The first draft of “meaningful use” came out early yesterday, and I was struck by two things. First, probably influenced by the NCVHS recommendations and the Consumer Partnership for e-Health (See Update), the work-group included a lot of consumer-facing aspects in the concept of meaningful use. Here’s the full draft. Comments are being accepted now (but hurry as they’re going to come back with version two in a month, you have 9 days!).
But in terms of getting consumer activities into the 2011 definition the “Objectives” suggest that meaningful use includes:
Providing patients with electronic copy of or electronic access to clinical information (labs, medication list, allergies, medical “problem” list)
Providing access to patient specific educational sources
Jane mentions in her post our testimony before the Subcommittee on Privacy, Confidentiality and Security of the National Committee on Vital and Health Statistics (NCVHS) on the future of PHRs. Our panel, including me, Jane and Daniel Weitzner, the W3C Technology and Society Policy Director, opened the hearings on PHRs. Our role as the opening panel was to try to set the stage for the context of the discussion on the future of PHRs and consumer facing health care information technology.
As the opening speaker at the hearing I decided to stay away from immediately diving into the legal issues and instead give the committee a landscape view of where I think we are in the history of health information. My goal was to provide a historic framework for PHR development by drawing some historic parallels to the history of the development of our transportation system. By analogy I compared today’s PHRs to the Model T era of the automobile area and taking a page from Dave deBronkart told the committee my personal family e-health information story. Below is a complete copy of my written testimony submitted to the committee.
As the discussion continues on “meaningful use” the role that PHRs play is important. Focusing on health care consumers and their practical use of PHR tools is vital to the future of our health care system. As I said in my testimony there will be game changers but we need to see the potential of today’s Model T PHRs and build toward the Prius Hybrid PHRs of the future.
Prepared Statement for Subcommittee on Privacy, Confidentiality, and Security National Committee on Vital and Health Statistics (NCVHS)
Discussion on the Future of Personal Health Records
Good morning. I want to thank the Co-Chairs, Subcommittee and Committee Staff for the opportunity to participate in today’s discussion on the current state of the personal health record (PHR) and the future use of this and other health care technology tools by the health care industry and the health care consumer.
My name is Bob Coffield. I am a health care attorney from Charleston, West Virginia, with the law firm of Flaherty, Sensabaugh & Bonasso, PLLC. I have a broad-based health care practice, providing legal and business services to a variety of health care clients. A large portion of my practice focuses around health information issues, regulatory compliance, privacy, security, and health technology. Over the past five years, I have become involved in the social media movement, and that involvement has changed the way I live, work, collaborate and communicate. My involvement and interest in the social media movement and its impact on our lives has led me to focus a portion of my practice on legal concepts and issues generated by the use of social media tools and technologies in health care, law and other industries.
Introduction: Today’s PHR is the Model T
As the opening speaker, I want to set the stage for today’s discussion on the questions raised by the committee. As the committee examines the issues, I recommend that you look toward a longer horizon of 20 to 50 years. In this age of information and accelerating technology, it is often easier to predict what may happen in 50 years than what will happen next year. As information technology advances and new technologies are developed, it has become more difficult to conduct short-term strategic planning in the three to five-year range. Over the past 10 years of the maturing information era, we have seen incredible advances and significant disruption in all business, including health care.
At its center, the information age is characterized by the ability to create and transfer information and knowledge freely and to have instant access to knowledge that would have been impossible, difficult or too expensive to find in the past. Jane Sarasohn-Kahn and others today will provide the Committee with an understanding of the current health care consumer marketplace and the major motivators driving health care consumer empowerment in the information age, and also will provide a perspective on the current state of consumer engagement in health care. It is my belief that this changing era is having a profound impact on today’s health care industry. The strategies, systems, approaches and governing rules used today and by past generations may not be successful in today’s and tomorrow’s changing information era.
A part of today’s process should be to consider what the long-term goals are for health information technology, including the PHR, and how it can be used to drive consumer-focused and controlled health care in the information age. Along with this discussion, we have a responsibility to talk about why involvement of the consumer matters and what impact it will have on improving care, reducing costs and creating efficiencies in the health care system.
As we discuss health information technology and PHRs today, we have a responsibility to stay focused on this question: “What will improve the quality of care for you and me, as consumers of health care?” This single question needs to remain at the center of today’s discussion and the continuing debate on consumer health information technology. As the health care industry becomes more and more specialized, complex and technologically advanced, we often lose sight of the purpose of the health care system. That purpose is human care and compassion. You and I, as health care consumers, must remain at the center. My hope is that the future of our health care system will use technology, including PHRs, to improve the human experience and interaction between the professional caregiver and health care consumer.
