The electronic medical record system: health care marvel or morass? - Surfing the Information Technology Wave - patient privacy

FRONT PAGE STORIES IN THE BOSTON GLOBE ("Computerized Medical Records Put Privacy On Line," "Attorney General's Office Examining Privacy Of HMO Files," and "Patient's Files Allegedly Used for Obscene Calls" *) have reported that patients of a well known Boston HMO were shocked they had not been informed that the most private details of their medical and psychiatric histories had hit the electronic Information highway. Not limited to just one area of the country, these news stories provided a wake-up call that tradition-bound health care institutions, until recently bastions of retrograde operational methods, (1) are on a collision course with high tech electronic medical record keeping systems (EMR). (2)

While the theoretical advantages of EMR systems have been heralded for many years, (3-7) it is clear that the reality of sensitive medical information surfing the information waves of cyberspace strikes fear in the hearts of patients and many of their health care providers as well. Gostin et al, (8) citing a 1993 Harris-Equifax poll on health information privacy, reveal how this anxiety has taken the form of deep distrust on the part of consumers, who in overwhelming numbers, "believed that (they) had lost all control over how personal information about them is circulated and used."

This article considers the potential advantages and disadvantages, as well as possible unintended consequences, of implementing electronic medical record systems in health care institutions. Special consideration will be given to the issues it raises concerning privacy, (9) confidentiality, (10) and quality of care from patient and provider perspectives. In the following discussion, I adopt Gostin et al's (8) distinctions of privacy as "the right of an individual to limit access by others to some aspect of the person;" confidentiality as "a form of informational privacy characterized by a special relationship, such as the physician-patient relationship," in which information shared is, by definition, privileged and not to be disclosed without the knowledge and consent of the patient: and security as "encompass(ing) a set of technical and administrative procedures designed to protect data systems against unwarranted disclosure, modification, or destruction and to safeguard the system itself."

Potential advantages of the electronic medical record

Consideration of the potential gains to be derived from computerizing the medical record should begin with the benefit of instantaneous availability of patients' medical history, treatment regimes, and health status in routine and emergency clinical situations. Ease of access to this information should reduce adverse outcomes, such as missed diagnoses, unnecessary repetition of dangerous procedures, unintended drug interactions, or use of contraindicated treatments. The added value of a complete and up-to-date medical record immediately available to medical caregivers seems undeniable.

Additional benefits of a "real time," centralized, paperless record include reducing the need for costly reproductions of laboratory findings and diagnostic reports (e.g., radiological studies, EKGs, etc.) which in many health care facilities are still typed, copied, and physically carried to a hospital floor, clinic office, or medical records room to be placed in the patient's chart. Loss of reports or delays of hours and, in some cases, days, are common until this information reaches the chart and the providers who must integrate it into a meaningful mosaic in order to implement appropriate care.

Next, imagine taking these potential benefits of the EMR a step further by adding sophisticated hardware to the mix. At the bedside, the doctor or nurse swings a wall-mounted compact keyboard and color monitor system out and calls up the results of recent studies, orders daily treatments and medications by touching pre-formatted fields on a screen, and in one quick and integrated process, writes progress notes while clinical findings are fresh in mind. What once required multiple steps of pulling the chart (if it could be found), searching for missing or misfiled data, transcribing orders, filling out multiple lab, diagnostic test, and pharmacy requisitions, or writing progress notes hours after having actually examined the patient are now all completed immediately and routed to their appropriate destinations with far fewer errors of transcription, loss of information, or patient misidentification.

Charting completed and orders dispatched, when the doctor wants to explain something to the patient and family, he or she simply touches an interactive icon on the monitor screen to switch to multimedia mode, where videotapes of operative and treatment procedures or a "replay" of the patient's actual diagnostic test done earlier in the day can be displayed as the physician instructs and informs.

From the perspective of care providers, in the highly specialized, fragmented, and geographically dispersed world of medical care in this country, the capacity to have immediate access to data concerning their patient's current illnesses and treatments from anywhere in the world would be enhanced by interacting with an electronic medical record system network. The ability to share information among the multiple providers often involved in the care of patients would also be facilitated. Improved coordination and communication between patients' care providers and between providers and patients, could allow less redundancy in history taking, diagnostic interventions, and potentially dangerous treatments.

