Think back to the last time you planned a business trip or family vacation. You called up your favorite travel agent, and after a few minutes on hold, scheduled an appointment to meet with him in his office across town. When your appointment day arrived, you spent a few minutes describing the vacation you'd like to plan, and he pulled out stacks of dusty paper catalogs, one for each airline, destination city, and activity you described. Several of the catalogs were a few years out of date, but you didn't want to be rude by mentioning it. Together you spent a good hour on the telephone dialing numbers out of your agent’s Rolodex, making reservations, and jotting confirmation numbers down on your legal pad. You pulled out your checkbook several times, writing individual checks to each airline and hotel, and left with several pages of handwritten notes documenting the itinerary and transactions. Over the next week, your paper airplane tickets and handwritten confirmation of your accommodations all arrived in the mail, some containing errors you had to call your travel agent’s assistant to correct. When you arrived at the airport, you presented your paper tickets to the airline’s agent, who looked you up in the fat stack of printed reservations for that day, and matched yours to the handwritten list of flight numbers on the large whiteboard behind her. As you boarded the aircraft, you were comforted to see how carefully the pilot and copilot were planning the route with their protractor and the Thomas Guide.
Is this not exactly how you plan your travel? Would you continue to give your business to that travel agent or fly that airline? Despite the enormous technological and intellectual sophistication that is the modern practice of medicine, information continues to be recorded, stored, and communicated in largely paper-based systems that should be the embarrassment of any major industry. The reasons for medicine’s long laggard status in information technology are complex. However, in recent years the imperative to move health information in to the digital age has gained the national spotlight.
Electronic Health Records
Beginning in 2004, three consecutive State of the Union addresses included a line naming an electronic health record for all Americans as a national goal. The administration established the Office of the National Coordinator for Health Information Technology to promote the adoption of modern information systems in health care nationwide, with particular emphasis on the ability of health care providers to share information electronically. The policy is motivated by the belief that replacing paper health records with electronic records will make health care delivery better, safer, and less-expensive, as digital record-keeping and communication has in other industries.
One historic reason for the underuse of information technology in health care has been that the market for clinical software was dominated by niche vendors with limited money and personnel to invest in software development, at least relative to the major computer and software companies. The last few years have seen dramatic changes in this situation, with several of the largest brand name software companies making forays into health information technology. To help make the choice of software easier, software companies have partnered with national health care organizations and the Department of Health and Human Services to create certifying criteria for clinical software. The Certifying Commission for Health Information Technology (CCHIT ) uses a consensus process to create a set of voluntary, annually updated criteria that software companies can choose to have their products tested against in the hopes of receiving the CCHIT seal of approval.
For clinicians, clinics, and hospitals, the hardest part of implementing an electronic health record is not choosing or installing the right software, it is adapting the way work gets done to the new tools. Many software systems have been installed only to be used incompletely or not at all, because of either an under-appreciation of how difficult it is to adapt clinical work without interruption, or because the necessary expertise was not obtained. For large hospitals and networks of clinics, it is feasible to directly hire clinicians with a background in information technology and information technology professionals with experience in health care to jointly lead a successful clinical software rollout. For smaller practices, consultants can be hired on an as-needed basis, although the expense can still be substantial. The considerable investments in software and specialized expertise required for a small hospital or small practice to implement an electronic health record continues to be one of the most important barriers to wider adoption of modern information systems, and whether this instead should be funded regionally or nationally is a topic of ongoing debate.
For patients, the benefit of doctors or hospitals using an electronic health record is in knowing that your important health information will be available whenever it is needed. Although having a doctor seated at a computer while talking about a your health history might feel awkward or intrusive, studies have shown patients view this positively as long as the physician is skilled at focusing their attention on the patient, and avoiding letting the computer interfere with the quality of the conversation. A shared computer screen in the exam room or at the hospital bedside can facilitate the patient and the physician looking at information together, which can help patients understand their health status, and make sure the information maintained by the clinician is correct.