The questions I often struggle with and hope to hear discussion on today are: How will PHRs drive consumer empowerment, and how will this consumer empowerment lead to improving care? We can all sit around and discuss the best ways to build PHRs, but the questions remain whether or not the health care consumer will be attracted to use PHRs and whether providers will be willing to incorporate PHRs into the treatment and care process.
As I said at the opening of my remarks, I want to set the stage for the discussion and testimony today by sharing a story and painting a historical perspective. As I looked over the agenda of those speaking today, I was struck by the level of experience and diverse backgrounds that each of us brings to the discussion. However, because of the level of specialization represented in this gathering, there is the risk of remaining deep in the weeds, dealing with details, and failing to step back and take a wider view of the landscape. The story and analogy I want to share with you is my attempt to take you on a tour of that broader view.
I am a believer in the adage that history repeats itself. What we are trying to do today is to provide you with a perspective and prediction of the role that the PHR will (should) play in the health information technology infrastructure over the next 10 years. So a historical sketch of where we have been and where we are is valuable to the discussion of where we may go.
I want to start the story with a quote from the 1800s, by inventor Oliver Evans, as he spoke about the future of the transportation system in the United States.
“The time will come when people will travel in stages moved by steam engines from one city to another, almost as fast as birds can fly, 15 or 20 miles an hour . . .
A carriage will start from Washington in the morning, the passengers will breakfast at Baltimore, dine at Philadelphia and supper in New York the same day . . . .
The 1800’s saw the dawn of the railroad system in the United States, as a result of the development of the steam engine. These developments led to the widespread use of trains as a mode of transportation for a growing population that, until that time, had been relatively immobile. The growth of the railroad system started at the local level, grew to regional connections and ultimately led to a national network of railroad tracks from east to west and from north to south. Prior to this time, personal travel required one to travel on foot, by horse or by carriage.
My ancestors, who grew up in the hills of northern West Virginia, came to West Virginia (then Virginia) in the late 1700’s. As we say in West Virginia, “they lived out on the ridge.” A number of generations went by, and there was little mobility of my family. They lived out their lives on those same ridges for well over 150 years. They raised their families and farmed. They lived a relatively isolated and stationary life. Traveling beyond a few miles was difficult, impractical and largely unnecessary, at least from their perspective of the world.
However, by 1900, the landscape had changed, and the Industrial Revolution was having a profound impact on the world. My great-grandfather and grandmother had two sons who were teens in the 1890s. In the 1890s, my great-uncle went to college, came back and taught school for a few years and then went on to law school. Likewise, my grandfather went to college, came home like his brother to teach school for a few years, and then continued on to medical school in Cincinnati, Ohio – at that time a long distance from the northern part of West Virginia. He came back and practiced medicine in Wetzel County, West Virginia, from 1911 until his death in 1936. He saw home patients initially by horseback, and then in 1915, he traveled to Pittsburgh, Pennsylvania by train to pick up a brand new Ford Model T, which replaced his horse in his rural medical practice.
As the rail system in the United States matured, it grew into a more complex mass transportation system. Individuals who, prior to that time, had used their own modes of transportation, whether on foot, by horse or carriage, started to rely upon the system for transportation. They became passengers who didn’t own the train or the rails. As the railroad system developed, we saw issues related to standards, such as the gauge of tracks. Local, state and federal government become involved in furthering the growth and expansion of the railroad system by providing financial support, political influence and regulatory assistance to the growing railroad industry.
At that stage in history, no one in the powerful railroad industry would have predicted the disruptive influence by a young, different type of engineer – Henry Ford. With the advent of the automobile and the mass production of the Model T in 1908, our transportation system in the United States was forever changed. Over the next 20 years, the adoption of automobile travel was unprecedented. This revolution led to a demand for better roadways and improvement of the largely privately built turnpike roads. The Federal Highway Act of 1921 authorized the Bureau of Public Roads to provide public funding to help state highway agencies construct paved systems of highways, and this led to the Federal-Aid Highway Act of 1956, which authorized the creation of the Interstate Highway System.
