Who benefits from computerization of patient-specific clinical information?

Electronic health record (EHR) systems are big news (and big money) these days.

Our government is pushing adoption and “meaningful use” of EHR systems because computerizing patient-specific clinical information can benefit our nation’s health care system. The primary focus has been on the benefit to the care of individual patients, but computerizing patient-specific clinical information can also benefit other parties in the health care system.

I believe that there are 6 major parties that serve to benefit from the computerization of and access to patient-specific clinical information. I refer to these parties as the 6 P’s.

The six P’s are as follow:

  • patient
  • provider
  • payer
  • public (as in public health)
  • posterity (alternatively PhD’s)
  • product makers (alternatively pharma)

Patient

At this juncture in the national discussion of EHR systems, it should be self-evident why patients serve to benefit from the computerization of patient-specific clinical information. I will thus not further belabor the point.

Provider

Ditto for provider. By “provider” I refer to all individuals and organizations that deliver care to patients, including but not limited to physicians, nurse practitioners, nurses, physical therapists, hospitals, home health agencies, etc.

 

Payer

By “payer” I refer to third parties that pay for patients’ care. I use the term broadly and include both for-profit and not-for-profit health insurance carriers, government-run health insurance programs such as Medicare and Medicaid, and even the many self-insured corporations that utilize health insurance companies solely for their administrative functions but not for their assumption-of-risk functions.

Payers will ideally be able to automatically monitor the quality of care that their patients are receiving. While many payers currently analyze claims data for this purpose, actual patient-specific clinical data will likely provide a much more precise and useful dataset. Knowledge of the quality of the goods and services that payers are purchasing should help them to design programs to improve value for their covered patients.

Public

By “public” I refer to the population overall, as in public health, whether on a local, regional, national, or even international level. The potential public health applications of having large quantities of computationally tractable patient-specific clinical information are enormous. Examples include real-time detection of emerging infections, simplified identification of locations of environmental hazards, and real-time access to community-wide antibiograms.

Posterity

By “posterity” I refer to the use of patient-specific information for clinical research. I use the term “posterity” because good research adds permanently to the scientific knowledge base, and, well, I needed a word that starts with the letter P. Since PhD scientists do a lot of research, you can alternatively think of this one as PhDs.

Product Makers

Like it or not, medicine cannot be practiced without products that health care providers use, such as pharmaceuticals and medical devices. Manufacturers of these products, of course, rely heavily on patient-specific data for FDA approval of their products but also—and possibly more relevant with respect to EHR systems—are under increasing pressure to monitor the safety of their products in the post-marketing phase.

Conclusion

While patients and providers benefit mostly from providers’ direct use of patients’ individual clinical information, the other 4 P’s benefit mostly from analysis of many patients’ clinical information in aggregate (de-identified where appropriate). Because patients seek care from providers who will be using disparate EHR systems, this is yet another reason to implement national terminology and communication standards for clinical information sharing; the value contained within EHR systems will likely not be realized without it.

In closing, when you are thinking about who are the users and re-users of patient-specific clinical information, think the 6 P’s.

Adam Rothschild is a family physician and the CEO of Doctrelo.  He blogs at The Doctrelo Blog.

 

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  • doc99

    You left out “Powers-that-be” and “Perpetrators.”

    • Adam Rothschild, M.D., M.A.

      My intention with this piece was to highlight LEGITIMATE parties who serve to benefit from the computerization of and access to patient-specific clinical information, but you make a good point. Your two additional parties would also serve to benefit, albeit illegitimately. The 8 P’s?

  • Marc Gorayeb, MD

    It should be self-evident why patients serve to benefit? Not so fast.
    Speaking as a patient, my medical information already can get to my providers by various reasonably secure means:
    -by fax directly from one provider’s office to another
    -after hours, by fax directly from one hospital to the ED or inpatient ward of another
    -by fax from secondary sources (e.g. lab, radiology dept.) if a requesting provider’s office is open and the source provider’s office is closed.
    This system may not be perfect, but the distribution of my private medical information is point-to-point and remains well-circumscribed.

