patient care. On the basis of my unscientific study with a sample of one, I conclude that there may be appropriate uses, that there are privacy implications that must be accepted by the implantee, and that we need to establish standards that permit seamless, secure access to information.”

Halamka pointed out another use of emerging RFID technology as a replacement for bar codes. The Beth Israel Deaconess Medical Center has been looking at ways to accomplish their goal of positive identification - making sure patients receive the correct medication for example. The two technologies they have been focusing on are bar codes and RFID. Although bar codes have been used successfully in the healthcare industry for years, are inexpensive and highly reliable, they do have limitations. The bar code has to be flat when scanned, and on a wristband for example this can be difficult, they also prove problematic when wrinkled, wet or torn. Can RFID prove useful in the healthcare industry? Halamka believes that the information needs to be weighed up carefully because “separating reality from hype can be challenging”.

There are two types of RFID tags, active and passive. Active tags contain a battery and transmitter which can be used as a geo-location, constantly providing information about physical location. They are currently the size of a pager and require battery replacement every 6 months. They cost $50 each. The Beth Israel Deaconess Medical Center has found these tags useful for tracking equipment, patient beds and even staff. They have found that it has reduced search time for ventilators, IV pumps and EKG devices to near zero.

Passive tags (the type that is embedded in Halamka’s arm) contain an antenna and a chip but no battery. They can be as flat as a piece of paper and small as a grain of rice. The data that this tag holds can be as simple as a medical record number or as complex as name/gender/birth. The Beth Israel Deaconess Center is currently using passive RFID tags to track NICU (neonatal intensive care unit) babies via wristbands and to track mother’s milk in tagged containers. A software application and RFID scanner is used to ensure the right infant receives the right milk and to automatically create an audit trail.

RFID tags have several advantages over bar codes, they do not require sight reading and are resistant to moisture, crushing and tearing. However, tags are more expensive than simple printed bar codes and typically have up to a 20 percent failure rate in manufacture, resulting in a non-readable wrist band. The Beth Israel Deaconess Center have come up with a sensible solution – using a combination of bar codes, passive and active RFID. Halamka adds, “Although we favor bar codes over passive RFID in the short term, we do expect to eventually replace bar codes with RFID once the technology is more robust, standardized and cost effective.”

Privacy

Privacy is a major issue in healthcare. When asked about information security at Harvard Medical School Halamka states, “Security is foundational to all we do in healthcare IT. I have three dedicated staff to ensure we protect patient data from internal and external risks. We audit every lookup, limit access to those who need to know and fire anyone who violates our policies.”

EHR

Electronic Health Records (EHR) are personal health records in a digital format, providing information to aid clinical decisions by providing access to a patient’s health information, including medical referrals, previous treatments and medications. The EHR is becoming more common in America, with Halamka suggesting that there is a 52 percent adoption rate at the moment, and predicting that it will be standard practice within five years. This will not come cheap. The price is estimated at $25,000 per clinician, costing Massachusetts for example, $400 million.

In January 2007, North Adams in Massachusetts was the first town to adopt an EHR network – 20,000 patients, 70 doctors and one hospital came together and said that for the health of the community, with patient consent and patient protection, they would share records with doctors who need to know. Mail outs were sent to 20,000 people about the project and just 11 said they felt uncomfortable with it. Halamka believes that this is ‘revolutionary’ and comments, “Your primary care doctor, your specialist, your hospital can now work together as a team – and that really gives you patient-centric care. North Adams has taken a bold move to really carry us forward into the future.”

Future

Asked about his hopes for the future of healthcare IT, Halamka points to genomics. “Genomics will enable us to deliver therapies which are specific to each patient’s condition, metabolism and potential for disease. Personalized medicine based on the genome will be the next revolution in healthcare.”

Dr John Halamka has numerous roles and responsibilities including being the Chief Information Officer for Harvard Medical School. In this position he oversees all educational, research and administrative functions including all electronic courseware development and he continues to integrate his knowledge of medicine and technology focusing on the internet to exchange clinical patient data.

History of RFID…

“We audit every lookup, limit access to those who need to know and fire anyone who violates our policies”

“Your primary care doctor, your specialist, your hospital can now work together as a team – and that really gives you patient-centric care”

“Personalized medicine based on the genome will be the next revolution in healthcare”