By analogy, we can compare the development of the transportation system to the development of today’s health information system and draw many comparisons and parallels. The health information system, up through the 1950’s and 1960’s, was paper-based, centrally located and uncomplicated. The medical record system for my grandfather’s practice – to the extent that it was used – was simple. Likewise, the medical record system and documentation used by my father and uncle during their medical careers, roughly 1940-2000, was relatively non-complex. During this time, there was little specialization: Physicians were generalists in everything. In large part, physicians from this era cared for their patients from birth to death and, in the case of my grandfather, father, and uncle, cared for multiple generations of families. Providers during that time had a relatively comprehensive picture of the medical history of each individual, as well as that individual’s immediate and collateral family members. Prior to specialization in health care, we had a health system focused on the individual patient, and health information was centered on that individual and the individual’s family.
By the 1970’s, we saw the development of the first electronic health record – the problem-oriented medical record (POMR), predecessor of today’s current Electronic Health Records (EHR) and Electronic Medical Records (EMR). At this same time, we saw the expansion of medical litigation, which has played a significant role in the health information system over the past 30 years.
Prior to 2000, little had been written or heard about PHRs. Back in 2001, in a report called Strategy for Building a National Health Information Infrastructure, the National Committee on Vital and Health Statistics mentions PHRs and the growing consumer use of Internet-based health information services. This was important because it was the first time that a national health body acknowledged or officially recognized PHRs. In 2005, the American Health Information Management Association (AHIMA) formed a work group to examine the role of PHRs in relation to EHRs, and the pace and interest in PHRs has continued to increase since that time.
Over the last year, interest and activity in the development and use of PHRs has accelerated. This new-found interest has now culminated in the first law directly regulating PHRs and PHR vendors, under the Health Information Technology for Economic and Clinical Health Act (HITECH), which is a part of the American Recovery and Reinvestment Act of 2009, signed into law on February 17, 2009.
How is the history of our transportation system analogous to our health information system? On a basic level, both provide transportation – one transported humans, and the other, human information. Both started as uncomplicated systems that were not interconnected. I imagine you are already formulating other parallel points between these two systems.
To begin today’s discussion on PHRs, we need to examine where PHRs fit in this historical perspective and timeline. What is the equivalent of the PHR in the history of our transportation system? Today’s PHR is the equivalent of the Ford Model T. The PHR will be the vehicle to individually transport health information in the future, introduce the involvement of consumers in their own health information and wellness and inspire a time of innovation and creativeness over the next five to 10 years. If the age of the PHR takes off, it will bring about a wholesale change in the way that health information technology is structured and will radically disrupt traditional health care industry models.
There are various other analogies to be drawn between the two historical perspectives. For example, do the trains and the rail system represent the traditional health care providers and payors in the industry who are maintaining data in silos and segregated systems? Can we draw comparisons between the powerful railroad industry versus the nascent auto industry and the current health care and insurance industry and the emerging Health 2.0 technology movement? Are the disagreements that occurred in the railroad industry over the gauge of railroad tracks analogous to the debate occurring over the need and process to develop standards for health information technology? Can we draw parallels between our country’s development of a national network of railroads through local, state, and federal initiatives to those ongoing efforts by state health information exchanges (HIEs), regional health information organizations (RHIOs) and the national health informational network (NHIN)? Will there be similarities between the freedom that consumers felt the first time they bought an automobile and drove it down the road and the feeling of empowerment experienced when a health care consumer adopts and uses a PHR? In the coming years, will the connecting of EHR and EMR systems and the development of the NHIN be relegated to being used to transfer bulk health data, not unlike the role that the railroad system plays today?
As we look toward the future of PHRs, we have to understand that we are now looking at the Model T stage of PHRs: Call it PHR 1.0. The PHRs of the past 10 years and, in large part, the PHRs of today, are still relatively rudimentary and impractical, not unlike the first automobiles. I suspect my grandfather’s experience of traveling to Pittsburgh by train, having never owned a car before, to pick up his new Ford Model T and drive it back into the hills of West Virginia, was not unlike Dave deBronkart’s experience when he set up his Google Health account and imported his own health information from his providers. Prior to their experiences, neither knew how to drive the vehicle, but they learned in the parking lot. Once they both bought into the product, they didn’t have any good roads to drive on, and when the vehicle broke down they had to fix it themselves. However, through their efforts the world began to change, and their lives were and will be forever changed.
