This article was first published in the 4th-quarter 2015 edition of Personal Finance magazine.
There’s nothing new about doctors taking and keeping notes about your medical history, and there’s no reason why, like much else, these records should not go digital. The ease with which electronic health records can be shared – and the benefits that healthcare providers and funders see in doing this – has created a wealth of opportunities, and, potentially, some threats to your privacy.
However, the risk to your privacy is mitigated by laws and guidelines issued by the Health Professions Council of South Africa (see “Protecting your privacy”, below).
There have been rapid changes over the past two years, and more developments are set to take place. Large medical scheme administrators, in particular, believe that sharing electronic records will enable you and your doctor to improve your health and the standard of treatment you receive.
For the same reason, the government has an interest in you having an electronic health record. In its 2011 green paper on National Health Insurance (NHI), the Department of Health stated that NHI will include a patient card and an electronic information platform. The platform, the green paper said, will link a patient database with accredited and contracted healthcare providers, enabling you to obtain healthcare services wherever you are in the country.
A year later, the Department of Health produced its e-health strategy document, in which it acknowledged that the different systems used by the private and public healthcare sectors to store records electronically hinder the sharing of information. The department again committed to implementing a national electronic health-record system and said standards for electronic medical records were needed so that different systems could work together.
In April last year, Health Minister Dr Aaron Motsoaledi issued, under the National Health Act, the national standards for what is termed “inter-operability in e-health”, with which all patient information systems must comply.
In the meantime, the private sector has been working on its own electronic medical records.
Various providers have developed software for doctors so they can integrate their medical records with the software used to bill you. These electronic medical records are, and probably will remain, the property of medical practitioners.
However, your medical scheme, its administrator and its managed-care provider are keen to share the information they hold with you and your doctor, because this will improve the quality of treatment and reduce waste in the healthcare system. If both of those aims are achieved, it will cost less to provide you with health care and, ultimately, lower the contributions you pay.
The entry of medical scheme administrators and other players into the record-sharing arena has resulted in a distinction between:
* Information held by doctors in electronic medical records – or your doctor’s notes – which remain with your doctor and will not be shared, except possibly with other healthcare providers treating you, or the managed-healthcare entity of your medical scheme, if you give your informed consent.
* The information held by the administrator of your medical scheme about your claims for hospitalisation, consultations and medicines, declarations about previous conditions made when you joined the scheme, disease-management programmes and, sometimes, when you grant your consent, the results of medical tests. This information is known as your electronic health record (EHR). Sharing this information with your doctor(s), with your consent, can optimise and co-ordinate the care you receive, to ensure you receive the best-quality care at an affordable price.
* The records that are useful for you to keep about the treatment you receive, your test results, and other health indicators. These records are known as patient or personal health records (PHRs). Granting your consent to share these records can also optimise the care you receive. PHRs can be used to schedule appointments and monitor your health through measures such as your weight, body mass index (BMI) and how much you exercise.
You typically consent to the results of tests and scans done by pathologists and radiologists being sent to your doctor, in which case the results would form part of his or her electronic medical record. But such results would be included in an EHR or a PHR only if you consented to the administrator of your medical scheme, or the provider of your PHR, sharing this information.
If you belong to a disease-management programme – for example, for the management of HIV – you may be asked to consent to the programme to assist in monitoring your CD4 count, so that, if it falls below a certain level, the programme can recommend that a doctor intervenes.
If your doctor does not have access to your EHR, your PHR can be an invaluable way of providing him or her with accurate information.
Both the EHR and the PHR can benefit you if:
* You cannot remember your or your family members’ medical histories.
* You cannot remember when last you suffered from one or more medical condition.
* You have forgotten what medications you are taking for these conditions and in what dosage.
* You cannot recall allergies or side-effects of medicines you have taken in the past.
* You cannot recall what medication you are taking for any other conditions that may affect the condition for which you are now being treated, or which may negatively interact with any new medicines.
* You haven’t been taking your medication as prescribed. Your doctor will be able to see what claims you have had at a pharmacy and check if you regularly collect medicine in line with a script.
* You don’t have, or can’t remember, the results of any laboratory tests, such as blood tests, or radiology investigations, and how your condition has developed. Having access to these results can prevent your doctor from sending you for duplicate tests, which saves money.
* You can’t remember when you were admitted to hospital, for what condition and for how long.