    An EHR system as contemplated above implies that my personal medical information will be stored in a server that is accessible to third parties. What hasn’t been shown yet is how this information can be secured; that is, made inaccessible to hackers, marketers, and a larger universe of non-physicians who are provided with the passwords to access the information. Having a series of privacy laws on the books is not enough. Laws are bent or broken all the time.
    It’s bad enough that Insurance companies already share my personal medical information. Drug companies and pharmacies already communicate with one another, sometimes improperly. Occasionally they get caught and get sanctioned, but how do we know that privacy breaches are not still occurring? If our government can deliver a Stuxnet virus to destroy a thousand nuclear centrifuges in Iran, how can anyone say with a straight face that my personal information will be secure on some distant server? The best way to assure that my personal medical information remains in the hands of the fewest number of people is to continue to severely restrict where that information gets deposited.

    • Killroy71

      If doctors and their staffs are so great at communicating, why do I have to fill out the same form every year with my medical history? Why does my doctor ask me the same dang questions I have already answered 10 times in the PAPER forms they have me fill out? WHY are my test results NOT where they need to be in time for my next appointment, so that I have to take time off work, come back, and pay the doctor AGAIN?

      Maybe it’s you, and not the system you’re using, so maybe EHRs wouldn’t actually help your practice. And your precious, faxable paper files still don’t prevent medical errors, medical ID theft etc, so paper’s not the answer to the confidentiality issue. But it sure cloaks outcomes data that could actually improve care and reduce medical spending.

      I dream of a day when I can carry around my entire medical history (such as it is) on a flash drive or have it encoded in a magnetic strip on a card. My finances already operate this way, no problem so far. Full disclosure: I have NO financial stake in any company that makes or sells these things. I’m just a patient.

      And please, if you don’t like pharmacies sharing your prescribing info with drug reps, take that up with your medical associations and elected officials and put a stop to it. That would be a brilliant first move on your part.

      • horseshrink

        Repetitive questioning usually necessary. There is liability attached to one physician not performing a full evaluation independent of other physicians.

        However, if one doctor is asking for the same static data over and over, that’s a problem.
        * * *
        Labs currently are usually faxed into offices as soon as complete. Weak link can be office staff getting labs to doctor.
        * * *
        Financial records and medical records both have central maintaining authorities,and the customer doesn’t generate those records.

        As such, your primary source, master bank account info cannot travel with you on a thumb drive. It lives at your bank. Multiple entities then generate transactions that are recorded by the bank.

        In medical practice, the same thing happens. The main medical record for an office also has multiple sources of input … from the office nurse, other consultants, radiology, lab, hospitals, insurance companies …

        A key difference lies in the nature of the data. Financial transactions lend themselves well to fairly simple data constructs. Medical transactions don’t. Clinical data fields are vast in number and rapidly/constantly evolving.

        Another key difference is data input. Financial transactions are largely automated. Human fingers and time are infrequently needed. The human interface is not very important, except on the customer end.

        Medical data relies preponderantly upon manual input by humans in the course of performing their data gathering. The human interface for data input can make/break EHR system feasibility.

  • Adam Rothschild, M.D., M.A.

    Please see my reply to doc99′s comment above about my intent in this piece to focus on LEGITIMATE users of patient-specific information. Your general concerns about the confidentiality of patient-specific information are, of course, legitimate. That said, discussion of confidentiality was outside the scope of what I set out to discuss in this piece. What if I added 2 more P’s per doc99′s suggestion above?

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    There is very little that office-based EHRs can add to the availability of objective medical data. Payers already have diagnoses, visits, procedures, hospitalizations, medications, DME, most immunizations and every single test (without results). Laboratories have test results and so do imaging systems. The only pertinent data elements that may be missing are vitals, although many lab results include those too. I do understand that there is much more nuanced information that can be captured by providers, but the bulk of data is already out there beyond physicians & patients control, in massive databases, and it has been so for a rather long time.

