The Credit Card System Is an Ideal Model for a Coordinated Medical Record System

James McGauley, M.D.

A look inside a new and innovative approach to healthcare information technology.

Editor’s note: This article is the second in an ongoing series by James McGauley, M.D., on the idea of a Coordinated Medical Record system and how it could reshape healthcare. Read the first installment here.

A Coordinated Medical Record system literally produces a single comprehensive record for every patient. The record contains all of the patient’s clinical and financial healthcare information over space and time. This type of information system will do more to simultaneously improve the quality and reduce the cost of healthcare than any other single initiative.

The reason the credit card system is such an ideal model for the information component of healthcare is that both industries are dealing with the same problem: trying to capture and organize the billions of random transactions that take place between millions of people as they visit millions of disconnected points of service.

The credit card developers correctly recognized that this was a network management and data management problem. They obviously solved the problem because their system is ubiquitous, efficient and cost-effective.

For their network design, the credit card developers chose the star pattern, in which every point of service is connected to a common central hub.

Their data management design worked by collecting the transaction data from every point of service with a single common data capture mechanism, automatically transmitting that data to the central hub, where it was integrated into the cardholder’s comprehensive record and then making that record available to the cardholder. All of this was to be accomplished in a short period of time and by way of automated rule sets, with a minimal need for human intervention.

What the credit card model shows us is that if you want to track a person through a large complex network, your system needs to have three fully integrated components: a data capture mechanism at every point of service, a central hub where all of the data are organized and an administrative backend that handles all of the data and network management functions.

As our team designed and developed a Coordinated Medical Record system, we had no need to reinvent the wheel. We simply used the same basic technology, policies and procedures that make the credit card system work to develop a comparable three-component system that would work for the healthcare industry.

We found that the star pattern worked well as the network design. However, since healthcare data and interactions are more complex and varied than those of the credit card industry, we needed to develop a more sophisticated data management mechanism. To accomplish this, we did two things: We developed a unique use of object-oriented technology, and we put a distinctive switch in the system’s hub/data center.

As every critical piece of data is entered into a patient’s record, it is captured as a unique “object” to which a number of tags are attached. These tags contain information that facilitates the routing, organization, distribution, reporting and analysis of the information in the patient’s record. In order to accommodate the automatic distribution of information throughout the system, these objects exist in both dynamic and static states, which I will explain below with an example.

This object-oriented technology imparts a unique and unapparelled degree of freedom to the data in each record. Because every data element carries information about its own identity, it can easily be linked and merged with any other data elements in the patient’s record, irrespective of the data’s site of origin. Instead of being trapped inside the rigid walls of an individual encounter, all of the data elements in the entire record can be flexibly comingled into functionally useful configurations. This means that the entire record, or only selected portions of the record, can easily be made available, according to privacy and need-to-know protocols, for all of the various personal and industrywide clinical, financial and administrative purposes for which the record is needed.

In the system’s unique data center and in front of the actual database that contains all of the patients’ Coordinated Records, we installed a switch. This is essentially a set of rules that govern the automatic distribution of data throughout the system.

This is basically how the system works: When a patient is seen in a physician's office, all of the new pieces of data from that encounter, such as diagnoses, procedures, medications, referrals and lab orders, are captured as “update objects.” These are the dynamic forms of the objects because their tags contain information about routing instructions and other processing requirements. All of these updates are integrated into the patient's record at the originating care site, but they are also automatically forwarded to the data center, where they hit the rule sets in the switch.

From the switch, all updates are automatically sent by default to the patient’s Coordinated Record in the master database, where they are merged into the patient’s existing record. This automatically provides the data backup function that is required for all medical records. It provides this function in near real time, and very significantly, the data are never deleted. The data are never lost or unavailable when a patient changes their physician, job or insurance carrier.

If the rules in the switch indicate that the patient always wants their cardiologist and oncologist to be updated with any new information that enters their record, then the new data will automatically be forwarded to those physicians, updating the patient’s record at those care sites. And the information from any subsequent encounters at those care sites, as well as the information from any emergency department visits or hospitalizations, will automatically flow back to the original physician.

Every time a piece of data is entered into the system, it remains in a dynamic mode until it reaches and is successfully installed in every care site or administrative database where it is needed and an acknowledgement has been sent back to the switch, indicating that the intended transaction has been completed. When all acknowledgements have been received, it means that all of the copies of the patient’s record, in all of the various databases where it exists, are in a fully synchronized static state.

If a target database is disconnected from the system for any reason, the dynamic data elements will remain in the switch until communication with that database has been reestablished. An audit trail for all of these transactions is maintained in the master patient database indefinitely.

Although every point of service can access the central database at any time, the system’s automated, redundant and fail-safe data management mechanisms eliminate the need to be online for every transaction.

Embedding the processing rules within each data element and within the network architecture itself is one of the key features that contribute to the significant efficiency and cost effectiveness of this type of information system.

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