* You and your doctor want to understand your medical scheme benefits.
* You want to track your biometric data and link a range of monitoring devices.
What the main administrators offer
Three large companies dominate the medical scheme administration sector in South Africa. Together, Discovery Health, Medscheme and Metropolitan have captured almost 80 percent of medical schemes’ business.
Discovery Health was the first administrator to introduce an EHR to encourage collaboration between the administrator and doctors who treat members of Discovery Health-administered schemes, which include the country’s largest open medical scheme, Discovery Health Medical Scheme, and a number of restricted schemes for employer groups.
In mid-2012, Discovery Health introduced HealthID, an application it developed that contains a record of each member’s medical history. The records are based on the administrator’s data on members’ claims. Discovery asked members to give their doctors their consent to use it.
Doctors who use HealthID can look up your claims and laboratory results. They also benefit from its integration with Discovery Health’s information system in the following ways:
* Your doctor can generate an electronic script, which can be printed and given to you, or emailed to your chosen pharmacy, or emailed to the scheme’s pharmacy delivery service.
* Your doctor can see the costs of all medicines, including generic alternatives, available for a particular condition. This may help you and your doctor to decide on an affordable treatment.
* Your doctor can complete online any application forms your scheme requires – for example, an application for chronic medication or to change existing chronic medication. Your doctor will, in the case of common chronic conditions, be able to obtain approval from the scheme instantly and will be alerted to any co-payments, so he or she can discuss your treatment options with you.
Doctors are increasingly charging patients for the time it takes them to complete the paper forms required by a scheme.
* Your doctor can see the medical scheme option to which you belong and the benefits to which you are entitled. This may help you and your doctor to decide on the most cost-effective treatment for your condition.
* Your doctor can quickly generate an electronic referral letter if he or she wants to refer you to another practitioner, and can attach your test results to the letter. This letter can be emailed to the practitioner, or it can be printed out and given to you. This may obviate the need for you to return to your doctor’s practice to collect the letter.
When generating the referral letter, your doctor will be able to check the option you are on and therefore which doctors charge at the scheme’s rates.
* If you belong to Discovery Health’s Vitality programme and have had certain health indicators measured, – for example, your BMI, weight, blood pressure, glucose or cholesterol – your doctor will be able to see these results.
To encourage doctors to use HealthID and, in turn, encourage you to give your consent, Discovery Health incentivises doctors with interest-free loans to buy a tablet on which they can operate the application, subsidises their 3G costs while using the app, and pays a small fee to doctors who use HealthID when treating a certain percentage of their patients who belong to Discovery-administered schemes.
A doctor who uses HealthID will ask you to provide your consent by signing a form on his or her tablet, or a printed form, or you can give your consent to Discovery Health directly. Confirmation that you have given your consent is SMSed or emailed to you.
If you are referred to another doctor, you will have to give that doctor your consent to access your record on HealthID. If you want to withdraw your consent, you can do so through Discovery Health.
Dr Jonathan Broomberg, the chief executive of Discovery Health, says 4 700 doctors are using HealthID and more than 811 000 members have consented to their doctors viewing their medical records.
Since its launch, HealthID has been enhanced to include Personal Health Programmes for members of Discovery Health Medical Scheme who have diabetes or heart disease.
Members of schemes administered by Discovery Health have been issued with stickers with a Quick Response Code (a type of barcode that can be interpreted using a smartphone) that enables paramedics to access your records using HealthID, as well as the contact details of your next of kin.
Discovery Health has also developed a PHR for members of the schemes it administers. The PHR, which can be accessed online or via the Discovery Health app, gives you access to your claims data, as well as any health indicators recorded through the Vitality programme, for the past three years.
Metropolitan Health introduced an EHR for members of its largest restricted scheme, Bankmed, in 2014. The primary objectives, Metropolitan Health says, were to reduce waste, enhance interaction with your doctor and enable continuity of care. Members move between healthcare providers who do not always have access to the members’ medical histories or their latest test results.
Metropolitan’s web- and app-based EHR includes data on members’ medical conditions, allergies, acute and chronic medication, pathology results, hospitalisations, consultations and any disease-risk programme for which the member is registered.
If a doctor wants to view your profile, he or she can log in to Metropolitan Health’s provider portal and request access. This will generate an SMS or email containing a one-time PIN that will be sent to you. You send the PIN to your doctor before your appointment. Entering the PIN on your profile will unlock your medical history. You can withdraw your permission at any time.