    For example, what is the logic behind mandating that lab results be dispersed to hundreds of thousands of physicians in structured format, just so these can be rolled back up in structured format, when it would be so much more cost effective to get the results from the source?
    So where were all those PhDs working for Posterity all these years? Why hasn’t anybody done anything significant with the existing centralized and structured data? Other than risk assessments and pharma marketing, of course.

    Is this some sort of recent epiphany? Or perhaps the ninth P? Private Capital, and those backed by it, hoping to make a “killing” from developing ever more complex HIT to move data in every which direction and/or coming up with even fancier (=more expensive) applications to replace the currently, already expensive, technology.

    The current common wisdom is that more care is not necessarily better care. By the same token, more technology is not necessarily better technology. Assuming that technology has a purpose other than perpetuating its own existence.

    • Adam Rothschild, M.D., M.A.

      Margalit, I’m a bit puzzled by what you have written in response to my post. The thrust of this piece was to lay out who are the parties that serve to benefit from the computerization of and access to patient-specific clinical information. I simply wanted to canonize which “players” can potentially derive utility from patient-specific clinical information. The issues that you raise are worthy of discussion but seem to me to be orthogonal to my post’s intent.

      • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

        Yes, I guess it was a bit of a rant… :-)

        I just wanted to point out that there is another way to collect data and that there is another P involved.
        I’m not even sure that the main consideration is the patient/provider dyad anymore….

  • DCPharm

    As a patient, I can tell you that providers with EHR’s are much more organized and efficient as a result. In fact, I stopped seeing one provider because her paper system was extremely error prone. I had the knowledge to catch the errors, but average Joe would not.

    • John Ryan

      Oh I don’t know about that. Ever hear the saying about computer data “garbage in, garbage out”? Now the errors spead from one place to another at the speed of light.

  • horseshrink

    As a life long geek who started writing code on a MassComp 8088 in a new language called “C,” I’ve lately had the dubious benefit of working daily with a badly designed EHR that’s been implemented state-wide, a very fertile source of frustration and related thinking. I’ve not yet found a doc in my system that prefers this EHR over a paper chart.

    It is my impression thus far that EHR products have not been written by clinicians for clinicians.

    They’ve been written by programmers for administrators who make purchasing decisions.

    Once the sale is made, the product deployed, and a patient database created … everybody’s stuck with the product, like a bad marriage. Why?

    It’s too difficult to leave one EHR product for another. Nobody’s happy, except for the financial beneficiary, and it’s too expensive to divorce.

    Data migration cost + new product cost = prohibitive cost

    Solution:
    Standardized data constructs. If data migration cost can be eliminated, and clinicians can change EHR products at will … guess what?

    The EHR industry will become very interested in making products CLINICIANS actually WANT – and at much more competitive prices!

    • Adam Rothschild, M.D., M.A.

      Horseshrink, I agree with what you are saying. My company, Doctrelo, is squarely focused on creating software that doctors love. Serendipitously Dr. Gregg Alexander, a practicing physician and health IT blogger, blogged the following yesterday about our first product (almost in beta): “Doctrelo’s eRx Plus e-prescribing system, based on clinical problems and designed around how providers actually think, is the slickest e-prescribing tool I’ve ever seen.” http://www.histalkpractice.com/2011/01/19/intelligent-healthcare-information-integration-11911/

      With respect to the vendor lock-in that you describe, Doctrelo does not plan to play that game. We want clinicians to use our products because they like them and what we stand for as a company. With respect to the desire for EHR products written by clinicians and for clinicians, I agree wholeheartedly but might even one-up you there: How about EHR products written by clinician/INFORMATICIANS for clinicians? There aren’t too many of us who are both practicing clinicians and formally trained medical informaticians, but I believe that we have the unique ability to give doctors not just what they want, but what they didn’t even know that they wanted.

  • pcp

    “Patient

    At this juncture in the national discussion of EHR systems, it should be self-evident why patients serve to benefit from the computerization of patient-specific clinical information. I will thus not further belabor the point.

