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Peer to peer: Sharing patient data online

One company promises cheaper, easier sharing of information as it tries to become the Napster of health care. But is this something physicians will buy?

By Tyler Chin, amednews staff. March 12, 2001.

You need the results of all tests and a list of all medications other physicians have prescribed for one of your patients during the past six months.

So you log on to a computer. You learn that a group practice, a laboratory, two hospitals and two pharmacies around town have eight records matching your criteria. You click on a hypertext link for each record, and -- boom!

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You're connected and able to download the data you need directly from the computers of those entities. You're now ready to treat the patient in your office.

That scenario may sound exciting, scary or merely far-off. But thanks to a new technology called peer-to-peer file sharing, obtaining clinical data as easily as that is moving closer to reality.

CareScience Inc., a 9-year-old Internet health care company led by physicians, is developing a peer-to-peer product, Care Data Exchange, that it says will enable physicians and other providers to securely share clinical information among themselves over the Internet without having to invest in expensive servers or central computers.

How does it work?

The phrase "peer-to-peer" came into vogue with the development of firms such as the controversial music-sharing site Napster.

Here's how peer-to-peer works: Instead of having to place all shared files on a central database or server, members of a peer-to-peer network can pull those files off of each other's individual computers and access them through the Internet.

For example, under CareScience's model, a physician could link up with data in hospitals, laboratories, other practices and elsewhere -- and vice versa. But all of those groups would be restricted to a certain network and certain files, so no one outside the network could randomly pull patient files.

Philadelphia-based CareScience contends that peer-to-peer computing will solve the problem that all providers face -- getting the data they need to make decisions -- better than community health information networks, clinical data repositories and other technologies that other health systems have tried to implement before.

That's because peer-to-peer doesn't involve the huge cost, data ownership and political issues that have sunk those networking initiatives, said David Brailer, MD, PhD, the company's CEO.

"I don't want to say this is the dawn of a new era, but I'd be shocked if peer-to-peer doesn't fundamentally alter the way information is shared. Nothing has worked so far," Dr. Brailer said.

Some technology experts say that peer-to-peer isn't exactly new. It could be argued that the Internet was a peer-to-peer network when it was first created for the use of academics, said Wayne Crews, director of technology studies at the Cato Institute, a "market liberal" think tank in Washington, D.C.

Hospitals and other industries also have used shared hard drives and collaborative software to share information on a small scale. What is new, however, is that the computing power and availability of high-speed Internet connections enable file-sharing to be done on a much larger scale, faster and more efficiently, Crews said.

The peer-to-peer buzz burst on the scene in 1999 when controversial start-up Napster Inc., Redwood City, Calif., released software that enabled users to download digital music files over the Internet for free.

The recording industry quickly sued Napster for copyright infringement. Lower courts so far have agreed. As a result, Napster, which has been accessed by more than 50 million users, may be forced to shut down as a free site.

Regardless of the legal outcome for Napster, the technology will not disappear, experts say.

"Peer-to-peer is here to stay," Crews says. "This company -- CareScience -- may not be, but this sharing of information is the wave of the future. ... As long as patients' privacy preferences are honored, sharing information means better diagnosis, which is good news for patients."

Challenges to overcome

Rachel Terrace, a health analyst at Jupiter Research, said she was aware of several health systems interested in using peer-to-peer technology to move electronic records around. But she doesn't expect the technology to be adopted anytime soon because of privacy issues. Other barriers are the fact that most patient records are on a paper format and that providers' systems often can't talk with each other inside, much less outside, their walls.

Dr. Brailer agrees that CareScience will have to overcome those obstacles. Nonetheless, he is convinced that peer-to-peer will succeed in health care.

"It makes absolute sense," he said. "The way we're doing it now is an absolute wreck, and this technology gives us huge hope to get this [data problem] under control."

In January, CareScience began testing its peer-to-peer product with about 20 provider organizations in Santa Barbara County, Calif. The group, collectively known as the Santa Barbara County Care Data Exchange, delivers medical care to most of the county's residents.

CareScience is hoping that the project, ending in 2002, will show that its technology works, improves care and is cost-effective.

Participants, including the Santa Barbara County Medical Society and major local hospitals, are developing policies for sharing information, said Cindy Bowers, MD, an internist in Santa Barbara. Dr. Bowers also is the director of student health at the University of California, Santa Barbara, and immediate past president of the Santa Barbara County Medical Society, both of which are participating in the test.

"What [CareScience's technology] means is an opportunity to provide better medical care because it will provide rapid access to all information," Dr. Bowers said. "In the long run it has the potential for revolutionizing the way we practice medicine because we will be rid of paper and time wasted running around trying to find pieces of paper we're supposed to have but don't."

