Deryk Van Brunt, Dr.P.H., Chronology.MD Principal Investigator, University of California, Berkeley, Healthy Communities Foundation
Kathleen Morrison, M.P.H., Chronology.MD Project Manager, Healthy Communities Foundation
We live in a country where the American Trial Lawyer’s Association is one of the biggest contributors to political campaigns — to whichever party is in office. Although several attempts at federal legislative overhaul of our medical malpractice system have been introduced in the last 25 years, none has succeeded. The threat of medical malpractice lawsuits can influence the way providers practice medicine. One consequence is the practice of “defensive medicine,” which often results in more expensive care — including unnecessary tests and procedures, as well as recommended protocols. Although attempts have been made to reduce the fear and threat of malpractice liability in the medical profession (e.g., clinical guidelines, best practices, etc.), the reality is that this threat remains quite salient for many providers.
It should come as no surprise, therefore, that liability was a significant concern in the early phases of the design of our technology. On Pioneering Ideas, Steve Downs recently mentioned the Crohnology.MD ODL Prescription (read his post). The concept of the ODL Prescription, put forward here by Dan Bernstein, Nikolai Kirienko, Deryk Van Brunt and Kathleen Morrison, was developed out of a collaboration between iMedic8 and the Healthy Communities Foundation and has been embraced by the Crohnology.MD team.
The ODL Prescription is an agreement between patients and providers that details which biometrics and observations of daily living (ODLs) will be captured between visits. An ODL Prescription is the outcome of a patient/provider negotiation and represents a balance between collecting what’s important to both parties while also considering what’s most relevant in managing the patient's health. The ODL Prescription identifies which ODLs the patient will track and designates how often and when they will be collected. This patient ODL data will be captured and viewable by the patient, and it will then be shared with the provider during the next clinical appointment.
Some members of our team were concerned about the liability risk to our participating providers. For example, is it possible that once a patient logs ODL data, then the provider could be liable if a negative outcome were to result? And what if clues in the patient’s ODL data had pointed toward the negative result?
Our clinical partner, Dr. Jonathan Terdiman, quickly put the liability fears to rest. From his perspective, the ODL information that would be shared at the time of the clinical visit does not represent new information beyond what was previously being discussed; the information is just being captured and shared more thoroughly and reliably. Because the ODL data will only be shared with the clinician at the time of the clinical visit, this data is, in effect, no different from any other information a patient discusses with his or her provider at the time of the clinical appointment. The key element is that initially the system will not even allow the physician to retrieve and see the data between visits. This data workflow will be reinforced once we make our clinicians and patients aware of this protocol. Because there is an understanding that the data will not be shared between appointments, nor reviewed by the clinicians outside of the appointments, we see the ODL data as a visually enhanced — and perhaps more comprehensive — patient narrative.
This approach does, however, raise questions for future versions of our system — and other systems — as we consider sharing the ODL data in real time. Certainly, if a patient’s ODLs indicate that a situation is urgent and requires immediate clinical attention, then that data could be used to inform the clinician of the situation and to instruct the patient to seek treatment immediately. In such a case, would the clinical team be held responsible and liable if they do not act upon this data? The answer will likely relate to the expectations established and agreements made between the patient and his or her care team.
In the meantime, the ODL Prescription will allow our Chronology.MD patients to collect data that may be both clinically and personally significant, allowing us to evaluate whether the information positively impacts the efficiency and value of the patient narrative.