    Provider

    Ditto for provider. By “provider” I refer to all individuals and organizations that deliver care to patients, including but not limited to physicians, nurse practitioners, nurses, physical therapists, hospitals, home health agencies, etc.”

    I don’t think either of these points even comes close to being self-evident, and this is supported by lack of evidence to support the claims that EMRs lead to better, more efficient healthcare.

    As always, Ms. Gur-Arie, even when ranting, is spot on. The benefits of EMRs are, it is becoming evident, not accruing to patients and doctors, but rather to insurers, government agencies, and profiteers.

    • horseshrink

      “benefits of EMRs are, it is becoming evident, not accruing to patients and doctors, but rather to insurers, government agencies, and profiteers”

      Agree.

      In my state level work group activity, and in-the-trenches experience in a variety of practice settings, I’m impressed that the point-of-care end user has the least interest in forging ahead with EHR technologies. This is the purview of administrators, bureaucrats, politicians and vendors.

      If EHR usability does not improve sufficiently before federal carrots and sticks expire, I expect clinicians to shrug their shoulders in frustration and dump their charts back to paper.

      Smart phones should be a lesson for EHR vendors. The feds didn’t have to lure us or punish us into buying them. We like them … so most of us now spontaneously use them.

      We don’t need feds to get us to use EHR technologies, either, if they are manifestly desireable/useful … making us work faster, smarter, safer and more profitably.

      • http://future.doctrelo.com Adam Rothschild, M.D., M.A.

        Pcp and horseshrink, I hear what both of you are saying and agree that “insurers, government agencies, and profiteers” serve to benefit from physicians adopting EHR systems… and might be the ones currently benefiting the most. Again, however, I must point out that the aim of this piece was simply to establish the parties who SERVE to benefit from the computerization of patient-specific clinical information (i.e., those parties who have the POTENTIAL to benefit). I am aware that many of the studies done heretofore do not yet illustrate a convincing benefit to patient outcomes (although here is a recent one that does: http://www.annfammed.org/cgi/content/abstract/9/1/12). But I would strongly argue that the main reason why no such benefit has been shown is because of the low quality of the PARTICULAR EHR systems being used (and currently available in the marketplace), not because of some general shortcoming inherent to ALL possible EHR systems. Contrary to what the current big EHR system vendors would have us believe, I submit that most physicians (myself included) would say that most currently available EHR systems suck. I refer you to a recent blog post of mine in which I address this very issue: http://blog.doctrelo.com/?p=29

        Just because currently available EHR systems suck, though, does not mean that future systems have to suck. I beg you please not to throw the baby out with the bath water.

        • pcp

          “Just because currently available EHR systems suck, though, does not mean that future systems have to suck.”

          True. But that would require seeing the physician as the customer whose needs must be met, and I don’t think CMS and the insurers will allow that to happen.

          • http://future.doctrelo.com Adam Rothschild, M.D., M.A.

            At least in small practices, physicians are the ones who decide which (if any) EHR system to purchase: The physicians ARE the customers. Perhaps this suggests why EHR adoption is so anemic in small practices? I don’t understand what you mean when you say that you don’t think that CMS and the insurers will allow “seeing the physician as the customer” to happen. Yes, certain functionality needs to be engineered into the software for reimbursement and quality reporting purposes, but that does not dictate the entire user experience.

          • pcp

            “The physicians ARE the customers”

            Well, the physicians are the ones who pay the bills, I’ll agree to that.

            ‘I don’t understand what you mean when you say that you don’t think that CMS and the insurers will allow “seeing the physician as the customer” to happen’

            I mean that their needs will always take precedence (through various forms of coercion, mandates, legislation, etc.) over those of the physician. Meaningful use (talk about Orwellian language!) always trumps usability.

            Have enjoyed your comments.

  • horseshrink

    I have faith that EHR products will improve – but it’s important for me to remember I’m using the word “faith” re: future utility of these technologies. “Faith” probably shouldn’t be driving major purchasing or national policy determinations.

