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Scott Shreeve, MD

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I'm the CEO of Crossover Health, a patient-centered, membership-based medical group that is redesigning the practice, delivery, and experience of health care. We offer urgent, primary, and online care to our members who can access our technology platform, practice model, and provider network from anywhere and anytime to optimize their health. Email Me



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A New Dimension: Introducing the XHR

Dimension (dĭ-mĕn’shən) n.
  1. A measure of spatial extent, especially width, height, or length.
  2. Extent or magnitude; scope.
  3. A physical property, such as mass, length, time, or a combination thereof, regarded as a fundamental measure.

The time has come for a new definition within the world of healthcare information technology (HIT). As many of you know, the debate over the proper use of Electronic Medical Record (EMR), Clinical Information System (CIS), Health Information System (HIS), or Computer Based Record (CBR) ultimately deteriorated into the Acronym of Choice (AOC). To further complicate matters, the National Health Information Infrastructure (NHII) was introduced, complete with the idea of creating a Community Health Information Network (CHIN) as part of a larger Regional Health Information Organization (RHIO). These efforts held the promise of pervasive interoperability, but they too delved into the standards quagmire of Clinical Continuity Record (CCR) versus Clinical Continuity Document (CCD) versus Clinical Documentation Architecture (CDA) concept. Not to mention dealing with the HL7 standard (sure its a standard, its just that everyone has their own), DICOM compliance, and a host of other nauseated bits and bytes that make up the current healthcare information technology alphabet soup.

(Zofran, please!)

This backgrounder leads me to the reason why a new definition is required. The internet is changing the very relationships between all the different players. The old paradigms around the physician-patient, physician-plan, and patient-plan interactions are all evolving in new dimensions as part of the technology explosion and a marked cultural shift to focus on patient value. This is an important shift, one that will take years to complete, but companies who are quick to adapt to the new thinking will reap not only the competitive rewards of first to market, but will build consumer loyalty by providing the best consumer “experience“. These new relationships also mean that information will need to be shared in different ways to accomplish the quality objectives of care, including a health care delivery system and healthcare information technology that is safe, effective, patient centered, timely, efficient, and equitable.

I just spent 5 years of my life laying railroad tracks – putting the information system in place that would serve as the central nervous system or operating system of the hospital organization (the current healthcare aggregation point). We deployed an ENTERPRISE Health Record (my definition of an EHR) which included not only the electronic medical record, but the departmental systems (Rads, Labs, Pharm, Diet, etc) that were integrated into a common system across the continuum of acute care. This was hard work, including ground-breaking, back-breaking efforts to hack through the wilderness in order to leave a solid foundation from which hospital organizations could build their information architecture.

These efforts had natural spillage into the associated clinic market, where a Clinical Health Record (CHR) could be deployed to manage the unique features of this segment. These characteristics included a much more detailed practice management function, scheduling/referral modules, ancillary department interfaces, and billing/financial component. Others have effectively picked up the banner to lay the foundation of electronic medical records in the clinic setting. All this work by all these people, despite its scale and scope and just like it was for all the efforts to create a transcontinental railroad “system”, is just laying the foundation for the future “build out” to come.

Which leads me back to the personal health record (PHR). I have had a few things to say about the PHR recently, because I believe it will be a very important piece in the Health 2.0 world. The market is still very formative, and currently all 5 Bazillion PHR vendors are struggling to come up with a business model that makes sense (even to them). One thing is for sure – having an employer, insurance company, or some other conflicted third party hold your PHR information is not only crazy, it is not smart. As a consumer, you need a trusted, non-conflicted third party that you create a healthy, health-focused relationship with. Someone who can offer valuable Healthcare Advisory Services where, when, and how you would like to receive them. This Health Advisor will have your best interest at heart (literally!), will help you obtain health care prior to it becoming disease care, and will be compensated to help you achieve your objectives for “life, liberty, and the pursuit of health“.

Piecing these concepts together, I see a future where the EHR, CHR, and PHR (as I have defined them) will be a seamless set of information systems, complete with the privacy, security, confidentiality, and interoperability equivalent to the type of efficiency we now enjoy in the financial services industry. Each actor in the healthcare system will have access to the right information, at the right time, with the right degree of control. The XHR will be the inclusive currency of this information exchange and will contain the aggregated information of the EHR, the CHR (subset of EHR), and the PHR (subset of CHR). While the patient will maintain control of the record, the physicians and other providers will also maintain shared custody of the portion that is required for them as professional health advisors. The XHR will be virtual, and will assemble on the fly (in true mash-up form) as needed, for appropriate health care interactions to occur (I’ll provide further definition later). This degree of flexibility, functionality, and efficiency of the XHR will be the required infrastructure to practice the personalized medicine of the future. Truly, a new dimension within healthcare.

Can’t you just hear Rod Serlings voice, “You are about to enter another dimension, a dimension of not only sight and sound but of mind. A journey into a wondrous land of imagination. Next stop, the XHR!”

4 comments on “A New Dimension: Introducing the XHR

  1. Charles Vaz says:

    Hello Dr.,
    Good addition to the vocabulary.
    In fact this is what my blog article at was trying to hint at.

    XHR – “Mashup” – What’s in a name? The truth lies is in the perfect implementation of an EMR that gives a Web 2.0 type experience to the Patient, Physician, Consultant and the Insurance Company.

    Thanks for an innovative article that gave me a concluding thought to my article.

    Keep writing,
    Best Regards,

  2. Tom Munnecke says:

    I think you are going in the right direction, here, Scott, but I don’t think you’ve gone far enough. I think that the fundamental notion of framing things as transactions in a record needs to be looked at. Health is not really the sum-of-transactions of what the patient “consumes” from the industry. It is a personal transformation, and the most valuable aspects of health might be those that keep us away from needing those transactions.

    Avoiding an infection, an epidemic, a lifestyle that causes medical transactions, or increasing safety may all contribute greatly to our health, but are completely invisible to the sum-of-transactions medical model.

    For example, consider the success of Alcoholics Anonymous over the years. It generates no transactions, maintains no records, but has spread “virally” around the world and evolved to other addictive problems.

    We need to get a better grip on just exactly what the health process is independent of the billable transactions. We need a language of health to complement the UMLS language of disease. We need to look at the transformative aspects of health and look at ways of using new network technologies to weave networks around them.h

  3. Scott Shreeve, MD says:


    Fair enough – I agree with you. The “transaction” perspective puts us back into the old “Procedure vs. Prevention” problem that we are dealing with. I believe most people orient to a transaction based model because it is discernable output. However, I agree with you that the things which remain “unseen” (prevention, behavior modification, and education) are perhaps the most important of all.

    I would be willing to explore how to incorporate the non-transaction side of healthcare into the concept of the XHR. Your thoughts?

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