Friday, May 8, 2009

Followup on Dispute Resolution

In my earlier blog about Dispute Resolution, I described the planned gathering of computer scientists, electronic health record experts, and dispute resolution professionals called "Online Dispute Resolution in a Technology-oriented Healthcare World"

I attended the event and enjoyed the multidisciplinary discussion, learning a great deal about possible disputes among the data stakeholders in healthcare - patients, providers, payers, employers, compliance organizations, public health, government, national security, research etc.

Here are a few lessons learned

1. There's a need to web enable dispute workflow in healthcare. As e-patient Dave pointed out, I did not hear about any data concerns regarding personal health records likely because there was no easy way to raise the issue. Hospitals have policies regarding medical record disputes. Generally the workflow involves writing letters, making phone calls, and resolving disputes via committee. As the country implements more electronic records and shares more data (with patient consent), among more stakeholders, we need to embrace automated dispute resolution workflows such as are used by eBay. In healthcare, the issues are complex because the medical record is a legal record and there are many compliance issues involved in annotating it. However, I can imagine adding a comment field to the problem list which could be electronically annotated by the patient, so a clinician examining the record could understand the patient's point of view if data is disputed. In our medication reconciliation application, we give clinicians the ability to make notations about patient compliance with medications i.e. discontinued, taken infrequently, changed to a different medication etc. I can imagine gathering this input directly from patients.

Thus, the work of the dispute resolution community working with the healthcare data community will be to think through the workflow that can be supported via web-based dispute resolution tools, while still ensuring the non-repudiability of the medical record and complying with federal, state, and local medical record policies.

2. For issues that cannot be resolved via automated tools, an electronic escalation to an Ombudsman is a reasonable workflow. Complex issues are generally more easily resolved when two people speak directly rather than virtually. However, a web application could be used to identify the issues, exchange background information, and schedule the discussion.

3. If there is assertion of malpractice or harm caused to the patient, then workflows involving risk management and insurance organizations are appropriate.

The full report of the meeting will be available soon, but in the meantime, I will be more sensitive to the need to consider the modes of failure in electronic health records, especially those which are shared with patients, and the desirability of automated dispute resolution workflow.


e-Patient Dave said...

You know, it's funny that this is called "dispute resolution" (in all industries), because it's not always a dispute.

Example: When I don't recognize an American Express charge, they don't have a button for "Inquire," or even a *process* for inquiries when I call in. All I wanna know is "What is this?" But they say I have to dispute it.

To me this is a semantic error that can heighten tensions in relationships. After all, the existence of five "disputes" on an account sounds quite different from five open inquiries.

I think it implies an unwitting arrogance on the part of the system people: "Of course we presume our system is right; we put a lot of thought into it. You disagree? Dispute us."

And, interestingly, here we are again, faced with another example of what something SAYS it is, versus what is ACTUALLY is. Among us relative geeks we can understand those distinctions, but as we increasingly bring ordinary mortals into the discussion, the discipline of Customer Experience (another part of my day job) teaches "I don't know what I said until I know what you heard."

So, John, although I recognize that the discipline is currently called dispute resolution, perhaps you can help lead folks out of the dark ages by encouraging a more friendly - and accurate - term. Inquire, question, whatever - just something not restricted to suggesting being argumentative.

btw, for export, I like what HealthVault did: all imported info comes into a holding pen, where I can pick through it and choose what goes into my record. Love it. Wish I could do that in my day job!

Ahier said...

(off topic shout out)
John is Vice Chair of the HIT Standards Committee - WOO HOO!!!

Ethan Katsh said...

Dave, as one of the organizers of the meeting, your point is not only well-taken but was discussed at some length. Actually, I already have a growing list of possible alternatives. There is a famous saying in the dispute reoslution field that the "forum should fit the fuss" and I think it is also fair to that the label should fit the fuss as well. In any event, what happened to you will continue to have an impact as systems and processes are developed to allow complaints/issues/problems etc. to be responded to.

e-Patient Dave said...

Thanks, Ethan. As John knows, I'll do anything I can manage, to participate, contribute, be a sounding board, etc.

In fact I'd love to know the specifics of what was said about my adventure. I find that even people who were pretty close to it have sometimes come away with a different impression than I had. Write to me, if you want, at epatientdave at

As I've said many times, my goal in putting so much personal time into this (and it does cost me sleep and pay) is to help build a new world of stuff that works really well. The odds of achieving that are diminished if we respond to a slightly off-base version of what actually happened. (For instance at one point an outright error in my record was described as "confusing"! And some media reports mixed up who discovered what when, which would be directly relevant to the "inquiry resolution" discussion.)

Increasingly I'm finding that the story is getting trued up as we recursively filter out the skewage. That's good. So let me know if I can help. I have all the first-hand data, straight from the system, culled by my doctor and me. (How participatory!) :–)

Donald Green MD said...

On data entry there has to be clear responsibility of that input. What seems proper to me is some interchange between the patient and whoever created the data. Siphoning it off to 3rd or 4th or more parties so like a lifetime job. Maybe the basic levels of having accurate information or some description of how the information was obtained needs to be straightened out before it is allowed out in cyber space.

e-Patient Dave said...

I know it's years later, but for the record I'll update my 2009 comment (top of list here).

Today the American Express site *does* say "Inquire/Dispute." And the picklist includes "I don't recognize this charge" so I can SAY that without implying "You guys are lying cheaters." :-)

(Amusingly, I stumbled across this thread when I googled the "I don't know what I said" phrase - this post was near the top!)

Ahier said...

And your American Express card says e-Patient Dave which is pretty cool :-)