With electronic record keeping systems, data can be collected to facilitate care coordination, quality assurance activities, assess practice patterns and treatment outcomes, and conduct medical research. From the patient's point of view, this should help to produce higher quality care. Adapting parts of these health care databases for direct access by patients through their personal computers could allow them to make better informed decisions about their treatment options and may serve to encourage them to take a more active role in illness prevention and health maintenance.

Other potential advantages of EMR include: Integrating clinical decision support systems to reduce the use of more expensive or less effective procedures and treatments by prompting clinicians about alternative options when they enter orders in the system (e.g., equally effective, but less costly antibiotic choices); preventing the phenomenon of clinical cascade," where clinicians can be informed that they are ordering screening tests or treatments related to medical conditions that are likely to have an extremely low-prevalence in their patients; avoiding adverse outcomes by monitoring care and alerting providers to contraindicated treatments; and improving the ability to defend in malpractice suits due to more complete and legible records of the treatments actually provided.

Moving to the "back office" operation of the hospital or ambulatory care center, with a fully integrated computerized record keeping system, local area networks linked to a central clinical information database could automatically monitor all entries of diagnostic and treatment procedures completed by providers and translate them instantly into appropriate charge codes while generating billing statements.

Using insurance data collected on admission, these real-time statements would correctly indicate covered services and self-pay responsibilities in an understandable fashion, while producing a document to be handed to patients the minute their hospitalization or outpatient visits are completed in the same manner Baron von Hilton readies your hotel bill just before check-out.

While the billing process is occurring, relevant information would be extracted and linked to an electronic claim form to be transmitted to the patient's insurance company for reimbursement. In the world of the fully integrated EMR, the hospital or clinic's billing and accounts receivable departments might no longer require more staff and space than most of their clinical units combined.

While as yet unproved, there is a strong likelihood that using a fully integrated electronic medical record as the informational matrix of a collaborative treatment approach would produce more cost-effective care through the efficient use of clinical, as well as administrative, staff and services. Whether such systems would measurably improve the quality of care delivered remains difficult to measure and prove scientifically, but this seems possible, particularly if the time saved is used to free providers to focus on more individualized patient care, rather than merely to "treat" greater numbers of patients and charts.

Potential disadvantages of EMR

At first glance, it may be difficult to distinguish EMR's disadvantages from those related to hard copy based systems of medical record keeping. In fact, it may be that many of the differences are more a matter of degree than of kind. As to matters of privacy and confidentiality, easy availability of sensitive material to large numbers of providers through the EMR system, compared to the apparently more limited circulation of a written medical record, may be something of an illusion.

The widely shared observation that in a hospital, "anyone wearing a white coat can read any patient record they can find and perform any procedure they wish without resistance from patient or staff," is part of medical folklore. The reality of "migratory" charts abandoned at the patient's bedside, on the nursing station coffee cart, or at the radiology reception desk does not inspire confidence about the security of paper records. In fact, while the EMR may allow access to the record by numerous providers from multiple locations, such systems can dutifully demand the use of several levels of "screens," such as personalized codes to unlock it, while recording the electronic "fingerprint" of the user to create audit trails of all persons entering the record. The same simply cannot be said about the security of a paper chart system that can be breached easily without any trace of who has accessed it.

While it is an apparent disadvantage that EMR systems make the health data of patients available to large numbers of providers, such systems can include a monitoring function that requires anyone other than the primary care provider to identify himself and to type in an explanation of why he has accessed the patient record. Obviously it is possible for secret codes to be "borrowed" or stolen, but perhaps the point to be made is not that EMR systems are inherently more vulnerable to unauthorized or inappropriate use than paper-based systems, but rather that the security of both depend greatly upon the ethical conduct of their users.

On the other hand, as described in the Boston Globe article ("Patients files allegedly used for obscene phone calls (11) the automated power of the EMR used by someone determined to abuse it proved to be a labor saving device that facilitated rifling through hundreds of records to locate the type of patients an alleged victimizer sought to contact. A spokesperson for the local chapter of the Coalition for Patient Rights summarized the problem succinctly when she said, "Unauthorized access to paper records was always feasible, but the computer takes a small problem and magnifies it enormously."

