Electronic Medical Records: Imagining the End Game Shapes The System, So Who Gets to Imagine the End Game?

“When you have a hammer, everything looks like a nail.” When you are a doctor, it is all about you.

According to Dr. David Kibbe, spokescritter for the American Assoc. of Family Physicians, the whole point of switching to electronic medical records is: “for doctors’ offices and hospitals to be able to easily share patient information, something the vast majority can’t do today. That would cut down on mistaken and unnecessary procedures and give doctors faster access to more accurate information about patients’ medical histories and drug regimens.”

But there are, in fact many other advantages to electronic medical records. One, for example, is to facilitate patient choice of doctor or specialist by making it easy for the patient to access, or provide access, to all medical records in one place. Right now, my ability to switch from my current practitioner to another practitioner is dependent on my collecting my medical info and moving it to my preferred doctor. The law requires my current Doctor to allow this, but it does not require them to make it easy for me.

Electronic medical records with easy patient access, would make it possible for me to change doctors easily, or consult new ones. Mind you, I might make some foolish choices. And there are non-trivial privacy safeguard issues in building a system with such access. But I will not even get to think about the cost/benefit analysis if those designing the system do not consider this the “end game” or, possibly, even a desirable feature.

For an example of how imagining the end game shapes the outcome, consider the internet. It was designed by people who thought the end game was making it possible to exchange all manner of information. This is the famous “end-to-end” principle, which became one of the foundational design feature for the TCP/IP protocol suite in the early 1980s. This design principle produced a network in which it became very easy to send anything to anyone. This had many good features — if you are reading this you are enjoying one right now — but also made the easy transmission of “malware” possible. Because those designing the system did not envision “secure transmission” as the end game but “maximizing the ability to transmit” as the end game.

But there are always trade offs in any system. The rise of TCP/IP and other packet-switched networks using “best efforts” and decline of the super-reliable “five 9s” (99.999% reliable) public switched telephone network (PSTN) demonstrates that, for all its flaws, best efforts has a lot going for it. Similarly, an electronic medical record system built to maximize patient utility rather than the narrow purposes conceived by family doctors and hospitals will have a very different set of benefits, costs, and vulnerabilities. But as a patient, I’d rather make that the end game.

As always, it boils down to who gets to be in the room when the decisions get made. While I have no doubt that room will include doctors, hospital administrators, health insurance reps, and probably some engineers, I hope it will also include a good selection of others people whom patients would like to give access to their medical information to facilitate treatment. This could include my pharmacist, the nurse taking care of a home-bound patient, a physical or occupational therapist, a nutritionist I wish to consult . . . .

Or perhaps it might be easier to let me, as the patient, imagine the end game and the desired outcome.

Stay tuned . . . .


  1. Hi, it looks like the EU may be close to killing net neutrality. see http://euobserver.com/9/27859

  2. “Because those designing the system did not envision “secure transmission” as the end game but “maximizing the ability to transmit” as the end game.”

    The purpose of the IP system by DARPA was a survivable transmission above all else. It had to have multinode routing so that if one site was loss the remaining nodes could route to the end node in real time. Why such demand. It was the time of the cold war and that ‘lost node’ was gone in a billion F fireball.

    Your point on patient records is valid but I don’t think electronics is going to solve it. The reason has less to do with technology and all to do with ownership. The doctor or HMO view those records as their property not yours. So it takes inordinate effort to get them. And to date I have been totally unsuccessful in getting a personal copy of them.

    I have also seen the other side of the coin as well. I personally observed the Russian medical system having cataract surgery there 5 years ago. Under their methodology the patient maintains their own medical records (ie they take them home with them). Practitioners provide patients new data sheets or updates on current procedures. Hospitals only keep records for the current stay which are archived for approximately a year then destroyed. I still have my copy of everything that was performed on me those 5 years ago. I can’t say that about US hospital procedure done just a year ago.

    We have the best medical technology in the US. The system however treats the patient like a piece of meat with brains to match. Till that changes don’t expect a lot of improvement.

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