We once thought medical records belonged to doctors and hospitals. They were not to be seen by patients because they might be alarmed or find errors. Now personal medical records, like personal bank and credit card accounts, belong to patients. They are confidential unless voluntarily and selectively released to physicians or hospitals of a patient’s choice.
A century ago records were hand written. A doctor took notes as he listened to and examined his patient, then thoughtfully and legibly wrote in the patient’s “chart” what he had learned and advised. The process was personal. It aspired to be scientific in describing nature so clearly and concisely that outcomes and options were predictable. Information transcribed in letters to consultants was also concise and free of irrelevant distractions.
Then multiple choice checklists replaced handwriting. Lists composed for an average patient often missed relevant facts. Checking boxes was delegated to patients and confirmed by a nurse before cursory review by a hurried doctor. After a ritual touch with a stethoscope, the doctor dictates information to a computer that assigns codes and files them digitally in a clinic or hospital’s electronic health record (EHR). Each hospital’s EHR system is copyrighted and inaccessible to most other systems.
This is now the state of the EHR in America. Its strength is its ability to share images (x-rays, ECG’s, etc.) so tests can be instantly compared and not wastefully repeated. Its principal weakness is that records are not yet “interoperable” between hospitals, insurance companies, et al. Meanwhile patients and doctors are dissatisfied with their encounters. Patients complain that doctors are fixed to their computer screens. Doctors complain that EHR’s are cluttered, designed for commercial rather than professional use.
Since hand written records will not and should not return, can the EHR be refined to solve the foregoing problems? There is strong evidence that it can.
What Are the Challenges of Improving Patient Medical Records?
The first challenge is “interoperability,” making clinical information as moveable between providers as checking and credit card accounts are between banks. This will require one language and a standard style of data entry and storage, which in turn will require one agency with authority to deny access to a noncompliant provider. The first incremental step in developing our American health care model must be to identify the agency in charge.
The second challenge will be to protect each patient’s privacy from unwanted invasion of his or her confidential EHR. All data on an EHR will be stored in “the cloud,” accessible to the agency in charge and to a computer chip in a card carried by its patient-owner. As with France’s Carte Vitale, the owner will present his or her card to each health care provider, only for the duration of their encounter. The health care provider, using an authorized PIN, will add new data and bill an insurer, then return the card to the patient. The provider will keep no paper record unless authorized by the patient. The patient must be able to limit the provider’s access, such as on visiting a dentist to exclude access to all but dental information. The technology that assures the safety of this process must be tested and in place before the system is in operation.
A third challenge is to enable providers to selectively access information in a patient’s EHR. If a hospital bills fee-for-service, its accounting office should be able to access billable services without distraction by clinical data. Conversely, clinicians should not be distracted by itemization of entries they do not need.
A fourth challenge (and a great opportunity) is to enable the overall responsible agency to release anonymous data for use in quality control, clinical research, budget planning and resource distribution. These functions will play vital roles in controlling costs of health care.
A fifth challenge will be to share with physicians, nurses and other providers the satisfactions and rewards of creating thoughtful clinical records – documents that render more accurate diagnoses, rather than more items to charge for. This will require emphasis in medical and nursing schools, as well as digital searches for possible diagnoses and their probabilities.