
As anecdotal evidence of the need for better
technology in healthcare, I listened to a presentation from a vascular surgeon
who explained how he annotates relevant images on a PACS viewing station, then
takes a picture with his iPhone of the screen and shares it using Chat with his
residents and surgical team to prep for surgery. The reason for him to have to
use his phone, is that we don’t yet have the “connectors” that tie these
phones, tablets, and other smart devices with our big, semi-closed healthcare
imaging and IT systems. The good news is that Apple just announced an interface
allowing information exchange, which can be used, among other things, for
patients to access their medical information from a hospital EMR. Also Google cloud
announced an open API.
Here are my top observations from
HIMSS2018:
![]() |
Demonstration of new Apple App accessing health records |
Regardless,
it allows patients to access and keep their own information. It provides a
mechanism for patients to share the information, as the hospitals are
struggling to meet that demand (only one out of three hospitals can share
information according to a recent AHA study, despite the fact that
more than 90% of them use electronic health records).
In reverse,
it is not that hard to upload this information back into an EMR of a physician
or a specialist, together with information collected from blue-tooth enabled
blood pressure, pacemaker, insulin pump, and other intelligent healthcare
devices as well as wearables. At the IHE interoperability showcase
demonstration areas, there were several demonstrations of how this upload can
be achieved using standard interface protocols, often using FHIR.

There are a
couple of exceptions, for example, at the Mayo Clinic they are using FHIR to
access diagnostic reports, utilizing the EPIC FHIR interface, but there are
still very few. One of the major obstacles with FHIR implementations is that it
took them a long time (5 years to-date) to get to a standard that has at least
some normative parts in it, which will be release 4 to be balloted soon, which
means that any implementation you do right now is subject to changes as
upgrades are non-backwards compatible. As an example, the Apple FHIR interface
is based on release 2. So, I am officially upgrading my FHIR implementation
status from “very limited” to “spotty,” but I believe that there is definitely
a lot of potential.
![]() |
Demonstration of VA to DOD gateway based on FHIR technology |
As a case in
point, there is a connection between the VA EMR and the one from the DOD that
allows for a smooth transition of veteran data between these two entities,
which is based on FHIR. What is significant, is that of the many FHIR resources
that FHIR has defined (more than 100 up to now, planning to be at about 150),
the VA is able to exchange all of the information needed with only very few
FHIR resources, notably Patient, Imaging Study, Questinonnaire, Observation,
Clinical Impression, Diagnostic Report, Encounter, Condition, Composition,
Allergy and Medications. This means that implementing a relatively limited
subset can still be very effective. Hopefully their replacement EMR (Cerner?)
will have the same kind of interoperability, which seems to be a point of
contention right now in the contract negotiations for replacement.
· The big EMR companies are doomed (or are they?): This millennium has shown a major shift in healthcare IT as
the past ten years the number of hospitals in the US having an electronic
record has gone from 10% to more than 90%.
However,
these monolithic, semi-closed systems which accumulate all the patient
information in big databases that are hard to access with limited tools for
dashboarding and quality metrics, and who often charge a hefty fee to provide
yet another interface to get information in or out, might be on their way out
unless they change their architecture and focus. For what it’s worth, even the
White House is taking notice as Jared Kushner mentioned during the meeting that
“Trump has a new plan for interoperability.”
Let’s look at
an analogy on how other industries solve the information access problem, for
example, a website for a hotel. If you would like to find directions to the
hotel, you click on a link to Google Maps, if you want to know what the local
sightseeing tours are, you click on “tripit”, for reviews you click on “Tripadvisor”,
and so on.
Now let’s go
back to our ideal EMR user screen, wouldn’t it be nice if you can get the
patient information from a “source of truth,” which is a web-accessible source
for patient information, the latest lab results from the lab, either internal
and/or external, the past 6 months progress on a weight loss program from the
patient’s Fitbit located in the cloud, diagnostic reports from the radiology
reporting system, and so on. And by the way, arranging transportation for the
patient is just another click on the Uber or Lyft App (note the announcement from
Allscripts to embed a Lyft interface to their EMR).
The EMR would
be a mash-up of multiple resources accessible through standard protocols
(FHIR), in some cases guaranteed immutable, using blockchain technology, and
the only functionality left would be a temporary cache and workflow engine that
guides health care practitioners through their job in a very easy to use
manner.
