If Facebook Designed Your EHR: A Timeline Approach to Patient CareJanuary 2, 2014 by Melissa McCormack
Like many industries these days, healthcare is increasingly digital. Many doctors are now using electronic health record (EHR) software rather than pen and paper for patient records. EHRs have taken medical records into the 21st century and solved many of the administrative problems of paper charts (think illegible handwriting and the inability to quickly pull up information).
But naturally, new challenges have arisen with the digital modality. Because there are so many different vendors creating different types of EHR software, interoperability—the ability to share the same records across different providers—is a major challenge. And in an age where people can conduct banking transactions on their smartphones, most patients can’t access their own digital medical records.
It’s time for medical records to take the next evolutionary step and become patient-centric. How? Medical records should follow the lead of an outside innovator in sharing information about individuals: Facebook.
Making Medical Records Patient-Centric
Dr. Rob Lamberts is a practicing physician, speaker, blogger and health IT evangelist. He’s been an EHR supporter since their early days, but he also recognizes a need for EHRs to move in a new direction.
The challenge, Dr. Lamberts tells me, is the way the U.S. health system pays for care. Because physicians are typically paid based on the specific services they provide during an office visit—e.g. tests ordered, drugs prescribed—they need their software to document complex medical and billing codes to ensure they’re properly paid.
As a result, EHR features have become focused on billing and coding. “It’s not a patient-centered [medical record]; it’s payment-centered,” Dr. Lamberts explains.
But the landscape of healthcare payment is changing. The Affordable Care Act emphasizes the need for payment models based on value, rather than volume—i.e. whether a patient is getting well, rather than how many tests the doctor is running.
Dr. Lamberts himself recently transitioned to a value-based concierge medical practice, where the patient, rather than insurance reimbursement, becomes the primary focus. With such shifts already underway, the time is ripe for medical records to evolve along with this trend.
What might a patient-centric medical record look like? Let’s explore some of Facebook Timeline’s key features to see what medical records could learn.
Medical Records as Seen Through Facebook’s Timeline
“Timeline” is the name Facebook uses for the style of its user profile pages. In other words, my personal Facebook page is my Timeline. As its name suggests, the Timeline is laid out linearly: the latest posts are at the top, while scrolling down shows older activity.
The Timeline provides both a snapshot of who a user is and a historical record of that user’s activity on Facebook. It’s also a single record of a user. I have my profile, and anyone else I allow to view it sees the same profile—they don’t each have their own copies of my profile.
This is another area where medical records could greatly benefit. Rather than each doctor I visit having their own version of my medical record, there should be a single, unified “master record” accessible by me and all of my doctors. Here’s how it would work.
➔ “About,” or Patient Medical History
The “about” section of a user’s Facebook profile contains basic information about a user. It features a user-selected picture and lists user-provided information such as gender; relationship status; age, political and religious views; interests and hobbies; favorite quotes, books and movies and other biographical information.
In medical records, the “about” section would summarize a patient’s health and background. It would include the patient’s age, gender, smoking status, height, weight and contact information, as well as the name of the patient’s primary care provider and any insurance information.
It would also include family history, as well as a summary list of the patient’s current diagnoses and medications. Unlike most medical records today, both the doctor and the patient would be able to add details.
➔ “Privacy Settings” and “Permissions,” or Sharing of Records
Facebook’s privacy settings allow users to control who can see the information they post or that is posted about them. For example, in my default privacy settings I can choose to make my photos visible only to the people I’ve accepted as “friends.” I can also choose to change the default privacy settings for specific photos I upload.
Additionally, Facebook users can give “permission” for third-party applications to access their profiles. For example, if I want to use TripAdvisor to read travel reviews, TripAdvisor will let me sign in to its site using my Facebook account, rather than having to create a separate TripAdvisor account. To do this, I have to give TripAdvisor “permission” to access my Facebook account.
Medical patients could use “privacy settings” to control whether some or all of their personal information can be seen by an outside party. For example, my aging mother could give me access to her “events” (upcoming doctor’s appointments), or my college-aged son who is still on my health plan could give me access to his recent knee X-rays.
Patients could use “permissions” to allow other doctors to access their records. When I see a new doctor, instead of signing a form granting my previous doctor permission to fax over copies of my records, I could simply give electronic “permission” for my new doctor to have instant online access to my unified record.
Doctors could also use “permissions” in lieu of the paper forms patients typically have to sign during office visits today—e.g. to get patients to sign off on the sharing of their information with insurance providers or other doctors, in compliance with the latest HIPAA regulations for patient privacy.
➔ “Status Updates,” or Treatment and Plan Documentation
“Status updates” are a Facebook user’s way of sharing what’s going on with them at any given moment. My status update, for example, could say: “I just had a great idea for improving medical records.” New status updates appear at the top of a user’s Timeline, while older statuses can be viewed by scrolling down through the Timeline.
Doctors could similarly post “status updates” on a patient’s record to document new diagnoses, medications or treatments. When a doctor prescribes a patient a drug, a status update documenting that prescription would be posted automatically. These types of new prescription updates would also generate drug interaction alerts for the doctor.
