What If Your Electronic Medical Record Is Wrong?

The Perspective column, by Robert Steinbrook, M.D. (pp. 1653-6) in The New England Journal of Medicine (N Engl J Med 358:16, April 17, 2008) describes social and medical complexities of computerized online medical records. Steinbrook describes the push towards online records provided by Dossia ("a nonprofit consortium of major employers"), "Google Health, Microsoft HealthVault and other Web services that are seeking expanded roles in the $2.1 trillion U.S. health care system." In other words, there is a lot of entrepreneurial money at stake (consider advertising revenues) pushing this project, which means that profit and return on investment may come first and patient health and well-being may move to lower priority. Since money buys political influence, beware when current Presidential candidates, Senators and Representatives talk about "health reform" and describe electronic medical records as the salvation to our health care systems' ills.

Based on my past experience as an attorney negotiating related issues, I am concerned about the risk that our medical records will become another commodity. After all, as I have described in earlier blogs, HMOs and PPOs have commoditized health care during the last fifteen years: why should our private medical records be different? Who will own the vital facts contained in your medical record? Will it be you, your doctor, your clinic, your hospital, Microsoft, Google, your employer, an HMO, PPOs, insurance companies or venture capitalists? Who will have the right to sell medical records if, for instance, a major repository goes bankrupt and the court system must dispose of the asset for the benefit of creditors to the highest bidder? What happens if a foreign company acquires the records?

The second April 17, 2008 article, "Off the Record - Avoiding the Pitfalls of Going Electronic," by Drs. Hartzband and Groopman (pp1656-8) takes a seasoned and cautious view of the electronic medical record. It describes the mindless repetition of information: "Senior physicians also cut and paste from their own notes, filling each note with the identical medical history, family yhistory, social history and review of systems." The authors warn that important new data may be obscured. Even the relationship between a physician and patient may be warped as the physician stands at the computer, focused on the screen, providing an impersonal detached experience for the patient.

My experience as a hematologist, taking care of very sick patients, highlights another issue which is scarcely mentioned. Previous physicians may be absolutely wrong in their diagnoses but the momentum developed in the electronic record may make it difficult to understand whether, how or why they went wrong. I saw patients with voluminous paper records from respected instutitions that diagnosed cancer when there was no cancer, that diagnosed essentially untreatable cancer when the disease was relatively benign, that made patients uninsurable because a doctor did not understand the difference between an adenomatous polyp in the colon and familial adenomatous polyposis of the colon and wrote a note which echoed through the chart for years.

Even competent physicians will, from time to time, look at a familiar patient with blinders of past experience, chart entries and sterotyped interactions. Sometimes, the safest record for the patient is no record (except for the list of medications taken and drug allergies provided by the patient) - which requires the physician to start from the beginning, as if he or she had never seen the patient before, with an open mind and challenges to every sacred diagnosis, treatment and prejudice which has affected their relationship and patient care.