Broken Records

One of the promises of a computerized age was that patients would be able to control their electronic health records (EHRs), and have all the reams of data produced by their tests and doctors’ appointments in one easily accessed online location. Of course, as all of us who use our doctors’ patient portals know full well, what we have in reality is a collection of interfaces that would look more at home in 2000, function poorly at best, and don’t talk to each other. Patients find them bewildering and often don’t even use them. Doctors spend far too much time, they say, filling out interminable lists of questions for electronic health records (EHRs)—one study in 2016 found they spend fully half their time filling out forms. The resulting record for a single visit, if printed, can be more than one hundred printed pages long. Too many doctors copy and paste data from older forms, sometimes preserving outdated information and leading to errors.

The worst part about this is that the only people with real incentive to change the system are policymakers. If all records were interoperable, EHR vendors would have less of a hold on their customers. Meanwhile, doctors and hospitals also like keeping their patients, and it’s harder to switch providers if you can’t easily take your records with you. And though the law that incentivizes the EHR adoption did recognize the importance of interoperability, it wasn’t a first-order requirement, probably due to the extra expense. Of course, now that these systems are up and running, making them interoperable now is both more expensive and more complicated. (While sharing health records always brings up questions about security and privacy, about 90 percent of providers already use EHRs. They aren’t going away, so the best we can do is make them more useful.)

Is this fixable? Yes, says Julia Adler-Milstein, a scholar working on EHRs. Of course the government could incentivize interoperability across the board, but it might be more effective to make it unavoidable, practically speaking. If, for example, regulations require providers to cut down on unnecessary tests by making sure that the same patient doesn’t get the same test twice, vendors will have to share their records. Alternatively, requirements for community monitoring would have the same effect—make providers responsible for reporting whether their patients get immunizations, whether they get it from that doctor or from any other provider.

These recommendations dovetail nicely with recent calls for better monitoring of opioid prescriptions. The President’s commission on the opioid crisis recently called for all state monitoring programs, called PDMPs, to be interoperable. PDMPs collect data from pharmacies, and doctors treating an opioid-addicted patient are not required to talk to the patients’ previous doctor. (Shockingly, according to a 2016 report, few doctors actually request information from their state PDMPs before writing prescriptions.) As alarm rises over the steady increase in opioid deaths in this country, there might be political momentum (and thus public funds) available for mandating the interoperability of doctors’ and hospital records, so they can treat addicts better and forestall further deaths.

On the other end of this problem from the political difficulties, there’s the technology to consider. Making systems talk to each other is always an expensive proposition, but what if there’s a digital-age solution? Researchers at the MIT Media Lab and Beth Israel Deaconess Medical Center propose turning our health records into blockchain, so that the patient controls a security, time-stamped log of all her records, and can order them to be sent to whoever she wants, whenever she wants. Best of all, it doesn’t require giving all the data to another company to control; blockchain devolves the responsibility for these records to the patient herself. Though this isn’t likely to become tomorrow’s solution, the next decade may bring such revolutionary changes the technology—if this particular innovation than something just as dramatic.

Meanwhile, many recent innovations make managing conditions easier for the patient—remote monitoring of diabetes and heart conditions, to take two examples. These kinds of monitors really lend themselves, and demand, a comprehensive record system to go with the comprehensive data they provide.

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