The iotaMed Suite
The iotaMed series of applications interoperate around patient care. Different parts of iotaMed interact with the physician, the patient, the medical experts, the legacy system, and delegated care providers.
Can you imagine an accounting program that doesn't know what money is? Can you imagine an architect designing houses using only email? Can you imagine an air traffic controller using only signal flags to talk to his planes? All of these examples sound absurd, but this is what current electronic medical record systems work like, by analogy. If you think there is something seriously wrong with a market where only very mediocre systems compete in a race to the bottom of useability, then you may appreciate what we're trying to do with iotaMed.
iotaMed is based on the idea that patients have diseases or problems (we call them "issues") and that is what the medical record should be based on. It should also help us manage these issues according to current standards. We're putting "issues" into "medical records", just as others have put "money" into "accounting systems".
Evidence Based Medicine (EBM) produces new medical knowledge at ever increasing rates. It is very difficult for a practicing physician to keep up. It's amazingly difficult to even know when you're falling behind. What is missing is a direct link between new medical knowledge and the immediate plan and documentation for the ongoing care of the patient. Most, if not all, current systems for distribution of medical knowledge require an active search by the doctor for new knowledge, using a multitude of mutually independent systems, without knowing exactly what he is looking for. In other words, all these systems, however sophisticated, depend entirely on the doctor initiating the search and to know what he is looking for and how to go about it. This principle simply doesn't work, as evidenced by an average delay between the initiation of a medical study or trial and the penetration of the result in medical practice of 17 years!
iotaMed changes this situation radically. Using iotaMed, the medical record actually consists of evidence based plans. This leads to an immediate awareness in the doctor of the current state of knowledge as it applies to the exact disease or issue he is managing for his patient. Any change in medical practice due to new findings wil l result in a modification of the clinical guideline which will be automatically signalled to the doctor at the next encounter with the patient. iotaMed is the only system that promises to automatically inform the doctor of relevant changes to medical knowledge, at the right time, the right place, and at the right level of abstraction.
There is a need to reuse data from medical records for epidemiological and quality oversight purposes. In our current systems, this is extremely difficult since the necessary terminology and structure is missing. A great number of failed projects also attest to the difficulty of implementing these structures on the existing records. It is increasingly obvious that what is missing is an input structure for medical information, but it has proven just as difficult to provide a useful structure that delivers the necessary information to external systems.
iotaMed turns this question around, and thereby finds the answer. We shouldn't try to provide a structure for external registries and then try to make them useful in clinical practice. The key lies in providing the clinically useful structures, and only then try to reuse them for other purposes. iotaMed issue templates turn out to be exactly that structure. These templates provide a clinically useful tool, which not so coincidentally turns out to work almost flawlessly for the purposes of epidemiology and quality registries. This only goes to show that as long as you don't reason out the correct data structure and relationships in an information handling application, even immense amounts of work will not get you the desired results. iotaMed issue templates, however, make extracting data almost trivial while still being perfect for clinical care, which is a very important sign that the right structures and semantics were established.
There is an increasing pressure to provide the patient access to his or her records, but current EMR systems are unsuitable for this. Since they in principle only contain the patient history, with very little reference to future planning, the patient will even in the best of cases only discover what has already been done to him. What most patients need to see, however, is not what was done, but why it was done and what will be done. They also need to know on what basis these plans were set up, what the evidence is behind the plans, and what authority was responsible for the plan itself. Armed with this knowledge, the patient can ask for second opinions about the plan proper, instead of just guessing as to what planning was going on inside the head of the doctor, but was never written down in the records.
The second problem with giving the patient access to current implementations of the medical record is that the terminology and abstraction level of the language is only suitable to doctors. Worse, you can't force doctors to write in layman's terms for the benefit of the patient, since the records lose too much functionality in medical care if difficult but meaningful terms must be left out of the narrative. iotaMed, however, enables reuse of clinical information in different "issue templates", each adapted to a professional role or to the terminology level of laymen. This way, the patient does indeed have real access to the reasoning of the medical professionals without the need for a separate manual translation step or the compromise of the integrity of the medical record.
As we already mentioned, current efforts to provide knowledge based support at the point of care result in systems that are loosely connected, or not at all connected, to the medical record proper. Any such connection always seems to be a clumsy compromise and does not cover more than a minor fraction of clinical situations. iotaMed solves this by not connecting to a preexisting medical record, but to replace it entirely as the primary tool for the physician. The legacy EMR system as such, however, remains the backbone to which iotaMed is connected and maintains its role towards all other clinical and administrative roles in the healthcare organisation.
By replacing the legacy record for the doctor, there is no need for the doctor to deliberately interrupt the normal clinical workflow to check up on the advance of science while seeing a patient. He will be alerted to such changes if they are relevant to what he is doing at that point in time. Similarly, iotaMed provides the doctor with the means to keep his collegues updated on changes to medical management principles in areas in which he himself is a leading expert.
The iotaMed client can be used on the iPad, in a browser, or on another mobile platform. It is the primary tool the doctor or specialized nurse uses to interact with the iotaMed system. If the client is on a standalone system such as the iPad, it allows read-only access to legacy records, while posting any new data to the legacy system via the iotaMed servers. The way the iotaMed client interacts with legacy systems differs according to the environment where it runs. The primary implementation of the iotaMed client is on the iPad and on that platform it interacts only with an iotaMed base server which in turns interacts with the legacy system and the outside world.