Currently user
friendliness, especially, still leaves a lot to be desired, as a recent study showed
that during an average patient visit, providers spent 18.6 minutes entering or
reviewing EHR data on digital devices, and only 16.5 minutes of face-to-face
time with patients. We’ll see what happens over
the next 5 years and who will win and who will lose but it appears that FHIR
might facilitate a disruptive development.
![]() |
Standing room seats only for blockchain presentations |
What
is blockchain?
It is an immutable, decentralized public ledger that could be used
to securely share transactions without a central authority. Knowing that most
of the patient’s health information is not intended to be public, and that some
of the files (think a 1.5GB digital pathology slide) are just too big to simply
move around and copy multiple times, it makes the application for blockchain
very limited in scope. The immutable aspect is also hard to accomplish, even
for objects or entities that you might think are immutable such as a
patient/person.
Imagine that
you would store the patient information in a blockchain (e.g. a url and
“fingerprint” or “signature” of the data), can you really guarantee that there
would be no changes? Some of the content might need to be updated such as a “disease
status” in case someone dies, a different name in case a woman who marries, and
it is not uncommon anymore for a patient to change sex.
Apart from
the “content,” the structure might change as well, due to database changes such
as allowing storage of multiple middle names, aliases, etc. Some of these
solutions such as providing a unique, immutable person identification, will be
resolved by other industries anyway as financial institutions have a lot of
interest in making sure that they provide credit to “real persons” and identify
if a financial transaction is requested by the actual person instead of a
hacker or intruder.
There are
however a few blockchain candidates for healthcare, one example was shown at
the recent RSNA show dealing with certification and accreditation of
physicians, which should be public and from a reliable source. Another example
is dealing with consents, so that a healthcare provider can trust the fact that
patient information can be shared with for example a parent or caretaker, and
what part of the record can be shared and what not (e.g. limit access to mental
illness records or the fact that a 16 year old daughter uses contraceptives).
So, in conclusion, yes there are some limited applications for blockchain
technology, many of them we can “borrow” from other industries, and some of
them we can implement for medical purposes, but in practice it will be few.
![]() |
Salesforce: Patients are customers?! |
· Artificial Intelligence is making small progress: It would not be right not to mention AI in this report as it
is in the top ten tweets about the conference. However, machine learning and
Artificial Intelligence is still not as easy as one might think. Some
researchers indicate that the IQ of intelligent machines to be equivalent of a
4 your old right now. But, as of now, machines are unbeatable for chess and
jeopardy, so there are definitely some applications that can benefit from AI.
Examples are predicting ER re-admission rates of certain patients and taking action
accordingly, assisting a physician to make a better diagnosis, or, even better,
ruling out any findings with an almost 100% accuracy, which would assist in
routine screenings. In addition to the technology having to become more mature,
there is also an issue with data access as I talked with one user who is in
charge of entering manually textual data from old records in structured format,
and the fact that much of the accessible data is not very structured. There is
a lot of emphasis on AI, so much that some companies are re-branding their
whole healthcare business around it (think IBM: Watson Health), which also
seems an overkill to me. But AI will silently enter into many applications
where it can impact workflow, enhance diagnosis and clinical outcomes.
![]() |
Yes, I want theVespa |
In conclusion, this was another great
event, with some hype as usual, but I found especially the promise of “outsiders”
getting involved in the business of healthcare to be very encouraging. A “fresh
look” from these companies using some of the practices that make our life
easier when we are not sick, could definitely make our life easier and improve
patient care when we are sick. There is no reason that financial transactions
can freely move between banks so that I can go to an ATM any place in the world
and access my account, while my physician has trouble getting timely lab
results, medications, allergies and other pertinent information. I can’t wait
for the sleeping giants to not only wake up but get actively involved and make
an impact.
Herman Oosterwijk is a healthcare imaging and IT trainer/consultant. In case you like to learn more about new standards, in particular FHIR, check out the upcoming web training and in-depth face-to-face training.
Herman Oosterwijk is a healthcare imaging and IT trainer/consultant. In case you like to learn more about new standards, in particular FHIR, check out the upcoming web training and in-depth face-to-face training.