“A pharmacist in Alaska can look at the records of his daughter’s fiancée in Florida…and there’s no way the system right now can track that down.” What’s the solution?

Question: Why have you spoken out against electronic medical records?

Jacob Appel: I'm concerned about electronic medical records.  I think you could develop a system where electronic medical records work, and in theory, it would be a wonderful system.  The paramedics would show up at your doorstep when you have a heart attack, they would press a button and they would instantly know your entire medical history, they would know what medicines you were allergic to, they would know whether you had had a heart attack in the past.  They would be able to see your last 10 EKG's. 

The downside of that, if you create that system, is any paramedic in the country pushing a button can see what medicines you are allergic to, your past EKG's, whether you'd ever had an abortion, a psychiatric hospitalization, the estimates are it would be between 12 and 15 million people that would have to have access to your medical records to have a successful interoperable system.  The example you can use is when a celebrity checks into the hospital.  For example, when Bill Clinton checked into Columbia Presbyterian several years ago, even though the hospital sent out stern warnings to all of its employees, if you look at his records, you will be fired, a substantial number of employees, it was 30 or 40, looked at his records and a number of them were fired.  The hospital had a way for catching that because they were on the look out for people looking at Bill Clinton's records.  Nobody in the hospital is looking at your records to make sure somebody else isn't looking at them. 

Right now because it's just one hospital, and we don't have an interoperable system, where all healthcare providers can see all healthcare providers records, the risk of someone knowing you and working in the hospital is fairly low, particularly if you are from out of town.  If you have the entire system connected, then a pharmacist in Alaska can look at the records of his daughter's fiancée in Florida to see if the guy has a cocaine problem, and there’s no way the system right now can track that down. 

There are things we can do to change that.  We could use, for example, the same mechanisms the credit card companies use to pick up unusual or illogical interventions or access to records, and we could use those unusual interventions to flag people.  Or, as Medicare or Social Security do, we could send people a list every year not of your benefits, but a list of people who have seen your healthcare records.  And if you see, wow, my father-in-law's been looking at my records, you could check that box and act accordingly.  We aren't doing that right now.  

The other downside of these methods is once the genie is out of the bottle, it doesn't do you any good to put it back in.  Once your father-in-law knows that you had a cocaine problem, it really doesn't do you much good to say, "Okay, now I'm going to sue my father-in-law for breach of privacy," because your marriage or your future marriage is a wreck and everybody he has spoken to already knows this.

Recorded on March 1, 2010
Interviewed by Austin rnAllen