Will Electronic Records Really Improve Health Care?

March 10, 2009— -- The movement toward electronic medical records is supposed to guarantee, among other things, a more secure means of storing medical data. But it doesn't always work that way, as Steve Brozak discovered in 2006.

Back then, a stolen laptop was initially believed to have exposed the personal medical record of Brozak, a former Marine, along with the medical records of many of his fellow veterans.

As the move is made to electronic medical records -- acknowledging a push by the Obama administration as part of the recent stimulus package -- a number of issues are being raised.

"In principle, this sounds pretty good, but in practice, how is it going to work?" said Brozak.

In the end, it was concluded that the medical records on the government laptop were likely never accessed. But the experience served as a warning to Brozak and others about the possibilities the electronic age brings to medical records when the wrong person gains access.

Now comes a new study from Kaiser Permanente, a nonprofit health insurer, which implemented an electronic medical records program in Hawaii in 2004. Its findings are published in the most recent issue of Health Affairs.

The study, say the authors, highlights the importance of finding new ways to deliver health care in addition to new ways of storing the information from medical practice.

Catherine Chen, the manager of national clinical systems planning and consulting for Kaiser Permanente, said that the move to electronic health records came in part because of a demand for contact with physicians in ways other than visiting the office each time they needed something from their doctor.

"We have to start thinking about different financial incentives to allow for those different modes of care," said Chen, the study's lead author.

"If you look at the financial incentives... it's really up to the private insurers to decide whether they want to reimburse for e-mailing their providers."

As for the patients, Chen noted that they seemed slightly happier with the electronic system, even with reduced doctor face time but an increase in phone calls and secure e-mails with their doctor.

"They feel like they have a better relationship with their providers because of it," she said.

While the Kaiser study of its system in Hawaii gave some reassurances about patient satisfaction, cost remained a concern and the authors of the study said it was outside their scope. They also noted that unlike most physicians, who receive fee-for-service payments, Kaiser's physicians are paid a set salary.

Skeptics have questioned the cost savings that electronic medical records are said to bring. While many have expressed that it makes intuitive sense, Dr. Caroline Lubick Goldzweig, associate chief of staff for clinical informatics at the Veterans Affairs Greater Los Angeles Healthcare System, and her colleagues expressed skepticism in a late January article in Health Affairs.

In the article, she said a lack of meaningful cost-benefit analysis "makes creating the business case for health IT adoption a challenge, and costs still remain the number-one barrier cited by all surveys assessing adoption."

Security Matters

For patients, though, the main concern about electronic medical records is their privacy -- certainly a worry that could keep many people up at night. But some say that these patients may be relieved to hear that a larger system will be more secure than what we have now.

"The reality is, of course, today, many of our records are already digitized," said M. Eric Johnson, director of the Glassmeyer/McNamee Center for Digital Strategies at Dartmouth's Tuck School of Business.

"The U.S. health-care system is made up of a ton of unsophisticated players," he said, noting that current digitized records are held in a variety of small laboratories and clinics.

"I would much rather have Google or Microsoft or someone else doing that rather than my doctor's office in Hanover, N.H.," said Johnson. "I think the reality is those companies are in the business of IT and security, and they're much better than my local doctor."

When he speaks about potential problems in a piecemeal health records system, he isn't speaking hypothetically.

Last week, Johnson released a paper in which he said he and his fellow researchers were able to uncover a number of medical records and other files with medical information online, using file-sharing services generally associated with song-swapping, like LimeWire and Kazaa.

Because the networks operated by pulling information from shared folders from other users, someone who is not taking the proper precautions could expose files on the hard drive by downloading and running a peer-to-peer file-sharing program.

So, simply having a doctor whose secretary's son likes getting free music online might cost you your medical privacy under the current system.

"It's a symptom of a fragmented system without a universal, enterprise technology in place," said Johnson.

Lee Tien, the senior staff attorney with the Electronic Frontier Foundation, expressed a bit more skepticism about potential problems with centralized electronic health records. For one thing, he noted, Microsoft and Google are not currently covered by the Health Insurance Portability and Accountability Act (HIPAA), which regulates privacy of patient records.

"It's more convenient," he said of a centralized health records system, "but it also can lead to rapid disclosure of information that people might not want disclosed."

He said that having one large database of health information can have what he called the Fort Knox effect, where a single vault of information becomes more attractive to hackers.

"It's not easy to say this is definitely going to be more secure or not," said Tien. "How many people are you trusting, and with how much information?"

A Concern for Some Is Others' Peace Of Mind

While some might be concerned with their medical records' security, others find the portability might give them peace of mind.

Sameer Samat, the director of product management for Google Health, noted in the company's blog last week that a few years ago, he found himself in the emergency room for his father and had no idea what medications his father took. Though he gave this as his personal reason for wanting a way to grant adult caregivers access to their parents' medical records, Google is not the first to offer this service.

In Kaiser's records, adults caring for their parents may be granted access to medical records for parents in the same manner that parents are granted access to medical records for their minor children.

Doctors who have used Kaiser's system, such as Dr. Peggy Latare, chief of the family medicine department at Kaiser Permanente in Hawaii, noted other benefits.

"You can set a system up to alert you if someone hasn't had a mammogram in a while," said Latare. "One of the receptionists here in my clinic was going to have elective surgery and her surgeon noticed that she was due for a mammogram, because the system alerted him that she was due."

The woman underwent a mammogram and, as it turned out, she actually had an early stage of breast cancer. Latare said the test caught it early so the cancer was fairly simple to treat.

"The surgeon probably wouldn't have gone through the chart to find that out," she said. "In her case, it probably saved her from having been diagnosed as a higher stage of breast cancer."

The new records do take some getting used to, however, noted Latare.

"One of the things that was hard to get used to was how much information that you had at your fingertips," she said.

On one hand, Latare said it cleared up the constant problem of a foggy memory: Was that surgery last year, or two years before? Did my child get the latest immunizations or was that the ones before?

"A lot of times people forget," she said. "You'll say, 'when was your last pap smear?' and they'll say it was last year, but you look it up and it was three years ago."

Yet on the other hand, Latare and her colleagues said they sometimes felt their heads swirling in the deluge of information.

"That's the thing that you have to learn -- you could spend an hour going through every single patient's chart. It's about learning how much information you should review. It's learning how to filter and keep organized."

Latare said the learning curve goes beyond reading electronic medical records and into how doctors do their job. For the first time on the job, Latare found herself spending a significant amount of time typing.

"For some doctors change is not easy. It's stressful. They're used to being efficient in a certain way," she said. "It takes a couple months for them to get back to their previous productivity levels."

All in all, Latare said the change was worth it. She said things are less likely to be lost and not only is the information all at her fingertips, she can show her patients charts of their progress over time.

"We would never, ever want to go back to paper," she said.