➔ “Photos,” or Delivery of Imaging and Test Results
Facebook users can upload photos to their Timeline profile. When more than one photo is uploaded at a time, the photos are organized into albums. There’s even a special “photos” section on a user’s profile where viewers of the Timeline can go to see all of a user’s photo albums.
Similarly, doctors could upload scans, X-rays and other test results to a patient’s “Timeline” medical record. The doctor would be prompted to provide specific details about the images, which would yield a photo album and title, for example: “X-Ray – Left Foot – 1/7/2014.”
The Timeline record would serve as a single repository for all such “photos,” rather than each doctor or facility having their own copies. The patient or any doctor granted permission to access the record would be able to view past images and test results.
➔ “Tagging,” or Collaboration
Facebook lets users “tag” other users to indicate their involvement with the content being posted. For example, if I upload a picture of myself with a friend, I can “tag” the friend in that photo, which adds the photo to her own Timeline in addition to mine.
When this happens, my friend receives a “notification” telling her that she’s been tagged. If she doesn’t want the photo to be included on her Timeline, she can choose to “untag” herself.
With a Timeline medical record, providers could use tagging to alert other providers involved in a patient’s care of pertinent updates. Let’s say, for example, that my primary care physician has referred me to a specialist for several tests. When the specialists uploads the test result “photos,” she could “tag” my primary care physician to ensure he’s notified of the test results.
➔ “Notifications,” or Results, Alerts and Reminders
Facebook users are alerted by red “notifications” when another Facebook user interacts with them in some way (e.g. tagging them in a photo or sending them a message). These notifications ensure users are aware of any interactions or content they’re involved in.
With a Timeline medical record, patients would receive “notifications” when a provider uploads “photos” (such as diagnostic imaging or lab results). Notifications would also be triggered if patient vitals are out of normal range at an appointment—for example, if their blood pressure is low or temperature is high. Both patients and providers would also receive “notifications” when a patient is due for a preventive care visit or test.
➔ “Places Check-Ins,” or Office Visits
Facebook users can “check in” to locations to indicate where they are (or were) at a certain time. For example, I could “check in” to the restaurant where I’m currently having dinner. Photos can also be marked with places to record where they were taken. A user’s Timeline keeps a record of the various locations at which that user has “checked in.”
Medical patients quite literally “check in” when visiting a doctor. In a Timeline medical record, a patient checking in would automatically note on the patient’s Timeline (a) the date and time and (b) which provider the patient is seeing.
A patient “checking in” with a specialist would also trigger a “notification” to their primary care provider, allowing that physician to better track their patient through the continuum of care.
➔ “Friendships,” or Provider Relationships
Facebook users can establish electronic “friendships” with other users when one party electronically requests a friendship and the other party electronically accepts. These friendships are marked on the user’s Timeline (e.g. “Jane Doe is now friends with John Smith”) along with the date the online friendship was created. Being “friends” with someone allows users to more easily share content, “tag” one another and otherwise interact on Facebook.
“Friendships” in a medical record would be documented relationships a patient has with medical professionals and caregivers. When a patient checks in to an appointment with a doctor he’s never visited before, the Timeline would automatically note the new relationship (“friendship”) with that doctor. This would serve as a record for both the patient and his doctor(s), indicating all of the patient’s touch-points for care.
➔ “Events,” or Upcoming Appointments
Facebook users can create online “events” to manage attendance and other details for in-person events. I might create an “event” for a birthday party I plan to host; I could then invite my Facebook “friends” to that online event, where they could RSVP and receive reminders as the date approaches.
“Events” in a medical record would correspond with upcoming doctor appointments, scheduled tests or upcoming procedures. When a patient schedules an appointment, a digital “event” would be created automatically. As the time of the appointment gets closer, the patient would receive reminders about the upcoming “event.”
The Challenge: Patients Over Payments
Dr. Ken Mandl, director of the intelligent health laboratory at Boston Children’s Hospital, is a long-time EHR user who has pioneered and published extensively in the area of personal health records. Dr. Mandl commented on both the value of a medical record modeled after Facebook’s Timeline and the biggest obstacle to creating one:
“The reason why it’s a great idea is because it solves these issues of fragmentation, because the data is in one place. The reason it’s a difficult-to-implement idea is that a lot of places already have electronic health records…they would need to replace what they’ve already invested in with a new system.”
He’s right—the type of record I’m proposing would change the way digital records work. The U.S. healthcare system has been oriented around paying doctors for volume of services rather than quality of care, and existing software solutions have necessarily been designed to support that system. The key is that there must be an incentive for developers to design the type of medical record I’m describing: once centered around patients rather than payments.
And that’s the direction the U.S. healthcare system is starting to take. As reimbursement models shift to reward quality of care, technology providers will be incentivized to create solutions aligning with that goal.
Developers in the healthcare industry have long been solving huge challenges with innovative technologies, so I know they’re up to the task. Bringing some of the magic of Facebook to medical records just might be the way to address the patient-centric needs of tomorrow’s health ecosystem.