Threat or opportunity in the doctor-patient relationship?

The driving force in health care for the last several years has been - and continues to be - managed care. It is becoming the preferred model for integrating both the delivery and financing of health care services, as is evidenced by its growth in private insurance and its adaptation into government programs, such as Medicare and Medicaid. Managed care represents not just a new payment system, but an integrated arrangement of health care services, directed by primary care providers for a defined population at a fixed price. Increasingly, independent providers, such as hospitals, physicians, home health providers, and others are coming together in alliances or networks of integrated health services to negotiate contracts with employers and insurers.

Managing the costs, claims, services, and the health of enrolled populations across the variety of sites within such systems is a major challenge. A response to this challenge is the development of community health information networks (CHINs). A CHIN functions like an ATM system. It provides the electronic exchange of financial and clinical information among the various components of the health care delivery and financing systems: hospitals, physicians, pharmacists, other health care providers, payers, and employers. A CHIN differs from a proprietary enterprise network since it connects components of a number of systems (including competitors) and unaffiliated providers in a geographic area. That geographic area may be a city, county, state, or regional area.

There are approximately 100 CHINs being planned or in various stages of implementation nationwide.(1) Some of these sites are Milwaukee, Chicago, Cincinnati, Columbus, Dayton, Cleveland, Memphis, Dallas/Ft. Worth, San Antonio, Atlanta, and Springfield, Virginia.

Benefits and costs

Since CHINs are relatively new, it is difficult to do a cost/benefit analysis in dollar terms. However, there are several projected benefits that may result in cost savings: (1) results of patient tests and procedures can be quickly provided electronically between and among physicians and tests sites, potentially reducing unnecessarily repeated tests; (2) urban specialists can receive patient information from remote rural areas; (3) insurance enrollment can be quickly verified and updated; (4) speedy electronic transfer of payments can occur; (5) quality of care standards can be electronically available and easily accessed, thus improving quality of care; and (6) researchers will be able to access data and databases for health services research.

On the other hand there are many costs associated with developing and maintaining a CHIN, such as the time and expertise needed. The following steps outline the phases in developing a CHIN and explain these costs. First, the planning stages require the input of numerous professionals: information system specialists, financial experts, physicians, payers, and community representatives. Contracting with consultants in the planning stages is necessary, since there are diverse and, sometimes, competing interests. A critical factor here is determining community readiness for a CHIN. Focus groups, surveys, and interviews are tools in this process.

The next step is to decide how the CHIN will be structured, owned, managed, and operated. Legal expertise is essential at this point. Then comes the process of evaluating potential vendors to assist in the technical aspects - this may involve travel costs to vendor sites to observe their systems in operation. After the vendor is selected, developing the software or modifications to satisfy the CHIN requirements begins. Implementing the CHIN and providing ongoing administrative, technical, and training support is the last - and continuous - step.

Developing and maintaining a CHIN is not inexpensive, as is clear from both the human and technologic resources involved. But cost savings may occur in processing claims, reducing unnecessary duplicative tests, and supporting community health status research. Developing a CHIN, rather than individual competing proprietary networks, will also preclude the expense developing multiple competing networks; this in itself ultimately lower costs to each user.

Privacy and confidentiality

As exciting as the benefits promise to be, a CHIN entails significant sensitivities about possible violations of privacy and confidentiality of patient information. The public's concern about this intrusion has been reported in the popular press and documented booth in the Institute of Medicine's Committee on Regional Health Data Network Report and the Harris-Equifax Study.[2] This latter study reveals that Americans are "deeply concerned about threats to their personal privacy in general and., when asked specifically, express concern about the possible misuse of confidential medical records."

The majority (87 percent) of those surveyed believed that health professionals can be trusted to protect the confidentiality of medical records. However, they were not so positive about employers, insurers, government officials, or analysts who have access to their medical records. Not surprisingly, the public's concerns parallel those reported by the Institute of Medicine's Committee on Regional Health Data Networks Health Data in the Information Age. These concerns are:

1. Releasing inaccurate information. Sixty to 75 percent of the public expressed concern that mistakes in billing, inaccurate recording of medical information, and information given to those who have no need to know occur more often today because of the increased use of computers.(2)

The Committee on Regional Health Data Networks included under this heading not only mistakes in coding and data entry, but also beneficent attempts by providers to protect a patient from a stigmatizing diagnosis or to permit insurance coverage for a test that might not otherwise be covered.3 Whatever the cause of the inaccuracy or the justification for it, inaccurate data are released both to authorized and unauthorized entities.

