Why Specialists Need Specialty-Specific EMRs That Understand More Than Their Specialty

Short Link: http://j.mp/6J0J2e

[4/19/12 update: I renamed this post from "Why Pediatricians Need Pediatric EMRs That Understand More Than Pediatrics" because its argument applies to any specialty-specific EMR intended to communicate and coordinate with other EMRs. Substitute your specialty for "pediatrics." Specialty-specific EMRs need to know about more than just their own specialty to coordinate care across networks of EMRs. Workflow technology such as business process management and case management software will be essential to creating EMRs and EHRs that can adapt to medical specialty workflow.]

This post is fourth in a series about EMR workflow systems and the high performance medical home model. The first post presented 12 key quotes. The second post introduced coordinated workflows among pediatric, subspecialty, and other primary care practices. The third stressed creation of well understood, consistently executed, adaptively resilient, and systematically improvable workflow within and between practices. This post discusses how to select a future proof pediatric EMR.

I took a short virtual tour of just a few websites of pediatricians. I read their staff bios and mission statements. Guess what? Many pediatricians practice with subspecialists in such areas as cardiology, neurology, gastroenterology, endocrinology, nephrology, allergy/immunology, emergency medicine, and developmental-behavioral pediatrics (and that was just a sampling). Many pediatricians also practice with other primary care physicians in family medicine, general internal medicine, and obstetrics & gynecology. Some pediatricians are double (or even triple) board certified.

Communication of Shared Meaning across Specialty Boundaries

If you are a pediatrician, reflect on how much you know about the other medical specialties that you call on when you refer a patient. Throughout your career, starting in medical school, you’ve been exposed to much more than pediatric medicine and you use this knowledge to better coordinate your patients’ care. Consider how you communicate with a physician from another different specialty. Each of you share a common foundation of basic medical knowledge, plus you both understand enough about the other specialty in order to communicate. You use words to mean the same thing.

Soon your EMR will need to be like you, and know enough about other specialties in order to coordinate care with other EMRs. They need to mean the same things.


Meaning is shared between two systems (human or computer) when the following occurs:

  1. An external real world entity (drug, diagnosis) is referred to by an internal concept
  2. The internal concept is encoded as symbol (word, number, ICD-9 code)
  3. The symbol is transmitted across a channel (air, paper, TCP/IP, string)
  4. The symbol is decoded to an internal concept
  5. The internal concept refers to the same external real world entity (drug, diagnosis)

Two systems that can do this are “semantically interoperable.”

Of course, it is more complicated than I make it seem. For example, meaning is usually composed smaller bits of meaning (AKA “words’” as in my “Chuck likes workflow”  sentence diagram). However, my simplified portrayal is sufficient for the main point I will make below.

General-purpose versus Specialty-specific EMRs

You may be aware of a recurring debate about so-called general-purpose EMRs versus specialty-specific EMRs. Applied to pediatrics it goes like this: general-purpose EMRs were designed for adult medicine and lack pediatric-specific functionality (screens, picklists, and workflow). As a result they cannot do what a pediatrician needs quickly and easily. Homegrown pediatric-specific EMRs on the other hand started with pediatric-specific functionality, carry out stereotypic pediatric workflows, and don’t try to be anything besides a pediatric EMR.

Sounds like a slam-dunk for the pediatric-specific EMR, right? The problem with this debate is that only makes sense for traditional EMRs that lack customizable workflow. An EMR workflow, or BPM, system can support multiple specialties (including general adult medicine) working off the same patient database and make is seem to each specialist (or generalist) as if they are using their own specialty-specific EMR. That was the point of quotes 6 and 8 in the post that kicked off this series on the relevance of EMR workflow systems to the medical home.

Think about the implications for coordinating workflow between pediatricians, subspecialists, and other primary care physicians to achieve the high performance medical home. Some multi-specialty practices already market themselves this way:

“When your family physician or your child’s pediatrician determines you or your child should see a specialist that usually means a trip down the hall. Don’t worry about carting your records. Our modern electronic medical record system makes sure you have the best care from each specialist under the watchful eye of your personal physician. And when your child grows up, transition is seamless to a family medicine physician who will also coordinate the best care possible”

These practices are taking advantage of a multi-specialty capable EMR to implement a version of the medical home, by taking advantage of the default “semantic interoperability” gained from sharing the same EMR database.