The iotaMed client provides a set of issue templates from which the doctor can choose which ones should be instantiated for a particular patient. It also provides the list of instantiated templates, called “issue worksheets” for the patient, and a view that lets the doctor interact with the worksheets. Additionally, the client provides views to retrieve lab results, referrals and answers, legacy EMR notes, medication lists, and minimal clinical data from legacy systems. It also provides import and export functions for worksheets being exchanged with the myIota client.
The Issue List
Adding an Issue Block
Synopsis of New Block
Resulting New Block
Worksheet: Entering Data
Remove a Block
It is also possible to work entirely stand-alone with just a disconnected iPad in situations like home calls without network connectivity.
In most cases, however, the iotaMed client cluster will interact with local and regional iotaMed services, allowing tracking and updating of clinical guidelines and feedback to regulatory agencies on incidences and prevalence of conditions for which guideline templates are in use. Other iotaMed services include interconnect to external healthcare providers, exchange of records, dictation and translation services.
The iotaMed iPad clients are supported and managed through a local server. The number of iPads that can be managed by one server varies according to workload and the type of server hardware you provide. The local server maintains an encrypted communication tunnel to each iotaMed iPad client on the one hand, and exchanges data with hospital information systems and legacy EMR systems on the other hand.
If the legacy EMR system can fully support the entities iotaMed uses, such as issue templates and worksheets, all medical data is kept in the legacy EMR system database. If the EMR database cannot be easily adapted for this, templates and worksheets are kept in a database on the iotaMed local server instead. To the user, there is no discernable difference between these two scenarios. In any case, no medical or personal information is ever stored on the iPad itself.
All versions of an issue template will be made searchable through distributed index servers and provided to clients from distributed storage servers. Issue templates are distributed top-down, but can also be amended and extended at every level. The servers also take care of verifying the authenticity of the source of the templates. Each template can be made available subject to attributes set by the originator, such as language, area of distribution, access by certain groups, or access on condition of license, etc. This allows for both open and commercial distribution and use of templates.
iotaMed can send and receive issue blocks with patient information. This is very useful for instructions to the patient and collecting feedback from the patient back into the central iotaMed system, making it part of the regular record. These forwarded fragments of the record can also be used for communication to and from home care and social workers, or workers of any category in the field. The feedback servers have the task of authenticating users and worksheet blocks so they can be picked up and returned by patients or paramedics.
A quality register form is a special kind of issue template which can be exported to quality registers. The iotaMed quality register server accepts such forms from iotaMed local servers, validates, and distributes the form to the right external system.
Any export of personal data carries with it the risk of compromise. To reduce this risk as far as possible, we separate the personal identification data from the medical data already at the source, the local iotaMed server, and randomize the link between the personal data and the medical data. Only the medical data is sent on to the quality register server (QR server) and from there to the quality registers. The personal data takes another route to end up at a third party identifying system (PID). This way, the quality register will never possess any identifying data and must enlist the cooperation of the third party identifying system to match records as coming from the same patient. The identifying system, in turn, never sees any medical data. We suggest that the identifying system should be controlled by an independent authority so that any collusion to derive personal medical data will be made highly unlikely.
The functionality of the iotaMed client is also available as a web server, allowing use through any client machine that incorporates a modern browser with HTML5 capability. This project is in the early development stages.
The myIota client is somewhat similar to the iotaMed client, but is limited to worksheets that have been exported from the iotaMed system. After entering data, these worksheets can be re-exported to iotaMed. The myIota client is suitable for patients, offering them a selective view into their medical record while at the same time providing structured input into the iotaMed system. Such structured input could include self measurements of glycemia, pain estimations in joints, wound status, physical exercise statistics, and more. The actual content types and structure are determined by the issue templates that are created by iotaEd and managed for the patient using iotaMed.
The myIota client is especially well-suited for delegated care, such as home care situations, or management of diseases far from medical centers. For example, one could export a template for TBC care and follow-up to a myIota client, which could then be used for management of these patients by nurses in far-flung locations. These mobile-care providers would report back to a central location using the Export Worksheet function and the data would them be merged into the central records. Since the export is entirely asynchronous, it can be done over any online or offline data carrier as a simple file transfer.
The Patient App
Patient Form in iotaMed
Reading and Responding
Doctor Receiving Patient Feedback
The Feedback Form
Verify and Include
The iotaKid application provides custom made tools for follow-up in child care, prividing growth curves, standard vaccination schedules, and more. The iotaKid client is similar to the iotaMed iPad client, but with provisions for the special layout and graphics that make it extra useful for the followup of children. The unique iotaMed issue template format allows you to customize these care guidelines any way you need for your practice or for specific groups of patients. The iotaKid application is in early development and more info will be forthcoming at a later date.
iotaEd, issue template editor
The iotaEd editor is used by doctors to compose issue templates or to adapt them to changing guidelines or local conditions. This editor removes all the technical details and considerations, making it easy for the user to concentrate on the medical scientific content of the template. Only those physicians who are responsible for clinical guidelines need use this editor.
We are uniquely positioned to help create your guidelines with the optimal structure and at the same time train your maintainers in the creation and maintenance of your own set of guidelines. We are also more than happy to provide a long-term service of adapting guidelines from your clinical principles into a form suitable for iotaMed.