But the project won't be successful unless it can ensure privacy and include adequate controls to allow patients to manage their own information, Dr. Bowers said. "Even if [CareScience] is technically secure but can't convince everybody of that, then it's not going to work," she said. "In my conversations with colleagues, that's the biggest area of concern. And that is what CareScience assures us it can manage."

Patients must give their informed consent before data can be shared over CareScience's "care data exchange," Dr. Brailer said, "just as consent is required for the manual sharing of data using paper files or other means in today's current data market."

Patients won't be notified when someone accesses one of their files, but CareScience's system will keep an audit trail of what data were requested, by whom and when. This audit trail will be available to physicians, who can make it available to patients, Dr. Brailer said. Doctors and other users also will be able to configure the network so they can approve data requests or be notified when a request is made.

Access to CareScience's system will be highly restricted. Each participant decides what type of data it wants to share and with whom. The company uses digital certificates to authenticate identities of authorized users and all data transmissions are encrypted. Physicians also will be able to see only the records of patients with whom they have an existing relationship.

CareScience is now marketing its product to health systems, hospitals and large medical groups. Physicians would gain access to CareScience's peer-to-peer network through these entities.

The total cost would depend on the size of implementation, the readiness of an organization's technology infrastructure and whether their data are even in an electronic format. Dr. Brailer estimates that a medium-sized health system will pay several hundred thousand dollars annually for CareScience's system.

CareScience's product will be available for implementation this year, the company said.

Will finances kill it?

Even if physicians and others wholeheartedly accept peer-to-peer computing, there are skeptics who wonder if it is a financially sustainable model.

"I'm skeptical," said Rick Mace, a corporate vice president at the Orlando, Fla., office of Superior Consultant Co., a health care information technology consultancy. "History has shown that so far, while some technologies may be great ideas, the return on investment has proven to be the single leading indicator for success and failure. Without [that return], hospitals aren't going to buy it."

For CareScience to succeed, it will have to show that its product addresses federal medical privacy rules, and that it's simpler and costs less than other products that health systems can use to electronically disseminate data, Mace said. The company also must demonstrate that it and its product have staying power. "If they meet all these criteria, they have a shot -- like anybody else," he said.

CareScience, founded in 1992, claims it was the first company in health care to become an application service provider and is the only health care company that's using peer-to-peer technology.

But that pioneering status hasn't translated into financial success. Since its inception, CareScience has lost millions of dollars. It went public in June 2000 at $12 a share but its stock price was trading just above $1 a share in mid-February.

The company, however, said that neither its poor financial performance so far or stock price will affect implementation of its technology in Santa Barbara or elsewhere. CareScience raised $45 million when it went public, Dr. Brailer said. Also, the California HealthCare Foundation has awarded grants to the company to build the California network and underwrite most of the development costs of the Santa Barbara project, Dr. Brailer said.

CareScience also has taken steps to attain profitability by the end of this year, he said. These included laying off staff and discontinuing two product lines it was developing for health insurers.

"We're a company that until 2001 has put innovation ahead of growth and profitability," Dr. Brailer said. "I think that if we had tried to become profitable [before] and failed, I'd have said there's no hope for us."

ADDITIONAL INFORMATION:

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Here's how CareScience's peer-to-peer system works:

1. When authorized users log on, the peer-to-peer network automatically verifies their identity and checks whether they are authorized to use the network by using digital certificates from organizations such as Intel Corp. and the AMA.
2. After users' identities are authenticated, they are automatically logged on to the peer-to-peer network in an encrypted session.
3. Then they key in patient selection criteria such as patient's name, Social Security number or date of birth and launch a search for that patient.
4. The system will search the identity correlation system and return a list of all people who meet the search criteria, acting like a master patient index so that it will come up with listings for a specific patient. That will happen even if that patient is registered under different names in the information systems of other participants in the peer-to-peer network.
5. Users then verify the patient they want and click on the "locate records" button. They can see information only about people for whom they can verify an existing treatment relationship.
6. The system will run the search through its central directory of clinical records as well as query the different information systems connected to the network.
7. A list of records for that patient will pop up on the authorized user's computer screen. The user then simply clicks on a hypertext link for each record, which then requests that the system where those data are stored send a Web page of that information to the user.
8. Some records will be available online, but others will not. That's because the provider or institution that owns the records may not want them to be electronically accessible for confidentiality reasons or may be unable to provide them in an electronic format. In that event, the user will be told what type of record is available on paper, who has it, whom to contact to get it and how to generate a request for that information.
9. All access requests are tracked and logged by the central system for auditing and security control.