Another important disadvantage of EMR involves the enormous capital investment for computer hardware, the design of the complex software programs necessary to integrate and implement such systems: and the expense of the intensive data entry required from multiple sites, (e.g., laboratories, diagnostic facilities, and ambulatory treatment centers) as well as system maintenance. These costs may prove prohibitive for some health care delivery systems.

The impact of EMR at the integrated delivery system level

It is at the integrated delivery system level that the potentially problematic effects of EMR diverge more clearly from traditional paper record systems. Beyond altruistic concerns physicians may have about the confidentiality of their patients' records, we begin to find less selfless worries emerging about the impact of EMR systems upon physicians ability to practice without excessive electronic scrutiny. (12)

Extending the analysis on the impact of computer-mediated work to the organizational level, new possibilities for greater monitoring, supervision, and control of medical care then already exist may result from implementing EMR systems. These systems have the capacity to collect vast amounts of clinical data and link them to cost and performance-related measurements of individual providers, such as length of stay, use of expensive procedures or medications, and adverse outcomes. Whether one views such developments as positive or negative may be a function of one's position in the health care system "food chain."

More optimistic observers would argue that the ability to analyze the costs and outcomes of standard medical practices and treatments that have never been subjected to systematic study could lead to improved quality of care at lower costs and could lessen the need to ration the amount of care that can be afforded. EMR systems offer the possibility of quickly comparing the variation in the quality and costs of care produced by physicians within a health care organization or between competing provider organizations and relating these measures to clinical efficacy.

For pessimists. such systems will be able to "detect" procedures and treatments that apparently "add no value" in narrowly defined terms of cost or discover errors in delivery of care that could increase legal liability or become the basis upon which third party payers reduce or refuse reimbursements. demand deeper discounts, shorten lengths of stay (if this is still possible). and, on a darker note, exclude certain providers, group practices, or facilities from their networks.

Additional caveats about the creation of the enormous databases associated with EMR systems seem similar to the privacy concerns that have emerged in the insurance and consumer credit rating industries. In a famous example of broad public outcry to the diversion of huge databases to other uses, Lotus Development Corporation had to forego plans to market a compact disk product targeted to small businesses containing information about 80 million U.S. households. (13) What outraged some 30,000 consumers who protested the release of Lotus Marketplace: Households[R] was the invasion of personal privacy they felt upon learning that information they had given to banks, mortgage companies, or retail merchandisers in order to obtain consumer credit was being put to other uses without their consent. Beyond privacy concerns, many consumers felt that property" belonging to them, such as their financial, purchasing, and life-style histories, was being sold for profit without their expressed permission, any mechanisms for sharing the proceeds. or simply opting out.

What the health care world should draw from the Lotus Marketplace case is that, as a rule, patients, and for that matter, their physicians, may know little about the uses that may be made of patient level and clinical performance data. As if to confirm their worst fears, a recent report (14) described the refusal of some insurance companies to sell disability, life, and health insurance to patients whose electronic medical records revealed that they were currently or had been in psychotherapy in the previous five years. The disinclination to sell health insurance in these cases seems particularly ironic, as the article cited studies confirming that patients who receive psychotherapy use fewer medical services. The somewhat chilling general conclusion must be that implementing powerful EMR databases will allow insurers to extract, analyze, and distribute vast amounts of highly sensitive data on the millions of "insured lives" under their control at relatively little added cost.

EMR and issues of patient care and confidentiality

Gostin et a (18) make several critical points about the present state of legal protection of privacy and confidentiality of health information in this country. First, they correctly point out that in the world of electronic records, "location has less meaning... (and) protecting privacy requires attaching protection to the health record itself, rather than to the institution that generates it." Currently, patients' privacy and confidentiality are protected by a hodgepodge of conflicting federal and state constitutional law, federal and state statutes, and state common law.

Traditionally, medical care has been conducted and documented under the concept of the protective cover of privileged communication. Medico-legally, this has meant that information shared by the patient with care providers has been considered confidential. Release of information to third parties (such as insurance providers, employers, other health care providers, and institutions) occurs only with the expressed consent of the patient. While most states acknowledge the common law confidentiality concept of privileged communication as related to health care professionals, in many states, the legal responsibility of physicians to keep patient communications confidential does not apply to other health care providers, medical researchers, or health care institutions.

