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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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The XHR revisited – Riffings of a Physician Champion

Riff (rĭf) n.

  1. A short rhythmic phrase, especially one that is repeated in improvisation.
  2. A clever or inventive commentary or remark:

Almost two years ago I threw out a new term that I think needs to become a part of our new health vernacular. With all that I have  been reading and seeing people banter about regarding  Obama’s health care reform agenda (especially ideas like a “Marshall Plan” being advocated for the complusory implementation of EHR’s throughout the US health care system), it is time to revisit the notion of an “XHR”.

But first, a little context for EHR’s. I started my technology career as chief medical office selling an open source enterprise EHR (from the VA) into community hospitals that could not afford the multi-million dollar price tag of typical commercial systems. I also oversaw the implementation and clinical transformation efforts of our team as it partnered with one of these hospitals to actually complete this challenging work – including going on rounds with physicians, creating templates, evolving workflows, staffing to train 24×7, and patiently enduring the inevitable chaos that ensued and ultimately yielded the promised results. This case study has been well described elsewhere (here, here, here, and here).

I have also written extensively and recently regarding the power and promise of EHR’s. But the above case study represents the extreme case when huge, integrated delivery system (like the VA) has the ability to invest billions of dollars into technology that becomes backbone of vertically integrated health “systems”. Besides the VA, Kaiser Permanent and Geisinger are other examples of similar achievement.

While their results are impressive but do they translate? Is the implementation of an EHR the end goal? Will processes automatically become better? Will quality indicators improve? Will costs be reduced and safety increased? Will the health care “magic bullet” come in the form of 1’s and 0’s delivered by these systems?

Just in case you have never attempted to implement an EHR  – they are no panacea, let alone is their implementation a worthy “end” goal. In fact, a nationwide network of EHR’s that can communicate with each other is not the end goal either. It is the information and the associated analytics that can occur once the data can be collected that get us to the end goal of outcomes data that we so desparately need to begin to understand how to truly improve health.  I believe there is growing awareness that the EHR is a foundational requirement – necessary but not sufficient – in our quest to improve health.

In an interesting series of posts, long-time EHR advocate and Health 2.0 thought leader  David Kibbe posts his own personal and professional “Confessions” regarding his evolving thoughts on the EHR (see Part 1 and Part 2, Part 3 is forthcoming). He confesses that he was overly optimistic, that he assumed too much, and that he has had to revise his thoughts about what most accurately reflects his thoughts on how to advance improved health care outcomes. This series was followed by additional thougths co-authored by Brian Klepper Part I and Part II essentially demystifying the EHR panacea concept while also suggesting we do a national three finger salute [CTRL-ALT-DEL] and reboot the entire conversation.

Having worked in the trenches as a physician champion myself, I couldn’t agree more. In fact, David offered some very interesting insight into what he thinks EHR’s specifically and health care technology in general need to morph into. His list is well described on his post but included in outline form here:

Goal of Future Health Communication Technology

  1. electronic data and information collection and access;
  2. communications among providers and patients;
  3. clinical decision support;
  4. population quality, performance, and cost reporting ; and
  5. consumer/patient education and self-management.

So what he is describing, and which I completely concur, is something that goes far beyond the typical EHR that we THINK about today. Completely re-visioning this, and given the development of other platforms that are occuring before our eyes (when my mother has a facebook page that she regularly uses, you can be gauranteed that the technology has crossed over), what should the “ubiquitous” Health Record future look like?

  • Function as a “platform” with core functionality that can be enhanced by “apps”
  • Completely controlled by the patient
  • Completely interoperable with other applications
  • Completely open to developers to enhance anyway that is compliant with development standards
  • Completely standardized information sharing protocols
  • Ability to control multiple forms of media (pictures, images, videos, sound, etc.) that can be selectively shared by patient with whomever/whenever
  • etc . . .

You get my point – what I am describing is a Facebook-like or iPhone-like platform with enhanced health care functionality. Here is how it might work for me as an individual:

  • I pull out my new 9 inch iTablet
  • I connect wirelessly or on my 3G network
  • Enter into the base XHR product which contain all my personal information, health finance information, personal health alerts, and core EMR functionality (rads, labs, meds, notes, etc)
  • I fire up the apps that I am interested in, including my daily health trackers (which automatically capture / import data from my other devices)
  • I communicate as needed with my personal health advisor, make requests for appointments, check against my integrated calendar, review my physicians twitter notes, and report back on my treatment plan to my nurse coordinator.
  • All of this is captured in the cloud by my approved health management company who is churning through my data in the background looking for interventions, gaps in care, or other warning signs or opportunities for improvement.
  • I can compare my health status to those of my peers in my area and tap into existing social networks for the collective intelligence of specific / targeting health groups I am interested in.

This is not novel thinking or futuristic thinking either, as Jay ParkinsonMyca, and undoubtedly others are actually working on this concept right now. Like all great innovations, even Myca’s (furthest along) thinking is not necessarily novel but it is the application of that thinking (within healthcare) that increases the novelty ten fold. Myca is exceptionally well positioned in their current approach (based on all teaser snippets that Jay puts out on his blog) in attempting to build the “platform” for the XHR as well as its associated widgets. I hope that they take it even further by opening up that platform to a worldwide audience of users and developers who will take it in new directions faster, farther, and more pervasively than previously conceived (ala the App store at Apple!).

The ubiquity of the XHR – in its range of features, functionality, connectivity, and peformance – will allow the technology to move from the centerpoint of conversation to the facilitator of it. We will know the technology has been abstracted out of the equation when its features/functions become assumed as part of any interaction with the physician. This will then place technology in its appropriate place as an enabler of the transformation we all seek.

There will be lots to riff about on that day!

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