What are MyOSCAR Apps

As defined by the National Alliance for Health Information Technology in a report to the National Coordinator for Health Information Technology (NCHIT), “a PHR is an individual’s electronic record of health-related information that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared and controlled by the individual.” 

The core principles in the design of a sustainable, widely adopted PHR should therefore include the following:

• There should be strong adherence to nationally recognised interoperable standards in order to promote health information sharing.
• PHR users should be able to interpret their health information in order to manage their health and illnesses.
• The system should make it a priority to address privacy and security issues.
• Cost should be sustainable, both to individuals and the public.

What is MyOSCAR

It is designed from the ground up as a Personal Controlled Health Record (PCHR). We apply everything we know in the design of a multi-national, multi-language, ISO-certified, Electronic Medical Record (i.e. OSCAR) to create an electronic health record, managed and controlled by the individual owner. It is created as a life long medical legal health and wellness record. It takes a pragmatic approach to conform to interoperable standards. As such, it uses what is currently acceptable standards with the flexibility of migrating to future standards. It uses the eXtensible Markup Language (XML) for data modelling and Clinical Document Architecture (CDA) to store it's documents. The document database is encrypted for security and is designed to be extremely difficult, if not impossible for data mining. Moreover, as part of the future work plan, an individual can have multiple PHR accounts distributed across multiple servers, very much like an individual owning multiple email accounts. These accounts can be merged or consolidated even at a local storage device level, using technology such as the smart phones or thumb drives, for ultimate portability.

What are MyOSCAR Apps

Broadly speaking, these are web applications that interact with the individual's MyOSCAR data to produce clinical or administrative benefits. Apps can be native or remote. The following is a summary of the differences between the two types of Apps:

1. Native Apps are fully integrated with the distributed software and are managed by the MyOSCAR server owner. Remote Apps operate on their own web servers typically residing elsewhere on the Internet. These remote Apps interact with MyOSCAR using published terminology and messaging standards.
2. Native Apps use the same User Interface (UI) as the native MyOSCAR Client whereas remote Apps may operate within the MyOSCAR Client UI, typically as a "frame" or may use a completely different and independent UI, typically in a pop-up window or a new tab on the Internet browser.
3. Native Apps, once added by the individual user, have full read and write access to all the MyOSCAR data whereas remote Apps are restricted (by the MyOSCAR access control layer) to read only, or read and write the data elements that have been specifically permitted by the user at the time when the App is added.
4. Native Apps keep their aggregate data within the same MyOSCAR server. This data is accessible by users who are known to the MyOSCAR server. Remote Apps keep their aggregate data outside of the MyOSCAR server. The use of this data is dictated by its own privacy policy as published and known by the MyOSCAR user.
5. Development of native Apps follow the same ISO process in the production of the MyOSCAR software. Remote Apps are developed and maintained by the App code owner.  However, remote App developer may choose to follow the same Open Source Software license as the MyOSCAR project and place the code in the same code repository. However, the App code may follow its own release cycle and may or may not need to be part of the ISO quality management process.
6. Endorsement of native Apps are typically done by the MyOSCAR community through its volunteer supported management structure. Remote Apps are rated by MyOSCAR users and can improve ratings by endorsement from reputable organizations.
7. Native Apps usually do not receive industry funding.

The following discussion applies only to remote Apps. In general, a remote App must publish its compliance in three important areas:

1. Type of data to be pooled
• (1A) No data of any kind will be stored. Individual health information is used only once and promptly removed from the App after each use.
• (1B) Anonymous or de-identified data - data that have been stripped of all subject identifiers and that have no indirect links to subject identifiers.  There should be no limited identifiers in anonymous or de-identified data set.
• (1C) Coded data - data that have been stripped of all direct subject identifiers, but in this case each record has its own study ID or code, which is linked to identifiable information such as name or medical record number.  The linking file must be separate from the coded data set. 
• (1D) Fully identifiable data -  it is assumed that this App must comply with the legislative requirements of a Health Information Custodian (HIC).       
2.  Use of pooled data must be stated clearly in the privacy policy
   
   • (2A) Data captured in the App server is never shared. It is possible that the App server may use the data to generate internal use statistics or other administrative reports.
   • (2B) Data can be used to generate population based report. The App must seek consent at the time the App is added by the user.
   • (2C) Aggregate Data may be shared with other outside applications. The App must seek consent at the time the App is added by the user.
   • (2D) Individual/identifiable data may be shared with other outside applications. The App must seek consent every time an individual data is shared with an outside application. Individual may set "break glass" policy at the time the App is added.
   
