Wednesday, May 15, 2013

Universal EHR? No. Universal Data Access? Yes.

A recent blog posting calls for a "universal EMR" for the entire healthcare system. The author provides an example and correctly laments how lack of access to the complete data about a patient impedes optimal clinical care. I would add that quality improvement, clinical research, and public health are impeded by this situation as well.

However, I do not agree that a "universal EMR" is the best way to solve this problem. Instead, I would advocate that we need universal access to underlying clinical data, from which many different types of electronic health records (EHRs), personal health records (PHRs), and other applications can emerge.

What we really need for optimal use of health information is not an application but a platform. This notion has been advanced by many, perhaps most eloquently by Drs. Kenneth Mandl and Isaac Kohane of Boston Children's Hospital [1,2]. Their work is being manifested in the SMART platform that is being funded by an ONC SHARP Award.

Mandl and Kohane point to the iPhone as an example of building a platform on top of a common data store. I see this in action every day on my iPhone, when different applications make use of various data stores built into the phone, such as its GPS data. (Android and other phones offer similar functionality.) Not only Google Maps uses this data, but also my LA Fitness app that tells me where the nearest club is located when I am in a different city and hoping to find a gym.

A common data store, on top of which a thousand flowers (or apps) can bloom, is the ideal situation to the health information system "ecosystem." This will allow new ideas and innovations to flourish, while insuring that interoperable data will be accessible by all apps that have appropriate and authorized access. It will insure competition and a healthy marketplace to bring out the best in health information technology.


1. Mandl, KD and Kohane, IS (2009). No small change for the health information economy. New England Journal of Medicine. 360: 1278-1281.
2. Mandl, KD and Kohane, IS (2012). Escaping the EHR trap--the future of health IT. New England Journal of Medicine. 366: 2240-2242.


  1. Bill, I couldn't agree more. I actually wrote a blog post on the subject.

    EHR 2.0 will be the unEHR, with three components, Cloud, HIE and Apps. The EHR of today, mostly desktop applications are antiquated. We can provide the exact tools that the physicians want without the overhead of an EHR vendor.


  2. You don't need a "platform" to regulate and restrict who and how can access the data. All you need is a data store with a published open schema, and good access control.
    The problem is that a truly universal data store can only be created and maintained by a governmental agency, and it seems that this is not acceptable to most people. Why? I don't know...
    From over a year and a half ago....
    Universal EHR Part I
    Universal EHR Part II

    1. Thanks for your comment and links to your postings. I think we are mostly in agreement. The point I am trying to make is that we do not a universal EHR application, which the post that I linked to advocated, but instead, as you describe, a data store (though standards are essential) and a way to make that store accessible to appropriate users and applications, and secure from unauthorized use. Thanks!

  3. Margalit, Good point but you do need some type of access point, same as with your home router. I have worked in data transmission for many years and even if we had a standard it would have incompatibilities and custom integrations would have to be performed. However, we do need a tighter standard than we have, less optional fields, less overhead.

    As for the common DB, it will never happen, at least not in the USA. Your rights, states rights... It is difficult to design from the top down (e.g., NHIN) . What is needed is a federated system as we do with the Internet, a few standard protocols and a mandate. Look at our landline phone system, it works great, however to connect to it you have to follow the rules and be tested for compliance.

    I think I will rename from a platform to a gateway,

    Cheers Jeff

  4. We got to get the regulators to start thinking in terms of the components of software, such as the data store, instead of thinking of "computer systems", which are really applications. In the nearly 25 years I have been doing Blood Bank Informatics, this has been my frustration.

    Stephen J. Levine, MD

  5. As an IT guy I'm very sceptical. Especially about the interoperability of diverse systems. EHR systems constantly change. It may be due to changes in procedures, regulations, or as technology evolves. In any event it is a constant moving target. In the long run, the more complex a system becomes, the more difficult it is to maintain. And if you think regulations are the solution then good luck.

    1. Skeptical of what? I agree that interoperability is hard. Healthcare will always be changing. That makes it more imperative that we standardize on a solid underlying data model that can accommodate change and be used for diverse systems on top of it.