Over the next five to 10 years, and probably longer, we may see PHRs become the multi-colored, sleek-designed, more powerful automobiles, analogous to the golden era of the automobile industry from 1940 to 1950. Continuously over that time period, new personal options will be developed as add-ons to the PHR. As PHR adoption grows, we will have to develop larger, longer and more robust highway systems to allow for the transfer of health data by and between PHRs. Likewise, new standards will come into existence, not unlike those adopted by industry or those created by government. Safety features also will be developed continuously to protect and secure the health information maintained, stored and transferred through PHRs. Think of these as the modern-day innovation, adoption and enforcement of traffic signals, the use of seat belts and requirement for guard rails.
As we look toward the future, we also have to be aware that there will be game changers that we can’t envision at this time. Although PHRs might now be the industry solution to change the way we aggregate and store health information, new technology may be invented that disrupts this strategy and approach. For example, consider the impact that air travel had on the automobile industry. We must remain open to change in this new information era – change will be the norm and not the exception.
Using PHRs to Transform the Health Care Industry
The efforts by large technology companies and other Health 2.0 technology companies could transform the health care industry by triggering advancements in health information technology and laying the groundwork for overall health care delivery and payment reform. Although it is too early to say whether the PHR, in fact, will be the catalyst for health care reform, the Committee, government and the larger health care industry and community need to understand and explore PHRs and their role and consider how the consumer-focused PHR revolution will impact the health industry.
A convergence of factors could cause a comprehensive shift in the way health information is stored and used. Innovations in health information management technology are altering the way that patients, health care providers and payers maintain, use, control, and disclose health information. Through such technology, the current, decentralized system of records maintained by multiple providers and entities at multiple locations – often with conflicting and duplicative information – is being transformed into a centralized record maintenance system that may rely on personal health information networks (PHIN), where the PHR serves as the central repository for health information shared through a system of developing regional or national health information exchanges. Vince Kuraitis of the e-CareManagement Blog calls this change a “transformation from Industrial Age medicine to Information Age health care.”
This transformation in the way information is maintained, stored, and exchanged empowers the health care consumer by offering a new level of control and responsibility over his or her care. It will directly impact the patient-provider relationship.
The traditional model for maintaining medical records, in which the provider of care stores, maintains, and updates the record, is based upon the need to provide continuity of care. The medical record reflects the plan of care, documents the care provided, and records communications among providers. Also, the medical record assists in protecting the legal rights and interests of both consumers and providers.
In the 21st century, our health care system simultaneously has become more fragmented and specialized, on one hand, and more coordinated and wellness-focused, on the other. Health care consumers have become mobile and now seek the services from a variety of providers engaging in numerous specialties. These same consumers change providers on a regular basis and take advantage of new models of care, like urgent care services, to complement traditional primary care services. The increasingly mobile population has caused breakdowns in continuity of care. As individuals move from city to city and state to state, they leave behind a trail of partial medical records – some on paper, some electronic – with various providers, insurers, and others.
The increasing popularity of EMRs, EHRs, RHIOs, and HIEs signals a need to address the increasing complexity of maintaining and sharing these different types and silos of health information. The PHR may be the disruptive technology that provides a simple alternative to ongoing efforts to create an interconnected network of interoperable health information systems with detailed querying functions, capable of making accessible in one place the health information and continuity of care record for individual consumers. In contrast, PHRs would travel with health care consumers and provide a central location for information regarding the consumers’ individualized needs.
Ownership of Health Information
The shift to a consumer-controlled PHR from a provider-based and controlled medical record raises traditional property law issues. As health information becomes increasingly networked and technology permits health information to be transferred more easily, the lines demarcating ownership of health information become further blurred.
Health information is often viewed under the traditional notion of property as a “bundle of rights,” including the right to use, dispose, and exclude others from using. This legal application of historic property law may not be well-suited to the information age, in which patient information is shared through a variety of formats, copied, duplicated, merged, and combined with other patient records into large scale databases of highly valuable information.
Who owns health information? The physician? The insurer? The health care consumer? Under the traditional theory, providers own the medical records they maintain, subject to the consumer’s rights of access in the information contained in the record. This tradition stems from the era of paper records, where physical control meant control and ownership. Provider ownership of the record is not absolute, however; HIPAA and most state laws provide consumers with some right to access and receive a copy of the record. Health care consumers have received other rights out of the bundle of property rights, including the right to request corrections to their medical information and the assurance that such records are maintained confidentially.
The PHR model, where all records are centrally located and maintained by the consumer, flips and realigns the current provider-based ownership model of managing health information. Instead of provider-based control, where the provider furnishes access to and/or copies of the record and is required to seek patient authorization to release medical information, the PHR model puts the health care consumer in control of his or her medical and health information.