2. Improper disclosure. In the Harris-Equifax Survey, 27 percent of the public reported that their confidential medical information had been inappropriately disclosed. Additionally, 24 percent of the health care and business leaders indicated that they knew of such violations and could describe them in detail. Further, 71 percent of the leaders recognized that the public is concerned about medical confidentiality, and 59 percent of the leaders themselves thought that violations constitute a serious problem.

The Committee on Regional Health Data Networks noted that providers routinely release information to insurers when much of the information does not relate to the claim.(3) The Committee also expressed concern over "insider information trading," which is the sale of information by those who have legitimate access to the record.

3. Release to third parties without the subject's knowledge or consent. Sixty percent of the public surveyed in the Harris-Equifax study did not find it acceptable for pharmacists to give patient information to direct marketers so that the consumer could receive new medication offers in the mail, unless the pharmacists had patient consent. In addition, 64 percent would require patient consent for the use of their medical information in research, even if no personally identifiable information were published.

The Committee on Regional Health Data Networks also expressed several concerns: (1) sharing health record information between the benefits division of a company and an employee's supervisor; (2) sharing information between a current employer and a potential employer; (3) and sharing information between a credit bureau and an insurer. Another concern centered on the use of the Medical Information Board (MIB). The MIB is a repository for medical information submitted by its 750+ member life insurance companies. This information relates to claims and conditions, but also to adverse driving records, aviation activities. and hazardous sports activities. In return for these data, the MIB compiles a report similar to a credit report that is available to all members. Of particular concern for physicians is the increased pressure to reveal patient genetic information to family members (whether or not the latter are the physician's patients), insurers, and employers.(3)

4. Impact on job opportunities. In the Harris-Equifax Survey, 41 percent of the public were concerned that medical claims information submitted under an employer health plan might be used by the employer and negatively affect their job opportunities.

The Committee on Regional Health Data Networks expressed similar concerns. In order to control/manage the costs of benefits plans, employers,particularly those that are large and self-insured, are given access to personally identifiable patient information. Some third-party administrators have provided human resources departments computer access to such information. There is no way to guarantee that these data would not be used in other personnel decisions. It is, indeed, questionable that the employer has a right to this information.(3)

These concerns can be simply summarized. More people will have more access to more information in an electronic environment. The information in the patient's medical record can be used for unauthorized purposes; it can be linked to other databases, or it can be used to form new ones. Although there are violations of privacy now, the very cumbersome nature of the paper medium prevents greater violations.

There are many security measures that can be implemented in an electronic environment. These can ensure privacy and confidentiality and they can also allay the fears around electronic data interchange. Some common technical security measures include:

* Encryption. This is a process of scrambling data so that it can be translated only by those who have the access code, algorithm, or key. User passwords, patient identifiers, and data can be encrypted. Password encryption protects the system from external hackers, as well as keeping internal hackers from reading patient identifiers and data. * Time out. The screen will go blank and the user can be dropped out of the application if there is no activity for a specified period of time. Time out prevents an unauthorized person from accessing the system from an unattended workstation. * Logs. Logs can be kept to track the transaction invocation by user. This allows the system administrator to identify inappropriate requests. * Dialback. When a user wishes to connect to the system, the system will initially disconnect and call back only authorized users.

In an electronic environment, the security systems can be stringent. However, these measures are only as strong as the administrative policies and procedures that accompany them. For instance, if passwords are encrypted and the user gives his or her password to an unauthorized person or tapes it to the monitor, encryption is ineffective. Technical security needs administrative support to deal with human failures. If technical security is breached, the efficiency of the electronic system will allow unauthorized access to greater amounts of information from immediate or remote locations. Security threats are real in any environment.; security measures, policies, and procedures are necessary to safeguard privacy and confidentiality.