   
3. Endorsement and funding must be explicit
   
   • (3A) App does not receive any external funding
   • (3B) App receives funding from not-for-profit or government organizations
   • (3C) App receives industry funding which has not direct control over the App or its data
   • (3D) App receives industry funding which may have control over the App and or its data 

At this point of the MyOSCAR development, it is a balancing act to promote Freedom or to impose Constraint. The "policing" of individual App regarding its adherence to its declared compliance to the above will be difficult. Until we have a critical mass of MyOSCAR users as well as App developers, we should take a more flexible approach and focus on educating developers the importance of these principles.

In the following blogs, I will give examples of Apps that have been developed or at various stages of development and examine how they fit with the above principles.

What are the potential clinical and business benefits for using MyOSCAR?

I have been a MyOSCAR user since 2005. I had no idea where it was going at the time. We started with the free software from MIT/Harvard. We made some changes to OSCAR to make it easier to communicate with patients right from OSCAR. I had some research money to hire a few students in the summer to stuff envelops and to create accounts for my patients. We invited some 500 patients to participate. So what have I learned so far. Am I closer to convincing my colleagues (and patients for that matter) to use MyOSCAR?


Before addressing the clinical and business benefits, I have learned over the years that there are still a lot of misunderstanding and myths about the the whole idea of Personal Health Record. Here is a list of common objections and my arguments for using MyOSCAR:

(1) I don't want my patients to see all my record
You don't have to if you don't want to. MyOSCAR is a different record outside of your OSCAR record. Patients don't have access to their records in OSCAR. You provide a copy of anything you think would benefit your patient, or if a patient requests for it.

(1b) I don't want to see all the stuff my patients record, or records from other providers (like naturopaths!)
This is similar to (1). You don't have to read anything if you don't want to. It's there if it is helpful - like patient's home BP monitoring. MyOSCAR is the patient's record, owned and controlled by the patient. You don't have any legal responsibility in making sure all the stuff there are accurate or useful. It's no different from patients coming in with a spreadsheet of their BP readings.

(2) I don't have time to check all the emails from my patients
Patients cannot contact you if you don't give them permission. You get to choose who can contact you and if you think the patient has abused that privilege you can remove that privilege anytime you want (I have only done that once over the years). The patient will get a message "You don't have permission to contact this provider" when he/she tries to contact you. You choose to give permission to someone whom you think would benefit from having this method of access. I have found that I have fewer phone calls if patients can write me via MyOSCAR. I decide when and where to return their message. I get on average 1 to 5 messages a week.

(3) What about legal liability if you write something down and patients act on your advice? Or if you send patients their reports and patients misunderstand the results?
This is no different from offering your advice face to face or by phone. Apparently about 40% of phone conversations are never documented in the chart. It's your word against your patients. If the conversation is clearly documented, it tends to be better thought out, with references from reliable sources, and patients have more time to digest the advice. You also provide opportunity for patients to clarify your advice further if necessary.

(4) I don't want "frequent flyer "patients to fill up all my appointments
Again, it's a privilege you give to your patients for online booking. Our clinic has chosen not to post any restriction but your clinic can decide who, when, what kind of appointments, which (participating) provider, how many appointments etc.

(5) Many of my patients don't have a computer or Internet access
Most of them do and they are quite computer/Internet literate. In many situations it is the caregiver, or the Power of Attorney who will gladly manage the MyOSCAR account on behalf of the patient.

(6) It is too expensive and who is paying for it
MyOSCAR is free(!). Well, the cost of using MyOSCAR is fairly low even if you are not the techie, do it yourself kind. Patients are quite happy to pay for it according to the many surveys we have done.


Well, once you have "disarmed" your colleague with great arguments above, you can then present these benefits, starting with business, then clinical. Many of these have fairly good supporting evidence.

(1) Online Self Booking will save you money
At least one university health service is banking on reducing one receptionist position because of this feature. My patients will be very happy not to have to be put on hold (sometimes at the back of a queue of 25 callers at 8:30 in the morning!). I don't have experience with this but our surveys suggested that patients are willing to pay for this service!

