Information technology: E-records must be treated with caution

Over the next five years, the US government will inject $19.2bn into healthcare IT, with the goal of providing electronic medical records for all citizens by 2014.

President Barack Obama has described the initiative as "the most meaningful steps in years towards modernising our healthcare system". The administration believes electronic records will cut costs and improve results by reducing errors and improving care.

Few observers doubt that electronic medical records will bring better care and, against the five-year timescale for Mr Obama's reforms, some employers and IT companies, have already started to develop and deploy their own health record systems in North America.

This could set the scene for a conflict between healthcare providers and patients over who should supply and control medical records.

Similar conflicts could surface outside the US, even in countries such as the UK and China, where the trend is towards more centralised systems for managing patients' medical information.

Companies such as Google and Microsoft have already launched electronic databases aimed directly at patients. While an organisation, Dossia, set up by employers including Intel, AT&T and Wal-Mart, is also trying to plug the single patient record gap in the US.

In the UK, meanwhile, the National Health Service has committed itself to providing electronic health records to GPs and hospitals.

Private sector providers of health information management say they are addressing the needs of individuals who want to take more control over their medical data and other health information, such as fitness.

"Health information is very fragmented today, and we think we can help," says a Google representative. "We have a lot of experience storing and managing large amounts of data."

Like Google Health, Microsoft's HealthVault goes beyond just storing medical data.

"Consumers want health information for themselves and for their families in one place," says George Scriban senior global strategist for consumer health platforms at Microsoft.

"When we think about healthcare, we tend to overlook the things that happen outside the health ecosystem, or outside hospitals," says Mr Scriban. "That might include visits to a nutritionist, orthodontist or opthalmologist." Integrating such information should, he says, also help with preventive medicine.

But "personal health record" or PHR systems, such as HealthVault and Google Health, have met with opposition, both from information privacy advocates and from clinicians.

This is despite the apparent benefits of such systems, especially in the US, where patients often have to deal with more than one insurer or provider during a course of treatment.

"Individual health records target consumers in multi-payer systems, where people might have to change insurers, or doctors," says Judy Hanover, research manager at Health Industry Insights, an industry analyst. "Having a repository of information that is with you, not the doctor or payer ... could help improve the accuracy of your medical history."

But some clinicians worry that personal records might weaken the doctor-patient relationship, expose physicians to liability issues, and lead to a growth of "diagnosis by internet", where patients come to see the doctor with reams of web print-outs and even a pre-formed opinion of the medicine they need.

Privacy groups worry that organisations collecting and controlling medical data might be vulnerable to attacks by hackers or identity thieves.

Both Google and Microsoft state that they will not use medical information for financial gain, but will fund the projects from other revenue streams.

Nor is there clear evidence that HealthVault or Google Health are any more, or less, vulnerable than hospitals' inhouse systems. One of the main reasons privacy breaches occur in the US healthcare system is not because of problems with electronic records but the loss of paper files.

A greater concern is whether personal records can - or even should - be integrated with hospital or provider-based electronic records. Doctors will also be unwilling to rely on information in a personal health record, if patients can change data, such as test results.

Measures, such as signing data so doctors know it has not been changed by the patient, will help to ensure trust.

So will integration of personal health records with other systems, such as the - mainly localised - health information exchanges, which allow hospitals to exchange patient details in a number of US cities.

"We are working to connect personal health records to the health information exchange, rather than relying on paper forms," says Irene Koch, executive director of the Brooklyn Health Information Exchange (BHIX) in New York.

Ms Koch adds that systems aimed at clinical use need to ensure data quality. And consent remains an issue. For emergency care, BHIX has a "break the glass" feature, allowing clinicians some access to its data without patients' permission.

Similar problems will need to be addressed if personal health records are to play a role in the emergency room. But, as Paul Keckley, executive director of the Deloitte Center for Health Solutions, points out, attitudes are changing.

"We are comfortable using web-based tools for banking and travel. There is an emerging digital divide between the healthcare industry and others we interact with," he says.

Doctors, have concerns about systems that might be seen to question their medical judgments and about who pays for electronic records.

"Ultimately, the end-users, the patients, will vote with their feet and go to doctors who use electronic medical records or personal health records," Mr Keckley says.

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