The future role of the Internet in Healthcare, PHR

Final Assignment for UCDMD Ext. course: The Internet and the Future of Patient Care (102MHI214)

Subject: "Critique on the Future of Health on the Internet"

By: Larry Silver, MD

12/4/2010

The Internet and its role in Personal Health Records

I have found during this course that four elements have emerged as the primary future roles for the Internet in modern healthcare.   These include: Use of Personal Health Records (PHR), Individual Research by the patient using the Internet as the modality, Doctor-Patient relationships using the internet as an interface and finally Internet based Data Mining to be used for Public Health purposes. For this critique, I will focus only on Personal Health Records.

PHR's have a promising future in healthcare.  They are already gaining widespread adoption in certain environments.  For Example, Kaiser Permanente[i] has now developed a PHR that is Internet accessible to their clientele. The Centers for Medicare and Medicaid have adopted the Blue Button[ii] which is essentially a PHR for the Medicare population.

In addition, multiple sites are now available on the Web for PHR's that are maintained by the consumer or a paid service. These types of interfaces serve to improve the patient care in many potential venues.

PHR's have a variety of potential uses. These include the following categories: Personal Health Record, health and wellness, administrative roles (like health plans and services), medication, pharmacy and physician interfaces such as email or a  "physician locator".

A typical PHR interface might look like this:

This has revolutionized the patient's access to their own record. Historically, the medical record was the property of the physician's office  or the hospital. Patient access was limited and required a formal signed request. Often only the relevant portion was made accessible to the patient. This served to highly restrict the patient's access to their own information. It was recorded as a paper medical record format (PMR) and thus typically uninterpretable by the patient. The result was a total lack of information transfer.

Why has this occurred? Why were charts not used as a vehicle to give patients' their healthcare information directly?  Was it a turf issue?  Was it a legal issue? [iii]

The answers are of a historical basis. The medical record originated over 100 years ago and functioned as a simple method for physicians to store the data they had just gathered[iv]. The structure typically included Historical Record, Physical Findings, Laboratory results, etc. It served as a Legal Record as well. It was not designed to be a communication tool for the patient's use. As the decades transpired the PMR became more sophisticated. Physicians learned to convey enormous information quickly and effectively using structure, established standards and multiple types of abbreviations.

This format is essentially foreign to non-medical personnel and therefore easily misinterpreted. A typical operative report might look something like this:

I think it is obvious that this is almost a "foreign language" to most non-medical personnel. Patients could not be expected to understand their own medical record. The concept of creating a second PMR for patient use was not even considered.  However, with the evolution of the electronic medical record or EMR everything has now changed.

The PHR is derived from the EMR data base[v]. It is made accessible via the Internet to the patient population. This represents a fundamental shift towards using the Internet for patient care.  It is actually a selective, narrow portion of the entire EMR. Some elements are omitted while others are condensed to make it a consumer friendly database[vi]. The key quality is that it is derived directly from the robust EMR.  The physician reports, labs and other patient visit information all carry over into the PHR.  The challenge has been deciding what information to restrict and what methodology to employ for this process.

The PHR now allows direct and secure transfer of patient health information to the consumer via the Internet.  This increases the level of patient education. For example, the patient can learn about their disease using a  "Health Encyclopedia". This engages the patient and potentially leads to a better partnership with their personal healthcare provider.

The role of the PHR in future healthcare models is unclear. It stands to reason that involving  patients in their own care is bound to be beneficial.  It could potentially reduce patient care visits, reinforce medical therapy and improve communication. It is also targeted to be developed in a more universal format.[vii]

[i] (KP.org)

[ii] https://www.mymedicare.gov/

[iii]  HIPAA (1996) Template:Cite U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services 42 CFR Parts 412, 413, 422 et al. Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Final Rule

[iv] Shortliffe, E.,   Cimino, J.  (2008). Biomedical Informatics, Computer Applications in Health Care and Biomedicine (3rd ed.)   2: 46-64

[v] "Computerization of personal health records". (1978)  Health visitor 51 (6): 227.

[vi] AHIMA Body of Knowledge. (2005) : The Role of the Personal Health Record in the EHR.

[vii] Morgenthaler, J. (2010)  Smart Publications. Moving toward an Open Standard Universal Health Record

http://www.smart-publications.com/articles/view/moving-toward-an-open-standard-universal-health-record/

---

Can "Second Life" play a role in the traditional Doctor-Patient relationship?

