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Monday, September 28, 2009

What's the point?

The piece by Jamie Heywood: Forget Medical Privacy in Wired Magazine last week ( regarding patient access to medical records makes perfect first. However it raises a number of questions. Why have we not shared such records in the first place? What is the historical background regarding information conveyed from physicians to patients? What exactly is the contractual relationship between doctor and patient? Who hires the doctor? What is the specific agreement between patient and physician in terms of deliverables? What is the purpose of the medical records? Are all the purposes of the medical record the same for all parties who may need access to the record?

When you start to think about the medical record in this light, it appears that many elements and aspects of the medical record have never really been defined. For the physician, the record developed as a tool which allowed him (or her) to recall key elements of the patient’s history at subsequent visits. It was primarily a tool which allowed future care to be done with sufficient information about the past. The patient had little interest in these notes since they did not contain information which could be interpreted by the patient. There was generally no agreement that the physician would create any sort product such as a written document relating to the patient’s care. The physician’s job was to diagnose and treat.

At some point, the medical record developed additional purposes. It took on legal importance, perhaps sometime in the 19th century during the nation’s first “malpractice crisis”. In the 20th century it became an essential piece in justification of billings. In order to get bills paid, both physician and patient acquiesced to having a third party be privy to the physician notes. One of the third parties was the State since state payers became dominant players in the game. Furthermore, the medical record took on legal importance in that it took on specific and perhaps onerous legal protections in the form of HIPPA.

While the ambiguity regarding ownership and purpose of the medical record was not critical in an earlier era, it creates problems in the present environment. It represents only a piece of the ambiguity inherent in the entire structure of the medical encounter as currently structured. There is a contractual relationship between physician and patient and perhaps it is desirable to better define the nature of the deliverables. When I go to an attorney to deal with a specific legal issue, I generally have a defined expectation as to what I will have when the encounter is completed. Similarly, I have comparable expectations when I see my accountant or other financial advisors. These are fellow professionals who have created a much less ambiguous relationship with their clients.

The ambiguity theme permeates medical encounters. Our present encounter structure harkens back to an earlier era where the doctor patient relationship bore scant resemblance to our current times. We (as clients) now schedule meetings with a host of professionals in the hope that we derive some benefit. For anyone who has any concept of time management, an agenda-less meeting is an anathema. Yet, we actively discourage patients from bringing an actual agenda. Bringing a list is generally evokes outright hostility but why is this? Shouldn’t patients and physicians welcome transparency in regards to actual goals and objectives?

As it stands, some vague rationale for a visit may be understood. It may be represented by some brief and often misspelled reason for a visit typed into the schedule by by some call center employee who might as well reside in Banglore. It may be as nebulous as here for a “check up”. Ultimately what is the product of a specific visit? Would it not be reasonable for both patient and doctor to have defined the anticipated deliverables before the visit?

At least one of the deliverables might be a summary report which is geared to the patient. It should be structured is such a way that the conclusions of the provided are obvious as is the rationale for any specific interventions and tests. The report need not be available immediately after the encounter since not all conclusions and plans can be formulated in real time. This report unquestionably would belong to the patient. Whether all notes and information collected as part of the visit would belong to the patient could be open to debate. However, the simplest approach to this problem is to define the deliverables as everything the patient paid for; all tests billed to the patient as well as a summary report which contained defined elements. These elements would include the diagnosis, a modifier which could convey the degree of certainty (unquestionable, likely, possible, atypical), prognosis, reasons for treatment, and recommended interventions.

Instead, we engage in factory medicine, encouraged by payment schemes which were openly designed to encourage volume. Patients of earlier generations raised in a culture of deference to physicians and general stoicism tolerated the movement toward cattle call medicine, occasionally erupting in sporadic annoyance but more commonly responded with bewilderment. The newer Gen X and Yer’s failed to understand why, in a world increasingly engineered to cater to their individual needs, medicine was so unresponsive. Not surprisingly no one has a good answer other than this is how we have always done things.

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