Communication Among Electronic Health Records
Imagine if the local branch of your bank was the only place your financial information was stored, on paper, and it was the only place you could go to obtain cash or make a deposit. This approximates the current state of the interoperability of health records. Presently, if someone becomes suddenly ill or is injured and is brought to the nearest emergency room, very likely no information will be available to the doctors and nurses beyond what that ill person and their family can provide, even though the patient's primary physician’s office might be just down the street.
As electronic health records become more widely used, the opportunity to share electronic records between health systems increases. Although such sharing raises important questions for the security and privacy of health information, well-established regulations exist. A number of large national healthcare provider networks do have integrated national health records for their members, but even these leading systems are closed to any provider outside that system. The current national policy approach to this challenge is Regional Health Information Organizations, or RHIOs, which are locally operated voluntary information exchanges among cooperating health systems. Although there have been a number of promising initiatives, there have also been a number of significant and disappointing failures, and the extent to which RHIOs will be a viable solution remains to be seen.
The most progressive electronic health records have a “patient portal” feature, allowing patients to connect to their health records just like they connect online to their bank or the airlines. After much controversy surrounding the possible risks of having patients reading medical jargon they may not fully understand, the accumulating experience suggests the benefits outweigh the drawbacks. Patients have a greater opportunity to be informed partners in their health management, and to update or correct information that may be out of date, such as medications they no longer take or old health problems that have resolved. Patients also have the opportunity to view and book appointments online, request medication refills electronically, and read medical references assembled for them by their health care providers.
Personal Health Records
Despite substantial progress in electronic health records, health information remains an anomaly among vital personal information, in that it continues to be maintained and controlled by an outside party rather than the person themselves. No homeowner would imagine not having a copy of the title to their home or the registration for their car in their possession, yet personal health information is seldom in the possession of the person to whom it is most important. The reasons are largely historical rather than conspiratorial – the medical record began as physicians’ personal notes about the care of his or her patients, as reminders to themselves for when they next saw the patient. In a time of country doctors, small community hospitals, and there being not much that medicine could offer in any event, it made sense. With patients now seeing a multitude of primary care providers and specialists, traveling widely, and with medicine now enormously powerful and complex, the model of health information being maintained by clinicians and institutions is being questioned.
Personal Health Records, or PHRs, have existed in some form for decades, but the last few years have seen a sharp increase in interest and availability. PHRs are available that live on a USB flash drive and can be carried on one’s person, or that can be burned onto a CD or DVD, or that exist on secure Internet servers and can be accessed like a web page. The principal challenge is the willingness of health care providers to adopt and collaboratively maintain these records, and whether health care providers will find them satisfactory for their own purposes. If in effect multiple records need to be maintained – a PHR controlled by the patient and separate paper or electronic records by the providers of care – the completeness and accuracy of the information may not necessarily improve. Several initiatives are trying to solve this by establishing electronic communication links between the PHR and the other sources of electronic information, but remain in development.
Electronic Prescribing and Clinical Decision Support
Although it has been many years since the major airlines routinely issued paper airplane tickets, the majority of prescriptions in the United States are still handwritten on slips of paper. Unlike air travel, where the airline that you chose flights from is the same entity from which you purchase the ticket and that provides you the travel, the doctor who writes your prescription usually has no relationship to the pharmacy that will actually fill it. Prescriptions therefore must be communicated using a technology that is the lowest common denominator between physicians and pharmacies, and this usually means paper.
Physicians’ bad handwriting is a running joke, but is a real and important problem and a source of well-documented dangerous mistakes in filling prescription medications. Furthermore, regardless of good handwriting, a paper prescription has no connection to the rest of the information known about a patient, including other medications they may be taking or drugs they are allergic to. Although physicians check for both of these problems when writing a prescription, mistakes are easily made, and often the information available to the physician is incomplete.