    I think the most useful role that the government can play here is a fostering of standards development in a manner that can unleash market competitive forces into this arena to the benefit of end-users.

  • http://bit.ly/9wmOLT Dyck Dewid

    I also say, re patient benefits… not so fast!

    Privacy laws and policies are impotent and mostly for show. For example, I see nothing explicit about Responsibility and Public Trust. Nor, have I ever seen addressed Consequences for those responsible for a breach.

    It is a strange existence and not my idea of a free society that would have Government determine for me what are my privacy rights. Are not Rights higher than laws and thereby not doled out by one man to another?

    Last week I was refused medical treatment because I preferred to give my history verbally, not in written check boxes with signature testifying that I certify truth and completeness. Some of my basis is that
    1. no one had an explanation that they wanted to say.
    2. what if I have memory problems?
    3. what if an entry error was made on data entry.
    4. what if I mis-interpreted what was meant by the questions?

    I expected that this intake was actually not for patient benefit at all. If this was for the patient benefit how would the info be verified to ensure correctness and completeness? Is this what a doc would look at before prescribing meds?

    Will doc-patient dialogue eventually all be recorded? Will self-protection paranoia eventually destroy us and our medical system?

    Are the benefits of EHR rationale that justifies something else more sinister?

    I am content with the colossal aim to make the doctor-patient relationship once again solely a two party deal… without insurance and without government and without lawyers.

    • http://future.doctrelo.com Adam Rothschild, M.D., M.A.

      Dyck, as I mention in a comment above, concerns about the confidentiality of patient-specific information are, of course, legitimate. That said, discussion of confidentiality was outside the scope of what I set out to discuss in this piece. The aim of this piece was simply to establish the parties who SERVE to benefit legitimately from the computerization of patient-specific clinical information (i.e., those parties who have the POTENTIAL to benefit).

      • http://bit.ly/9wmOLT Dyck Dewid

        Well taken, Adam. My other three points are:

        1. Consequences of inaccuracy of data storage & sharing.
        2. Benefit/risk to patients medically, financially, respectfully of rights. Is it all about economics, dealing w insurance pushing factory medicine? What must patient give up?
        3. Mandatory versus discretionary, e.g. coercion to get treatment (The camel getting his nose under the tent of patient self-determination & participation).

  • horseshrink

    I looked a bit at the Doctrelo website. First thought that occurs to me is that this could be a good SourceForge project.

    http://sourceforge.net/search/?q=medical+record

    However, I’m pretty sure you’ve already thought of this and have decided to keep this in the realm of a financial enterprise. Understandable.

    Second … in reviewing the issue of entrusting third party vendors hosting the medical records for a practice … definitely worrisome. I agree with the problem of their selling supposedly de-identified information to other industries, but I also think about the problem of records ownership and who has final authority over them.

    This lead me to a series of disturbing questions. I imagine some of these questions have already been asked in one way or another in the context of paying for paper records archiving. However, there are new dimensions that incorporate active records on a current patient panel, ease of duplication (and what to do with copies), roles of international companies, and corporate dynamics.

    Some questions:
    1. Who owns the medical record? Me? The EHR company?
    2. What if I don’t pay my bill? Do I show up one day to my office to discover I no longer have access to my patients’ records?
    3. What if I decide to change EHR vendors? How do I get my records “back?” What does the EHR company then do with its copy of records for which there’s no longer a paying client?
    4. Will my records be stored in the U.S.? Or, will they be stored in China or India, where our legal jurisdictions won’t extend? What happens if political problems cut me off from my records? What will they do with my records if I terminate services?
    5. What happens to my records if my on-line EHR company is bought out by another company – something over which I have no control? What if the acquiring company is not a U.S. company … or a company with a financial interest in having such data … e.g., a large pharmacy chain?
    6. Can my highly dangerous, paranoid patient circumvent me to request a copy of his records directly from the EHR company (with the assistance of an attorney interested in pushing the limits of law?)
    7. Can a court officer subpoena the EHR company for my records, circumventing me and my own attorney?