I would like to start a thread on the role of electronic mail in
medical computing.
I will begin with the punch-line: I believe that an entire
medical record system that would actually be used by physicians and
other providers can be constructed using IMAP server technology.
With open source components including Exim, Mozilla (an IMAP
client if ever there was one), and one of the open source IMAP servers
( http://asg.web.cmu.edu/cyrus/
ftp://ftp.cac.washington.edu/mail/imap.tar.z [be careful
with the latter as it just shoots the server, all 6 megs-worth at
you]) a completely secure system can be placed on the 'Net
today.
HL-7 compatibility? Well, in the e-mail world view, HL-7 is
just another MIME-type, is it not? If one thinks about it, there
really is no such thing as a message "body" in e-mail:
that's just another name for an e-mail *attachment* that's plain ASCII
text. The sort of e-mail message that one would find in a
medical information system based on e-mail would simultaneously
fulfill several roles: a plain text message that humans could
understand, an HL-7 version that other (benighted) medical computing
systems could understand, a billing version that third-party payors
could understand, a comma-separated text version that databases could
understand, a prescription, a referral, etc. These are all
accepted MIME-types and can be generated automatically in the same
message. They also, with a little Exim-Perl magic, can find
their way to the appropriate destination automatically.
Medical records fulfill two, orthogonal purposes. First,
they serve as communications between medical providers to further care
given to a particular patient. This is their clinical role, and
the only role that clinicians are really interested in on a day-to-day
basis. These communications, per force, are couched in human
language. Yes, they can be highly stylized and stereotyped human
language, but medicine just has not reached the point where human
language can be eliminated.
Second, medical records fulfill an audit role. They are
used for all the things that have nothing to do with day-to-day care
of patients: billing, regulatory compliance, science, education,
administration, etc. This role is burgeoning and it captures an
undue proportion of the interest of medical informaticians. It
has absolutely nothing to do with immediate patient care except
indirectly.
The first purpose of medical records: communication is very
poorly captured by current EMR's. In contrast, a system based on
e-mail would capture it perfectly AND would have no learning curve:
physicians are already familiar with e-mail.
The law, which is completely reliant on human language, has
embraced e-mail completely. Many law firms will now only accept
pleadings etc. in the form af e-mail.
I am struck by how simple it would be to implement an EMR using
e-mail. And, it could be done piecemeal with total scalability.
I would close with a reiteration of my comment about security.
This system is totally secure. How? Very simple. You
put a copy of Exim on all the clients. In this way, not only is
each client a client, it is also a mail transfer agent. It has
total control of who it talks to and what path it uses to transfer
mail. The system would exist in parallel with other e-mail
systems.
Comments?
John