The best solution would be electronic medical record systems that can truly communicate with one another, so that all necessary information would be available at all times. The physician could write prescriptions in this electronic system, have the prescription automatically checked against the patient's allergies and for interactions with other medications, and have this new prescription electronically available to any pharmacy the patient might choose to fill it. This ideal electronic prescribing situation remains a long way off. In the interim, there is a competitive marketplace for intermediary systems that can receive prescription information from a variety of electronic medical records, maintain an internal list of the patient's medications and allergies, and communicate this to pharmacies that subscribe to the service.
Computerized Provider Order Entry and Clinical Decision Support
The benefits of electronic prescribing in the hospital setting may be even greater. In hospitals, the physician is mostly an indirect provider of the actual physical care of a patient. Although the physician is responsible for diagnosis, the treatment plan, and directing the care, that direction mostly consists of writing out instructions, referred to as “orders”, for the various nurses, respiratory therapists, physical therapists, and other professionals who provide most of the direct care of the patient. Historically the orders have been written in hand on paper, and in the complex hospital environment with sometimes very sick patients, the risks of unsystematic handwriting are magnified. Software systems that allow physicians to write the orders electronically, known as “computerized provider order entry” or CPOE, have the potential to eliminate handwriting errors, speed communication among the various providers of care, integrate with other electronic systems that assure the accuracy of medication dispensing and delivery, and provide physicians with complex decision support to help assure the highest quality care. Over the last 10 years, a great deal of national attention has focused on promoting adoption of computerized provider order entry systems. Several large health care delivery systems have had considerable success, and there have been a few spectacular failures. However, implementing a CPOE system is a major challenge, both from a technology standpoint and in the re-engineering of the work processes of the hospital. Entering orders into a computer is usually more time-consuming than scrawling a few words on a piece of paper. However, the efficiency can be increased by the careful use of predefined sets of orders and excellent user interface design.
Once physicians are writing orders electronically, the opportunity exists to provide “clinical decision support”, a term that simply means helping the physician do the right thing under the circumstances and avoid mistakes. Checking to make sure a patient is not allergic to a medicine or that it does not have dangerous interactions with other medications is easy to computerize. More advanced systems can provide physicians with the most current guidelines for the patient's situation, or update the physician with recent advances in the field applicable to that medication. By integrating with insurance systems and with public agencies that pay for healthcare, the computer can help the physician choose medications that would be more affordable to the patient or that are covered by the health plan, eliminating paperwork and potential saving the patient money.
Another key challenge is “alert fatigue”, a phenomenon first well-described in the F4 Phantom fighter aircraft. When the number of lights, alarms, and buzzers providing information or warnings of a dangerous situation becomes more than the pilot – or the physician – can take in at once, the brain starts tuning them out. Furthermore, if the warning systems are overly sensitive, providing unnecessary alerts under routine circumstances, the physician learns by experience to ignore them. Alert fatigue already exists in hospitals in the case of the warning alarms that constantly ring from heart monitoring systems, where in order to avoid missing any dangerous abnormality, the system rings for every bit of electrical interference or when the patient rolls over in bed. Over time, less attention is paid to the alarms altogether. Finding the appropriate balance in a CPOE system between providing physicians with the right kind of information and warnings when they are needed, without numbing them to alerts altogether, remains an open problem.
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Nonetheless, the benefits of CPOE are considered so promising that policy makers, such as the California state legislature and the influential Leapfrog Group (a coalition of healthcare purchasers) have sought to make it universal. Software companies compete heavily to make CPOE systems easier and safer to use, and less expensive to install and maintain. The recent market entry of a number of large multinational software publishers has increased investment in this fast-moving area.