Alternatively, you can access your record on a mobile device during the appointment and share the information with your doctor, or you can print out your medical history before the appointment and take it to your doctor.
Dylan Garnett, the chief executive of Metropolitan Health, says patient empowerment is a critical component of health care, and, although the provider is essential to the management of your health, you need to be aware of and take responsibility for your health.
There has been a high acceptance of Metropolitan Health’s patient record, and the administrator is focusing on coaching doctors and other healthcare providers on how to use the information to serve their patients best, Garnett says.
Medscheme, which administers large open schemes Bonitas and Fedhealth, as well as a number of restricted schemes, is the last of the “big three” administrators to enter the electronic record space.
Medscheme announced in July this year that it was partnering with Med-e-Mass to launch a customised version of that company’s HealthOne Connect platform, which will integrate the software that many doctors use for medical records and billing services with the administrator’s claims data.
Med-e-Mass is the largest provider of medical records and billing software to general practitioners (GPs) and specialists in South Africa, serving about 65 percent of the market, Medscheme says.
A subsidiary of Bytes Healthcare Solutions, a company within the JSE-listed Altron group, Med-e-Mass’s software is used in Ireland, Belgium, France, Switzerland and the United States.
Medscheme’s announcement means that doctors using Med-e-Mass for medical records and billing will, when logging into the system, also find the electronic health records of patients who belong to the schemes administered by Medscheme.
In addition, the customised HealthOne Connect platform will be available to other administrators, Kevin Aron, the chief executive of Medscheme, says. It complies with the Department of Health’s standards of inter-operability for patient information systems, which means that, in future, doctors using Med-e-Mass’s system may be able to access electronic health records held by other administrators.
Aron says healthcare providers have been frustrated by lengthy processes required to capture patient information and having to use multiple platforms from different administrators, each with its own access specifications. This has hampered doctors’ use of electronic medical records, he says.
Medscheme believes the new platform will streamline and improve workflow for doctors and reduce the time spent on administration.
The administrator can pre-populate the system with members’ details, medical history, pathology results, approved chronic medications and medical scheme option and benefits. The system can alert a doctor if a patient has significant health risks that need to be monitored, and it can prompt practices to schedule appointments with high-risk members.
As with Discovery Health’s HealthID, doctors using the customised HealthOne Connect platform will be able to generate electronic scripts and referral letters, check that the treatment they recommend is in line with what the scheme would approve, and motivate for the modification of a treatment plan.
Asked to comment on Medscheme’s use of a platform that can function across administrators, Broomberg says Discovery Health agrees that the needs of the overall healthcare sector would best be served by a common platform that all health professionals, hospitals, providers and funders could access. He says Discovery is in discussions with many industry players on the best way to achieve this.
Aron says Medscheme has been using the customised HealthOne Connect platform in a pilot project with a number of family practitioners in a network since April 2015; because the feedback has been positive, the platform is now being introduced to a wider group of doctors and specialists.
A web-based PHR for members of Medscheme-administered schemes will be rolled out in January 2016. This will be followed shortly thereafter by mobile phone app versions. Each medical scheme beneficiary over the age of 12 will have his or her own record. Parents will be able to access their children’s records only to the age of 12.
Your PHR will include a health risk or wellness assessment that will tell you what your health status is and how to improve it.
Aron says the Med-e-Mass system and the PHR provide Medscheme with two ways of getting information to your doctor:
* You, as the patient, have the information in your record and you can share it with your doctor if he or she doesn’t want to access Medscheme’s EHR; or
* If you don’t have a smartphone, your doctor can access the EHR.
In an emergency, Medscheme can send your health data to a doctor who doesn’t know your his-tory, to ensure that he or she treats you optimally.
In future phases, your PHR may include alerts that remind you that you need to take medication, order new medication, have a test or see your doctor for a check-up, Aron says.
If you leave a Medscheme-administered medical scheme and join a scheme with a different, or no, EHR, your doctor will still have your medical history in his or her electronic medical records, including your claims data, and only your new claims data will not be available.
While medical scheme administrators are providing EHRs to scheme members, other providers have set up PHRs and digital medical diaries in which you can record data relevant to your condition.