Ethical considerations

Privacy and confidentiality are deeply held moral values in our society. The concerns expressed in the Harris-Equifax Survey indicate the priority the public places on these values. Privacy is not simply secrecy; nor is confidentiality just a promise to keep a secret. Privacy is the control of another's access to oneself (e.g., one's thoughts, opinions, attitudes), to information about oneself, as well as access to one's body. Privacy is an aspect of autonomy. It is the control of one's environment, either to exercise the liberty to speak freely to friends and/or a trusted one, knowing that revelations will not be published, or to choose not to speak or to reveal information about oneself to others - friends, relatives, professionals.

Privacy is also a precondition for love, friendship, and trust. It provides the conditions, the environment within which love, friendship, and trust can occur.[4] it is this last relationship of trust that is important to health care. Patients would not reveal personal, family, and financial information, nor would they reveal themselves bodily to physicians and other clinicians, if they were not secure that the professionals would respect them by keeping this information in confidence. By so revealing themselves, patients do not waive their right to privacy; rather they are exercising their right to communicate to achieve a mutual end, which is improved health. Confidentiality is implicit in a physician-patient relationship the patient can assume it unless the physician specifically disavows it.[5]

The rights to privacy and confidentiality are not absolute. There are justifiable limitations, usually in terms of public safety and public health. The public's concern is not with the justified limitations to these rights, but with unauthorized access to personally identifiable information, potential abuses, and resulting harms.

The ethical concerns among consumers, leaders, and experts must be addressed in developing a CHIN. Physicians, in particular, need to preserve privacy and confidentiality, because the trust that exists in the physician-patient relationship is the foundation for delivering care, creating a medical record, and documenting services. The original and fundamental trust that exists between patient and physician is extended to other professionals. The patient accepts this extension because he or she trusts his or her doctor. Patients trust that (1) the information they give and the conclusions reached by physicians and other health care professionals in examining their bodies and minds will be maintained in confidence, (2) it will be shared only with those authorized, (3) it will be used only to the patient's benefit, and (4) their privacy will not be invaded by those who are not authorized and/or have no right to know. If this trust is at the heart of health care, the physician is at the center of this heart.

Consumers believe that health professionals honor confidentiality and privacy obligations. It is encumbent upon health professionals, particularly physicians, to lead in protecting that trust. This can be done by initiating or becoming involved in a collaborative approach in developing a CHIN. Physicians, hospitals executives, consumers, insurers, and employers need to work together to develop procedures and establish the principles that will be the basis for protecting and confidentiality of personally identifiable or traceable information.

Proactive steps

for physicians

Physicians, individually and as organized groups, such as the local medical society, must become involved from the beginning in developing and implementing CHINS. This involves a the commitment - a precious resource.

During the planning period, the focus, direction, and business structure for a CHIN needs to be determined. For instance, the focus will determine whether or not the CHIN will be patient-centered and concerned about privacy and confidentiality, and will give direction to policy, as well as programming. The following questions will need to be addressed: Will there be a patient/consumer rights statement? What kinds of electronic security will be used? Who will be responsible to monitor these measures? What are the sanctions for unauthorized access or use?

The CHIN's structure will determine the legal form of the business and, thus, the role that stakeholders, including physicians, can play in influencing and/or controlling it. There are three basic ownership models. The first is an accountable health plan (AHP) or integrated delivery network (IDN) ownership model. The second and most popular is the vendor-owned model: The vendor owns and operates the CHIN and derives profits; it operates like a cable TV company. There may be several competitive vendor-owned CHINs in a community. The third is a community coalition CHIN, which is formed by coalitions of providers, payers, employers, and governments. It is important to note that stakeholders other than owners or key sponsors will have greater influence in the last type of CHIN.

Physicians need to participate in CHIN planning to have input about the strategic direction, technology, cost structure, timeframe, financing, organizational structure, and operational management. Certainly, a benefit of being involved in planning a CHIN is to determine whether the policies and procedures protect the patient's privacy and confidentiality.

