As a physician transitioning from hand-written patient charts to electronic medical records, I have observed the blooming of pop-up alerts prior to my completing each patient visit. These alerts remind me what I should do for my patients: age and gender appropriate screening tests and procedures, vaccinations, pain management suggestions, and prescription renewal reminders, to name a few. These reminders are a great support to caring physicians who find themselves fully engaged and preoccupied with managing other aspects of patient care.

I have always wondered who is behind these well-designed pop-up alerts built into many of the electronic medical record platforms used for patient care. And, as an inquisitive scientist, I always ask myself how solid the data are supporting the utility of these windows to patient outcomes. It is reasonable to believe that, at any given health care institution, experts from the information technology department work closely with the quality improvement office for the sole purpose of developing medical record strategies that improve patient outcomes. But the Purdue case may lead us to suspect otherwise.

Purdue Pharma, the large company that put OxyContin on the market in 1995, agreed this week to plead guilty to federal criminal charges for helping to create the nation’s opioid crisis, pay more than $8 billion in fines, and shut down the company. The company has collected more than 1,000 lawsuits from 47 different states alleging the company misled doctors and the public to promote the use of their drugs. Despite pleading guilty to federal charges in 2007 for deceiving doctors about the dangers of OxyContin, the company continued to be involved in kickback practices to motivate physicians to write more opioid prescriptions. In January 2020, Practice Fusion, one of the biggest cloud-based electronic health record companies in the country, paid $145 million to resolve criminal and civil allegations that it received kickbacks from Purdue to influence opioid prescription writing.

Kickback practices have a domino effect that falls hardest on the frail. Our patients, the end-users of the health care enterprise chain, clearly remain the victims of marketing strategies leaking into health care practices and influencing medical decisions.

Here’s how it works. Let’s say I sit on the advisory board of a company that developed a new safe, and effective strategy to reduce serum phosphorus in the blood of patients with chronic kidney disease. High phosphorus levels in this patient population are associated with high mortality rates, but, despite sitting on the pharmacy selection committee of my institution, I can’t get the drug approved, even with a detailed, cost-benefit analysis. The company can now work around my expert opinion and subcontract a data management company to collect state-wide data on how prevention of high phosphorus levels may improve outcome and hospital expenses. This data management company can now enter into an agreement with the institution to create pop-up windows in the electronic medical records to influence the prescribing of medication for phosphorus lowering purposes. The pop-up window may even suggest which drug may be indicated and what the best path would be to get authorization to prescribe the drug. As a provider, driven by a genuine desire to improve my patient outcome, I would boost the market sales of the company developing the new drug while not being at all aware of the marketing strategy hidden in the electronic medical record of the patients I care for.

Best practice alerts (or pop up windows) were found to reduce unnecessary tests, resulting in cost savings. Some companies, while improving health record technology, may even have more dramatic implications.  One particular company has been emailing appointment and prescription reminders to patients. By doing so, the start-up also got access to 75 million patient prescriptions and conditions and made them available to analysts, pharma companies, and market research for a cost. A subsidiary of this company also developed to contact patients after each visit to collect reviews on the patient experience. What patients writing these reviews did not know was that these “anonymous” reviews with sensitive medical data were made public, and patients were identifiable, like a Facebook page with tons of medical records data and patients’ contact details. This is just one example of how agreements between electronic medical records driven enterprises and third parties can negatively affect the end-users, i.e., patients and their families.

As a physician working in a busy practice, I am not opposed to pop-up windows appearing every time I open patient-specific encounters on the electronic medical record, as I truly believe they help me streamline the procedures needed to ensure proper patient management and care.  I am simply requesting full transparency, where physicians can requests that pop-up windows provide them with access to multiple studies that support the information in the alert. I also would like for physicians to be made aware of the financial source behind the establishment of these alerts.

And if I am the patient? When recommended to seek physician attention for a given procedure or prescription, I would be interested in having access to the data supporting the physician’s recommendations. I would also expect my physician to disclose to me any conflict of interest related to the provider or the practice involved in the medical care decision. Only this level of transparency will ensure that educated decisions and trustful relationships between patients and physicians remain in the era of information technology ruling health care.

Alessia Fornoni is a nephrologist and pharmacologist and a public voice fellow, The OpEd Project.

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