The potential medical applications of Second Life represent  a new and intriguing concept. Traditionally, this software had been used for purely entertainment purposes.  The idea of a virtual second existence was indeed a huge success as it had attracted a multitude of visitors from all over the world.   Individuals could live a different reality at their convenience. Thus allowing them potentially to be someone they always dreamed of or experience things we are unable to normally. This originally "entertainment" based software is now expanding into much broader applications.

The medical field is now embracing this virtual technology for educational, diagnostic, and developmental purposes. A classic example would be the virtual hospital developed by Cisco for Palomar. Even better yet is the creation of a virtual clinic for diagnostic purposes related to sexually transmitted diseases or STD's.The beauty lies in that this subject is often quite taboo and not openly discussed! Frequently patients avoid going to their doctors due to the fear of embarrassment   However, via Second Life now an individual can discreetly visit this site and learn about STD's. A patient can privately see visual displays of STD patterns and appearances.  This once taboo subject now has an interface that allows delivery of diagnostic aids into the comfort and privacy of one's own home.   The idea is that now individuals have the ability to assess themselves.  They can potentially identify their need for further evaluation with a medical doctor. The individual might pursue it with a better sense of confidence and a potential diagnosis in hand.  In addition, this particular STD site could be used as a parent teenager or school environment teaching aid.

The future role of Virtual Reality and simulator based software has potentially a multitude of applications in medicine.  Distance learning, procedure simulations, disease diagnosis and treatment protocol simulations are just a few ideas.

Medicare Fraud

The headlines read;

""I.T. and data mining capabilities had a role in dismantaling what authorities are calling the largest Medicare fraud scheme ever, involving 73 memebrs of organized crime and more than $163 million in fraudulent billing"".

So the acused are a group of Armenin-American organized crime (AKA mafia!) members.  They submitted fraudlent bills to medicare for treatments never performed. The defendants stole the identity of thousands of doctors and beneficiares in 25 states using 118 phony clinics!

They got caught because of todays IT capabilities! Pretty cool.   ""The DOJ has  created the IOC-2  crime center in an effort to combat international crime'' said acting Dept Atty. Gen. Gary Grinder. An undisclosed Information Technology played the critical role. Essentially the HEAT intiative of 2009 developed by HHS Secretary Kathleen Sebelius is the basis for this advancement.   this program uses IT that does in a few days what used to take months!

The EHR implementation and the US health care system

Welcome to my HIT blog. 

My primary purpose is to share my experiences and perspectives from a clinicians point of view during a rapidly changing world of Health Care and Information Technology.

As a result of the recent Federal Government incentives and dis-incentives, I think the EMR is going to finally begin to take shape in the U.S. health care system.  This change will not be a simple one.  In fact, I think it will be far more complex here in this country as opposed to elsewheere.  This is due to the fact that we are not a uniform centralized government controlled health care system (AKA national health care).  In reality, we are a vastly diverse, private based, often for profit, multi level system with 3rd party payors.  In addition, there are large independent systems such as Kaiser and there are government run systems like the Veterans Adminstraion.

In countries where it is centralized it is easy to mandate a single approach to EMR implementation and HIT structures.  In our country we will need to work with all the parties.  In fact, we will need to win over the hearts and minds of both the Clinician and the Patient.  Our patients will soon play an even greater role in their own care as they are able to gain easy access to their records, contact their physicians etc.

A true metric for success in this arena is the integration of HIT into health care in a way that clearly benefits the involved parties.  In other words, the Physician actually improves health care delivery, by being more efficient and thorough.  The patient benefits by being far more actively involved in their own care, and thus playing a preventive role as they gain access to their own EHR.  The EHR should not just be a "techy" tool for the 21st century but actually transform how we practice medicine and therefore improving care overall.

History has shown that these tools of technology  can be beneficial or counterproductive depending on their application and the limits on their use.  Cell phones are now a fabulous avenue for personal communication, but they are also clearly demonstrated to be dangerous to use while driving. Or in the extreme example, the advent of the atomic bomb during the manhattan project showed the world that atomic energy is incredibly useful and yet equally dangerous!



As informaticists we are charged with the task of guiding the process of automation integration into healthcare while maintaining the uniquely "human element" that is so fundamental to health care.

I would love to hear you point of view!!