The following questions may be helpful in analyzing office practices. Are there written policies and procedures to protect patient privacy and confidentiality? Do staff follow policies and procedures? What actually happens when another physician's office, an insurer, or an attorney calls for patient information? Is patient written consent required for each of these? Must the request come in writing? Are written requests time-limited, specific as to condition; do they indicate a purpose, and are they authorized? Do policies and procedures need to be revised? Do staff need training in matters of privacy and confidentiality?. Does the office have a confidentiality pledge for employees?

Physicians can encourage the facilities where they work to review their policies and procedures on patient privacy and confidentiality. It is also a good time to review the staff s behavior. Many questions can be asked, for instance: Where are patients' charts held? Who has access to these charts? When an external utilization reviewer wants to look at specific patient information, what process must he or she follow? Who authorizes the release of person-specific information? In a tertiary facility, do all staffed physicians and resident physicians have access to all patient charts?

All physicians on a CHIN will not have access to all patient data. There should not be two disparate policies regarding physician access to patient charts in a CHIN organization and the CHIN itself. Physician convenience often dictates how a hospital will function regarding releasing patient information to physicians. These processes can be accurately documented only with the involvement of physicians. If patient privacy and confidentiality are to be preserved, physicians must collaborate in die review of the processes, encourage revision of policies to protect privacy and confidentiality, and begin to relate these processes to an electronic environment.

Physician leaders need to become involved in educating other physicians/users of the CHIN, and urge facilities where they are staffed to institute consistent policies, procedures, and to encourage consistent behavior among staff.

Finally, physicians must emphasize the need for privacy and confidentiality. Generally, patients or consumers do not participate in developing CHINs, so their concerns are not heard directly. However, the physician is a powerful partner in the patient-physician relationship. Physicians are essential to the functioning of a CHIN. The physicians' concerns will be heard. Furthermore, physicians initiate the patient record, although other professionals add to it. The record is an expression of patient trust. It is important for the physician as the holder of trust and the initiator of the record to be the patient advocate.

Conclusion

The importance of CHINs will grow as health care moves steadily toward a managed care environment. The role that physicians can play in planning and implementing these CHINs is important from several perspectives. Since physicians will be key users of the CHINs' financial, clinical, and telemedicine capabilities, they should have a pivotal part in designing the system. Also, as critical partners in the patient-physician relationship, physicians have a responsibility to protect the patient confidentiality. Physicians can influence not only the technological, business, and administrative structures of a CHIN, but also review and revise policies and procedures related to patent privacy in their own practices and the facilities where they are staffed.

Typically, physicians do not involve themselves or stay involved in such management activities, because these are outside their area of interest - the practice of medicine. However, there may be no one else at the table to protect the patient-physician relationship. It is in the patients' and their own best interests for physicians to become involved in planning and implementing CHINs in their communities.

References

[1.] Bergman, R., "Data Detente," Hospitals and Health Networks. June 20, 1994, pp. 46-50. [2.] Louis Harris and Associates, and Westin, A. Conducted for Equifax, 1993. New York: Louis Harris and Associates, 1993. [3.] Donaldson, M., and Lohr, K. M. (editors). Health Data in the Information Age. Use, Disclosure, and Privacy. Washington, D.C.: National Academy Press, 1994. [4.] Fried, C., An Anatomy of Values: Problems of Personal and Social Choice. Cambridge, Massachusetts: Harvard University Press, 1970. [5.] Beauchamp, T. L. and Childress, J. F. Principles of Biomedical Ethics Fourth Edition. New York: Oxford University Press, 1994.

Key Concepts: Community Health Information

Networks (CHINs)/Physicians' Role in

Developing CHINs/Privacy and

Confidentiality/Doctor-Patient Relationship

The last half of the 20th Century has been witness to numerous changes in the delivery and financing of health care services. These changes have impacted the one-to-one doctor-patient relationship that may have existed in the past to become a complex of relationships. The contemporary physician collaborates with many other professionals to assist in the delivery, financing, and monitoring of health care services. These clinicians and other professionals require access to patient information to deliver care and secure payment. The patient understands this. Yet the patient has concerns about the widening circle of persons authorized to access his or her information. These concerns have been amplified by the development of community health information networks - (CHINs). This article focuses on CHINs, both patient concerns and the role physicians can take in developing them.