In enacting the Health Information Technology for Eco- nomic and ... cial discharge information from their physician counter- ... By allowing users to associate in.
COMMENTARY
HITECH, Electronic Health Records, and Facebook: A Health Information Trifecta In enacting the Health Information Technology for Economic and Clinical Health (HITECH) Act, the Obama administration has devoted unparalleled resources to incentivize “the adoption and meaningful use of health information technology.” One important reason for this revolutionary legislation is the notion that information technology can improve health safety, quality, and efficiency. The vehicle of this transformation, electronic health record systems, promises a singular, standardized and universally accessible source of information, enabling data sharing across entities vested in patient care. Electronic health records facilitate abstraction of large quantities of information for research or quality improvement, modernize billing processes, and impact patient care by both reducing complications during hospitalization and lowering readmission rates. They also can serve important roles in the monitoring, measuring, and reporting of quality, safety, and efficiency.1-3 Despite these tangible benefits, perhaps the strongest support for the HITECH Act comes from the burgeoning health care information-exchange crisis. To state it bluntly, physicians simply communicate poorly. For example, many primary care physicians fail to receive crucial discharge information from their physician counterparts in the hospital. Patients thus frequently fail to understand medication changes or follow-up plans, lack insight as to when or whom to call for help, and do not have access to vital data after discharge as a result of poor information relay.4 Even perilous (and preventable) events such as hospital readmissions or medical errors have been associated with a lack of/poor physician communication.5 In ratifying HITECH, we pin our hopes on technology to streamline these deficits, promote transparency, and homogenize the quality of our documentation. Is this a sensible decision? Paradoxically, technology may widen the chasm of health information exchange. For instance, almost all major electronic Funding: None. Conflict of Interest: Dr. Chopra is supported by a Clinical and Translational Science Award from the Michigan Institute for Clinical and Health Research. Dr. McMahon reports no conflicts of interest. Authorship: Both authors attest that they had access to the data and contributed to writing this manuscript.
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record systems restrict access to providers at a site or health system, insulating accredited caregivers while isolating outsiders. Every electronic health record also employs proprietary technology, alienating providers operating on different platforms despite their common connection to patients. Electronic systems remain provider-oriented and arguably exclude the most important stakeholder, the patient, from data-sharing. Finally, no uniform standard exists to ensure that all electronic health record systems—irrespective of vendor, hospital size, provider, or location— have the ability to share information with each other. In sum, we may stand precariously poised on the edge of an electronic catastrophe. Is there a way to transform the noble intent of HITECH into a reality that avoids these pitfalls? One revolutionary approach is to take the focus off electronic health records and instead, consider shifting the responsibility of health care communication from providers to patients. The online networking giant, Facebook, provides a conceptual outline for precisely such a schema. For example, Facebook enables each user to generate a personalized, unique lattice of contacts dependent on when and with whom they connect. By allowing users to associate in this fashion, information is shared across geographic and demographic boundaries with ease and transparency. In contrast, medical information sharing remains a provider, not patientcentered, activity. Consequently, should a physician fail to transmit information or a patient remains unable to access their health information in times of need, harm may result. We thus argue that if HITECH is to attain its stated goal of improved information sharing, two fundamental changes are necessary: electronic health records must become patient rather than provider controlled, and they must be universally accessible to both patients and providers. How could such an online, patientcontrolled, provider-enabled collaborative be structured? An online information-sharing network would comprise several key components (Figure). First, a “cloud-based” central data repository is necessary to receive and securely store patient information. Second, control of health information must be placed into patients’ hands. As with Facebook, a patient (not a provider), would create an online “health page,” inviting/ permitting all involved in their care (providers, family, friends) to post to their page. Third, hospitals and data sources such as laboratories must feed data directly to a patient page for all to share and implement. Finally, a “smart filtering” system must
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Figure A conceptual schema showing flow of information in a patient-controlled, provider enabled model. Data enters from multiple sources (left) into a “cloud-based” data repository where it is centrally stored and archived. User defined filters identify data tags and priority levels to send specific alerts to patients, providers or family members (middle). All elements of an electronic health record are included in the model and shared equitably among stakeholders (right).
