Transparency is becoming a fashionable buzzword in many walks of life. In health care, it is rearranging the relationships between patients and those who care for them. Looking at health care from different vantage points, we believe that transparent interactions among patients, clinicians, and payers hold considerable promise for improving the quality of health care and containing costs. Here’s our vision for how health care may soon evolve.
Mr. J is 64 years old. The arthritic pain in his knees, and the limitations it is causing, is becoming unbearable. On his laptop, he reviews his personal health record. It contains the notes and plans that he and his primary care doctor developed during and after his recent visits. Turning to his smartphone, he dictates into his Health app a brief update on his medical history, focusing on his current symptoms. Along with his most pressing questions, he forwards the report to his doctor. At their next appointment, she examines him and they discuss his options. The next day, Mr. J opens his Health app and looks over his doctor’s draft of the visit note. It combines the narrative that he had sent her earlier with her assessment and suggested plan. He and his doctor agree that knee replacement is probably his best option.
After reviewing patient-generated ratings of orthopedic surgeons on his insurer’s website, Mr. J evaluates the health care value rankings (six quality measures and estimated out-of-pocket costs) for the two orthopedic surgeons he decided to consult. He examines their track records for quality and cost, their teams, and the settings in which they operate. He examines their relationships with device companies and the various facilities in which they operate, searching for financial incentives that may influence their practices.
He decides on one of the teams and, after his surgery, chronicles in his secure medical record both his care and his evolving functional status, information that automatically populates patient-reported outcomes metrics that hold the surgeon and the hospital accountable.
Some will say this scenario is far-fetched. But as we wrote recently in the Annals of Internal Medicine, we think it is on the verge of becoming reality. Mr. J’s experiences mirror how people go online and make decisions today. They seek, review, and evaluate information aggregated from multiple sources; retail and service industries live or die by their judgments.
Health care is headed in that direction, but it has a lot of catching up to do. Just 20 years ago, practically no information about the quality of health care providers was available, and just seven years ago it was almost impossible to find prices for something like knee replacement surgery before seeking care.
Here are a few indicators that greater transparency is on the horizon:
- Six U.S. senators have announced a bipartisan effort to increase the transparency of health care information and prices.
- The Centers for Medicare and Medicaid Services have launched the MyHealthEData initiative to diminish “information blocking” and broaden patients’ access to their electronic health records.
- The commonwealth of Massachusetts has once again signaled the imminent arrival of one-stop shopping for consumers who want to know the price of a common medical test or procedure.
Health insurance companies, employers, and entrepreneurs are also working aggressively to make health information transparent. All in all, we expect medical consumers will soon be far better equipped to figure out their own “best buys.”
Internet-based portals already enable millions of people to review their test and laboratory results and send secure email messages to their health care teams. Spurred on by the rapidly spreading OpenNotes movement, all across the country doctors, nurses, and a growing number of psychotherapists are now inviting more than 20 million patients to review and even contribute to what they write in their patients’ medical records. Patients and families helped by such fully transparent electronic records describe improved communication, a greater sense of control, better adherence to treatment plans, and shared decisions that lead to more trust.
Open communication may also lead to fewer tests and less invasive therapies by giving clinicians an incentive to guide their patients toward more value-based decisions, including referrals to both primary care clinicians and subspecialists known for higher-quality and more efficient care. As patients and clinicians take the price of care into consideration, we expect that clinicians will soon be paid specifically for addressing a range of options with their patients.
We also believe that everyone’s medical records will soon reside in the cloud, combining data from wherever care is delivered as well as from patients themselves on an individual, dynamic, constantly evolving personal dashboard that renders obsolete both the traditional medical record and today’s institution-based electronic patient portals.
In the late 1960s, the original ”Star Trek” series envisioned the “medical tricorder” that could instantly read an individual’s vitals; a working prototype was recently unveiled. In the film “2001: A Space Odyssey,” people used tablets to help them keep up with the news, much like they do now with iPads. Mr. J’s experience may seem like science fiction today, but in remarkably short order we expect it will become everyday reality.
Suzanne Delbanco, Ph.D., is the executive director of Catalyst for Payment Reform in Berkeley, Calif. Tom Delbanco, M.D., is professor of medicine at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston and a cofounder of OpenNotes.
I don’t doubt that transparency, involving price and records, is needed. And inter-operability, where I can access records on my patients from any facility, is overdue. I don’t however fully trust quality metrics due to unintended consequences like more cautious patient selection and other ways to game the system. And, like Rick W, I’m concerned about how many people would benefit in your scenario. Non-users could easily be stratified to docs with worse outcomes. They may often be less engaged in their care creating a self-perpetuating system.
Jerry Muller argues in in “The Tyranny of Metrics” that there remain areas that require judgment. I think he’s right.
This is all well and good, but we can barely motivate people in this country to vote or take an interest in the minutiae of most issues and decisions that affect them, do you really think 90% of the patient population is going to take the time and interest to do all the work on their part that this scenario would require?