Wait it minute, you say. You could stipulate that a multispecialty EHR database is an an ideal vehicle for implementing a high performance pediatric medical home *if* everyone uses the same database. However you are a solo pediatrician. Why should you care?

I wish I could say “Simple!…” but I can’t. Some answers deserve to be complicated, and this is one of them.

(That said, click here to skip the complicated stuff anyway and get to my point.)

Of Data Models and Medical Ontologies

Reconsider steps 1-5 to transmission of shared meaning and achieving semantic interoperability. In step 2 a concept refers to a real world entity and is encoded as a symbol. In step 4 a concept refers back to the real world entity. If either source or target EMR lacks the right concept, meaning is not successfully shared. Where do these EMR “concepts” come from?

They come from each EMR’s conceptual data model, which is:

“…a map of concepts and their relationships. This describes the semantics of an organization and represents a series of assertions about its nature. Specifically, it describes the things of significance to an organization (entity classes), about which it is inclined to collect information, and characteristics of (attributes) and associations between pairs of those things of significance (relationships).”

Let’s see if I can make use of my word substitution technique to make the above quote more relevant:

…a map of pediatric, subspecialty, and primary care concepts and their relationships. This describes pediatric or primary care practice clinical knowledge and operational workflow. Specifically, it describes the things of significance to an organization (patients, body parts, diseases, treatments, specialties etc.) , about which it is inclined to collect information, and characteristics of (such as size, weight, duration, etc.) and associations between pairs of those things of significance (such as has-assessment(Tom Smith, asthma), is-prescribed (Tom Smith, Albuterol), is-specialty(Dr. Jones, pediatric neurology), common-assessment(epilepsy, pediatric neurology)).

Data models are closely related to ontologies, increasingly proposed to provide semantic interoperability between EMRs.

“An ontology defines a set of representational primitives with which to model a domain of knowledge or discourse.  The representational primitives are typically classes (or sets), attributes (or properties), and relationships (or relations among class members)….The key role of ontologies with respect to database systems is to specify a data modeling representation at a level of abstraction above specific database designs (logical or physical), so that data can be exported, translated, queried, and unified across independently developed systems and services.” (Tom Gruber, Ontology, Encyclopedia of Database Systems, Ling Liu and M. Tamer Özsu, Eds., Springer-Verlag, 2008, retrieved 12/2/09)

(Ah yes…takes me back to my Knowledge Representation course in Intelligent Systems at Pitt.)

I could substitute in words from the pediatric and primary care domain as I did before, but you get the idea. A medical ontology or data model is the set of things, stuff, objects, entities, individuals, etc. (for examples, patients, body parts, diseases, treatments, specialties etc.) about which a community of medical agents can think and communicate. These entities have properties (such as size, weight, duration, etc.) and relationships (has-assessment, is-prescribed, is-specialty, common-assessment, and so on). And an EMR can only do things and communicate about them consistent with its domain model.

Again I simplify, as was the case when I described the five steps to successful transmission of shared meaning. It’s still sufficient to make my main point (which is…).

What’s my point? Intelligent systems (you, or increasingly, EMRs) cannot communicate about concepts they cannot represent. Specialty-specific EHR databases need to “know” a lot more than just their specialty focus, if they are to participate in creation of virtual medical home enterprises.

“I am a solo pediatrician, why should I care about multi-specialty EMRs?”

To future proof your practice.

  • You may eventually add a pediatric subspecialty or other primary care specialty to your list of board certifications.
  • Your practice may add a subspecialist or non-pediatric primary care partner—specialty-specific workflows will allow you and your partners to “Have It Your Way” while not stepping on each other’s toes.
  • Or you may need to communicate and coordinate with other general-purpose or specialty-specific EMRs as part of a high performance virtual medical home.

If you think any of these events may happen in your future, please consider getting a pediatric EMR that can do more than pediatrics.

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