After athenahealth CEO Jonathan Bush observed a patient transfer from a hospital to a
nursing home, Bush was shocked at the inefficiency of the process, commenting on how the
individuals involved typed “the printout from the brand new [electronic medical record] into their
EMR, so that their fax server can fax it to the bloody nursing home” (Whitney par. 2).
Unfortunately, such ordeals are ubiquitous in the United States; with 186 different electronic
medical record systems on the market, one might expect an effort to make these systems
interoperable, but when even the largest provider – Epic Systems Corp. – is reluctant to commit to
the process, it bodes ill for the future of healthcare (ONC par. 1).
Beyond the office drama, patients suffer the consequences of a lack of interoperability in
the form of doctor’s visits that are both rushed and lack the doctor’s full attention. For example,
Dr. James Smith of Emory Specialty Associates noted that his patients “felt [he] was very detached
and more focused on [the system]” while he was trying to enter their histories and orders (BHR
par. 20). Part of this issue stems from the sheer amount of material required to fill out the EMR,
with doctors spending two hours on the EMR for every hour spent with patients (Ramsey par. 5).
In addition, the rise of EMR usage has also been linked to hundreds of medical malpractice claims
yearly, with over 80% of such cases involving “moderate or severe harm” (Graber et. al. page 3).
When EMRs were first introduced to the healthcare industry nearly fifty years ago, they were
considered cutting edge technology designed to streamline medicine, but widespread adoption
about a decade ago brought to light issues unforeseen by their creators (Atherton pars. 7-8). The
technology of the present, however, provides a modern solution to EMR system communications.
With the focus of the current era being communication – whether it be interpersonal, like social
media, or purely technological, like smart homes – we can update the EMR system with a facet of
computer engineering known as “The Internet of Things,” or IoT. The essence of IoT is the
interconnectedness of electronics, whether it be through the internet or with each other (Morgan
par. 4). IoT has already pervaded medicine as a 117-billion-dollar industry in the form of such
items as fitness trackers and smart sensors that aggregate collected data and display it on mobile
devices (McCue pars. 1-2). With this technology, physicians would no longer have to waste time
on creating patient health records if the Internet of Things was applied to the nearly ubiquitous
insurance cards in the United States to shift the onus of health history to autonomous systems
instead of error-prone humans.
Unfortunately, medicine has been resilient to the integration of technology; rapid
technological growth often necessitates constantly adjusting the status quo of what is considered
“up to date,” but healthcare has traditionally been a technologically languid field that must now
adapt to remain effective. The current status quo fails to provide an effective solution for
integration of healthcare systems because of outdated tech and complicated policies. Though
EMRs have existed for nearly half a century, it wasn’t until the HITECH Act – a 2009 bill that
incentivized the adoption of EMRs with a monetary reward for “meaningful use” and the
withholding of 1% of all Medicare payments as a punishment for lack of adoption – that most
hospitals began to have EMRs, up 60% from 2001 to 2013 (Dept. of Health Policy pages 44-45,
HealthIT par. 1, Meigs and Solomon page 1). Unfortunately, the speed of the adoption left
physicians bewildered, isolating those that were not already computer savvy; Dr. Hayes Wilson of
Piedmont Rheumatology described a physician assistant who “quit because she typed with two
fingers,” with Dr. Wilson also expressing exasperation at having to take thirty-eight clicks to
review a single patient’s notes (BHR par. 15). On the physician side, the status quo forces
physicians to bear the burden of recording patient histories; Dr. Clement McDonald of the National
Center for Biomedical Communications conducted a study that revealed an average waste of fortyeight
minutes spent filling out patient histories on EMRs (McDonald et. al. par. 1). Attempted
solutions in the status quo predominantly feature Apple’s Health app, the latest attempt since
2011’s Google Health to get users to take control of their own health by collecting data from other
health apps and allowing users to send the data to their doctors. The biggest obstacle to Apple’s
scheme is the sheer lack of interest, with Massachusetts eHealth Collaborative CEO Micky
Tripathi noting that “only about 10 to 15 percent of patients care about this stuff” (Farr pars. 16-
17). Even when the service is used, the sheer amount of data overwhelms physicians, making it an
inefficient app (Carroll par. 9). As a result, it becomes clear that putting the burden of health history
on physicians wastes time, while putting the burden on patients fails to be a viable option given
patients’ lack of interest.
The reason the status quo fails is that doctors have been unable to adapt to the evolving
technological world, while patients don’t always have the technical understanding to keep track of
their own health records; this can be solved by placing the burden of health history on technology.
By integrating advanced smart card technology into current insurance cards, a portable health
record can be created that allows physicians access to medical history regardless of whether or not
the same physician treats the patient each time. Smart cards are currently widespread in Europe,
with national healthcare systems distributing cards such as France’s Carte Vitale, though these
cards come in two forms: a card with identification and insurance status, and a card with
identification and emergency data, as well as history of medications (Sembritzki par. 31-36, Keliris
et. al. page 1). The proposed card would take the current cards and upgrade them further to become
a complete repository of health information; upon acquisition, patients could go to their doctors
and get their complete medical record uploaded to the card, not just emergency data. Unfortunately,
before this step could occur, the United States would have to adopt the concept of the smart card,
which it has currently failed to do due to the lack of a widespread public healthcare system and a
government unwilling to move forward with development and production.