 Vince Kuraitis, E-CareManagement Blog, Birth Announcement: the Personal Health Information Network, March 8, 2008, http://e-caremanagement.com/birth-announcement-the-personal-health-information-network-phin/.
 Alcantara, Oscar L. and Waller, Adelle, Ownership of Health Information in the Information Age, originally published in Journal of the AHIMA, March 30, 1998; http://www.goldbergkohn.com/news-publications-57.html.
Bob Coffield is a health care lawyer who writes the Health Care Law Blog, where this post first appeared.
Healogica was one of the companies that presented at Launch! at the Health 2.0 Meets Ix conference in Boston in April. I felt that the quality of the Launch! companies as so strong that they all deserved to be featured to more than the 200 people in the room who saw it. So on the spur of the moment I offered all of them a spot on THCB to get them a little more visibility. And now there’s a flood of three minute videos headed our way.
First up is an innovative clinical trial recruitment service called Healogica. And yes it’s new (which is the point of Launch). Watch the short video below to get an idea and investigate further over at Healogica
In my recent blog about the Red Flags rule, GreenLeaves commented that biometric checking would help reduce errors by establishing identity and uncovering fraud.
Using biometrics to verify identity seems like a good idea, so I met with Jim Sullivan from BIO-key, a leading provider of biometric solutions.
the past, I've been reluctant to adopt biometrics because of the
expense of buying fingerprint or Iris scanners for each of my 8000
However, now that many laptops and hospital
ready tablets include embedded fingerprint swipe scanners and that the
price of USB fingerprint scanners has dropped significantly, it is
realistic to consider biometrics.
BIO-key has developed a
next-generation algorithm that reduces the fingerprint to set of
calculated unique identifiers. A person’s fingerprint graphic is not
the credential; their finger is. BIO-key ensures that only a real
finger is being scanned to produce these unique identifiers, making a
stolen fingerprint graphic useless to a potential imposter. It's the
computed values that are stored when the user's finger is scanned at
enrollment, and is later used for comparison with future scans. To me,
it's similar to the way NTLM authentication works – there is no need to
store or exchange the actual password, it's a mathematical hash of the
password that is compared to a stored mathematical hash of the original
password. BIO-key allows you to enroll and identify on most of the
different fingerprint scanners in the market, allowing an open,
heterogeneous fingerprint hardware environment.
The Stimulus bill catapulted health IT – previously the domain of clinicians with a passion for applying technology to improve healthcare – onto the national stage. When you inject billions of taxpayer dollars, politics inevitably comes with it. There have been valid observations that CCHIT’s approach needs to change in this new world, and I wholeheartedly agree. But I’m stunned by the level of dishonesty a few have stooped to in a desperate attempt to toss aside years of work by hundreds of public-spirited contributors. Perhaps they want to bypass the challenge of supplying robust electronic health records and re-educating clinicians to use them meaningfully in transforming care, and just get unfettered access to some stimulus dough.
For months, I’ve been “turning the other cheek” to Dr. David Kibbe because I believe in devoting my energy to solving problems rather than to criticizing other people or worrying about what others think of me. But his repeated use of falsehoods and innuendo to attack CCHIT have found an audience in the national media, reaching a level that can no longer be ignored. By implication, he demeans the integrity of everyone who has contributed to that work – and I must rise to their defense.
David, in your most recent quote for the Washington Post, you called CCHIT a “vendor-founded, -funded and -driven organization.” So let’s take a look at the Commissioners, in chronologic order of service, who have served since our founding in 2004 — people who have been at the core of an organization you claim to be tainted:
No surprise, these days more and more doctors are searching online for medical information. What is surprising, however, is that in a recent study, nearly 50% of physicians indicated that they use Wikipedia—the open-access encyclopedia that allows anyone to edit articles—as their source for medical information.
The study, conducted by Manhattan Research, and reported on here found that although physicians were visiting Wikipedia for medical conditions and other health information, only about 10% of the 1,900 physicians surveyed created new posts or edited existing posts on the encyclopedia.
“The number of physicians turning to Wikipedia for medical information has doubled in the past year alone,’ said Meredith Abreu Ressi, vice president of research at Manhattan Research. ‘Physicians, just like consumers, are heavily search engine reliant, and often Wikipedia results are what come up in the top of the organic results.’
