Chapter Two: Mediums and Policies

Chapter Two begins by looking at the various governmental policies that rather forcibly and abruptly thrust the healthcare system into the adoption of the EHR technology by mandating that it be used not only for record keeping but as a means of online communication about health. Three specific perspectives are taken in exploring how policies were developed to enforce this transition: physicians, patients, and media. That is, this chapter explores policies affecting how physicians had to implement the EHRs within their practices, how the patients were gradually taught to use this medium as a means for communicating, and how the overall technological landscape and infrastructure prepared for this new medium through social, economic, and telecommunications regulations.

This segment reviews in great detail the specific policies mentioned above and how they were responded to over time by the physicians, the hospitals, the patients, and even the variously affected outside organizations (such as health insurance companies). Each group adhered to the laws according to how they influenced their personal roles and professional obligations. Each reacted with cautious curiosity as EHRs became more user-friendly and familiar to them. Each responded more thoughtfully as the full appreciation of the new technology affected more and more aspects of their health and personal lives.

For the health professionals, EHRs largely created an economic concern about their ability to meet the financial demands of purchasing new equipment, training their personnel (and themselves), and teaching patients how to become more responsible for participating in their own health. After all, if they did not follow government mandates, they would be financially

penalized and eventually forced to retire, down-size, or leave their practices altogether.12 _Most

importantly, however, this conversion process was a moral and ethical obligation as they were told EHRs would improve their patients’ satisfaction and overall health. Challenged with wanting to adhere to regulations in healthcare and, above all, wanting to provide the best possible care for their patients, the physicians adopted EHRs into their practices at varying rates and levels of commitment. But most adopted with conviction to do what was said to be medically best for their patients.

For the patients, this technology eventually came to mean a mechanism for getting their records in electronic form to be transferred from one physicians’ office or hospital to the next so that care could be continuous. Records were made available on compact disc, flash drive, or, eventually, through the Internet allowing the sharing of information with patients for personal, physician-transfer, or travel purposes. This is what public media was selling to those who were listening; and to those who were not listening to this news, the physicians began offering the option directly to their patients in order that they could prove that they really were carrying out the mandates imposed by the new government laws. That is, the physicians were “selling” the change so that they could show that patients were actually adapting to it and accepting it as part of their health experience. Without evidence, they would not get reimbursements from the government. Patients had to use the medium to supply usage data, proving that EHRs had not only been purchased but that they were actively implemented and applied to the practice of medicine.

12 _{This was the established scenario at the time. Some physicians have survived this retreat by down-sizing their}

Eventually, patients started to look directly at the EHR information online in their own electronic chart to see what was written about themselves by their physicians,13 what the results from tests might be (perhaps even before the physicians’ office called to let them know the results),14 _{or even simply when their next appointment was scheduled. As EHRs became more}

common place in physicians’ offices and hospitals alike, other features besides secured patient health information (PHI) storage became introduced first to the physicians and then to their patients. Now the EHRs also provided a means for exchanging “emails” or electronic messages within a secured space. This meant that patients could reach their physicians at any time, night or day, through electronic messages sent through EHR portals that allowed for direct, continuous contact for follow-up questions, clarifications, or comments. This HIPAA (Health Insurance Portability Accountability Act) regulated communication within the EHRs and began to transform the very ways in which medical histories were obtained, office visits conducted, information transferred, and, most interestingly, relationships developed online through a new medium of communication with the physician. This made the EHR not only a storage device for recorded communication but a transmission device for ongoing, spontaneous, interactive

13 _{Of course this did not happen at first. Even today there continue to be objections about whether or not patients}

have the right to see “all” of their medical chart. The Robert Wood Johnson Foundation has researched this with their “Open Notes” project (2015) and so have Michael and Margaret Warner in their “Patient Advocate” program (Rise of the Patient Advocate: Healthcare in the Digital Age, 2015).

