Op-Ed: Patients first. Doctors second.

Arun As part of the recently enacted stimulus bill the federal government is spending $19 billion to promote the adoption of electronic medical records by physicians.  Yet, with all the focus on doctors, lawmakers have forgotten the most critical piece of the puzzle — patients.

Take the case of Joe (not his real name), a patient who came to see one of us recently. Joe is a thirty-something year-old with type 1 diabetes. After a rebellious few decades that included dozens of hospitalizations, he was finally re-engaged in his care. His most recent request — to access his electronic medical record. Joe wanted to track his hemoglobin A1c, an important marker of his diabetes, follow his blood pressure and take a closer look at his cholesterol. After all, it is his information in the clinic's commercially available electronic medical record.  Sadly, his request couldn't be honored. Patient-access features simply hadn't been built in.

Health information technology offers great promise to patients. Patients can access their medical information online, communicate with doctors by email, schedule appointments through the web and take advantage of numerous tools to manage their own illnesses. They can become equal partners in their care.

But without further intervention from policy makers, many of these tools will remain unavailable to patients. Doctors may adopt electronic health records, but those health records will be just as inaccessible to patients as today.

This doesn't mean that doctor-controlled electronic medical records won't make a difference. In the background, doctors may have access to tools that may help them make better decisions, be better positioned to measure their performance, and be able to identify patients who need a little extra help.

But focusing on doctors does mean that patients will miss out on a powerful way to improve their own health. Research shows that prevention and behavioral modification influence disease rates and costs on a scale that few biomedical advances can match. Stopping smoking, losing weight and making better daily decisions in caring for chronic illness are better than any pill a doctor can prescribe.

Although the evidence to a support patient-centered approach to health information technology is still emerging, some early evidence has been positive. Our colleagues at Harvard Medical School found that reminding patients to undergo colorectal cancer screening was more effective than reminding their physicians about the same test. And at Kaiser Permanente more than  25% of members now use their personal health record, Health Connect, according to a recent study in the journal Health Affairs. The site allows patients to view parts of their medical records, send clinical information to online tools, schedule appointments, request prescription refills, email their doctors, ask questions of pharmacists, and access tailored programs for behavior changes such as smoking cessation and weight management. The result of Kaiser's efforts is that office visits are down 26% and patients are more satisfied.

So why shouldn't any effort to expand health information technology be focused on accomplishing these goals? Why shouldn't we demand a system that gives patients equal access to all the data, equal rights in the decision making process, and the decision support to make good use of it? Wouldn't that be preferred by patients, save money, and make us healthier?

From where we stand, building a patient-centered health care system is the real promise of health information technology and activating patients is where the real return on investment will come from. That means instead of giving doctors billions to adopt records they don't want, we might be better off encouraging doctors to adopt just the parts of the record that will be useful to patients — problem lists, labs, medications and imaging results. It also means that perhaps some of those billions ought to be directed at helping patients adopt technology they clearly want.

Empowering patients should be the first step in transforming American healthcare. The central question that policy makers should be asking is if we are missing something by leaving patients out of the current discussion. From our perspective we're missing an important opportunity to engage patients, set a new standard for personal responsibility, and provide with them with the tools to make better decisions. Perhaps more importantly, a provider-centered approach to health information technology reflects an antiquated model of medical care where full responsibility for a patient's health is placed on providers. For patients like Joe this is simply not enough.

Gordon Moore, MD, is a Professor in the Department of Ambulatory Care
and Prevention at Harvard Medical School. He is formerly the Medical
Director and Chief Operating Officer of Harvard Community Health and
Board Member at BUPA, the largest private health insurance company in
the United Kingdom. Arun Mohan, MD, MBA, is a
Clinical Fellow in Medicine at Harvard Medical School and Resident
Physician at Cambridge Health Alliance. He is also a Co-Founder of
PictureRx, which is developing online tools to simplify medication

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13 replies »

  1. Hopefully with all the focus on doctors this will eventually have some postive effect on patients i would of thought ?. I currently work in IT for the health care, and IT is a major part of the running of a hospital. Without IT, the hospital will come to a standstill. We recently experienced a virus attack on our computer network which brought the entire hospital to a stand still costs $100,000 of lost revenue because our computer systems were down. So i think spending more money into IT is very well deserved in my view.