The website MyHealthSpace, for example, offers a PHR that is integrated with an EHR maintained by the doctors that MyHealthSpace has signed up to pay to use its system.
Although some of these records and diaries may prove useful to you, those offered by your scheme’s administrator have the advantage of collecting your claims data without your having to input it.
Reaping the benefits
The main benefit of HealthID has been an improvement in the quality of health care provided to members of Discovery Heath-administered schemes, Broomberg says.
“Quality of care is improved significantly when doctors can access comprehensive medical history on their patients, including their chronic disease and medication history,” he says.
Granting doctors access to important patient information provides them with a more complete view of your medical history, which improves the care you receive and reduces the likelihood of serious medical errors, as well as eliminating unnecessary tests.
Broomberg says Discovery Health has received numerous anecdotes about how HealthID has saved lives or enabled diagnoses to be reached, which occurred only because the patients’ EHRs could be accessed. However, to obtain some hard data on the benefits of HealthID, Discovery Health is collaborating with the University of Cape Town on a study of its effects on patient care, he says.
Looking to the future
Aron says administrators believe the future of managed health care lies in disseminating information to members and doctors to influence the behaviour of both.
Doctors treat people only when they present themselves as ill. To save healthcare costs, however, interventions have to be made to prevent members from falling sick in the first place. These interventions include monitoring the blood pressure, weight or smoker status of people who have a high risk of falling ill.
Medical scheme data shows that, on average, high-risk members make up only 20 percent of the membership but are responsible for 80 percent of the money spent on benefits.
Medscheme’s managed-care programme is using predictive modelling, which consultants have typically used to predict a scheme’s healthcare spending, to identify high-risk members. These may be members who have more than one chronic illness, or who have one chronic illness but are at risk of developing more illnesses. The aim of identifying these people is to support doctors in their work and to empower you to do something about your health.
Aron says telephonic counselling and health coaching of high-risk members have resulted in savings for the administrator’s schemes in the form of fewer hospital admissions, shorter stays in hospital, fewer emergency admissions and fewer specialist visits. To achieve these savings, however, schemes are having to spend more on chronic medication and on consultations with GPs and psychologists, he says.
Electronic medical records, EHRs and PHRs can help to identify high-risk members and positively influence their health. These records facilitate targeted interventions that save money, improve the quality of care and ensure that treatment is co-ordinated, Aron says.
PHRs can empower you to manage your health. Aron says they also provide an opportunity for a managed-care entity to engage with you and send you information that can drive a change in your behaviour to improve your health and wellness.
Members can be informed and incentivised so that they make better decisions about, for example, what they eat, how much they exercise, or what medication they take. In these ways, technology has created a range of opportunities for schemes and their managed-care entities to influence the behaviour of their members, Aron says.
PROTECTING YOUR PRIVACY
Are electronic health records a threat to your privacy? They are easy to share, so, potentially, yes. Fortunately, two pieces of legislation govern the confidentiality of your medical information held by either your doctor or your medical scheme administrator.
The National Health Act makes it an offence to divulge information about the user of a health service without the user’s consent, according to a booklet, “Medical records in South Africa”, published by the Medical Protection Society (MPS), a leading international organisation offering insurance to healthcare professionals.
The booklet says the only permitted exceptions are when the law or a court order requires disclosure, or if non-disclosure would represent a serious threat to public health.
Guidelines published by the Health Professions Council of South Africa (HPCSA), however, state that healthcare professionals can disclose information that may assist in the prevention or detection of a crime that will put someone at risk of death or serious harm, the booklet says.
The HPCSA also says your records can be shared with a professional not regulated by the HPCSA if you give your consent.
The Protection of Personal Information (Popi) Act is the second Act that will, once it becomes fully operational, afford you substantial protection from your scheme, its administrator or your doctor accidentally allowing someone to access your medical records without your consent.
In terms of the Popi Act, an entity and all its employees are obliged to treat all personal information they collect from you as private and confidential, and they may use it only for purposes they disclose to you when they obtain the information.
According to the MPS booklet, the Popi Act also obliges anyone who holds your personal information to make sure that all records containing patient information are kept securely.
Confidential records should not be left where other people may have casual access to them, and information about patients should be sent under private and confidential cover, with appropriate measures to ensure that it does not go astray, MPS says.
The Popi Act says you should be told about the kind of information being held about you, how and why it might be shared, and with whom it might be shared, MPS says.