14 _{In many physicians’ offices, test results are not reported back to the patient if they are negative. That is, the}

patient is not called to say that everything is okay. The patient is only called if the test is positive, meaning that there is something wrong and they need to come in to see the physician or get further tests right away. The “no news is good news” applies in this instance; and yet it is a very difficult and unsettling way to get negative test results. The waiting process can be long and worry some. Some offices call no matter the results—positive or negative. Most, however, do not do this due to the vast number of tests being done on patients each day, the size of the practices, and the employee time it takes to have results called back to patients. Even the return call process could take several calls and several messages. In short, having the information in the medical chart with immediate results certainly means that positive results could be seen quickly but it also means that they could be interpreted without the aid, knowledge, and consolation of the physician. This aspect will be discussed further in later chapters. It is important to keep this in mind, however, as the overall effect of all these factors are explored throughout this

communication as well. This marked a significant change in how physicians and patients communicated about health.

Ultimately the stated goal of the EHRs began to become a reality as the users began to incorporate this new medium at various levels into their lives to provide improved health outcomes through shared patient/physician access to all medical records,15 online access to health education and training, and ultimately participatory, shared decision making between patients and all involved healthcare professionals.16 Patients and physicians reacted both positively and negatively to the changes brought about by the introduction of this medium. Even though by 1996, roughly 45 million people used emails around the globe,17 _{it was not until the}

introduction of the HITECH Act of 2009, which required physicians and hospitals to convert to EHRs, that the means for secure electronic health message exchange was available to the general public.

Today, only 48% of American physicians say they communicate with their patients online—evidence of the fact that the change has been slow in coming (QuantiaMD, 2011).18

Patients and physicians alike have reacted to this process throughout recent years of adoption. Some have pushed to adopt this method readily and even before government mandates required this transition. Others have resisted adamantly, refusing to communicate online, and, in the case

15 _{Of course all transmission of information must uphold the Health Insurance Portability and Accountability Act}

(HIPAA) of 1996. See Chapter 2 for further explanation of this Act.

15 _{Many other benefits as well as limitations have been identified with the use of EHRs. The purpose of this}

segment is to provide a general overview of the EHR. Further discussion will be forthcoming. See Chapter 2 in particular.

16 _{Many other benefits as well as limitations have been identified with the use of EHRs. The purpose of this}

segment is to provide a general overview of the EHR. Further discussion will be forthcoming. See Chapter 2 in particular.

17 _{Go to http://www.infoplease.com/ipa/A0193167.html for an Internet timeline (infoplease.com, 2015). See also}

Chapter 3 for further discussion.

of physicians, even opting to retire rather than convert all office and hospital transactions into and EHR system. The key is, the change was introduced through the policies and government mandates outlined in this chapter. The path continues to be a challenge, but the process has definitely started. As more and more physicians and hospital systems convert, more patients realize the benefits to their own healthcare, and laws and regulations continue to push this conversion process ahead.

Finally, beyond the practical aspect of policy implementation and adoption, Chapter 2 examines the medium itself from a more McLuhanesque perspective. In short, the EHR is a medium or channel of communication through which information about health is produced, transmitted, and stored. At the same time, layers of mediums exist. There is the medium of the Internet which allows the medical information to be transmitted, the medium of the physical or “cloud” server which allows the information to be stored, the medium of the EHR program (software) which allows the information to be organized and retrieved, the physical medium of the computer which enables information to be encoded and decoded, the medium of the electronic message itself which allows people to exchange information, and so on. Together these mediums take on a form of their own, a “sense ratio” as McLuhan would call it (McLuhan M., Understanding Media: The Extensions of Man, 1994). These mediums reorganize the information and the experience of communicating about that information in a manner that is unique to each user. Each user experiences the mediums differently depending upon how they perceive, engage with, organize, explain, and use the patterns of information contained within this space. The “perspective,” therefore, of the physician and patient is unique yet dynamically whole for each person who enters that “space” and experiences this new form of technology.