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Between You, The Doctor, And The PC


Dr. David Bower, chief of staff at the Atlanta Veterans Administration Medical Center, got a call at home one night about an elderly man in intensive care. The patient had shortness of breath, and the medical resident on site wanted help with a diagnosis. Without returning to the hospital, as might once have been required, Bower went to his home computer, logged on to the hospital's intranet, and looked at the man's chest X-ray. His verdict: pulmonary edema, a potentially fatal buildup of fluid in the lungs. The patient was given a diuretic, and his condition improved.

Such stories are becoming more frequent as hospitals and physicians shift from paper to computerized health records. Right now, no more than 15% of U.S. hospitals and doctors use such systems, according to Dr. David Bates, chief of internal medicine at Brigham & Women's Hospital in Boston and an expert on electronic records in patient care. But with the government and health-care leaders pushing for expansion, Bates predicts 70% to 80% of all hospitals and 50% to 60% of physicians will be onboard in five years.

More than 500 groups answered a call from the government for suggestions on how to create a national health information network by 2014, a goal of President Bush. One of those responding by the Jan. 18 deadline was a consortium of 13 prominent health and information technology groups organized by the Markle Foundation in New York. It suggested linking medical networks via the Internet and called for the creation of an entity to devise standards and policies for this new medical Net.

HOW PRIVATE?

A move to electronic records could make a patient's medical files accessible anywhere in the world. Proponents point to reduced costs and increased patient safety. Meanwhile, privacy advocates raise questions about security. Of major concern is that there not be a central, national repository of patient information, but rather a network of records maintained by individual providers and health systems. "I don't think a national database would fly in this country," says Beth Givens, director of the Privacy Rights Clearinghouse, a nonprofit that focuses on such issues. She says such a system would be vulnerable to insider abuse and could become a target for hackers.

The VA system for which Bower works is a leader in information technology, with its doctors ordering drugs, laboratory tests, and X-rays by computer and typing their notes into terminals at nurses' stations and in physician offices. VA facilities have access to each other's information, but their system does not provide access to records in private hospitals.

Meanwhile, at Brigham & Women's, nurses carry mini laptops as they visit patients to dispense pills. They take along handheld bar-code scanners, similar to the devices used at department stores. With the laptop, they can look up what drugs the patient is to receive, then run the scanner over bar codes printed on the medication packages and the patient's wristband to make sure they match up.

For patients, the new technology means their medical information can move almost instantly over an Internet or intranet system to doctors, nurses, or other health-care workers. No more lugging X-rays or charts from one office to the next as you visit a specialist or switch physicians. It could also spell an end to some of the endless questionnaires filled out before initial doctor visits. Doctors will no longer have to go to the hospital or their office to examine latest lab results or X-rays while the patient waits for treatment. And there are no paper files to get lost under a stack of other records.

LEGIBLE AT LAST

The arguments in favor of electronic records are persuasive. Serious medication errors fell 55% when orders were typed into a computer rather than handwritten by doctors, Bates reported in a 1998 issue of the Journal of the American Medical Assn., as problems reading the handwriting and confusion over available dosages were eliminated.

Computers can also cut costs by alerting a physician ordering a test that it has already been done. Software can suggest less expensive drug options and flag interactions and allergies. By preventing errors, it can eliminate costs related to remedial treatment or even death. Dr. David Brailer, who worked at a medical technology think-tank before being named the government's new health information technology coordinator in May, estimates potential savings at $140 billion a year.

Patients concerned about privacy will need to ask their doctor if sensitive material such as psychiatric records is available in their electronic record and what safeguards exist to limit access. Also, what access do insurers and other nonmedical entities have? Be aware that patients have a right under federal law to know who has read their file. If you're worried, ask if you can opt out of the system or have some information excluded. Also, ask if your information will be shared with other medical entities without your authorization.

Supporters of electronic records argue there is actually more security -- given the passwords and audit trails -- with electronic records than with paper charts. But they admit the potential to invade a large number of files is greater.

Privacy advocates will be watching as the industry grapples with such issues. And it remains to be seen how fast small doctors' offices will spend the $10,000 to $30,000 to shift to electronic records. But sooner or later, expect to see a bar-code scanner at your wrist or a computer coughing up your medical files.

By Carol Marie Cropper


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