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Home » Healthcare Problems » Applying Participatory Principles to EHRs/PHRs

Neither health professionals nor patients can do it alone.

Let’s make no mistake: We are here to participate and to help!

e-Patient Dave original story of the health data transfer from his hospital EHR to Google Health PHR is remarkable in many ways and shows why participatory medicine could well be one of the fastest way to lower the overall cost of health care by helping fix some specific dysfunctions in the system. It took just one active and engaged patient to produce a remarkable change in the way interoperability between EHR and untethered PHRs is going to be defined at BIDMC and probably at HITSP, at a minimum.

In other words, one single real event, driven by a patient has given more effective feedback to improve the national standards than years of deliberations of the cream of the cream in HIT in their rarefied tower of knowledge.

It shouldn’t come as a surprise! Our dear friend Tom Ferguson, MD understood long ago that health professionals really can’t do it alone anymore. Month after month, year after year, we discussed the growing number of examples showing that invariably better outcome came from the active and engaged participation of the patients in their care. This, of course, could only happen in tandem with a drastic change in the model of patient-doctor relationship.

It almost always started to happen one patient at a time. One exceptionally engaged and informed patient, asking the right questions, navigating the medical maze of his/her particular condition, then communicating with others about his findings and in the process creating a community of hundreds and then thousands of patients. That is exactly how KIDNEY-ONC, the ACOR social network for kidney cancer was created by Steve Dunn, soon supported by Robin Martinez. That same KIDNEY-ONC that Dave calls his life-saver.

Isn’t it ironic that e-Patient Dave is now in the same position Steve Dunn was 13 years ago? Just as Steve had to convince many health professionals that his expertise was real and that he shared the goals of doctors to improve care, so does Dave, who has to constantly remind every one that his engagement is POSITIVE and that his goal is to work, in concert with the professionals, to improve, facilitate, accelerate the implementation of and, optimize the quality of untethered PHRs.

To some of us, it was clear, in the early days of the public access to the internet, that the switch from the paternalistic to a deliberative model of patient-doctor relationship was necessary to bring in the patient community and maximize their impact to improve care. Just as today it has become clear that we will never be satisfied until the EHR/PHR experts proactively involve e-patients to redefine/improve the current schemas. As Ben Adida wrote this morning, you must put the patient squarely in the feedback loop.

David Blumenthal, the newly nominated National Coordinator for Health Information Technology, will lead President Obama’s health information technology vision and will be the person charged with implementing the HITECH act, dispensing the $19 billion attached to the act. It is a fundamental role. He very recently wrote a “perspective” article in the New England Journal of Medicine about stimulating the adoption of EHR:

The nation’s economic woes have given birth to an unprecedented federal effort to modernize the information systems of a troubled health care system. It is now up to the government and the nation’s health care professionals and facilities to turn this opportunity into real improvements in the health and health care of Americans.

Unfortunately in this early vision, Dr. Blumenthal doesn’t mention any role for the growing number of informed and engaged patients. I hope that Dave’s story will change this. John Halamka (A BIG thank you for his willingness to be so responsive!) has shown that even the top experts can be convinced to change at a rapid pace.

As Jane Sarahson-Kahn writes today:

The $19 billion is not about electronic health record technology in and of itself. It’s about patients, health providers, their communities and connectedness. The latter is the raison d’etre of HITECH, not converting patient data from a paper file into a digital format. It’s about the connectedness and exchange of that data around the community for patient, provider and community benefit.

What lays ahead of us are very important decisions that will probably have profound influences on the methods used to reform/create the healthcare system of tomorrow. The US could easily fall back into the usual attitude of reforming within the dysfunctional system, not involving the patients, without whom, we must remind everybody, there would be no reason for medicine to exist and use 17% of GDP.

Already the battle lines are starting to be drawn. Do patients have the right to fully control their PHR and to require full data liquidity & interoperability. Or must we rely on tethered PHRs where only a portion of your health records will be made available to you? I believe the Nation should follow Rahm Emanuel’s now famous:

You never want a serious crisis to go to waste!

The best way to follow this glorious advice would be to involve e-patients, just as the DOD decided early on to involved breast cancer patient advocates in the BCRP program (now in its 10th years and the second largest funder of breast cancer research) to create:

  • Advocate participation in all levels of decision-making;
  • Limited bureaucracy that allows the program to be flexible and respond efficiently to emerging issues and public concerns;
  • Innovative Developmental and Exploratory Awards (IDEA grants) that have been critical in responding to new discoveries and encouraging innovative, risk-taking research;
  • Innovator Awards that are designed to recognize individuals, rather than projects, from any field of study by providing funding and freedom to pursue creative, potentially breakthrough, research.

There are many non-health professionals who understand a thing or two about data! Let’s embrace the idea of their active participation and we shall see a significant improvement in today’s systems. We are certainly not among those who profess that today’s systems have an “…ability to almost create a dreamlike world of health care perfection in which the work of doctors and the care of patients proceed with barely imaginable quality and efficiency…” But we are also not those who consider that too many patients do not have the education, cultural or intellectual capabilities to benefit from PHRs. On the contrary, some of us, founders of the Society for Participatory Medicine, believe that there should be no limit to the health data made available to individual patients, just like we believed 15 years ago that there should be no limit to the medical information made available to the patients. It should be entirely a question of choice. Let’s make the data available and let the individual patients decide the level of complexity they are comfortable with.