Abreu Ressi noted the concern about accuracy regarding Wikipedia, which allows its users to create content for the site essentially without restriction. Articles are subject to perpetual editing by Wikipedia’s readers. Inevitably, false information sometimes slips through the cracks.”
Wikipedia is not a reliable source of medical information for doctors.
I draw your attention to a troika of articles, all of which show how things can be slightly misinterpreted.
First, who knew that Blackford Middleton was either the most influential health policy wonk out there, or single-handedly responsible for the Haliburtonization of health IT? If you read the WaPo article about it, it looks as though there was some kind of terrible conspiracy to impose an evil fraud in terms of unnecessary health IT spending on the taxpayer. And for example MedinfomaticsMD over at Health Care Renewal (who appears to have jumped from the position that some health IT installations have real problems to the less tenable one that all EMRs kill) is just one going loopy about it.
I've known Blackford for a while, and even though I don't necessarily agree with everything he espouses I think two things are clear. One, the studies his team did (and does) at CITL were done honestly and competently, and they in general reflect what most of us have observed–EMRs have the potential to improve care quality and save money, but that most of the money saved flows back to payers. This has been the experience both in integrated systems in the US, and in health systems in Europe. There are those of us who think that much of the $2.4 trillion is wasted and IT might be part of the solution to trim that waste.
So it was not a great stretch for the Obama team to make the logical leap that health IT is a good thing, and and that subsidies will have to be given to physicians to get them to adopt EMRs (or wider uses of clinical IT). Fer chrissakes even many on the right agree with them. This was not Halliburton sticking it to the US taxpayer in order to boost Dick Cheney's stock options. (Insert your favorite conspiracy theory about the reasons for the Iraq war here if you don't like that one)
In the first and second parts of this series we talked about how and why there is no universal definition for the term “EHR.” Instead there is a legitimate, growing debate about the features and functions that “EHR technologies” should offer physicians seeking to qualify for HITECH incentive payments. We explored the layers of network technology, suggesting that federal regulators should “separate the data from the applications.”
We also argued that there is much to learn from development platforms, recently and in the distant past, that have used standards to open the aperture of innovation. The best of these standards have reflected the experience of what works rather than specifying how to make it work. Defining the standards for data, devices, and network technologies too restrictively could choke off innovation, rendering HITECH’s offerings whose expense and complexity are a barrier to, rather than an incentive for, adoption by physicians. Incoming National Coordinator for HIT David Blumenthal, MD seems to have been considering just this concern when he recently wrote:“… [M]any certified EHRs are neither user-friendly nor designed to meet HITECH’s ambitious goal of improving quality and efficiency in the health care system. Tightening the certification process is a critical early challenge for ONCHIT.”
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.
Preface by Michael Millenson: Lawrence L. Weed published a seminal article in the Archives of Internal Medicine on using the medical record to improve patient care back in January, 1971.
To give you an idea of how glacially the health care system changes, that same issue contained an article entitled, “Universal Health Insurance is the Wave of the Future,” by New York Gov. Nelson Rockefeller, and another, “What Possible Use Can Computers Be to Medicine?” by a Duke University physician that began this way: “The physician's attitude toward computing machinery has changed greatly in the last ten years. A bright future is predicted for its application within medicine.”
In an era when the autonomy of the individual physicians was nearly unchallenged, Weed boldly asserted that “modern data acquisition and retrieval systems” could help doctors make more accurate diagnoses and provide “proper care” more effectively. Weed has continued that same fight ever since, later joined by his son, attorney Lincoln Weed. In the process he has acquired neither fame, popularity or riches — merely become legendary to a small segment of us familiar with his work.
ABSTRACT: Medical practice lacks a foundation in scientific behavior corresponding to its foundation in scientific knowledge. The missing foundation involves standards of care to govern how practitioners manage clinical information. These standards of care, roughly analogous to accounting standards for managing financial information, are essential to exploit the enormous potential of health information technology. Moreover, without these standards and corresponding information tools, evidence-based medicine in its current form is unworkable. Medical practice has failed to adopt the necessary standards and tools, because its historical development has diverged from the paths taken in the domains of science and commerce. The culture of medicine tolerates unnecessary dependence on the personal intellects of practitioners. This dependence has blocked the use of potent information tools, and isolated medicine from forces of feedback and accountability, that operate in the domains of science and commerce. If the necessary standards and tools are adopted, health care cost and quality could become an arena of continuous improvement, rather than a quagmire of intractable dilemmas.