I Seem to be a Spime: Why Nobody Wants EHRs and PHRs

How’s that for an obscure subject line? Please bear with me; I will explain. And if you, like me, have been trying to figure out how to implement electronic health records (EHRs) and personal health record (PHRs) in the face of seemingly unrelenting foot-dragging and friction, you might even find this worth reading.

First off, we need to distinguish EHRs and PHRs from EMRs (electronic medical records). While there is some confusion and overlap is use of these terms, in practical terms an EMR is usually the electronic equivalent of the traditional paper medical record. An EMR, especially in larger organizations, is not a simple electronic “flat file” transformation of the paper record into something like a Word or Excel document, but is a system made up of various applications and databases which store and process patient data.

More to the point, however it is structured an EMR performs well-known, well established and valued functions for a specific entity. Like a paper medical record, an EMR is created, owned, and maintained by a specific healthcare provider (hospital, clinic, physician), and serves the mission-critical business purposes of that provider (patient care support, legal risk management, etc.). The provider does have legal obligations to provide medical record information to patients and other treating providers, but the core concept is that the EMR provides necessary business and compliance support to the entity which pays for it and assumes the burdens of maintaining it.

Terminology in this area is fluid and sometimes the same kind of system, under the same management and serving the same purposes, is called an EHR. This seems to be the core concept in the Stark and antikickback exceptions, for example, though that’s not altogether clear. So sometimes an EHR is an EMR. But not always.

EHRs are also (conceptually and some time in the future, if not typically in current practice) something more like a community resource for healthcare organizations and patients, including medical record and other relevant information on patients from all providers (and other healthcare organizations), up to and ideally including a lifelong record of all diagnoses and care from all providers. Sometimes this kind of EHR is said to be owned by the patient, and in this direction the EHR sometimes becomes indistinguishable from the PHR.

The necessary technologies to implement this kind of system already exist (albeit with many, many issues to be resolved on matters such as interoperation, etc., etc.), and the concept is pretty clear: Each of us will some day have a comprehensive, searchable, online electronic record which documents our health history and status. Our physical presence will be complemented by and linked to an online information service, which is used to guide highly customized decisions about our care – the kinds of products and services we might need or benefit from, in a medical sense.

In other words, we’ll all become spimes.

Science fiction writer-turned-design critic Bruce Sterling (one of the few people who has a job I want more than the one I have) coined the term “spime” to mean a sort of hybrid manufactured/network object: “[Spimes] are precisely located in space and time. They have histories. They are recorded, tracked, inventoried, and always associated with a story. . . . Spimes have identities, they are protagonists of a documented process. . . . They are searchable, like Google. You can think of spimes as being auto-Googling objects.”

I’m not sure what, exactly, auto-Googling might be, but here’s Sterling’s scenario for how you might encounter a spime, which should give some sense of how the concept applies to EHRs and PHRs:

“You buy a spime with a credit card. Your account info is embedded in the transaction, including a special email address set up for your spimes. After the purchase, a link is sent to you with customer support, relevant product data, history of ownership, geographies, manufacturing origins, ingredients, recipes for customization, and bluebook value. The spime is able to update its data in your database (via radio-frequency ID), to inform you of required service calls, with appropriate links to service centers. . . . “

This same notion can be extended from manufactured objects to biological entities with the greatest of ease. Consider what an ideal EHR/PHR could do and include: Demographic information, details of your physical and mental conditions, medical history, identification and contact information for your healthcare providers and health care payors, details of your available health benefits (and credit history?) – all updated to provide alerts for “service calls” you should make to physicians and pharmacies, accompanied by useful “customization” information about treatments for your specific conditions. Add some family history, maybe some DNA analysis. For some subjects maybe you even do add physical location information, via embedded RFIDs for institutionalized or incompetent patients, prisoners, military personnel, or in hospital patient wristbands, etc. . . .

With the implementation of this kind of system you will be recorded, tracked, inventoried and associated with the story of your own health history – you are the protagonist of the documented processes of your interactions with all the various aspects of the health system you’ve encountered in your life. So as far as I can tell this would make you, well, a biological spime – a hybrid biological/network object.

Sounds scary and pretty complex, no? Yes, actually, and the complexity may be what keeps it from getting too scary too fast.

Sterling knows that even manufactured spimes take a lot of work, and distinguishes between those who produce spimes (manufacture the objects and create the network space for them) and spime “wranglers,” a “class of people willing to hassle with spimes.” Spime wranglers have an interesting relationship to spime-producers: They do a lot of the customization work for them, and provide them with feedback about how useful and valuable the spime is.”

In the PHR world, then, you might consider Microsoft and Google as spime producers: They enable the network spaces necessary for information to be loaded and maintained, and for interaction with the applications needed for data processing for customized services, etc. But (as Sterling foresees), loading and maintaining this network resource is going to be a *lot* of work. Who’s going to wrangle your PHR?

Do I wrangle my own PHR as part of me-as-a-spime? This might be an empowering opportunity for those with the time, training, experience and skills needed to successfully manage their PHR, but it will be an enormous pain in the hind end for those who don’t. Most people these days take their health care as something produced by others, over which they have little control, and which they can only choose to consume (or not). (Interestingly, in the perspective Sterling brings, this puts most of us a couple of historical steps back from being able to manage ourselves as spimes.)

Does my physician wrangle my EHR as part of me-as-a-spime? I’m not sure why she would. She’s already overburdened by running her practice and providing care to my physical self. As to having staff do it, they’re busy too, and she doesn’t really have an incentive to pay for and assume the burden of creating a network object which is a community resource: Her practice gets a small part of the benefit in return for assuming all the costs? While it may be true that everyone, including her practice, will be better off once the entire community resource (i.e., EHRs for everyone) is built, until that happens those who do assume the spime-wrangling burden are at a competitive disadvantage compared to those who don’t.

The same argument seems to apply to hospitals, health systems, health plans and so on: Each possible candidate is at a competitive disadvantage if it assumes the very real burdens of EHR-wrangling. Unlike the EMR, there’s no mission-critical purpose served for any given organization by having this kind of community/network resource available. It may enable the organization to provide better care and maybe even get it some savings, some day, but as long as the EHR/PHR is not the market norm, no market participant is disadvantaged by its absence.

What I take away from all is that until we reach a point at which some critical mass of EHR/PHR spimes is established (and positive network effects take over), somebody is going to have to compensate the spime wranglers. This, of course, is what physicians say whenever the topic of EHR implementation is brought up – and the point is, they’re not wrong. Implementing an EMR for their own purposes is a lot of work; implementing and maintaining an EHR as a common resource for the general good is even more, and for less relative benefit (for them). And while some consumers might really like wrangling their own spimes, or find it genuinely beneficial (e.g. for managing chronic conditions), most probably won’t find it as rewarding as doing many of the other things you can do on the Internet.

Until we can find a way to make the incentives for EHR/PHR wrangling outweigh the burdens, I’m not sure how the ideal EHR/PHR system gets built (using only market factors). EMRs, sure; EHRs which are essentially EMRs, sure. EHRs/PHRs which are a community resource through which each one of us is a biological spime, I’m not so sure.

Sterling’s talk about spimes is at: http://www.boingboing.net/images/blobjects.htm

Bonus aging hippie/geek points if you recognized the source of the subject line as Buckminster Fuller!

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