  2. What a great piece! I think that patients need to step up and direct their healthcare much more closely — including their health information. Patient-controlled health info accounts like Microsoft HealthVault (the one I use) help edge us closer to the day when we are more fully in control of our own well-being.

  3. Thank you for the comments.
    In response to R Watkins we used the Kaiser experience to illustrate that a patient-centered approach to health information technology can improve the efficiency of care delivery while enhancing patient satisfaction.
    In many ways our thinking is aligned with the recently released report from the Markle Foundation regarding what constitutes meaningful use. It states, “Meaningful use should initially rely on standard information types, such as recent medications and laboratory results, that are electronic and already widely adopted and that can support metrics to improve medication management and coordination of care.”
    This doesn’t mean that we create two tiers of patients. Instead, it means that we gain an opportunity to engage patients in their care. And patient engagement is where the real cost savings in healthcare will come from.

  4. It is interesting to come across this today, as I was writing something yesterday about how hospitals should make decisions by focusing on how the outcome would impact 1) Patients 2) Doctors 3) The Hospital. I think healthcare providers would make better decisions if we kept that hierarchy in mind. We have to be willing to give the patient control of his or her own health.
    To John Ballard, Ix stands for Information Therapy, which is “Prescribing Information”. You can read more about this at http://www.ixcenter.org. This OpEd is more an example of Health 2.0, where patients use technology to be more involved in their own care, either by interacting with their providers (as discussed above), by interacting with other patients (patientslikeme.com), or by seeking out information on the internet (wikipedia).

  5. Is this what is meant by Ix?
    I’ve come across this (yet another) acronym/abbreviation a few places in a similar context.
    If this isn’t Ix, then what is?
    Sorry for the ignorance. Thanks for your help.

  6. I don’t have health insurance right now, but prescription costs have become increasingly difficult to manage. I started saving by switching to generic drugs by using Medtipster.
    Medtipster allows you to type in your drug name, dosage and zip code to search for and locate prescription drugs that are available on discount generic programs across the United States; many of which are available for as little as $4. Prescriptions that are not available on a discounted program often have therapeutic alternatives on a discounted generic program, which are also available on Medtipster.com

  7. Absolutely! As we all become more connected through the Internet, transparency and honesty are going to be a lot more apparent. Good shall prevail! We have to start taking care of each other. At least that should be the American way…

  8. 25% of Kaiser patients access their PHRs and visits are down 26%? Cause and effect is implied, so that would mean patients who access their PHRs now make NO office visits. Strange numbers.
    And what are we doing for the 75% who choose not to access their PHRs? Do they become second-class patients in the new model of health care?

  9. Emily,
    If we do it right, we can increase primary physician compensation by $25,000 to $50,000 per year without tapping into the government till or taking compensation away from other care providers!

  10. Excellent commentary! As a patient that likes being knowledgeable about my own care, I can say that I would like some of these advances targeted more at patient involvement.
    There is an unmet demand for this. People, in general, are very interested in their own health. Look at the popularity of an Oprah show with Dr. Oz that focuses on health. People are also getting more connected and comfortable with technology. If many people can bank online than we surely could handle some medical tasks online too.
    Because technology can help people connect to a great deal of information quickly, it’s not going away. My website focuses on helping people find more information (price, alternatives, etc.) about their prescriptions on a local level, (see http://emilysproject.com) and I am betting with the way the system is changing, patients are going to be looking for more technology to help them work through it.
    However, one of the big barriers to the adoption of the technology you mention could be the way in which doctors are compensated. I haven’t heard much about restructuring the way we pay doctors and medical professionals to compensate for the time involved in some of these technology scenarios. However, if we restructured physician payments to reflect these efforts, I’ll bet this would help make the change more popular.
    This doctor at Better Health describes his positive experiences with shaking up the traditional practice with technology. Sounds good to me.

  11. Amen!
    Thanks for your eloquent argument advocating consumer-focused healthcare and healthcare IT!
    There is no question in my mind that the consumer/patient should be center stage in their care and healthcare IT — from having access to their aggregated personal health records, to ensuring they are accurate, to controlling who may see and/or use them, to monitoring their progress towards wellness and disease management goals, to deciding which treatments to undergo, etc.
    The fact is we can accomplish this now — simply, cheaply, using proven technology, without requiring subsidies, and without forcing care providers to change the way they keep their patient charts!
    Not only would patents benefit, but so would their physicians, their families and their employers!

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