Diagnostic Decision Aids
One of the earliest historical applications of computer technology to medicine was actually the hardest and most ambitious – diagnosing disease using a computer. The human skill of collecting and integrating information about a patient's health and arriving at a diagnosis requires many years of training and experience, along with continuing study and practice. However, computers can store vast amounts of information, access it very rapidly, and perform calculations far faster than any human, making it easy to imagine software that either replicates the process by which human physicians perform diagnostic reasoning, or substitutes it with a computational process that could produce similar or even superior results. In the 1970s and early 1980s, researchers invested effort on a variety of computational approaches, some of which showed impressive results under specific clinical circumstances, even given the relatively primitive computer technology of the era. However, a true "Doc in the Box" proved elusive. Furthermore, because computers were not any part of the process of health care at the time, these "expert systems" stood alone outside the flow of clinicians’ work and were rarely used.
In recent years, interest in diagnostic decision aids has begun to pick up. Continuing advances in computer processing speed, new advanced statistical techniques for analyzing large amounts of information, and the explosion of information available on the Internet has opened new avenues for development. As an interesting experiment, try entering a list of symptoms and physical findings into the search box of your favorite web search engine. Although the results won’t be a reliable diagnostic advisory system, the statistical association of words describing a patient's symptoms and physical findings with those same words appearing in online medical references can produce startling results. The ISABEL Healthcare diagnostic reminder system takes a more direct approach, limiting its knowledge base to established medical references, adding in some curated medical expertise, and applying natural language processing techniques.
Regardless of the technological advances, computerized diagnostic decision aids are likely to remain poorly utilized as long as they remain outside the process of care. In order to be used consistently, diagnostic decision aids need to be implemented within the electronic health record both to gain direct access to the relevant patient information, and so that the advice can be delivered in the time and context in which it is needed.
Patients, Clinicians, and Email
While e-mail has become the dominant form of communication in many aspects of life and business, it remains relatively rare for physicians and patients to correspond over e-mail about health issues. This is partly for good reason. A physician’s assessment of a patient's health often requires their physical presence, so that the physician may formally examine the patient but also look for more subtle cues to the patient's physical and mental health. The subjects a physician and patient discuss are often complex, emotionally challenging, and of a nature not well-suited to e-mail and best discussed in person. However, many routine administrative matters, such as simple prescription refills, appointment scheduling, and billing questions could easily be resolved over e-mail, and e-mail is underutilized for these purposes. Furthermore, it is possible to effectively ask and answer some questions about health over email, particularly when in follow-up to a more complete conversation that has happened previously, supported by online references the patient can access.
Perhaps the most significant barrier to greater use of e-mail communications in medicine is time. The complex patchwork of health care financing in the United States generally requires physicians in clinic settings to see as many patients as possible in a given amount of time, and no time is set aside for also responding thoughtfully to clinical e-mails. Unlike other professions, such as the law, time spent by physicians responding to e-mails generally cannot be billed to insurance or otherwise compensated, making e-mail a financial drain on most physicians who might like to use it in their practice.
If a clinician and patient are going to use e-mail to correspond, they both must pay careful attention to the security and privacy of their e-mail communications. Most electronic traffic over the Internet is not well secured and is easily intercepted by a malicious third-party. The default settings on most home wireless network equipment is even less secure, with the traffic being broadcast over the air and trivial to intercept. Patients should only send e-mail to their clinicians if they are confident their home network is appropriately secure, and the e-mail service they are using provides secure and encrypted communication. For clinicians, the security and privacy rules of the Health Insurance Portability and Accountability Act (HIPAA) create a legal obligation to ensure the privacy and security of a patient's protected health information, including in the form of incidental e-mails. Although the clinician may not be responsible for the security and privacy of an e-mail in transit when sent by a patient, the physician is responsible for the secure storage of that e-mail as soon as they have received it. HIPAA does not provide for any mechanism of “consent” to insecure e-mail communication with patients, and there is no means for the patient to diminish the physician's responsibility.
Some hospitals or clinics use an electronic health record systems that offers a patient portal. If so, the patient and clinician can correspond entirely within that system, which both assures the privacy of their communication and also keeps it a part of the medical record. For hospitals and clinics not using an electronic health record, several commercial services are available that provide secure and private end-to-end e-mail communication specifically for healthcare settings.
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