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One Saturday afternoon was all internist Sam J. Sugar, MD, needed to prove to himself that using an Internet site to store patients' medical records was a good idea.

Over the summer, Dr. Sugar went to an Evanston, Ill., emergency department for treatment of acute pain due to complications from recent surgery. "I was taking intravenous pain medications, and then they wanted me to answer a bunch of questions about my medications, dosages, recent treatments," he recalled. "I was in no condition to remember that."

To make things worse, the staff at Evanston Northwestern Hospital, where he had had his surgery, couldn't find his paper chart.

And Evanston Northwestern was the hospital where, at that time, Dr. Sugar was medical director.

So Dr. Sugar reached into his wallet and pulled out his ID card for 4Healthylife.com, an Internet-based electronic medical records service based in Evanston. Dr. Sugar founded the site, which allows patients to enter their own medical histories. "Unwittingly I became the first beneficiary of my own system," he said.

Ten minutes later the ED staff had Dr. Sugar's entire medical history, he says. "The nurse said, 'This is cool. Where did you get this?'á"

Birth of an industry

Dr. Sugar's service, which became available to the public in October, is just one of many Internet electronic medical record services launched in the last few months or about to come online.

Individual physicians, entrepreneurs and large corporations, including Internet medical information giant drkoop.com, are spending from thousands to as much as several million dollars rushing into this totally untested market.

The founders of these sites believe that Internet medical records create a unique opportunity for physicians to learn more about their patients and then, on the other side, for patients to get more involved in their own care.

The field is so new that no standards exist for how online records services operate. The early entrants vary widely in how much and what kind of information they collect, what purpose the information is intended to serve, how it can be accessed and whether physicians or patients maintain the record.

In addition, fundamental questions about Internet security and reliability remain, despite the sites' claims that it's easier for some unauthorized person to fish your medical record out of a storage room than out of a Web site.

Nonetheless, Internet medical records will be a big business, predicts Steve Savas, a health care and technology analyst for investment bankers Goldman Sachs in New York. One firm, PersonalMD.com, based in Pleasanton, Calif., claims it has signed on 50,000 members since its March launch.

"It's an emerging market, but down the road I think we could see annual revenues in the $3 billion range," Savas says.

One reason is that universally available medical records could significantly reduce overall medical costs by eliminating redundant testing and unnecessary hospital admissions, Savas says.

The search for a portable record

The Internet may be a new place to store medical records, but the idea of having an easily accessible, portable record is not new.

For years, military personnel have carried their complete paper medical history with them as they moved from billet to billet. "You had a lot of confidence that the doctor knew your complete history when you went into the doctor at a new station," says emergency physician Wayne Pasanen, MD.

Dr. Pasanen spent three years as a medical officer in the Navy and is now medical director of Vitalworks, a Norwood, Mass.-based online medical records company; he's also chief of the ED and vice president of medical affairs at Lowell General Hospital in Lowell, Mass.

Portable records are primarily used for emergencies.

Since 1956, the nonprofit MedicAlert Foundation has provided bracelets and pendants alerting emergency personnel of patients' medical conditions. MedicAlert serves about 2.3 million members in the United States and has affiliates in 12 countries overseas.

Other non-Internet emergency medical records systems entail simply carrying a card with medical conditions, medications and dosages, allergies, and a copy of an ECG in the wallet or in a pendant around the neck. Some communities, such as Sun City, Ariz., have portable medical information forms for seniors that include both clinical data and advance directives.

Who owns the medical record?

To those operating Internet patient record sites, expanding onto the Web is a natural extension of these earlier efforts. The Internet provides an easy way to update and view records, and having an online record available can cut down the time physicians spend asking basic questions about a patient's history.

"What that does is it empowers the doctor to get timely information and empowers the patient to schedule his time more efficiently," Dr. Sugar says.

Many of the new Internet record services focus on basic emergency information, but some go much further, adding information on diet, exercise and content on managing specific diseases. Dr. Sugar's site even has a place to keep your pet's health record.

While many rely on patients to provide content, some request records directly from physicians. The most sophisticated systems get information directly from physicians' electronic medical records.

Whether patients or physicians provide information for the record is a subject of often intense debate.

Some, such as Dr. Sugar and emergency doctor Scott Cameron, MD, who operates Albuquerque, N.M.-based StatChart.com, argue that what patients can provide is sufficient, and may even be more accurate than doctors' notes.

"From the ER point of view what we want is an old EKG and what medications he is on so I don't kill him," Dr. Cameron says. "We want to get enough information so it is usable, but not make it so complex that the patient can't enter it."

Cardiologist Michael Kenner, MD, medical director for Phoenix-based MedRecsExpress.com (www.themedicalrecord.com), has a slightly different view. Even though his system is designed primarily for emergency use, he tries to get copies of original physician records to transcribe or scan into his system.

"We can't verify that the test is correct, but we can verify that what we have in the record is what we received," Dr. Kenner says.

Others, such as internist Blackford Middleton, MD, senior vice president for medical informatics at MedicaLogic, an electronic medical records firm based in Hillsboro, Ore., believe that physicians must have primary responsibility for maintaining records if they are to be really useful.

"As a doctor, accuracy is the critical issue," Dr. Middleton says. "If a patient brings in a ream of information, I read it, but it is not an authentic medical record. It is not a diagnosis."

MedicaLogic is testing an Internet-accessible patient module for its electronic medical record. The record is automatically updated as notes and test results are entered by the physician. Patient notes also are included, as are notes from specialists who also use a MedicaLogic records system.

No matter who it is that maintains the record, having the patient record available on the Internet represents a significant shift in ownership of the record from physician to patient.

That's good, says internist Thomas Booth, MD, vice president of medical affairs at PersonalMD.com. "It makes patients more aware of health and more proactive in improving their health care," he says. "It allows physicians to do some preventive care instead of just intervening when something goes wrong."

Analyst Savas believes that systems that link to physicians' records ultimately will become the standard because they will be more useful. But there are significant obstacles, not the least of which is physician resistance to using electronic records, that must be overcome before Internet medical record use becomes widespread.

But is it secure?

A perceived lack of security of Internet medical records may be another obstacle to widespread use. Yet those involved in Internet records believe that, if anything, they are more secure than paper records.

Dr. Pasanen points out that Vitalworks goes to great lengths to protect its records, as do other systems. Identification numbers are required to access patient information, which is sent over the Internet in an encrypted form, meaning it would be garbled if somebody intercepted the information.

Most systems also encrypt their databases so that if a hacker got in, they would still have to break the key to make sense of the information inside. Database encryption also prevents workers from accessing information.

Still, some possibility exists for breaching Internet records. "The technology is getting better, but it will never be perfect," Dr. Middleton says.

The other threat to security is through the record systems themselves assembling and selling data. All of those interviewed had policies not to sell or distribute patient information in any form, or only to allow access to records of patients who have expressed interest in participating in research through the records service.

"We would be cutting our own throats if we released the information," Dr. Pasanen says.

An old dog learns a new trick

MedicAlert has its own concerns about the Internet. It wonders not only about confidentiality, but also about accessibility.

"Now, any emergency responder can reach us," says Douglas Trigg, senior vice president of Trulock, Calif.-based MedicAlert. "You don't need Internet access, just a phone."

But that won't stop MedicAlert from considering expanding its services to the Internet.

As the world's largest supplier of emergency medical information, it hopes to give upstart Internet rivals a run for their money, Trigg says.

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