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#WoodsholeBMI Day #4: Will the real Slim Shady please stand up?

As we discussed HIE (Health Information Exchange) I keep going back to issues I have seen time and again. Junk in equal junk out.

“Will the real Slim Shady please stand up?”

This is what kept coming to mind every time we discussed Health Information Exchange.  But first what is HIE?


HIE is the exchange of health information across systems. If you were in an accident in New York, the hospital could pull your records from your primary care physician in your hometown in Atlanta. The information is pulled online, sent to the ‘cloud’ (virtual storage), and then comes back down in a format that will work for the New York Hospital.
There are a multitude of concerns here that have been discussed by several people in the field.

1. How do you secure the cloud? How will it be HIPAA Compliant? How do you keep it from being easily hacked and ensure only those who should be pulling your records are pulling them?

2. How do you get the different systems to talk to each other? Each system has it’s own language. Yes there is SNOMED-CT that should be the verbiage used for problem lists, but it won’t be used for tests (ok ICD9 or ICD10 will help with this one), clinician notes (nothing to help with this one yet), etc. No one calls items the same thing. Even in the same hospital there are different terms for diagnosis, diet, etc. depending on who you ask. The Dietician calls it the Consistent Carbohydrate Diet. The Nurse knows it as the ADA Diet. The nutritionist who serves the food and the patient, knows it simply as the Diabetic Diet. If there is so much inconsistency within one organization on a simple item such as diet, then how will information be sent to a cloud and come out in a readable & useable form?

3. Supposing the issues above could solve, then lets move on to a bigger issue. ” Will the Real Slim Shady please stand up?”


This is the issue I keep coming back to. Patient Identifier. Even if you can get hospitals to agree to an HIE, and even if (BIG if here) you could solve most of the issues with terminology, how in the world do you solve the issue with incorrect records being tied together? Or making sure you have pulled all the information on that patient?

If you have a savvy patient who knows all of their past medical history, and may even carry their records to each hospital visit then you don’t have this issue. This issue is caused by those patients who cannot remember what hospitals and physicians offices they have used. It is an issue for people who do not have a unique identifier. Not everyone who is seen in US hospitals has a SSN.

Another issue is not everyone wants to have their medical records linked. I know the VA just used metadata tagging so that some information could be sent and other information could be excluded based on tags.

There is also the issue of people who don’t want to have the system share information across an exchange. They don’t want to be in any system.

So why does this matter? Well what happens when you are traveling by yourself. You are in a major car wreck. Your allergy bracelet (listing your deadly allergic to __) comes off in the wreck and your ID is still intact and the responders have enough information to pull your health record. The hospital in anticipation of your arrival uses the information the emergency responders have to pull your records. The only issue is someone has stolen your ID in the past. You made sure to cancel your credit cards and other items, but you didn’t check to see if anyone had used your ID at a hospital. The most recent visit at the hospital, is by the person who stole your ID & not you. You are transferred to the hospital, where they start treating you for your wounds. They start an IV with the medication your are deadly allergic to. You start crashing. Now are you crashing due to an internal bleed or another issue? The hospital does not know. Your records shows you have no allergies so it must be something else.
This is just one scenario that keeps coming to mind. I mean just think about the episode on House (even if you don’t agree with the medicine or think this has ever happened, it could). The patient kept crashing until they figured out they had the wrong patient records.
Am I suggesting implanting computer chips in everyone? Or maybe a tattoo with information? No. I am just saying don’t think technology will fix everything. As I said other day, technology on top of a bad process is still a bad process with bad outcomes. Do I know how to fix this issue? No. I know there are several people working on the issues I mentioned above. Your hospital may even be working on these issues now just within their hospital.

What do you think? Do you think we will be able to create an HIE? Do you think it will work? What about the issues above… how would you address these issues?

Just some thoughts to ponder on a lovely Thursday afternoon.

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