Map of life expectancy at birth from Global Education Project.

Monday, March 05, 2007

Big Brother, M.D.?

As I was preparing to post on something else, I read Ana's comment on the previous post and realized I ought to do this instead. The issue she raises for Switzerland is one that we are facing here too, but with really minimal public awareness or general debate, and that's the issue of the integrated electronic medical record (EMR).

As of now, many hospitals have adopted EMRs. If you go to a community health center or ambulatory care practice affiliated with a major hospital, chances are your doctor already uses an EMR. The doctor probably logs on to the computer while you're sitting there in the examining room, rather than having an administrative assistant pull a paper record (or not get it there in time, just as likely). Along with the EMR, there is probably an computerized order entry system, so your doctor enters your prescriptions in the computer, and it prints them out, while automatically incorporating them in the record, along with the doctor's notes on your visit, lab results, etc.

Now, imagine if all the doctors and all the hospitals in the world had access to the same record, over the Internet. Voila! The problems with polydoctory I discussed below are solved, or nearly so, in the twinkling of an electron. Every doctor you go to can instantly find out about all the other doctors you are seeing, what they have found, and how they are treating you. Furthermore, if you change doctors, or go to a new specialist, no problem -- the record is right there. The software can automatically flag potential drug interactions and counterindications, remind doctors when screening tests are due, alert when test results should be followed up . . .

The potential of such a system to improve health care, eliminate waste, reduce medical errors and enhance patient safety is obvious, and the idea is causing a lot of excitement. Most doctors absolutely love it, and why not?

Well, of course, there's always a why not. Technical issues are fairly daunting, and the capital investment needed would be huge. It actually doesn't help that many hospitals have a head start with their own EMR systems, because those don't start out being compatible with each other, and you'd have a huge problem of integrating information across multiple existing systems and platforms. For small practices, even stand-alone EMR systems aren't cost effective, so there would need to be massive subsidies to get all of those family docs on-line.

But then there are the privacy and other human rights issues. I'll give one fairly obvious example. I mentioned below that most primary care docs have never seen a mental health record, but there's a good reason for that. Those records (and substance abuse treatment records) are even more protected than ordinary medical records, by federal legislation that pre-dates HIPAA. Mental health clinicians need to have information about history of incarceration, illegal drug use and other criminal activity up to and including serious violent crimes, suicide attempts, behavioral and personality disorders, and other stuff you really don't want in your medical record.

You might or might not want your primary care doc to know some or all of this, but you don't want every health care provider you'll ever meet to know all about it. You also don't want to take a chance that it could get out beyond the circle of health care providers, and become known to an employer or potential employer, perhaps relatives, insurers -- you get the idea. On the other hand, you certainly want behavioral health providers tied into the EMR system because they do need to have your medical records, and your primary care doc needs to know about your psych meds, at a minimum.

Of course the potential problems go beyond these relatively extreme cases.

So how do you feel about this brave new world? The theory is that the record is yours, it belongs to you. It goes wherever you go, and of course you can see it, even from home, just by entering your username and password . . . uh oh, we know those can be stolen or cracked. Can the problems be solved? Remember, the upside is huge. There are enormous potential benefits. Are they worth the risks?

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