Thomas W. Feeley, MD; Kenneth I. Shine, MD
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Donna M., Zulman, Kim M. Nazi, Steven M. Asch, and Todd H. Wagner
Stanford University and VA Palo Alto Health Care System
December 22, 2011
Early experiences with shared electronic health records in the VA healthcare system
In their editorial to our paper (1,2), Drs. Feeley and Shine pose questions to consider as health systems enable patients to access and share their electronic health records. The issues they raise are relevant and timely, and data emerging from the Veterans Affairs (VA) healthcare system provide some initial answers.
First, VA patients are embracing opportunities to take ownership of their medical records. In August 2010, President Obama announced the creation of a new "Blue Button" feature on the VA's personal health record, My HealtheVet (3). The Blue Button enables patients to easily download their health information and share it with providers and caregivers. During the Blue Button's first year, 311,863 (21%) registered My HealtheVet users downloaded their information, suggesting that patients' interest in sharing their health information is matched by their use of features that facilitate such sharing. On a minor point, while the VA does not yet enable patients to access encounter notes (contrary to the description in Drs. Feeley and Shine's editorial), this feature has been piloted and there are plans to incorporate it into My HealtheVet in 2012.
Second, as with medical care in general, it is the neediest patients who have the most to gain from the coming revolution in personal health records. Sicker veterans are using My HealtheVet and--perhaps contrary to the expectations of some--are eager to share their information. A disproportionate number of My HealtheVet users are in poor or fair health (40%, according to our survey, compared to 24% in the general veteran population) (2,4), and approximately 79% of these patients expressed interest in sharing their record with a caregiver or provider outside the VA system (2).
Finally, patients desire control over the specific components of their record that are available to individuals with whom they wish to share information. For example, among 4541 patients who expressed interest in sharing their information with non-VA providers in our survey, 57% were interested in sharing their medication lists but only 15% were interested in sharing their communications with VA providers (2). This finding suggests a need for tailored applications that allow patients to designate specific portions of their record that select individuals can access.
These early experiences from the VA's personal health record system provide insight into information-sharing preferences of patients who often have multiple chronic conditions and psychosocial comorbidities--the very patients who may stand to benefit most from a care network that is enhanced through information-sharing technology.
1. Feeley TW, Shine KI. Access to the medical record for patients and involved providers: transparency through electronic tools. Ann Intern Med. 2011:155:853-4.
2. Zulman DM, Nazi KM, Turvey CL, Wagner TH, Woods SS, An LC. Patient interest in sharing personal health record information. A Web-based survey. Ann Intern Med. 2011;155:805-10.
3. Chopra A, Park T, Levin PL. 'Blue Button' Provides Access to Downloadable Personal Health Data. October 7, 2010. Accessed at http://www.whitehouse.gov.laneproxy.stanford.edu/blog/2010/10/07/blue- button-provides-access-downloadable-personal-health-data on 12/12/11.
4. U.S. Department of Veterans Affairs. National Survey of Veterans. 2001. U.S. Department of Veterans Affairs: Washington, DC: 2001. Accessed at http://www.virec.research.va.gov/DataSourcesName/NationalSurveyVeterans/2001NationalSurveyofVeterans.htm on 12/16/11.
Mark A., LaPorta, General Internal Medicine and Healthcare Advocate
Mark Antony LaPorta MD FACP
February 9, 2012
Transparency -- AKA letting patients read their charts, by portal or anywhere else.
One more step in the degradation of the medical record? Perhaps.
I thought about writing you but was finally inspired and moved to do so when I saw an e-card graphic that said, staid and sober, "Don't be offended. I'm not insulting you, I'm describing you."
How much valuable observation of the individual seated before me will not make it into the record because someone might be offended-- by a true statement?
How much valuable material will not make it in because EHR protocol shoe-horns data bits into pigeon holes?
How many correct and useful statements -- the basics of longitudinal reporting and the truest purpose of the chart-- will be lost; already at the mercy of endless re-iteration of disinterestedly collected so-called facts? How many patients can read a properly-recorded note written above the 12th grade level, nevermind comprehend nuance?
I was on a state medical association executive committee a few years ago charged with collating and disseminating recommendations for membership to use while shopping for EHR systems-- this, even before the "meaningful use" rule or lack there-of showed its true colors -- and my suggestion/insistence was DO NOT ALLOW THE RECORD SYSTEM TO CHANGE YOUR PRACTICE. We are the humans.
Do not allow record keeping to reduce the interaction to mechanics and measurements.
Lastly, I did thousands of SSA disability exams from 2000-2010. Some of the adjudicators loved that they could get an understanding of a real person they'd never met by reading my reports; some hated it because it brought up implications in the applications that had not previously been thought of, issues that were not entirely, shall we say, somatic. Guess who won?
I also had the privilege of reviewing the new VA record-keeping format, said to be amongst the best in the world. I saw process, continuity of logistics, and ease of reading. But the men in front of me, claiming to have been disabled, even believing it, had been looked at like a process and product all along: make the chart do what the chart is supposed to do, follow the patient. But time after time, no one had gone back to the beginning and found the original source of the problem -- not that I'm alleging malpractice, because, after all, it was standard. It was MISSION DRIFT: the process and product had become more important then the contemplation of the individual seated before me. Mission drift is a ubiquitous hazard.
I became an internist to contemplate the patient -- with the problem -- seated before me. And despite time and financial constraints, that's what I do best. Fortunately, at the present height of my game, to use a sports analogy, when I'm there time seems to stand still and understanding opens up. How do you put that in a chart that a patient will see? How do you take the problem back to basics -- not just proforma -- and still submit the CPT -- we were in on that fiasco -- so that the next reader really understands what has transpired?
I await your response.
Mark Antony LaPorta MD FACP
Let me state one of my biases: Lawrence Weed's 1956 "Problem Oriented Medical Record" (the origin of the so-called SOAP note) was ideal. That despite that much "history" is not subjective symptom and much "physical" is not objective.
I compete with your for intellectual primacy.
Feeley TW, Shine KI. Access to the Medical Record for Patients and Involved Providers: Transparency Through Electronic Tools. Ann Intern Med. 2011;155:853–854. doi: 10.7326/0003-4819-155-12-201112200-00010
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Published: Ann Intern Med. 2011;155(12):853-854.
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