The idea of using powerful EMR systems is now central to the delivery strategies in immense "integrated health care systems growing rapidly in many parts of the country. (15, 16) The sheer magnitude of many recent medical care system mergers and the complex privacy and confidentiality, as well as quality of care, issues raised by such enormous combines should give pause to even the most fearless advocates of system integration.

While the potential benefits from the availability of real time information concerning patients' medical status, integration of care, and the ability to link aggregated clinical, financial, and outcomes data would seem to be compelling, there will be significant problems in translating these strengths into the delivery of health care, without the risk of compromising patient confidentiality and health care provider workplace privacy.

Simply put, the recent outcry in Boston underscores the fact that patients want to know who will have access to their health care data. Similarly, if their health care providers aren't already, they will soon begin demanding to know what EMR-derived performance measures they will be subjected to and to what uses this information will be put by their employers and third party payers.

Conclusion

While it is beyond the scope of this article to consider the complicated legal issues of privacy and security of health information systems that someday will be linked by powerful computers in national and worldwide electronic medical record networks, several questions have been raised concerning who will have access to individual patient's computerized records, as well as to the aggregated health data of large populations of patients and their providers. It is hoped that these preliminary considerations of the potential advantages and disadvantages of EMRs will serve to stimulate dialogue among health care consumers and their caregivers about the complex issues raised by implementing electronic medical record systems.

References

(1.) Lathrop, J. P., Restructuring health care: the patient focused paradigm. San Francisco, CA: Jossey-Bass, 1993.

(2.) Work Group on Computerization of Patient Records. "Toward a National Health Information Infrastructure," U.S. Department of Health arid Human Services. April, 1993.

(3.) Barnett, G. O., The application of computer-based medical record system in ambulatory practice, New England Journal of Medicine, 1643-50, 1984.

(4.) Vegoda, P. R., Dyro, J. F., Implementation of an advanced clinical and administrative hospital information system, International Journal of Clinical Monitoring and Computing, 3:259-68, 1986.

(5.) Gabrieli, E. R., Electronic healthcare records: A Discourse, Journal of Clinical Computing, 18: 130-143, 5&6, 1990.

(6.) Committee on Improving the Patient Record, Institute of Medicine. "The computer-based patient record: an essential technology for health care." Washington, D.C., National Academy Press, 1991.

(7.) Hudson T, Computerized patient records goal of new group, Hospitals, 65:48-52, 1991.

(8.) Gostin, L.O., Turek-Brezina, J., Powers, M., Kozloff, R., Faden, R., Steinauer, D. D., Privacy and security of personal information in a new health care system, JAMA, 270: 2487-2493, November 24, 1993.

(9.) Robinson, E. N., The computerized patient record: privacy and security, editorial in, MD Computing. 11(2):69-73, Mar-Apr, 1994.

(10.) Safran C, Rind D, Citroen M. Bakker AR, Slack WV, Bleich HL, Protection of confidentiality in the computer-based record, MD Computing. 12(3): 187-192, 1995.

(11.) "Patients files allegedly used for obscene phone calls," Boston Globe, April 11, 1995.

(12.) Piller C, Special report on electronic privacy: workplace and consumer privacy under siege, pp. 2-14, Mac World, July, 1993.

(13.) "Lotus Marketplace: Households," Harvard Business School Case 9-392-026, revised Nov. 28, 1994, copyright 1991 by the President and Fellows of Harvard College.

(14.) "Insurers spurn anyone in therapy," Boston Globe, April 3, 1995.

(15.) Scherrer, J.R., The integrated real-time hospital information system. World Hospital, 19(4):8-l1.

(16.) Bakker, A.R., The development of an integrated and co-operative hospital information system, Medical Informatics, 9:135-42, 1984.

* Boston Globe articles: February 22, 1995, March 1, 1995 and April 11, 1995.

Daniel C. Silverman MD, MPA, is Vice President, Clinical Effectiveness at BIG Health System in St. Louis, Missouri. He can be reached by calling 314/286-2025, via fax at 314/286-2050, or via email at dcs1614@bjcmail.carenet.org.

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