PHR data overload, legal liability concern docs
Like a recurring dream about having to take a test they didnâ€™t study for, some physicians view the idea of patients with electronic personal-health records as their own personal nightmare.
Visions of patients handing over a computer disk containing yearsâ€™ worth of blood-pressure readings taken every four hours along with random recollections of rashes and muscle strains that physicians are required to somehow make sense of and memorize are followed by thoughts of being sued because there was a kernel of important information missed in the deluge.
â€œThatâ€™s why folks like me are terrified of personal health records and what patients will bring to us,â€? internist Michael Zaroukian said earlier this year during a panel discussion at the Integrating the Healthcare Enterprise Connectathon, an event that brings electronic medical-record vendors together to solve interoperability problems (and sponsored by the Healthcare Information and Management Systems Society, the Radiological Society of North America and the American College of Cardiology).
While Zaroukian, who is chief medical information officer at Michigan State University, is now backing away from the word â€œterrified,â€? he still maintains â€œthere are certainly lots of reasons to be concerned.â€?
The reasons for concern that Zaroukian cites include: the accuracy, completeness, usefulness and volume of the records physicians receive from patients; the hours of uncompensated work it will take to slog through them; and the potential for a misdiagnosis if something important was overlooked.
â€œIn some ways, itâ€™s simply an electronic extrapolation of what weâ€™ve seen in the paper world,â€? Zaroukian says. â€œThe greater the volume, the more likely it is that relevant data will be lost.â€?
Zaroukian certainly isnâ€™t the only physician who feels this way.
â€œHe has every reason to be frightened by that, and I donâ€™t see what he is describing as an improvement over someone bringing in an entire paper chart,â€? says Joseph Heyman, a gynecologist and an American Medical Association trustee. â€œI donâ€™t blame a physician for worrying about that. I think the beauty of a personal health record is if itâ€™s a snapshot of a patient and their most important demographicsâ€”like their current condition, allergies and medicationsâ€”thatâ€™s entirely different from their entire medical history for their entire life.â€?
Peter Basch, medical director for e-health at MedStar Health in Washington, says â€œphysicians love a (hospital) discharge summaryâ€? that gives one to two pages of key points. What they may get from a PHR, however, could be something that has no resemblance to a discharge summary at all.
â€œElectronic records make it easier to share more information and images, so often what could be included on one page is now included on 10 and 12 pages,â€? says Basch, an internist who serves on the medical informatics subcommittee of the American College of Physicians.
He says, though imperfect, a quick two- to three-minute oral history taken during an office visit can be more helpful than an extensive PHR.
â€œItâ€™s like saying to a patient: â€˜Tell me about the rash,â€™ â€? Basch says. â€œDonâ€™t give me a seven-hour history of every rash youâ€™ve had in your life.â€?
Zaroukian says that while things like patient-recorded blood-pressure readings can be useful, the value is not in each particular entry, but in the average and the range of high and low readings.
He says diabetic patients often give him diaries of insulin doses and pre-breakfast blood-sugar levels recorded in meticulously arranged rows and columns, butâ€”despite their neat appearanceâ€”the numbers are not distilled into a useable format.
â€œYou have to skip between rows and try to average the numbers somehow, but itâ€™s impossible,â€? Zaroukian says. â€œThe data is so poorly organized that it not only does not improve quality, it could contribute to making a bad decision.â€?
Nevertheless, he says that PHRs could be an important tool in developing a partnership with patients, so he â€œgently forcesâ€? them to use the spreadsheetsâ€”either paper or electronicâ€”that he has developed.
â€œOver time, patients see how their own self-management can be improved, so over time they become more interested in doing so,â€? Zaroukian says. He adds that the key is to make it easy to record the information in a usable format so the patient-maintained record is not â€œjust a few jewels of data floating in a sea of debris.â€?
Organization and quality of the data are paramount to making the PHRs useful, says Heyman, who has a solo practice in Amesbury, Mass.
â€œI think at the AMA, we believe there can be great value to PHRs and they can save physicians and patients a great deal of time, while helping to avoid medication errors and duplicate laboratory tests,â€? he says. â€œBut there is a risk of â€˜garbage in, garbage out,â€™ and if the record is populated by the patient, there are errors of understanding that can be inputted by the patient.â€?
Basch says itâ€™s not the PHR alone that will create savings or improvements in care or efficiency, but it could be the tool that helps a motivated patient achieve those results. In fact, all the information included in the popular physician-provided PHR iHealthRecord from Medem, a San Francisco company founded by the AMA and several other medical societies, is entered by the patient (although if patients choose they can have data automatically flow into their PHR as it is entered in their physicianâ€™s EMR system).
â€œSome patients will rise to the occasion, and some wonâ€™t,â€? he says. â€œBut for patients with diabetes, hypertension or congestive heart failure, daily or weekly recordings of blood pressure and weight could result in useful information that could stem chronic conditions from going bad and save a lot of ER visits.â€?
And, for these patients with chronic conditions, Basch cites key barriers to primary-care physician involvement in helping develop and maintain a patientâ€™s PHR: a lack of reimbursement for coordination of care among specialists; uncertainty over the legal responsibilities of helping a patient maintain a PHR; and knowing what the record contains.
â€œWith personal health records, one of the issues is the core problem of financing healthcare where information management and discussions with patients are poorly reimbursable in the context of an office visit,â€? he says. â€œThose are currently seen as an uncompensated burden on physicians.â€?
Making sense of complicated and unorganized records can require four to five hours of workâ€”whether the records are on paper or in an electronic formatâ€”Basch says, but this is accepted in most sectors because â€œthereâ€™s an unwritten rule that a primary-care physicianâ€™s time is not relevant and that information management isnâ€™t really work.â€?
â€œThereâ€™s no payer who will say: â€˜Sure, Iâ€™ll pay you for your timeâ€™; theyâ€™ll say â€˜Too bad, learn how to do it in 60 seconds,â€™ â€? Basch says.
Steven Waldren, director of the American Academy of Family Physiciansâ€™ Center for Health Information Technology, says PHRs havenâ€™t caught the attention of most doctors yet. But for the relatively small portion of physicians who have implemented electronic records, PHRs are known entities and these doctorsâ€™ main concern is on workflow.
Establishing PHR data standardsâ€”what information to include and in what formatâ€”will be important to solving workflow and data-management problems, Waldren says, adding that itâ€™s time for physicians to get familiar with PHRs.
â€œPHRs are here and will continue to be,â€? Waldren says. â€œIf the healthcare consumer empowerment trend continues to move in the direction itâ€™s moving, weâ€™ll continue to see growth in the tools available for patients.â€?
Waldren mentions healthcare decision-support applications as one of the tools patients are going to be using soon, and this prediction is already coming true. Earlier this month, Verizon Communications announced it was offering PHRs to 900,000 of its employees, retirees and their family members, and the system would include alerts that would inform users when their care â€œmay not be consistent with evidence-based medicine.â€?