direct messages to appropriate individuals to prevent information overload. This architecture has several advantages. First, as principals of their online health hub, patients may invest greater effort into their health agenda. For example, a patient could find answers to common discharge perils such as what medications they should take, what symptoms to watch for, and who to contact in the event of an emergency through the physician and pharmacy data on their page. Second, any provider granted access by a patient could post clinical notes or answers to patient queries to their page, bypassing the “silo-mentality” of electronic health systems while enhancing the physical provider/patient relationship. Finally, this structure facilitates family members’ participation in patient care (irrespective of geographic or demographic constraints), simply by monitoring their page, adding a layer of additional security that does not exist today. An online collaborative also can expand in novel ways. For example, by incorporating biometric data, the heartfailure patient could post daily weights through digital scales to their health page, creating biologic “virtual windows” through which providers could identify worrisome trends or prespecify action plans (“take double the diuretic if your weight goes over X”). Patients could thus intervene in timely fashion on potentially dangerous conditions. A patient also may elect to share their health information with others, creating mutual engagement for diseases that are common, chronic, and otherwise isolating. An online partnership where experiences become a rich source of infor-
mation could mirror peer-support models, an emerging model to improve chronic care.6 The technology for this prototype currently exists: it must simply be utilized in a novel paradigm. Despite the theoretical appeal of this schema, numerous questions remain before this model can move towards implementation. First, would patients fear the responsibility of controlling their health data? Can patient-directed information sharing actually improve clinical outcomes? Who will pay for the creation and maintenance of this infrastructure? Would physicians resist opportunities for online communication? These unique issues call for a research enterprise dedicated to this agenda. Second, health policymakers must consider that the virtual, online care of patients is a valuable, cost-saving proposition; compensation and incentive structures must therefore be realigned to encourage providers to engage in this activity. Lastly, how should such systems be designed to facilitate use across a spectrum of disease and patient states? How can computers, cell phones, text messages, or automated calling systems be leveraged to reach those that are most likely to benefit but least likely to participate in this activity? These are but a few of the questions that must be considered before moving towards this model. The Institute for Medicine called for safe, effective, patient-centered, timely, and efficient health care. Although HITECH is an important step towards reaching this goal, our current deployment of electronic health records may not lend itself to attaining a health information nirvana. Em-
Chopra and McMahon
Commentary
powering patients through online networking adds new dimensions to the patient/provider relationship that could reduce cost, increase transparency, and improve clinical outcomes. It may be time to learn from Facebook.
ACKNOWLEDGMENTS The authors would like to gratefully acknowledge the efforts of Drs. Heisler and Flanders in the editing of this manuscript. Vineet Chopra, MD, FACP, FHM Laurence F. McMahon, Jr., MD, MPH Department of Internal Medicine Division of General Internal Medicine University of Michigan Health System Ann Arbor
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References 1. Blumenthal D. Launching HITECH. N Engl J Med. 2010;362:382385. 2. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009; 360:1418-1428. 3. Cook PP, Rizzo S, Gooch M, et al. Sustained reduction in antimicrobial use and decrease in methicillin-resistant Staphylococcus aureus and Clostridium difficile infections following implementation of an electronic medical record at a tertiary-care teaching hospital. J Antimicrob Chemother. 2011;66:205-209. 4. Bodenheimer T. Coordinating care—a perilous journey through the health care system. N Engl J Med. 2008;358:1064-1071. 5. Jha AK, Orav EJ, Epstein AM. Public reporting of discharge planning and rates of readmissions. N Engl J Med. 2009;361:26372645. 6. Heisler M, Vijan S, Makki F, Piette JD. Diabetes control with reciprocal peer support versus nurse care management: a randomized trial. Ann Intern Med. 2010;153:507-515.