(2) Secure messaging can be a revenue stream
This is a difficult one especially if you are on a Fee-for-service style practice. For a capitation type practice, studies have shown that secure messaging can reduce the number of office visits, or enhance the quality of a visit if prior communication via secure messaging has taken place. More about this under clinical benefit below. Again, surveys have shown that patients are willing to pay for this service. In the United States where supply exceeds demand for family practice, patients are willing to switch family doctor if one will provide secure messaging service!! One of the commonest type of messages I get is medication renewal. Although I don't charge patients (I have a capitation type practice), I have seen other clinics charging a fee for every medication renewal by phone. Likewise, you should be able to charge a "processing fee" for making copies of patient's record or forwarding test results with an annotated advice message. I have considered the MyOSCAR service as a "block fee" for individual, or a family.

(3) Installation and maintenance of MyOSCAR can be as easy as you like
If you can't provide technical support you can always out-source it; or if you don't want to install your own MyOSCAR server, you can send your patients to another MyOSCAR host out there. Once again, I think patients are very reasonable, they will be happy to pay for the service with support included. This is not for everyone in your practice. It's about a choice offered to your patients. I can now enroll a patient at the end of a visit with just a few clicks in OSCAR. I print the registration letter which includes the patient's username and temporary password and instruction of how to login. I can decide whether the patient can or cannot communicate with me right from the registration screen. There are more and more self-support Youtube videos to help patients using this service.

(4) There will be Apps (potential revenue sources as well as evidence based clinical management for patients)
MyOSCAR is a perfect platform to launch Apps. The Online Booking is really part of the Clinic App. The Clinic App can stream (RSS feed) from your clinic site important information and announcements right to the patient's MyOSCAR account. Patients can pick Clinic specific functions, such as Booking Appointments. The idea of a Clinic App is that patients can interact with the clinic at the clinic level. 

There have been many Apps going through their study phases:

• MyBP - hypertensive patients managing their cardiovascular risk factors with the help of a small group of professionals (pharmacist, dietitian, and a nurse practitioner).
• MyMEDS - medication monitoring of effectiveness and adverse reaction
• eDiabetes - screening of patients at risk of developing diabetes
• eAAPS - electronic Asthma Action Plan System
• BORN - antenatal care
• ORN - Ontario Renal Network managing Chronic Kidney Disease
• Chronic Pain - managing chronic pain
• HealthLink - managing complex patients who are using huge amount of health resources
• TAPESTRY - keeping patients healthy at home
• I-am--able, I-am-pregnant; these are some of the previous studies that used MyOSCAR as a platform for communication, patient entering their clinical status; and patient executing self-management care plans.

(5) Asynchronous secure communication can improve efficiency and outcomes
It will not be immediately obvious in the beginning but I have found a few particular situations where clinical benefits are quite immediate:

• Home bound patients: it will save a few home visits and even home visits will be briefer
• The sandwich generation will be the most grateful. I have looked after many complex geriatric patients with the children communicating with me via MyOSCAR. They are usually middle age professionals who would appreciate keeping in touch without taking time off. These busy professionals also happen to be parents with children in need of quick advice
• Some mental health patients require frequent follow-ups. MyOSCAR will reduce the need for 30 minute counselling. Patients will learn self monitoring of symptoms and side effects of medications and feedback can be done "virtually".
• Patients going through tough time can benefit from improved access and communication. These are patients going through cancer treatment, or after hospitalization.
• This is a particularly great forum to include allied health professionals in coordinating care with very complex patients (e.g. chronic pain or patients with multiple co-morbidities).

How I use MyOSCAR from day to day

It's been a while since anyone has posted here so I think it's time for an update.

I opened my email this morning and lo I received a notifier from a patient. The message simply said:

You have received a new message from JANE DOE. Login to MyOSCAR to view the message.

You can't click a link to open MyOSCAR. It's a safety feature to avoid phishing. But I have a bookmark for MyOSCAR so it's easy enough to open up another window (or a tab in the same browser). But I actually don't even have to do that because my EMR (OSCAR of course!) is fully integrated with MyOSCAR. So I simply go to my EMR and click the MyOSCAR tab (see the big red arrow):

I can see the new message(s) as well as the older messages I have left in my Inbox:

A glance at my Inbox revealed that I have received 12 messages this month so far. Not bad for a practice in which about 600 patients have been offered the MyOSCAR service.

