I Can't Even Play 78's Anymore

The Department of Health and Human Service is starting its drive to have all medical records available in an electronic format, and having such records accessible from anywhere. At first blush, this seems like a reasonable and positive use of technology.  However, I think there are some grave concerns associated with this process.

First of all, I should offer a little background on me. I work in a law firm that has a lot of paper. E-mails are printed and filed, and pretty much everything we do is reflected in written correspondence that is copied and filed. Lots of law firms (and probably even more solo practitioners) have moved to (almost) paper-free offices, but we aren't one of them.  I often wish we would do more, but so far .  .  . not so much.

The doctor I see more often than any other is an endocrinologist I see for my diabetes.  He is living the paper-free life.  He comes in with a PDA, takes notes, checks on me, uses drop-down menus for my prescriptions, and -- from the PDA -- faxes the prescriptions to my pharmacist very cool.

It seems to me, though, that making all medical records available in a consistent format is next-to-impossible, especially if you want to go back and digitize legacy files from decades past.  Obviously, it would be too time-consuming to analyze the contents of the record, and then keystroke its contents into a database. So, scanning the images is probably what would happen.  Some kind of image file would also be necessary for nontext documents (X-rays, MRIs, etc.) But image files would also be the least efficient method for inputting contemporary records. Most notes are dictated to some kind of text file anymore, and pharmacological and treatment records might do well in a format that uses treatment codes, drop-down menus . . . whatever -- some method that reuses those treatments and terms that are repeated over and over.

At the very least, then, we have two formats (images and text) and we probably have three -- a legacy image format, a primary text format, and an image format that coordinates neatly with the text records.  And that assumes that every single medical provider is financially able to change whatever method (computerized or otherwise) that they currently use into a method that facilitates the new format.

My other concern is about the tension between access and privacy.  Currently, each of us in theory has control over our own medical records -- HIPAA has reinforced this. Our medical providers maintain the records that they generate and act as a gatekeeper exclusively for those records.  If someone requests those records, they have to have some indicia of my desire to do so -- generally the patient's signature on request. However, once a database exists with access to all of my medical records, it gets a little more complicated. 

Is it possible for me to release a portion of my medical records to a current provider without releasing all of them? Perhaps I don't want my dentist to know about some rash I had in an unpleasant area.  And do all providers automatically have all access to all of my records?  One option would be to have each patient have a personal passcode that releases their information. But that seems mighty unwieldy, and when issued by Health and Human Service, seems a lot like a national I.D. card.  And it certainly wouldn't be practical in an emergency situation when I am unable to give my own passcode. 

Without such a passcode, it seems like we have to rely on the trust of doctors. Perhaps every doctor. "I pledge not to access your medical information unless you request it or there is an emergency." And that's basically the system we have now.  We trust medical providers to maintain our confidential files.  BUT under the current system, they only have access to the files of their patients, and only those files which have been requested for or generated by that specific office.  With a central database without the control of (I believe unworkable) passwords, then every medical provider has access to every medical record. That seems like a lot of trust to be spreading around.

The goal is good, but it seems impossible. I will be extremely impressed if it proves doable.