However, the lack of a widespread smart card can be solved with the second part of the
proposal: integrating the technology into extant insurance cards. Because insurance companies are
large corporations, they have the resources and knowledge to both integrate smart card technology
with current insurance cards and distribute these cards on a large scale. Though the insurance
companies might not want to bear the cost, the Government Accountability Office “confirms
financial incentives for card use are essential to encourage provider participation;” this would
create a strong public-private partnership, wherein the government funds the insurance companies’
development of these cards (DiChiara par. 8). Even without government assistance, insurance
companies might consider the new cards anyways, as the medical record-insurance card – MRIC
hereafter for brevity – would save the insurance companies a great deal of money in unnecessary
testing and procedures that the doctor might find already recorded in the card. In addition,
offsetting the cost of development would be as simple as initially offering the MRIC as an opt-in
service with a fee to have the new card, and then issuing the new card to the remaining individuals
once the development fees are recouped.
However, as the MRIC becomes widespread, the security risks also increase. Losing the
card could mean more than just a loss of medical history; it might lead to identity theft, blackmail,
or the manipulation of data. While individuals lose important items like their credit or debit cards,
those losses can be mitigated by simply calling the bank and getting a new card, but because people
go to the hospital much less frequently than they use their credit cards, they are unlikely to realize
that their card has been lost or stolen until the next time they go to the hospital. Currently, medical
identity theft from the loss of insurance cards costs affected individuals about twenty-two thousand
dollars on average, and the ramifications could be terrifying for the MRIC because it would allow
the perpetrator to more effectively impersonate the victim (Lerner par. 8). Although these are all
dangerous issues, recognizing them allows us to anticipate and defend against them. To circumvent
the loss of medical history, the data can be duplicated on insurance company servers, which, while
adding a vulnerable point of entry, keeps data secure in case the card is lost. This would also work
in reverse; if the data on insurance company servers is lost, patients would have their own copy of
the data. Because insurance companies are hosting the information, they are contractually
obligated to their patients and by HIPAA regulation to safeguard that data. To prevent identity
theft, the cards’ technology should be able to send owners alerts whenever they are used and bring
up the patients’ basic information – name, picture, date of birth – for administrators to confirm
their identities. To prevent data manipulation, proposed methods have included having a doctor
smart card that acts as a key to unlock patient data (Kardas and Tunali pages 68-69). However,
this method shares the same risk, as loss of a doctor card would be even more catastrophic because
it would act as a key for any other stolen card. Therefore, one possible solution would be to make
the MRIC like a USB flash drive that would be doubly encrypted behind both a patient’s and a
doctor’s password, with a memory wipe that occurs after too many failed password attempts,
rectified only by calling the insurance company and verifying one’s identity. This would both
safeguard the data and remove the need for hospitals to buy new technology to read the cards.
Beyond the security and storage issues arising from adoption of the MRIC, the biggest
drawback to this proposal is the large population of uninsured individuals; an alternative to the
MRIC must exist to improve the health of all, not just those with the ability to afford insurance.
The uninsured, impoverished, and homeless populations are the ones that most require medical
services and the benefit of this proposed system, but their status causes difficulties in keeping track
of medical history. Though many of these individuals come to emergency departments for
treatment, they often leave with a directive that physicians cannot guarantee they will follow, and
their lack of insurance makes it unlikely that they will return for a checkup. Even worse is the issue
of patient dumping, in which hospitals throw patients back out on the street instead of making sure
they are cared for; for example, in the heart of LA, a woman identified as Jane Roe was dumped
on Skid Row, “wearing only paper pajamas…[and] found wandering the streets” after being
admitted five times for depression, hallucinations, and substance abuse (Serna pars. 2, 8). Without
insurance, people like Jane are likely to return for increasingly pressing issues because there is no
follow-up care, and that would only be perpetuated with MRICs. However, if insurance companies
can reproduce the technology in the MRIC – likely with government financial incentive – and
distribute it to these uninsured individuals, the healthcare system would become much less
burdened by surprise admits that can’t describe their medical history from memory.
Though a small card might be easily lost without the luxury of a stable living environment,
other implementations of the MRIC may be considered, such as a wristband. Unlikely to be
accidentally taken off and not being too conspicuous, especially if there were personalization
elements such as color, the wristband would serve as an ideal identification tool that could integrate
the MRIC technology. Instead of looking like the medical wristbands that hospital patients get, it
could look more like a thicker version of the stylish silicone band or like a fitness tracker. The
wristband would serve as a lower-tech alternative to the MRIC, only requiring a doctor’s password
to safeguard against patients forgetting passwords because of mental illness-induced memory loss.
In this manner, patient dumping would become much less likely because doctors, knowing the
patient’s medical history, would have to do everything possible to treat the patient, and if they
didn’t, the next doctor to open the medical record on the wristband would see the failure of care.
As we look to the future of healthcare, technology seems to be the driving force behind
change in the field, with the Internet of Things spearheading the effort. As it stands, doctors are
thinly spread out, rushing patient interactions to move on to another. Adoption of the MRIC would
allow the doctors to save time wasted on patient histories, allowing them to focus on the patient’s
concerns; eventually, it could facilitate a complete decoupling of doctors and patient charts with
the integration of IoT into doctors’ instruments. For example, integrating current digital
stethoscope technology that can amplify sounds with the MRIC is just one way to utilize the power
of a ubiquitous record-keeping system (Synopsis par. 1). With a new generation of doctors from
the “Millennials,” the future appears to be bright and technology dependent. However, until all
doctors and patients have the tech savviness required to pilot the systems of the future, we can
offer a compromise between the tech experts and the novices by utilizing a system that works
autonomously, requiring only a password – already an indispensable facet of modern society – to
Simon Trinh is a first year undergraduate at USC studying Human Biology, with minors in Computer Programming and Health Care Studies. As a pre-med student, he’s at the start of his journey, but balances the science with real-world experiences, volunteering at Keck Medical Center through Trojan Health Volunteers. Besides medicine, he has recently become passionate about archery, and is part of the Trojan Archery competitive team. In his free time, you can find him devouring book series (esp. fantasy!). You can reach him at firstname.lastname@example.org.
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