电子医疗系统引领医生迈进21世纪

    截至今年2月17日，美国政府已经向近2,000家医院和41,000多名医生支付了近31亿美元的激励资金，莫斯塔沙瑞希望医院和医生的数量在接下来的一年里能够实现迅速的增长。

    古斯汀•霍的社区门诊位于旧金山的唐人街，前来就诊的老年人络绎不绝。霍医生的诊所也是该项目的早期受益者之一。他的办公室里堆满了各种文件，唯一能证明诊所里安装了新的电子病历系统的证据就是三个诊室里都安装了三星的平板显示器。霍医生说：“以前我们经常要说‘把这个复印一下’，‘把那个发传真’，现在我只要按一下钮，就可以把它整个发出去。”说话的时候，他的听诊器还吊在白大褂的口袋上。

    不过这依然是一个艰难的转变。霍医生承认：“对电脑我是外行。我用来对付电脑的精力好像比花在病人身上的还多。”不过自从他把平板显示器安装到墙上的支架上以后，就再也没收到过病人的投诉。诊所里经常能看见这样一幕：霍医生走进诊室，向一位患有心脏病的中年病人打招呼，然后把平板显示器拉过来，两个人一起转过椅子，在显示器上查看最近一次检查的结果。

    莫斯塔沙瑞称，这样一个项目要想成功，“必须简单易行，要让小诊所的医生也觉得足够简单。这个系统不仅要为那些有钱的大型机构服务，也要为小诊所的医生服务。”

    不过，并不是每家医院、每家诊所都愿意参与这个计划，有些人可能还会因为掉队而付出代价。从2015年开始，那些届时仍没有采用电子病历的医生将发现，他们原本已经很低的医疗保险和医疗补助报销金每年将被扣除1%，最多则可能被扣除5%。

    此外，有些摩擦难以避免，特别是有些人希望系统标准保持开放，而有些大公司则希望控制系统标准，以有利于自己的产品。印地安那大学（Indiana University）教授艾伦•卡洛尔医生指出：“对于一家公司来说，最能符合他们利益的做法就是确保用户无法从其它来源获得数据。他们想让用户购买他们的产品。兼容性高的系统会损害他们的利益。”

    莫斯塔沙瑞批评一个行业标准委员会去年年底给这个项目拖了后腿。他说：“必须推动这个项目。原地踏步比推动某件不完美的事的风险更大。我们不能再等另一个五年，不能到那时再去推动（美国的医疗数据）交换。我们等不起。”

    莫斯塔沙瑞面临的最大挑战可能是个他无法完全控制的问题——保护患者的隐私。几乎每周都有医院报告病历遭泄露的情况，流出的病历常达数百、甚至数千份。比如去年有人把斯坦福医院（Stanford Hospital）2万多名患者的姓名和诊断代码都贴在了一个商业网站上。某些主张保护消费者权益和隐私权的人担心的事情还不止这些。电子前沿基金会（Electronic Frontier Foundation）的高级律师李天（音译）说，许多公司都想染指病人的数据：“庞大的数据就是巨大的商机”。

    莫斯塔沙瑞也把隐私保护当成优先要务，并表示随着越来越多的医生部署了数据分享系统，以及随着各方对加密方法、访问规则、密码保护和审计追踪投入特别关注，这个计划将只会以“可信赖的速度”继续推进。今年二月发布的指导方针提案主要针对电子病历系统第二阶段的有效使用，包括进一步强调对患者病历的加密问题。

    尽管前面的任务还很艰巨，不过莫斯塔沙瑞的办公室去年还是迎来了一个具有里程碑意义的事件：他们通过互联网，借助一个（医生可免费使用的）行业和政府联合制定标准，利用电子邮件成功地发送了第一批电子病历。它在人类通讯史上的意义可能无法同亚历山大•贝尔在发明世界第一台电话时所说的那句著名的“华生先生，到我这儿来，我想见见你”相媲美。但对于医生来说，这是一个时代的开始。

    Kaiser Health News是亨利•恺撒家庭基金会的一个独立社论项目，它是一个非公益、无党派的医疗政策研究和交流机构，与Kaiser Permanente医疗集团无关。

    译者：朴成奎

    As of Feb. 17, the government had disbursed $3.1 billion in incentive payments to nearly 2,000 hospitals and more than 41,000 doctors, and Mostashari expects that number will balloon in the coming year.

    Dr. Gustin Ho, whose community clinic in San Francisco's Chinatown is crammed with elderly men and women, was among the early beneficiaries. In an office lined with paper files, the only evidence of Ho's new electronic health record system is a few Samsung flat-panel monitors in each of three examining rooms. "Before it was 'copy this,' ' fax that,'" Dr. Ho says, stethoscope dangling from a lab coat pocket. "Now, I just hit a button and send the whole thing."

    The adjustment, however, was tough. "I was an amateur," Ho admits. "I seemed to be paying more attention to the computer than to the patients." After he switched to flat panel monitors, however, attaching them on wall swivels, patient complaints ceased. Entering an exam room to greet a middle-aged patient with heart problems, Ho pulls out the screen while both wheel their chairs together to go over the results of a recent test.

    For such an effort to succeed, "you've got to make it simple," Mostashari says. "Simple enough for the little guy. It has to work not just for the biggest, deep-pocketed organizations, but for the small docs as well."

    Not everyone is on board, and some may pay a price. Physicians who fail to convert to digital records will see their already low Medicare and Medicaid reimbursements cut back 1 percent a year, beginning in 2015, to a maximum 5 percent reduction.

    There's also friction between those who want system standards to be open and some large companies trying to steer standards to benefit their own products. "It's often in a company's best interest to make sure you can't get the data from other sources," says Aaron E. Carroll, a physician and professor at Indiana University. "They want you to buy their products. Easily compatible systems hurt their bottom line."

    Mostashari chastised an industry standards committee for foot-dragging late last year. "Push!" he said. "There is a sense in which not moving on anything is a greater risk than moving forward on something that may be imperfect. We can't afford to wait another five years before we have (health care data) exchange in this country."

    His biggest challenge may be something over which he has less control: safeguarding patient privacy. Every week, it seems, another hospital reports a breach of hundreds or thousands of patient records, such as last year's posting of the names and diagnosis codes of 20,000 Stanford Hospital patients on a commercial website. And it's not just breaches that worry some consumer and privacy advocates. Many companies would love to get their hands on patient data, says Lee Tien, senior staff attorney at the Electronic Frontier Foundation. "Big data is big business," Tien says.

    Mostashari counts privacy protection as a top priority and says the program will only move forward "at the speed of trust," as physicians implement data-sharing systems in increments, with special attention to encryption and rules on access, password protection and audit trails. Proposed guidelines for the second stage of meaningful use, released in February, put a stronger emphasis on encryption of patient records, for instance.

    While the tasks ahead are daunting, Mostashari's office last year celebrated the first transmission of electronic health records sent securely over the Internet via email using an industry-government standard available to doctors for free. In the annals of communications history, the event won't rank with "Mr. Watson, come here, I want to see you," but for doctors, it's a start.

    Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.