Using my EMR to work with my patient's PHR makes it a lot easier to keep track of things. For example, the patient's message as well as my reply are automatically inserted into the patient's chart:

So when I see Jane next week I can review all that have happened leading up to that point.

I will describe more MyOSCAR features on my next post. But suffice to say that the secure messaging feature of MyOSCAR has become an indispensable tool for my patient care. I can deal with a lot of my patient's problems a lot sooner and at a much more convenient pace for both me and my patients. I am certain that my patients (the ones who use it anyways) really appreciate the improved access to getting help.

I have heard many objections from health care providers about letting patients send them electronic messages. Generally these are the common ones:

(1) I will be flooded with messages and where do I find the time
My answer to that is that my experience has been the opposite. Let's say this month I received 12 messages out of 600 patients. That's about 2 messages per 100 patients per month, or about 20 per 1000 patients which is the average size practice. I am sure I have saved at least a few physical visits (or phone messages) and when I actually see these patients in my office, the visit will be shorter and of better quality since so much of the needed information have already been communicated. And I can do my work without the constraint of my office schedule! And no more phone tags!

(2) I am afraid of the legal consequences since conversation will be on black and white!
My argument is that it is actually better to have everything documented. My correspondence tend to be more thoughtful and better prepared (like having looked up more information before I make a statement). I remember once being asked by a patient what she needed to do when she had to fly on a plane given that she was on a blood thinner. I actually looked things up and gave her an answer that I was more confident with. If she had come to my office and asked me the same question point blank, I would not be able to look things up, and would probably have given her an answer I was less confident with.

I am convinced that the future health care system will demand more online communication between patients and providers. It will provide better care, and hopefully improve health!

Online Booking

Online Booking is ready!! You can see a demo here:

http://www.youtube.com/watch?v=0o8zcaOLrWs&feature=youtu.be

The REAL benefits of MyOscar or how it should work!

From OSCAR Support:

One of the patients at our family health team is an elderly patient who can no longer speak.  The health status has changed significantly over the last year and the patient is no longer able to call our office to book an appointment and we are not able to communicate by phone,  but can write responses.  Prior to using MyOscar, we were required to call a family member or neighbour to go over to the house and speak with the patient in person. 

The introduction and utilization of MyOscar allows the patient and selected family members to communicate directly with us about various important issues. Because of the complex health issues, this patient is involved with several specialists and interprofessional care providers.  Following appointments, the patient is able to update us on immediately  on new recommendations and treatment plans. 

After a recent hospitalization, the patient and family contacted us through MyOscar to explain the patient had been discharged from hospital and had been advised to contact the  primary care provider. The patient requested an appointment for follow-up on health issues.  Family expressed concern that we would not be able to see consultation notes or discharge summaries prior to the follow-up appointments.  Because of the effective electronic communication, it was possible for us to obtain these documents, which assisted in advancing the patient’s treatment plan in a timely manner.  On another occasion the patient was requesting some medication adjustments, and our pharmacist was then able to review the patient’s medication profile and prepare recommendations prior to the appointment. 

This patient is now able to arrange appointments with us and keep us informed of changes in the medical condition and any changes in the treatment plan .   Because of MyOscar we are able to continue to provide excellent care to a elderly patient with complex health issues while minimizing the need for appointments and inconnvience  as well as keeping  the family informed.

This is a great example of how an integrated  EMR allows professionals and patients to communicate and improve patient care.

Helpdesk Calls Increasing Daily!

The volume of calls is increasing daily. I had to juggle 2 calls at once this afternoon.
One of the calls was a patient saying "Awesome! I feel privileged to be a part of this. I am so glad this is happening!".
I had to charge my headset to ensure proper ergonomics:-)

Great day at the Helpdesk!

Great way to use MyOSCAR

Great way to use MyOSCAR

Last week one of our staff, who is a patient at our Stonechurch Clinic sent me a myoscar message that she had received her flu shot at work. I copied her message, entered her Oscar EMR and added the flu shot to her prevention chart.

Everyone is happy-she didn’t have to call the clinic or come in to register her flu vaccine, and the clinic now has her recorded vaccine and will qualify for the bonus for that patient. A win-win for everyone